Pediatric Tarsal Coalition and Pes Planovalgus

  • Craig A. Camasta
  • Timothy A. Graeser


Tarsal coalitions are a frequent cause of “ankle pain” in pediatric patients. There is a wide variety of presentations, from incidental finding with no symptoms in a rectus foot to painful peroneal spastic flatfoot with significant arthritic findings. Plain radiographs commonly show a tarsal halo sign in a STJ middle facet coalition. Talar beaking is commonly seen on the lateral radiograph. Calcaneonavicular bar coalition shows a continuous bridge or square fibrous bridge of the dorsal-lateral calcaneus. Other coalitions in most any of the tarsal joints or adjacent bones can occur, but with much less frequency. Thin-slice CT imaging is recommended for further evaluation. Surgery is helpful to separate a CN bar, but other joints involving arthritis will benefit from fusion procedures. Ancillary measures should be considered to correct for equinus contracture (gastrocnemius recession), pes planovalgus (Evans osteotomy, Cotton osteotomy), and multilevel fusion when necessary. Distraction arthrodesis with allograft is helpful in correcting pes planovalgus in a middle facet coalition. In situ fusion with allograft bone grafting can be performed when there is a complete medial bone bridge of the middle facet and no valgus heel position. Individualized surgical planning is based on location of coalition, presence of deformity, and adjacent joint arthritis or malalignment.


Tarsal coalition Pediatric ankle pain Peroneal spasm Coalition surgery Equinus Pes valgus Obese juvenile arthritic flatfoot Subtalar joint distraction arthrodesis In situ subtalar joint arthrodesis Asymptomatic coalition 

Supplementary material

Video 11.1

(MP4 1368 kb)

Video 11.2

(MP4 1924 kb)

Video 11.3

(MP4 3290 kb)


  1. 1.
    Downey MS. Tarsal coalition. In: Banks AS, Downey MS, Martin DE, Miller SJ, editors. McGlamry’s comprehensive textbook of foot and ankle surgery. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2001. p. 993–1031.Google Scholar
  2. 2.
    Leonard MA. The inheritance of tarsal coalition and it relationship to spastic flat foot. J Bone Joint Surg Br. 1974;56B(3):520–6.PubMedGoogle Scholar
  3. 3.
    Mosier KM, Asher M. Tarsal coalitions and peroneal spastic flat foot. J Bone Joint Surg Am. 1984;66-A(7):976–83.Google Scholar
  4. 4.
    Harris BJ. Anomalous structures in the developing human foot. Anat Rec. 1955;121:399.Google Scholar
  5. 5.
    Ceroni D, De Coulon G, Spadola L, De Rose V, Kaelin A. Calcaneus secundarius presenting as calcaneonavicular coalition: a case report. J Foot Ankle Surg. 2006;45(1):25–7.PubMedGoogle Scholar
  6. 6.
    Solomon LB, Ruhli FJ, Taylor J, Ferris L, Pope R, Henneberg M. A dissection and computer tomography study of tarsal coalitions in 100 cadaver feet. J Orth Res. 2003;21:352–8.Google Scholar
  7. 7.
    Bohne WH. Tarsal coalition. Curr Opin Pediatr. 2001;13:29–35.PubMedGoogle Scholar
  8. 8.
    Jayakumar S, Cowell HR. Rigid flatfoot. Clin Orthop Relat Res. 1977;122:77–84.Google Scholar
  9. 9.
    Staser J, Karmazyn B, Lubicky J. Radiographic diagnosis of posterior facet talocalcaneal coalition. Pediatr Radiol. 2007;37:79–81.PubMedGoogle Scholar
  10. 10.
    Wheeler R, Guevera A, Bleck E. Tarsal coalitions: review of the literature and case report of bilateral dual calcaneonavicular and talocalcaneal coalitions. Clin Orthop Relat Res. 1981;156:175–7.Google Scholar
  11. 11.
    Blakemore LC, Cooperman DR, Thompson GH. The rigid flatfoot: tarsal coalitions. Clin Podiatr Med Surg. 2000;17(3):531–55.PubMedGoogle Scholar
  12. 12.
    Katayama T, Tanaka Y, Kadono K, Taniguchi A, Takakura Y. Talocalcaneal coalition: a case showing the ossification process. Foot Ankle Int. 2005;26(6):490–3.PubMedGoogle Scholar
  13. 13.
    Kumai T, Takahura Y, Akiyama K, Higashiyama I, Tamai S. Histopathological study of nonosseous tarsal coalition. Foot Ankle Int. 1998;19(8):525–31.PubMedGoogle Scholar
  14. 14.
    Brown RR, Rosenberg ZS, Thornhill BA. The C sign: more specific for flatfoot deformity that subtalar coalition. Skelet Radiol. 2001;30(2):84–7.Google Scholar
  15. 15.
    Lowy LJ. Pediatric peroneal spastic flatfoot in the absence of coalition: a suggested protocol. J Am Podiatr Med Assoc. 1998;88(4):181–91.PubMedGoogle Scholar
  16. 16.
    Lyon R, Liu X, Cho S. Effect of tarsal coalition resection on dynamic plantar pressures and electromyography of lower extremity muscles. J Foot Ankle Surg. 2005;44(4):252–8.PubMedGoogle Scholar
  17. 17.
    Yu GV. Asymptomatic tarsal coalitions. Reconstructive surgery of the foot and leg, update 1993. Tucker: The Podiatry Institute; 1993. p. 246–55.Google Scholar
  18. 18.
    Blair J, Perdios A, Reilly C. Peroneal spastic flatfoot caused by a talar osteochondral lesion: a case report. Foot Ankle Int. 2007;28(6):724–6.PubMedGoogle Scholar
  19. 19.
    Doig SG, Menelaus MB. Association of slipped upper femoral epiphysis and peroneal spastic flatfoot. J Pediatr Orthop. 1991;11(2):220–1.PubMedGoogle Scholar
  20. 20.
    Graves SC, Keuster DJ, Richardson EG. Dysplasia epiphysealis hemimelica (Trevor disease) presenting as peroneal spastic flatfoot deformity: a case report. Foot Ankle. 1991;12(1):55–8.PubMedGoogle Scholar
  21. 21.
    Glockenberg A, Weinreb A, Pevny J. Rheumatoid arthritis-induced peroneal spastic flatfoot. J Am Podiatr Med Assoc. 1987;77(4):185–7.PubMedGoogle Scholar
  22. 22.
    Cowell HR. Talocalcaneal coalition and new causes of peroneal spastic flatfoot. Clin Orthop Relat Res. 1972;85:16–22.PubMedGoogle Scholar
  23. 23.
    Jack FA. Bone anomalies of the tarsus in relation to “peroneal spastic flat foot”. J Bone Joint Surg. 1954;36(4):530–42.Google Scholar
  24. 24.
    Harris RI, Beath T. Etiology of peroneal spastic flat foot. J Bone Joint Surg Br. 1948;30B(4):624–34.PubMedGoogle Scholar
  25. 25.
    Downey MS. Ankle equinus. In: Banks AS, Downey MS, Martin DE, Miller SJ, editors. McGlamry comprehensive textbook of foot and ankle surgery. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2001. p. 715–60.Google Scholar
  26. 26.
    Crim JR, Kjeldsberg KM. Radiographic diagnosis of tarsal coalition. Am J Radiol. 2004;182:323–8.Google Scholar
  27. 27.
    Kricun ME. The normal foot. In: Forresster DM, Kricun ME, Kerr R, editors. Imaging of the foot and ankle. Rockville: Aspen Publishers; 1988. p. 25–43.Google Scholar
  28. 28.
    Berquist TH, Johnson KA. Anatomy, normal variants, and basic biomechanics. In: Berquist TH, editor. Radiology of the foot and ankle. New York: Raven Press; 1989. p. 1–34.Google Scholar
  29. 29.
    Lateur LM, Van Hoe LR, Van Ghillewe KV, Gryspeerdt SS, Baert AL, Dereymaeker GE. Subtalar coalition: diagnosis with the C sign on lateral radiographs of the ankle. Radiol. 1994;193:847–51.Google Scholar
  30. 30.
    Wright EM, Lieberman R, Brekke M, Reicher M, Green D. Tarsal coalition. In: Reconstructive surgery of the foot and ankle, update 1997. Tucker: The Podiatry Institute; 1997.Google Scholar
  31. 31.
    Wechsler RJ, Schweitzer ME, Deely DM, Horn BD, Pizzutillo PD. Tarsal coalition: depiction and characterization with CT and MR imaging. Radiology. 1994;193:447–52.PubMedGoogle Scholar
  32. 32.
    Crim J. Imaging of tarsal coalition. Radiol Clin North Am. 2008;46:1017–26.PubMedGoogle Scholar
  33. 33.
    Kulik SA, Clanton TO. Tarsal coalition. Foot Ankle Int. 1996;17(5):286–96.PubMedGoogle Scholar
  34. 34.
    Saxena A, Erickson S. Tarsal coalitions: activity levels with and without surgery. J Podiatr Med Assoc. 2003;93(4):259–63.Google Scholar
  35. 35.
    Emery KH, Bisset GS, Johnson ND, Nunan PJ. Tarsal coalition: a blinded comparison of MRI and CT. Pediatr Radiol. 1998;28:612–6.PubMedGoogle Scholar
  36. 36.
    Newman JS, Newberg AH. Congenital tarsal coalition: multimodality evaluation with emphasis on CT and MR imaging. Radiographics. 2000;20:321–32.PubMedGoogle Scholar
  37. 37.
    Nalaboff KM, Schweitzer ME. MRI of tarsal coalition: frequency, distribution and innovative signs. Bull NYU Hosp Joint Dis. 2008;66(1):14–21.Google Scholar
  38. 38.
    Napolitano C, Walsh S, Mahoney L, McCrea J. Risk factors that may adversely modify the natural history of the pediatric pronated foot. Clin Podiatr Med Surg. 2000;17(3):397–417.PubMedGoogle Scholar
  39. 39.
    Pfeiffer M, Kotz R, Ledl T, Hauser G, Sluga M. Prevalence of flat foot in preschool-aged children. Pediatrics. 2006;118(2):634–9.PubMedGoogle Scholar
  40. 40.
    Wearing SC, Hills AP, Byrne NM, Hennig EM, McDonald M. The arch index: a measure of flat or fat feet? Foot Ankle Int. 2004;25(8):575–81.PubMedGoogle Scholar
  41. 41.
    Mickle KJ, Steele JR, Munro BJ. The feet of overweight and obese young children: are they flat or fat? Obesity. 2006;14(11):1949–53.PubMedGoogle Scholar
  42. 42.
    Villarroya MA, Esquivel JM, Tomas C, Moreno LA, Buenafe A, Bueno G. Assessment of the medial longitudinal arch in children and adolescents with obesity: footprints and radiographic study. Eur J Pediatr. 2009;168(5):559–67.PubMedGoogle Scholar
  43. 43.
    Chen JP, Chung MJ, Wang MJ. Flatfoot prevalence and foot dimensions of 5- to 13-year-old children in Taiwan. Foot Ankle Int. 2009;30(4):326–32.PubMedGoogle Scholar
  44. 44.
    Blockey NJ. Peroneal spastic flat foot. J Bone Joint Surg Br. 1955;37B(2):191–202.Google Scholar
  45. 45.
    Thometz J. Tarsal coalition. Foot Ankle Clin. 2000;5(1):103–18.PubMedGoogle Scholar
  46. 46.
    Kernbach KJ, Blitz NM. The presence of calcaneal fibular remodeling associated with middle facet coalition: a retrospective CT review of 35 feet. Investigation involving middle facet coalitions-Part II. J Foot Ankle Surg. 2008;47(4):288–94.PubMedGoogle Scholar
  47. 47.
    Giannini S, Ceccarelli F, Vannini F, Baldi E. Operative treatment of flatfoot with talocalcaneal coalition. Clin Orthop Rel Res. 2003;411:178–87.Google Scholar
  48. 48.
    Scott AT, Tuten HR. Calcaneonavicular coalition resection with extensor digitorum brevis interposition in adults. Foot Ankle Int. 2007;28(8):890–5.PubMedGoogle Scholar
  49. 49.
    Cowell HR, Elener V. Rigid painful flatfoot secondary to tarsal coalition. Clin Orthop Relat Res. 1983;177:54–60.Google Scholar
  50. 50.
    Lemley F, Berlet G, Hill K, Philbin T, Isaac B, Lee T. Current concepts review: tarsal coalition. Foot Ankle Int. 2006;27(12):1163–9.PubMedGoogle Scholar
  51. 51.
    Field C, Ng A. Resection of middle facet coalition with arthroscopic guidance. J Foot Ankle Surg. 2009;48(2):273–6.PubMedGoogle Scholar
  52. 52.
    Hetsroni I, Nyska M, Mann G, Rozenfeld G, Ayalon M. Subtalar kinematics following resection of tarsal coalition. Foot Ankle Int. 2008;29(11):1088–93.PubMedGoogle Scholar
  53. 53.
    Hetsroni I, Ayalon M, Mann G, Meyer G, Nyska M. Walking and running plantar pressure analysis before and after resection of tarsal coalition. Foot Ankle Int. 2007;28(5):575–80.PubMedGoogle Scholar
  54. 54.
    Kernbach KJ, Blitz NM, Rush SM. Bilateral single-stage middle facet talocalcaneal coalition resection combined with flatfoot reconstruction: a report of 3 cases and review of the literature. Investigations involving middle facet coalitions-Part I. J Foot Ankle Surg. 2008;47(3):180–90.PubMedGoogle Scholar
  55. 55.
    Sammarco VJ, Magur EG, Sammarco GJ, Bagwe MR. Arthrodesis of the subtalar and talonavicular joints for correction of symptomatic hindfoot malalignment. Foot Ankle Int. 2006;27(9):661–6.PubMedGoogle Scholar
  56. 56.
    Beischer AD, Brodsky JW, Pollo FE, Peerebroom J. Functional outcome and gait analysis after triple or double arthrodesis. Foot Ankle Int. 1999;20(9):545–53.PubMedGoogle Scholar
  57. 57.
    Mann RA, Beaman DN. Double arthrodesis in the adult. Clin Orthop Relat Res. 1999;365:74–80.Google Scholar
  58. 58.
    Harris EJ, Vanore JV, Thomas JL, Kravitz SR, Mendelson SA, Mendicino RW, Silvani SH, Gassen SC. Diagnosis and treatment of pediatric flatfoot. J Foot Ankle Surg. 2004;43(6):341–73.PubMedGoogle Scholar
  59. 59.
    Downey MS. Tarsal coalitions: a surgical classification. J Am Podiatr Med Assoc. 1991;81(4):188–97.Google Scholar
  60. 60.
    Lawrence DA, Rolen MF, Haims AH, Zayour Z, Moukaddam HA. Tarsal coalitions: radiographic, CT, and MR imaging findings. HSS J. 2014;10:153–66.PubMedPubMedCentralGoogle Scholar
  61. 61.
    Mosca VS, Bevan WP. Talocalcaneal tarsal coalitions and the calcaneal lengthening osteotomy: the role of deformity correction. J Bone Joint Surg Am. 2012;94:1584–94.PubMedGoogle Scholar
  62. 62.
    Schwartz JM, Kihm CA, Camasta CA. Subtalar joint distraction arthrodesis to correct calcaneal valgus in pediatric patients with tarsal coalition: a case series. J Foot Ankle Surg. 2015;54(6):1151–7.PubMedGoogle Scholar
  63. 63.
    Guignand D, Journeau P, Mainard-Simard L, et al. Child calcaneonavicular coalitions: MRI diagnostic value in a 19-case series. Orthop Traumatol Surg Res. 2011;97:67–72.PubMedGoogle Scholar
  64. 64.
    Gantsoudes GD, Roocroft JH, Mubarak SJ. Treatment of talocalcaneal coaltions. J Pediatr Orthop. 2012;32(3):301–7.PubMedGoogle Scholar
  65. 65.
    Mahan ST, Spencer SA, Vezeridis PS, Kasser JR. Patient-reported outcomes of tarsal coalitions treated with surgical excision. J Pediatr Orthop. 2015;35(6):583–8.PubMedGoogle Scholar
  66. 66.
    Bonasia DE, Phistikul P, Amendola A. Endoscopic coalition resection. Foot Ankle Clin N Am. 2015;20:81–91.Google Scholar
  67. 67.
    Piqueres X, de Zabala S, Torrens C, Marin M. Cubonavicular coalition: a case report and literature review. Clin Orthop Relat Res. 2002;396:112–4.Google Scholar
  68. 68.
    Krief E, Ferraz L, Appy-Fedida B, Deroussen F, Plancq MC, Collet LM, Gouron R. Tarsal coalitions: preliminary results after operative excision and silicone sheet interposition in children. J Foot Ankle Surg. 2016;55(6):1264–70. Epub 2015 May 16.CrossRefPubMedGoogle Scholar
  69. 69.
    Khoshbin A, Law P, Caspi L, Wright J. Long-term functional outcomes of resected tarsal coalitions. Foot Ankle Int. 2013;34(10):1370–5.PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Craig A. Camasta
    • 1
    • 2
    • 3
  • Timothy A. Graeser
    • 4
  1. 1.Pediatric and Adult Reconstructive Foot & Ankle Surgery FellowshipAtlantaUSA
  2. 2.Department of SurgeryEmory St. Joseph’s HospitalAtlantaUSA
  3. 3.Faculty, The Podiatry InstituteDecaturUSA
  4. 4.Private Practice, Motio Foot and Ankle SpecialistsWinter SpringsUSA

Personalised recommendations