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Tarsal Coalition

  • "The first line of treatment for tarsal coalition is to rest the foot for about a month, then use arch supports and physical therapy. For about half the kids who receive this conservative treatment, their pain goes away, and they may never need surgery."

    –Samantha Spencer, MD, orthopedic surgeon, Boston Children's Hospital

    If your child has been diagnosed with tarsal coalition, you’ll have concerns and questions about her health, treatment, recovery and other issues. It may comfort you to know that Boston Children’s Hospital is a world leader in pediatric orthopedics, and we have a wealth of experience helping children with this fairly common condition. We specialize in innovative, family-centered care that supports your child and family.

    What to know about tarsal coalition
    The bones of the foot found at the top of the arch, the heel and the ankle are called the tarsal bones. A tarsal coalition is an abnormal connection between two or more of these bones. These coalitions can form across joints of the foot or can occur between bones that don't normally have a joint between them.

    • Although the condition is congenital present early in life, your child may not experience pain until she’s between 8 and 16 years old.
    • The chief symptom is pain—often recurring ankle pain or unexplained ankle sprains.
    • Your child may experience rigidity and stiffness in around her ankle, and a decreased range of motion.
    • Some researchers believe tarsal coalitions are an inherited trait, passed from parent to child. However, there is no gene identified at this point.
    • About 25 percent of children with tarsal coalition have a rigid flat foot.
    • Experts estimate that 3 to 5 percent of people have a tarsal coalition. Many never know they have this condition.
    • Treatment can be non-surgical or surgical, depending on its severity.
    • A severe case of tarsal coalition can interfere with a child’s foot function, and may alter a child’s activity level, but it’s not life- or limb-threatening.
    • Many children with the condition never need treatment. Of those who do need treatment, some don't need surgery.

    How Boston Children's Hospital approaches tarsal coalition
    The goal of treatment is to reduce the pain in your child's foot. At Children's, doctors take conservative, non-surgical approaches first. If pain persists despite these efforts, surgeons will be ready to help, and your child will consult with doctors for exercises to restore range of motion.

    Whatever observation or treatment your child needs, you can have peace of mind knowing that as a national and international orthopedics referral center, our Orthopedic Center has vast experience treating children with every kind of developmental condition, some of which few other pediatric hospitals have ever encountered. As a result, we can provide expert diagnosis, treatment and care for every severity level of tarsal coalition.

    One of the first programs. Our Orthopedic Center is one of the world’s first comprehensive pediatric orthopedic programs, and today is the largest pediatric orthopedic surgery center in the United States, performing more 6,000 procedures each year. Our program, consistently ranked among the top in the country by U.S.News & World Report, is the nation’s preeminent care center for children and young adults with developmental, congenital, post-traumatic and neuromuscular problems of the musculoskeletal system.

    The world's most extensive pediatric research enterprise

    At Boston Children’s, we’re known for our innovative treatments and a research-driven approach. We’re home to the world’s most extensive pediatric research enterprise, and we partner with elite health care and biotech organizations around the globe. But as specialists in family-centered care, our physicians never forget that your child is precious, and not just a patient. 

    Orthopedic care in lots of places

    Boston Children’s physicians provide orthopedic care at locations in Lexington, Peabody, Weymouth and Waltham, as well as at our main campus in Boston.

    Tarsal coalition: Reviewed by Samantha Spencer, MD

    © Boston Children's Hospital, 2012

    Orthopedic Center
    Boston Children's Hospital
    300 Longwood Avenue
    Fegan 2
    Boston MA 02115
    617-355-6021

  • Right now, you probably have lots of questions: How serious is my child’s tarsal coalition? Does my child need treatment? What do we do next? We’ve provided some answers to your questions on this site, and our experts at Children’s Hospital Boston can explain your child’s condition fully when you meet with us.

    What are the tarsal bones, and what is tarsal coalition?

    The tarsal bones in the middle and back of the foot—the calcaneus, talus, navicular and cuboid—together form joints that are extremely important to proper foot function. When there’s abnormal growth of bone cartilage or fibrous tissue across these joints (tarsal coalition), a child’s range of motion either decreases or ceases entirely, causing pain and rigidity in the area.

    • The most common coalitions occur either:
      • across a joint between the talus and calcaneus bones (talocalcaneal coalition, also referred to as a TC bar)
        -or-
      • between the calcaneus and navicular bones (calcaneonavicular coalition, also referred to as a CN bar).
    • Calcaneonavicular coalitions are more common than talocalcaneal coalitions. Together, these two types account for about 90 percent of all coalitions. There are other more rare types, as well.
    • More than 50 percent of the time, tarsal coalition occurs in both feet.
    • Sometimes both types of coalition are present in the same foot.

    What causes a tarsal coalition?

    • can be a genetic error in the dividing of embryonic cells that form the tarsal bones during fetal development
    • can sometimes be triggered by:
      • trauma to the area
      • infection
      • self-fusion of a joint caused by advanced arthritis (rare in children)

    What are the symptoms of a tarsal coalition, and when do they show up?

    Even though most children with tarsal coalitions are born with them, a child typically has no painful symptoms until sometime between the ages of 8 and 16—with two age peaks for the onset of symptoms (8 to 10 and 11 to 13). Late childhood/early adolescence is the time when a child’s bones are turning from mostly cartilage to mostly bone (ossifying). During this period, the hardening (calcifying) tarsal coalition grows more rigid and painful.

    The following are the most common symptoms of a tarsal coalition. Keep in mind that each child may experience symptoms differently:

    • pain, typically on the outside and top of the foot (although some children have no pain)
    • flat feet or a flat foot (although not all children with flat feet have a tarsal coalition)
    • rigidity and stiffness in the affected foot
    • muscle spasms

    Sometimes symptoms don't flare up until early adulthood.

    How common is tarsal coalition?

    Experts estimate that about 3 to 5 percent of people have a tarsal coalition. About 50 percent of these have it in both feet.

    How serious is tarsal coalition?

    The answer to this question depends on the child’s and family’s expectations. If sports are central to the child’s life, tarsal coalition could be viewed as a serious problem. If the child has only occasional aches, as when running in gym class, and sports are not very important to her, she probably won’t view the condition as a big problem.

    A severe case of tarsal coalition can pose a functional problem for walking and may alter a child’s activity level, but it’s not life-threatening or limb-threatening.

    What if tarsal coalition goes untreated?

    Over time, a child, teen or young adult may experience enough pain that she can’t do the activities she wants to do. Later in life, she may have a very stiff foot (indicating a large coalition). The foot may be so stiff and painful that there’s no longer an option for surgical repair; in such cases, surgery would be a joint fusion to alleviate the pain.

    Do orthotics, casts or walking boots help a tarsal coalition?

    Yes. In fact, wearing a cast or walking boot for a month to six weeks (immobilization treatment) can relieve a child’s pain, often permanently.

    Who’s at risk for developing tarsal coalition?

    Tarsal coalition is a genetically-determined condition. If it occurs sporadically (by chance), it means that a genetic mutation took place during a child’s fetal development. If one of a child’s parents has the condition, there is a chance that the child will also have it.

    There is no genetic test available yet for tarsal coalition. As many people living with tarsal coalitions have few or no symptoms and treatment of tarsal coalitions is only for symptomatic ones, evaluation for tarsal coalition occurs only for those people presenting with symptoms.

    How does a doctor diagnose tarsal coalition?

    • physical exam and family history, followed by:
    • standing x-rays
    • CT scan and/or MRI

    How does Boston Children’s treat tarsal coalition?

    Non-surgical treatments can include:

    • casts or walking boots
    • orthotics—special, custom-made shoe inserts that support affected joints
    • injection of an anesthetic and a steroid, such as cortisone, for temporary pain relief
    • anti-inflammatory medications
    • stretching and physical therapy

    If these treatments don’t relieve you child’s symptoms, her doctor may recommend surgery.

    Will my child be OK?

    This condition has a very positive prognosis. Only a small percentage of people who have tarsal coalition need treatment for it. And one-third to one-half of those who need treatment can be helped without surgery.

    Of those who are treated (removed either non-surgically or surgically), about 75 percent become free from pain or recurrence of the condition.

    There is a potential for the repaired joints or surrounding joints to develop arthritis later in a person’s life.

    Does Boston Children’s do research on lower-extremity developmental conditions?

    The clinical and basic science researchers in Boston Children’s Orthopedic Center are recognized throughout the world for their achievements in the field, including groundbreaking studies of the lower extremities. Our breakthroughs mean that we can provide your child with the most innovative care available.

    FAQ

    Q: What is tarsal coalition?
    A:
    The tarsal bones of the foot—calcaneus, talus, navicular and cuboid—together form joints that are crucial to proper foot function. A tarsal coalition is the abnormal growth of bone cartilage or fibrous tissue across these joints, limiting a child’s range of motion and causing pain and stiffness.

    Q: If my child has tarsal coalition, will she be OK?
    A:
    Tarsal coalition has a very good prognosis. Just a small percentage of children who have the condition need to be treated for it. And one-third to one-half of those need treatment can be helped without surgery.

    Of those who are treated either non-surgically or surgically, about 75 percent become free from pain or recurrence of the condition.

    Q: What are the signs and symptoms of tarsal coalition?

    A: A child who has tarsal coalition usually begins to feel pain or discomfort in her second decade. The foot loses range of motion and becomes rigid; it may or may not look flat-footed.

    Q: How is tarsal coalition usually diagnosed?
    A:

    • physical exam and family history, followed by:
    • standing x-rays
    • CT scan and/or MRI

    Q: How does Boston Children’s treat tarsal coalition?
    A:

    • casts or walking boots
    • orthotics—special, custom-made shoe inserts that support affected joints
    • injection of an anesthetic and a steroid, such as cortisone, for temporary pain relief
    • anti-inflammatory medications
    • stretching and physical therapy
    • surgery for severe cases that don’t get better with non-surgical treatment

    Q: If my child has tarsal coalition, what should I ask my Boston Children’s doctor?
    A:
    Some of the questions you may want to ask include:

    • What’s wrong with my child’s foot (feet)? Why is she having pain?
    • Are other tests needed to confirm this diagnosis?
    • Does my child need treatment? Does she need surgery?
    • Is there, or could there be, damage to her tissues or blood vessels?
    • Could there be long-term effects? Pain? Arthritis?
    • Could this condition affect my child’s ability to walk, run or play sports?
    • How long should my child be followed by her care team?

    Q: If my child has tarsal coalition, is she at risk for arthritis or other conditions later in life?
    A:
    For most children with mild cases of tarsal coalition, there’s no added risk of developing arthritis as a result of the condition. For children with more severe cases of the condition, adulthood can bring some risk for arthritis in the affected joint or surrounding joints.

    Q: What is the main risk factor for tarsal coalition?
    A:
    A child has a genetic predisposition for developing tarsal coalition(s) if one parent has the condition.

    Q: What is Boston Children’s experience treating developmental bone problems in children and teens?
    A:
    At Boston Children’s, we’re known for our clinical innovations, research breakthroughs and leadership in treating lower-extremity bone problems. Boston Children’s Orthopedic Center offers the most advanced diagnostics and treatments—several of which were pioneered and developed by Boston Children’s researchers and clinicians.

    Causes

    • can be a genetic error during fetal development in the dividing of the embryonic cells that form the tarsal bones
    • can be triggered by:
      • trauma
      • infection
      • advanced arthritis (rare in children) causing self-fusion of a joint

    Signs and symptoms

    • pain (in some children), usually on the outside and top of the affected foot
    • flat feet or a flat foot (not all children with flat feet have a tarsal coalition)
    • rigidity and stiffness
    • muscle spasms

    When to seek medical advice

    Contact your child’s doctor if your child has:

    • pain on the outside and top of the affected foot
    • flat feet or a flat foot
    • a rigid or stiff foot
    • muscle spasms in her foot

    Questions to ask your doctor

    If your child is diagnosed with tarsal coalition, you may feel a bit worried. It can be easy to lose track of the questions that occur to you. Lots of parents find it helpful to jot down questions as they arise—that way, when you talk to your child’s doctors, you can be sure that all your concerns get addressed.

    Some of the questions you may want to ask include:

    • Could you describe what’s wrong with my child’s foot (feet)?
    • Are other tests needed to confirm this diagnosis?
    • Is there, or could there be, damage to her tissues or blood vessels?
    • Does my child need treatment? Does she need surgery?
    • Could there be long-term effects? Pain? Arthritis?
    • Could this condition affect my child’s ability to walk, run or play sports?
    • How long should my child be followed by her care team?

    Complications

    Most of the time, the pain associated with tarsal coalition goes away with non-surgical treatment and therapy. But if your child’s case is severe enough to need surgery, the majority of procedures at Boston Children’s are successful, and occur without major complications. As with most surgery, after the procedure patients are at a very small risk for infection or bleeding.

    The main complication is that about 25 to 30 percent of affected children—who have non-surgical or even surgical treatment—still have some level of pain.

    Long-term outlook

    The long-term outlook for this condition is very positive. Many of the time, it can be corrected by rest and non-surgical treatment. The condition isn’t usually associated with any other underlying conditions or syndromes.

    Of those who are treated either non-surgically or surgically, about 75 percent become free from pain and recurrence of the condition.

    Tarsal coalition glossary

    • arthritis: joint inflammation and damage, resulting in pain, swelling, stiffness and limited movement. Arthritis can occur when a joint’s cushioning cartilage wears away
       
    • bilateral: both of two sides
       
    • bone bridge: another term for the coalition that forms between the tarsal bones
       
    • calcify: harden into bone by the deposit of calcium salts into cartilage; ossify
       
    • The Center for Families at Children’s: dedicated to helping families find the information, services and resources they need to understand their child’s medical condition and take part in their care
       
    • CT scan (computerized tomography scan): the gold standard for the diagnostic imaging of tarsal coalitions; uses a combination of x-rays and computer technology to produce cross-sectional horizontal and vertical images (called "slices") of the body
       
    • diagnosis, diagnostics: identifying disease or injury through examination, testing and observation
       
    • gait: manner of walking
       
    • lower extremities: parts of the body from the hip to the foot—includes hip, thigh, ankle, leg and foot
       
    • MRI (magnetic resonance imaging): a diagnostic imaging tool that produces detailed images of organs and structures within the body
       
    • onset (of signs or symptoms): the first appearance of signs or symptoms
       
    • orthopedic surgeon, orthopedist: a doctor who specializes in surgical and non-surgical treatment of the skeletal system, spine and associated muscles, joints and ligaments
       
    • orthopedics: the medical specialty concerned with diagnosing, treating, rehabilitating and preventing disorders and injuries to the spine, skeletal system and associated muscles, joints and ligaments
       
    • ossify: a natural progression as a child grows in which cartilage turns into bone or bony tissue
       
    • prognosis: outlook for the future
       
    • resection: a surgical procedure in which an organ or body structure is removed
       sporadic: by chance
       
    • tarsal coalition: an inherited condition in which there’s an abnormal connection between two or more of the tarsal bones. These coalitions can form across joints of the foot or can occur between bones that don't normally have a joint between them.
       
    •  x-rays: a diagnostic test that uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film; “standing” x-rays are x-rays taken while the child is standing up, as in diagnosing tarsal coalition

    See our extensive Glossary of Orthopedic Terms.

    Our complete orthopedic team

    Boston Children’s is the primary pediatric teaching hospital of Harvard Medical School, where our physicians hold faculty appointments. We’re the largest pediatric orthopedic center in the nation, with 13 specialty clinics; an onsite brace shop; a plaster room; and a clinical team of orthopedic surgeons, orthopedic residents and fellows, certified physician assistants, nurse practitioners, registered nurses, physical/occupational therapists, brace technicians and cast technicians.

    Boston Children's Teen Advisory Committee

    To help teenagers take a more proactive role in their treatment and to have their needs recognized, Boston Children’s developed the Teen Advisory Committee. The group—made up of current Boston Children’s patients, ages 14 to 21—serves as a team of peers who can listen to other patients’ needs, ensure their voices are heard.

    Unique expertise in problems of the teenage hip

    Many teens and young adults with hip problems need diagnostic and surgical techniques that are significantly different from what’s indicated for younger children. Boston Children’s Child and Adult Hip Preservation Program is the only program of its kind in the world. We offer the extensive experience and advanced techniques of clinicians and researchers dedicated to finding better ways to care for adolescents and young adults with hip problems.

  • At Boston Children's Hospital, we know that the first step to treating your child’s tarsal coalition is to form a timely, complete and accurate diagnosis. To diagnose your child’s condition, the doctor conducts a physical exam. During the exam, the doctor takes your child’s complete prenatal, birth and family medical history. The doctor also orders standing x-rays as the initial imaging tool.

    To confirm the diagnosis and give valuable information about the type of coalition, its location and how the joints have been affected, either of the following diagnostic tests may be performed:

    • computerized tomography scan (CT or CAT scan): Considered the gold standard for diagnosing tarsal coalitions, a CT scan is a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce cross-sectional horizontal and vertical images (called "slices") of the body. A CT scan shows detailed images of any part of the body—including bones, muscles, fat and organs.
       
    • magnetic resonance imaging (MRI): An MRI is a diagnostic procedure that uses a combination of large magnets, radio frequencies and a computer to produce detailed images of organs and structures within the body. This test is done to rule out any associated abnormalities of the spinal cord and nerves.

    Boston Children’s doctors routinely take images of both of a child’s feet, even if only one foot is painful. This is because sometimes the child can have the condition in both feet (bilateral), yet only one foot is painful.

  • Boston Children's Hospital's Orthopedic Center specialists provide comprehensive treatment—including evaluation, diagnosis, consultation and follow-up care.

    But in the case of tarsal coalition, about 75 percent of children with the condition never even need treatment. And of the 25 percent who do need treatment, up to one-half don't need surgery.

    If needed, specific treatment for tarsal coalition will be determined by your child's physician based on:

    • your child's age, overall health, and medical history
    • the extent of the condition
    • your child's tolerance for specific medications, procedures or therapies
    • expectations for the course of the condition

    Non-surgical treatments

    There are several non-surgical methods used to treat a tarsal coalition. The primary goal of conservative, non-surgical treatment is to reduce pain and muscle spasms by further reducing range of motion (immobilization) in the affected joint or joints. Treatments can include:

    • casts or walking boots
    • orthotics—special, custom-made shoe inserts that support affected joints
    • injection of an anesthetic and a steroid, such as cortisone, for temporary pain relief
    • anti-inflammatory medications
    • stretching and physical therapy

    If surgery is needed

    If your child's pain persists or recurs despite conservative measures, your child's doctor will probably recommend surgery.

    • The type of surgery depends on the type and location of the coalition, whether arthritis is involved, and, if it is, how extensive the arthritis is.
    • If there are no arthritic changes, the union between the bones is usually removed (resected), with fat or muscle placed where the tarsal coalition was so that normal range of motion can occur.
    • In more severe cases, surgery is aimed at limiting the range of motion in the joint that causes pain. In this instance, the surgery involves fusing affected joints and reduce pain.

    After surgery, as part of the recovery process, a splint or cast, along with crutches are used to immobilize the foot and keep the foot from bearing weight. Exercises to restore muscle tone and range of motion are encouraged early at one to two weeks after surgery. Walking and full strengthening begins about one month after surgery.

    Care after surgery

    After surgery, your child will probably stay in the hospital overnight, and be given pain medication. She'll wear a cast when she goes home; she'll need to limit her weight-bearing activities for about a month; and she may use crutches or a walker for a few weeks. At this point, therapy is aimed mostly at regaining range of motion and preventing the bone bridge (coalition) from re-forming.

    After about a month she'll go into a walking boot and begin strengthening exercises. Physical therapy will help her restore her muscle strength. She'll probably be able to resume full activities, including sports, after three to six months. However, a full recovery can take up to a year.

    Coping and support

    At Boston Children's, we understand that a hospital visit can be difficult. So, we offer many amenities to make your child's—and your own—hospital experience as pleasant as possible. Visit the Center for Families for all you need to know about:

    • getting to Boston Children's
    • accommodations
    • navigating the hospital experience
    • resources that are available for your family

    In particular, we understand that you may have a lot of questions when your child is diagnosed with tarsal coalition. Will my child need surgery? When will her foot be normal? Will it affect her long term? Boston Children's can help you connect with extensive resources to help you and your family through this stressful time, including:

    • patient education: From doctor's appointments to treatment to follow-up, our nurses and physical therapists will be on hand to walk you through your child's diagnosis, treatment (if any) and recovery. And once your child is home, we'll help you coordinate and continue the care and support she received at Children's.
       
    • parent-to-parent: Want to talk with someone whose child has been treated for tarsal coalition? Our Orthopedic Center can often put you in touch with other families who've been through the same experience that you and your child are facing.
       
    • faith-based support: If you're in need of spiritual support, we'll connect you with the Boston Children's chaplaincy. Our program includes nearly a dozen clergy—representing Protestant, Jewish, Muslim, Catholic and other faith traditions—who will listen to you, pray with you and help you observe your own faith practices during your hospital experience.
       
    • social work: Our social workers and mental health clinicians have helped many other families in your situation. We can offer counseling and assistance with issues such as coping with your child's diagnosis, stresses relating to coping with illness and dealing with financial issues.

    The Experience Journal

    Designed by Boston Children's psychiatrist-in-chief David DeMaso, MD, and members of his team, the Experience Journal is an online collection of thoughts, reflections and advice from kids, parents and other caregivers about a variety of medical experiences, including hip problems.

  • Research & Innovation

    For more than a century, orthopedic surgeons and investigators at Children’s Hospital Boston have played a vital role in advancing the field of musculoskeletal research. We’ve developed breakthrough treatments and major advances for lower limb and hip problems, as well as for scoliosis, polio, tuberculosis and traumas to the hand and upper extremities.

    Our pioneering research helps answer the most pressing questions in pediatric orthopedics today—to provide children with the most innovative care available.

    In Boston Children’s Orthopedic Center we take great pride in our basic science and clinical research leaders, who are recognized throughout the world for their achievements. Our orthopedic research team includes:

    • full-time basic scientists
    • 28 clinical investigators
    • a team of research coordinators and statisticians

    Orthopedic basic science laboratories

    Working in Boston Children’s labs are some of the leading musculoskeletal researchers in the nation. Our labs include:

    Children speak about what it's like to be a medical research subject

    View a video of a day in the life of Boston Children's Clinical and Translational Study Unit, through the eyes of children who are “giving back” to science. 

    Boston Children's Hip Program's unique insight and expertise

    Boston Children’s Child and Adult Hip Preservation Program enjoys a special degree of effectiveness—not just because of our long tradition of excellence in pediatric hip care, but also because we follow our patients through adulthood. This gives us a unique perspective, insight and expertise—we can track how the hip works in each age group, how the problems evolve, and how the hip’s function changes over time in adult patients who’ve had treatment in childhood.

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