This 13-year-old male player presented with a history of recurring ankle pain. This has become increasingly worse over a 3-4 month period. At the time of his assessment, he was found to have pronounced stiffness of his left sub-talar joint.
There is elongated of the anterior process of the calcaneus (known as the anteater nose sign) and the lateral plantar aspect of the navicular suggesting coalition between the calcaneus and navicular. This is further demonstrated on the MRI which shows an irregular osseous fragment and irregularity of the margins of the navicular and anterior process of the calcaneus. Bone oedema is present within the anterior process of the calcaneus.
Given the progressive symptoms this young player was treated with surgical debridement of the coalition. The coalition was excised and fat was interposed between the bones (to limit the risk of recurrence). The other foot was checked and found to be normal (as many as 50% of coalitions are bilateral). He was able to return to football at about five months following surgery.
Calcaneonavicular coalitions are one of the two most common types of coalition, along with talocalcaneal coalitions. It may be bony (synostosis), cartilaginous (synchondrosis) or fibrous (syndesmosis). It often remains undetected until the age of nine or ten years when the coalition often begins to ossify. When a coalition is suspected, an x-ray series should be taken including a 45° oblique view. If these are normal, and clinical suspicion persists, CT or MRI scans should be ordered. Bony coalitions appear radiologically between the age of eight and 12 years of age and can generally be readily demonstrated on an oblique view of the foot. Non-osseous coalitions can be more difficult to identify. They should be suspected when there is squaring off, or elongation of, the anterior process of the calcaneus and/or a narrowed calcaneonavicular interval. When a coalition is suspected CT and MRI scans can give a more detailed assessment. CT is the best modality for defining bony coalitions and allows both ankles to be imaged at once. MRI is the best imaging modality for the assessment of non-osseous coalitions.
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