A 24 year old female recreational football player presented with a 12 month history of worsening dorsal mid-foot pain. She was found to have a marked restriction in subtalar movements and generalised tenderness about the hindfoot.
A lateral x-ray image was grossly abnormal showing absent anterior and middle facets of the talocalcaneal joint. The CT scan show extensive bony talocalcaneal involvement of the anterior and middle facets of the subtalar joint, as well as the sustentaculum talus. There is marked reduction in the posterior subtalar joint space which appears hypoplastic. There was no evidence of secondary degenerative change.
An attempt has made to settle this player’s symptoms using non-surgical treatments. A short period of immobilisation in a walking boot, footwear changes and an orthotic have all been trialled. She has improved but is still unable to run without pain. The surgical options have been discussed with her, but at this stage she is uncertain about how she would like to proceed. Given that the coalition is so extensive it is likely she would require a fusion.
Talocalcaneal coalition is one of the two most common sub-types of tarsal coalition (the other being calcaneonavicular coalition). While all three facets of the talocalcaneal joint can be affected, the middle facet is most commonly involved. The coalition can often be seen on x-ray images. A ‘c-sign’ can be seen on a lateral image as a continuity between the talus and sustentaculum tali. A ‘talar beak’ is another sign that can be used to help diagnose this type of coalition. It is also best seen on a lateral x-ray image (as a spur on the anterior aspect of the talus). A dedicated x-ray view, Harris-Beath, can be obtained when there is a high degree of suspicion for a coalition. This view demonstrates the body of the calcaneus, middle facet of the sub-talar Joint and the sustentaculum tali. CT imaging is best for bony coalitions while MRI is best for cartilaginous or fibrous coalitions.
The results of the surgical management of talocalcaneal can be unpredictable (the generally do worse that talonavicular coalitions). Excision of the coalition is treatment of choice in younger patient where no degenerative changes are present. When there is a more extensive coalition, where there is associated degenerative changes or when excision fails a mid-foot fusion is generally the surgical treatment of choice.
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