The tarsal bones of the foot are important for stability and movement. Your tarsal bones are located in the rearfoot (also called hindfoot) and midfoot areas of your foot. These bones are also known collectively as the tarsus.
There are a total of seven bones within the tarsal bones group:
- Calcaneus – Also known as the heel bone.
- Talus – Also known as the ankle bone.
- Navicular – Which is located at the top of the foot between the ankle bone and the cuneiform bones.
- Cuboid – Provides stability for the foot and helps with the movement of the toes.
- Intermediate cuneiform – The intermediate cuneiform is important in the flexibility of the foot.
- Medial cuneiform – Anchors several of the ligaments in the foot.
- Lateral cuneiform – Helps form the arch of the foot.
Generally, the calcaneus is the largest of the tarsal bones and is the largest bone in the entire foot.
A tarsal coalition occurs when two bones grow into one another, connected by a bridge of bone, cartilage, or strong, fibrous tissue. These bridges are often referred to as bars and they can cover a small amount of the joint space between the bones, or a large portion of the space. The two most common sites of tarsal coalition are between the calcaneus and navicular bones, or between the talus and calcaneus bones. However, other joints can also be affected.
It’s estimated that 1 out of every 100 individuals may experience a tarsal coalition. In 50% of cases, both feet are affected. The exact incidence of the disorder is difficult to determine because many coalitions never cause noticeable symptoms. In most people, the condition begins before birth. It is caused by a gene mutation that affects the cells that produce the tarsal bones. Although the coalition forms before birth, its presence is often not discovered until late childhood or adolescence.
This is because babies’ feet contain a higher percentage of soft, growing cartilage. As a child grows, this cartilage mineralizes, resulting in hard, mature bone. If a coalition exists, it may harden as well, and fuse the growing bones together with a solid bridge of bone or fibrous tissue, similar to a scar. The ossification of the coalition typically happens between ages 8-16, depending upon which bones are involved. As a result, the hindfoot stiffens, causing pain and other symptoms.
Causes & Symptoms
There are a number of causes that are associated with tarsal coalitions, such as the following below:
- Genetic abnormality
- Foot trauma
Most cases of tarsal coalition are congenital due to a genetic mutation that affects how your tarsal bones develop. A process called mesenchymal segmentation fails to occur properly so rather than developing separate structures, two or three of the tarsal bones become connected. Certain symptoms of tarsal coalition include:
- Muscle spasms – Increased spasticity in the peroneal muscles cause calf pain.
- Limping – Limping is caused when walking longer distances.
- Foot & ankle stiffness – Stiffness and rigidity in the back of the foot, known as the hindfoot.
- Foot pain – Foot pain is caused below the ankle and at the back of the foot, worse when weight-bearing or with activity (such as standing, walking, and running).
- Flat foot arches – reduced height of foot arches in one or both feet.
Symptoms of tarsal coalition do not typically appear until a child reaches around 10 years of age as that is when their bones start to mature. Up until this point, much of the foot structure is cartilage which gradually changes and hardens, through a process called ossification, to the bone. If a coalition structure is present, it ossifies too. This ossification happens at different ages depending on which bones are involved, such as:
- Talo-calcaneal coalition – In this case, the talus and the calcaneus have not fully separated.
- Calcaneo-navicular coalition – In this case, the front part of the calcaneus is attached to the outside and lower part of the navicular bone.
Prior to ossification, people don’t usually develop any symptoms of tarsal coalition. However, once the area begins to harden it may start to cause problems. Only around one-quarter of people who have tarsal coalition will get symptoms from it; in most cases, it goes completely unnoticed.
Who gets Tarsal Coalition?
A tarsal coalition is a genetically determined condition – if one of a child’s parents has the condition, there is a chance that the child will also develop a tarsal coalition. If it occurs sporadically, it means that a genetic mutation to place during a child’s fetal development. Overall, many people patients living with tarsal coalitions have few or no symptoms. Treatment of tarsal coalition is only for symptomatic ones, therefore, evaluation for tarsal coalition occurs only for those people presenting with symptoms.
Other certain risk factors associated with tarsal coalition are:
- Obesity / diabetes – Most patients are prone to develop tarsal coalitions if they are obese or have diabetes.
- Pregnancy – Tarsal coalition during pregnancy is caused when the arch of the foot flattens out upon weight bearing. This causes the feet to roll inward when walking, thus causing stress on the plantar fascia band of tissue that runs from the heel to the forefront leading to significant pain.
- Injuries – Injuries that are usually caused located on the foot or ankle can increase the chances of tarsal coalition.
- Weak arches – Weakened arches, meaning that the arch is visible when you sit but your foot flattens onto the ground when you stand.
- Medical conditions – It has been proven that people with medical conditions like arthritis, infections, trauma, and abnormal bone growth are more prone to tarsal coalition.
- Other conditions – Sometimes abnormal motion or physical activities involving stress on foot joints may also lead to this condition.
How Does it Affect You? How Serious is it?
If sports are central to your child’s life, tarsal coalition could be viewed as a serious problem. If your child has only occasional arches, such as when running in gym class, and sports are not very important to them, the condition probably will not have a profound impact on their life. A severe case of a tarsal coalition can pose functional problems, make walking difficult, and may alter a child’s activity level.
Over time, a child, teen, or young adult may experience enough pain that they cannot do the activities they enjoy. Later in life, they may have a very stiff foot (indicating a large coalition). The foot may be so stiff and painful that a surgical repair is no longer an option. In such cases, a joint fusion would be the remaining option to alleviate pain.
Recommended Treatment & Rehabilitation
The first step to treating your tarsal coalition is to form a timely, complete, and accurate diagnosis. To diagnose your tarsal coalition, your doctor will begin with a physical exam. During the exam, your doctor will take a family medical history. They will also order standing X-rays as the initial imaging too. 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, as described below:
- Computed Tomography (CT) scan – 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 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 a large magnet, 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.
If this is done for your child, images will probably be taken of both of your 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.
During the midst of physiotherapy for tarsal coalition, a physiotherapist will begin by reviewing your issues to determine any underlying health problems. He or she will be able to design a treatment program in order to keep your feet strong while alleviating ankle, knee, and back pain. Some commonly suggested things in physiotherapy are better footwear with substantial arch support (such as custom-made orthotic shoe inserts), insoles to relieve foot pressure, daily stretching exercises for both feet and the legs, ice therapy to reduce inflammation, and wearing supportive ankle braces.
Below are the following exercises you can perform to help correct fallen arches and pain:
Stand with your feet directly underneath your hips. Making sure to keep your toes in contact with the floor, roll your weight to the outer edges of your feet as you lift your arches up as far as you can. Afterward, release your feet back down as you work the muscles that help to lift and supinate your arches. Repeat this method with 2-3 sets of 10-15 repetitions a day.
While standing, lift your heels as high as you can. Hold the upper position for 5 seconds, then lower back down to the floor. Repeat this exercise with 2-3 sets of 10 repetitions a day.
Stair arch raises
Stand on a stepper with your left foot one step higher than your right foot. Next, use your left foot for balance as you lower your right foot down so your heel lands lower than the step. Slowly lift your right heel as high as you can, focusing on strengthening your arch. Rotate your arch inward as your knee and calf rotate slightly to the side, causing your arch to become higher. Slowly lower back down to the starting position, while you repeat this exercise 2-3 sets of 10 repetitions on both sides, each day.
While standing, press your right big toe into the floor and lift up your other four toes. Then, press your four toes into the floor and lift up your big toe. Perform each way 10-15 times, holding each lift for 5 seconds a day.
Alternative & Homeopathic Treatment
There are various homeopathic treatments that can help alleviate the symptoms linked to tarsal coalitions. Some of these include:
- Custom-made orthotic shoe inserts – You can order orthotic supportive inserts or gel pads that are custom-made to shape your foot and your individual movement. Certain types include comfort shoes, insole shoes, and stability shoes.
- Therapeutic massage – such as rolling a ball under your foot may help improve arch flexibility while alleviating arches and pains.
- Rest – Avoid activities that aggravate your condition. Participate in low-impact activities (such as walking, biking, or swimming) rather than jumping and running activities.
- Medications – Over-the-counter pain relievers such as non-steroidal anti-inflammatory drugs (NSAIDs) may help reduce pain and inflammation.
- Ice application – Applying ice for 20 minutes (for example, a bucket filled with ice) can help reduce inflammation and pain linked to tarsal coalitions.