Review Article
A Review of Tarsal Coalition and Pes Planovalgus: Clinical Examination, Diagnostic Imaging, and Surgical Planning

https://doi.org/10.1053/j.jfas.2010.02.003Get rights and content

Abstract

Pediatric pes planovalgus deformity may be classified as flexible or rigid. The rigid pes planovalgus is often a result of a tarsal coalition, which is typically characterized as a painful unilateral or bilateral deformity, frequently associated with peroneal spasm. However, many tarsal coalitions are asymptomatic and demonstrate no peroneal spasm or pes planovalgus deformity. Likewise, the severe pes planovalgus foot type can demonstrate some of the same clinical and radiographic features of a tarsal coalition, especially in the obese adolescent patient. Also, peroneal spasm may occur in the noncoalesced foot, making diagnosis and etiology more difficult to elucidate. The authors believe that many patients with a pes planovalgus deformity lie in this “gray zone”: somewhere between the frank osseous coalition and the flexible pes planovalgus. The “step-forward Hubscher maneuver” is introduced as an effective means of evaluating the flexibility of a pes planovalgus foot by negating the effects of a gastrocnemius or gastrocnemius-soleus equinus. This article focuses on the clinical examination and findings of specific imaging studies to assist in an accurate diagnosis of these complicated patients. This will also help to reveal the various surgical options that are appropriate for the individual patient. Emphasis is placed on computerized tomography (CT) imaging and offers enhanced methods for ordering this test to specifically evaluate middle facet coalitions of the subtalar joint. The authors also introduce “lateral tarsal wedging,” an image finding associated with severe deformities, the implications of this finding, as well as its impact on surgical planning.

Section snippets

Clinical Examination

The patient with a frank osseous coalition commonly presents with a rigid pes planovalgus foot type, with or without peroneal spasm. This condition generally starts as a painless decrease in the range of motion of a joint and progresses to a symptomatic rigid deformity. Patients often complain of “ankle pain” that is aggravated with activity, or have a history of recent or recurrent ankle sprains (7). TC coalitions usually become symptomatic around the ages of 12 to 16, which correlates with

Clinical Examination

Whereas the clinical presentation and diagnostic imaging findings of the osseous TC coalition have been discussed, the more commonly encountered deformity is the collapsing pes planovalgus foot type, which remains flexible and is free of any arthritic changes. These 2 conditions differ dramatically with regard to clinical and radiographic findings. Collapsing pes planovalgus patients rarely complain of “ankle pain,” as seen in children with coalitions, and more commonly complain of pain along

The “Gray Zone”

The 2 types of patients discussed thus far, those with rigid coalition flatfoot and those with flexible pes planovalgus foot, represent opposing ends of the spectrum of painful pediatric flatfoot deformities, and the diagnoses are readily discernable with routine clinical and radiographic examinations. However, many patients have signs and symptoms that lie somewhere in between these 2 extremes, making an accurate diagnosis more challenging. There are patients with coalitions that have not yet

The Role of Diagnostic Imaging

Plain-film radiographs and CT will help to delineate the etiology in the rigid painful foot, whether it is arthritic or a coalition. Most importantly, this information will guide the surgical treatment plan. Radiographs are screening tools and are rarely totally diagnostic alone, with the exception of the CN coalition. A severely arthritic pes planovalgus foot may have changes similar to those observed in the foot with a TC coalition. A severely pronated STJ can obscure the visibility of the

Surgical Planning for Tarsal Coalition

The information gained in diagnostic imaging of coalitions assists in developing a surgical plan that is individualized to the patient based on age, clinical findings, and imaging characteristics. Two general surgical options include coalition resection and fusion, with or without adjunctive reconstructive procedures to address pes planovalgus and/or equinus. In the authors' experience, a CN coalition responds better to resection than a TC coalition and, in general, a coalition resection,

Conclusions

In conclusion, the pediatric pes planovalgus deformity encompasses the flexible deformity, the osseous coalition, and everything in between. Algorithms exist to help establish guidelines for surgeons in the diagnosis and treatment of these disorders 1, 58, 59. Although these can be helpful, they provide vague direction when a patient presents somewhere in between the flexible pes planovalgus and the frank osseous coalition. Tarsal coalitions are far from black-and-white disorders. The authors

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    Copyright © 2010 American College of Foot and Ankle Surgeons. Published by Elsevier Ltd. on behalf of the American College of Foot and Ankle Surgeons All rights reserved.