Overview

Tarsal coalition, also called tarsal synostosis, is an abnormal union of tarsal bones typically in the back of the foot(heels).¹ Being congenital in its nature, it mostly occurs during fetal development, leading to improper development of the individual bones. However, the pain typically starts during adolescence. The non-congenital causes of tarsal coalition include arthritis, foot trauma, or infection.²

It is rare and occurs in only 1% of the population.³ It usually manifests itself in the form of pain and stiffness in the foot. Although it is present at birth, symptoms do not appear until late childhood or adolescence. ​In approximately half of the individuals diagnosed with tarsal coalition, the condition affects both feet.⁴

Investigations

An effective treatment approach requires a thorough investigation. While the majority of tarsal coalitions are asymptomatic, effective management can reduce discomfort in those affected. The diagnosis starts with the examination of the foot and ankle, which includes checking foot flexibility, mobility, and gait. Individuals diagnosed with tarsal coalitions may present with a diminished arch that fails to achieve complete rectification when elevating the toes and lifting the heel.⁵

The imaging tests may include;

• X-rays: These diagnostic tests yield high-resolution images of osseous structures. Numerous coalitions can be discerned on X-ray imaging 
• Magnetic resonance (MRI) scans: These imaging modalities produce comprehensive visual representations that encompass soft tissue structures. Your physician may recommend this investigation to assess for atypical bars formed by cartilage or fibrous connective tissue
• Computed tomography(CT) scans: The images generated through computed tomography offer enhanced visualization of bony anatomy. CT scans are regarded as the gold standard for tarsal coalition imaging due to their ability to reveal more nuanced bars that may be overlooked in standard X-ray examinations

Conservative management of tarsal condition 

As we know, tarsal coalition mostly occurs among children, and children respond better to simple therapies, including conservative therapies.⁶ Conservative management mainly focuses on alleviating symptoms and enhancing foot mobility through various non-surgical strategies. They are particularly effective in mild to moderate coalitions. If children do not respond to such treatments, that usually indicates the symptoms are more critical and may require surgical treatment.

These are often regarded as the first-line approach for mild to moderate coalitions.⁷ It includes a trial of at least 3 months focusing on rest, orthotics, and physical therapy, achieving success in up to 85% of the cases. These strategies typically include rest, orthotics, footwear modifications, and physical therapy.

Rest and activity modification

The immobilisation of feet for a period of 4 to 6 weeks reduces the stress on the affected area, which helps in faster recovery. During this period, the use of crutches is recommended to prevent weight-bearing on the foot while it is immobilized in a cast or cast boot. Temporary pain alleviation is possible, according to studies, but long-term effectiveness is limited, particularly in children (98% short-term relief). Temporary immobilization alleviates symptoms in 30% of the cases. It is often used in combination with other treatments such as orthotics, physical therapy, and activity modification to achieve more sustained symptom control.⁸

Orthotics and footwear modification 

Orthotics depend on mechanical and synthetic devices to provide stabilization and repair of weak joints and bones through specifically designed shoe inserts. The most common type of orthotics exists to promote foot health. Orthotic devices used most frequently consist of arch supports together with heel wedges, along with custom-molded orthoses.⁹ The redistribution of plantar pressures through the use of orthotics, together with movement restraint, supports patient satisfaction in 65%.¹⁰

Moreover, the success rate of tarsal coalition conservative treatment depends heavily on selecting proper footwear as an essential part of the management plan. The specific construction of hindfoot-limiting footwear substantially alleviates symptoms by reducing load on affected joints. For example;

Rigid Soles: Shoes with rigid soles help restrict excessive movement in the hindfoot, reducing stress on the coalition site 

Rocker-Bottom Design: By encouraging forward motion, a rocker-bottom sole, which has a little bend, helps to create a smoother gait. This design lessens the strain on the coalition by reducing the requirement for hindfoot flexibility¹¹

Supportive Structure: By distributing pressure uniformly across the foot, footwear with sufficient arch support and cushioning can improve comfort and lessen pain¹²

Physical therapy approaches

The primary objectives of physical therapy in managing tarsal coalition are to reduce pain, improve joint mobility, strengthen surrounding muscles, and restore functional activity. These goals are achieved through a combination of exercises, manual therapy, and adjunctive modalities.

Pain Management

• Techniques such as ice, heat, and ultrasound are commonly used to reduce inflammation and alleviate pain¹³ 
• Activity modification and deloading protocols are essential to avoid exacerbating symptoms

Improving Flexibility and Mobility

• Stretching exercises targeting the Achilles tendon, peroneal muscles, and plantar fascia are often prescribed to improve hindfoot and midfoot mobility
• Joint mobilization techniques, such as subtalar joint mobilization, can help restore normal joint mechanics¹⁴ 

Strengthening

• Strengthening exercises for the intrinsic and extrinsic foot muscles, such as toe curls and heel raises, are critical to enhance arch support and reduce stress on the coalition
• Core and lower extremity strengthening exercises are also beneficial to improve overall biomechanics and reduce the risk of recurrent pain¹⁵

Proprioceptive Training

Balance and proprioceptive exercises, such as single-leg stance and wobble board training, are used to improve foot stability and prevent recurrent ankle sprains.

Evidence Supporting Physical Therapy

• The research study analyzed 50 patients with symptomatic tarsal coalitions to determine that 53% experienced pain relief through nonoperative strategies, which included physical therapy¹⁶
• Another healthcare research showed that nonoperative treatment succeeded for 79% of calcaneonavicular cases alongside 62% of talocalcaneal cases¹⁷
• The long-term results from patients demonstrated that coalition resection produced better physical function, together with pain reduction, so physical therapy plays an essential role before and after surgery¹⁸ 

However, the success of physical therapy interventions depends on coalition severity, along with deformities existing in the foot and patient involvement in their treatment plan.

Nonsteroidal anti-inflammatory Medications 

Medications like ibuprofen or naproxen can also help manage pain and reduce inflammation. These are often recommended as part of the conservative treatment plan to help patients cope with the discomfort associated with tarsal coalition

Effectiveness of conservative management 

The research shows that a 77-year-old male patient received bilateral calcaneonavicular and talonavicular bar diagnoses.¹⁹ The patient received treatment for his condition through plaster cast immobilization of his foot below his knee. The therapist treated his symptoms successfully, which led to him experiencing no pain during the follow-up at two years.

Another study²⁰ has confirmed that two out of four conservatively managed feet underwent symptom relief as part of their treatment course. Most conservatively managed patients displayed limited movement in their hindfoot area, though some patients experienced positive symptom outcomes. Research findings suggested that treating the condition without surgery offered potential benefits, mainly to patients with a mild presentation of symptoms.

Factors influencing conservative treatment success rates

A paper discusses several factors that influenced the success rates of conservative treatment for symptomatic talocalcaneal coalition.²¹ 

Patient Response to Immobilization: The research revealed that all five feet of three patients recovered completely without pain following cast immobilization treatment. Call-and-response patterns between patients and immobilization methods positively or negatively influence positive treatment results. Success in symptom relief occurs when certain patients demonstrate good healing abilities or adaptive potential towards immobilization treatments

Coalition Characteristics: The characteristics present in coalitions between bones play an active part in determining how successful conservative treatments will be. The effectiveness of immobilization therapy depends on the size of the coalition and how extensive it is. The success rate of conservative interventions tends to be higher for smaller coalitions as well as those that do not disrupt joint function

Absence of Degenerative Changes: Talonavicular joint treatment results depend on whether degenerative arthritis exists in that joint. Conservative approaches succeed better in cases where degenerative changes are absent since such changes worsen both the diagnosis complexity and reduce the power of non-operative care

Duration of Symptoms: Patient treatment success depends on their symptoms duration before starting medical care because both factors influence non-operative treatment outcomes. Immobilization works best for patients who have recently started showing symptoms because extended symptoms typically signal more serious conditions in the body

Summary 

The fusion of foot bones due to tarsal coalition occurs in a small group of people (1 in 100 people), causing teen foot pain. The medical confirmation of the Tarsal coalition requires doctors to perform X-rays along with MRIs and CT scans. The treatment success rate for children and teenagers with foot coalitions approaches 85% since medical professionals usually prescribe rest alongside supportive inserts and physical therapy in conjunction with anti-inflammatory drugs. Success rates in foot healing require existing patients to receive proper care at the early stages of mild conditions and strict adherence to medical interventions. Relief from surgery exists for most patients because studies demonstrate a 50% success rate without surgery.