Introduction 

Tarsal coalition is an uncommon condition that affects the bones in the feet. It occurs when two or more tarsal bones (the bones in the midfoot and hindfoot) are abnormally connected by fibrous tissue, cartilage, or bone¹. This connection restricts movement and can lead to pain, stiffness, and flat feet. While the condition can be present at birth (congenital), symptoms typically emerge later in life, often in adolescence or adulthood¹. How tarsal coalition presents and progresses differs significantly between children and adults, impacting diagnosis, treatment, and management strategies. Understanding these differences is crucial to creating effective care.

Understanding tarsal coalition

The tarsal bones include the calcaneus (heel bone), talus, navicular, cuboid, and cuneiform bones. The most commonly affected coalitions are the calcaneonavicular coalition (between the calcaneus and navicular bone) and the talocalcaneal coalition (between the talus and calcaneus). These coalitions can be composed of different tissue types, including: 

• Fibrous (soft and flexible but still restrictive)
• Cartilaginous (semi-rigid and often painful)
• Osseous (rigid bone connection, completely limiting movement)²

Tarsal coalition is estimated to affect less than 1% of the population and is often discovered incidentally or after symptoms begin to interfere with daily activities³.

Presentation in children vs. adults

Children

In children, tarsal coalition is typically asymptomatic in early life. However, as the bones develop and harden, the symptoms begin to emerge. This usually happens between the ages of 9 and 16, depending on the type of coalition: calcaneonavicular coalitions tend to become symptomatic earlier (around ages 5-12), while talocalcaneal coalitions typically present later (around ages 12-16)⁴.

Symptoms in children include: 

• frequent ankle sprains, as the limited foot flexibility and abnormal motion lead to an increased risk of sprains
• Pain in the foot, usually located in the midfoot or hindfoot, is particularly common after physical activity
• Stiffness and reduced range of motion, especially with side-to-side movement⁴
• Rigid flatfoot that does not correct when standing on tiptoes
• Parents and caregivers often notice that a child avoids running or engaging in high-impact activities due to discomfort

 Early diagnosis can be challenging because children might not recognise or communicate their symptoms clearly.

Adults

In adults, tarsal coalitions can present in different ways. Some people remain asymptomatic throughout childhood and adolescence, only experiencing symptoms later due to factors like increased weight, prolonged activity, or joint degeneration⁵. When symptoms appear in adulthood, they are often more severe due to chronic stress on the affected joints⁵.Symptoms in adults include: chronic foot pain, which is typically persistent rather than intermittent. Unlike children, adults with tarsal coalition often experience secondary osteoarthritis due to long-standing coalition, leading to additional pain and stiffness. Over time, adults may develop a more rigid and painful flatfoot deformity⁶. They may also struggle with increased stiffness and immobility, particularly in high-impact activities like running or prolonged standing. Some adults discover they have tarsal coalition only after an injury, such as an ankle sprain or fracture, prompts imaging studies that reveal the condition⁶.

Differences in diagnosis

Diagnosis of tarsal coalition is similar in both children and adults, but may vary in ease and presentation. In children, because symptoms often appear in adolescence, paediatricians or orthopaedic specialists might suspect tarsal coalition based on recurring ankle sprains and foot pain. X-rays are the first step in diagnosis, but CT or MRI scans provide more detailed imaging, particularly for cartilaginous coalitions¹.

In adults, diagnosis can be more complicated due to the presence of arthritis or other foot conditions. Many adults undergo X-rays for unrelated foot pain, leading to an incidental discovery of the coalition. MRI or CT scans are useful for assessing the extent of the coalition and any associated degenerative change.⁶

Progression of the condition

In children, symptoms often begin during growth spurts. Standard treatments, such as physical therapy and orthotics, are used to help manage pain. Some children remain asymptomatic into adulthood³. However, symptoms in adults tend to worsen over time, especially with increased exercise or weight gain. Chronic joint stress can lead to arthritis. The flatfoot deformity also gets more rigid and uncomfortable. As pain and stiffness worsen, surgical intervention may become more important to restore function and relieve discomfort.⁶

Treatment approaches

Non-surgical treatments

In both children and adults, initial management is typically conservative. Rest and activity modification are essential to reduce the strain on the affected joints. Orthotics and supportive footwear, such as custom insoles, can provide arch support and reduce pressure on the coalition⁶. 

Furthermore, physical therapy, including stretching and strengthening exercises, can improve foot flexibility and reduce discomfort. Pain management with nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, can help relieve pain and inflammation⁷. In children, temporary immobilisation with a cast or boot is sometimes used to reduce symptoms and allow inflammation to subside.

Surgical treatment

When conservative therapy fails to alleviate symptoms, surgery is then recommended. Resection, which is a procedure that removes the coalition and inserts fat or muscle tissue to prevent reformation, is a popular treatment for younger people with less severe coalitions⁷. In more severe situations, particularly in adults with arthritis, arthrodesis (the fusion of the affected joints) may be needed to reduce discomfort and restore function.

The choice between these surgical approaches depends on multiple factors, including the individual's age, the extent of joint damage, and overall medical condition. While resection aims to preserve joint mobility by removing the abnormal bone connection and preventing its regrowth, arthrodesis provides a more definitive solution for those experiencing chronic pain and significant joint deterioration. Consulting with an orthopaedic specialist is crucial to determine the most appropriate surgical intervention for individual cases⁸.

Conclusion

Overall, Tarsal coalition presents different challenges in children and adults, with each life stage showing unique symptomatic patterns and treatment considerations. In children, the condition typically emerges as a subtle challenge. Young people may experience occasional foot pain during physical activities, slight stiffness, or an unexplained limp that parents and physicians may initially dismiss as normal developmental variations. Their symptoms are typically less consistent and can be managed more conservatively, with treatments focusing on preserving mobility and preventing progression.

Adult manifestations of tarsal coalition greatly contrast the childhood experiences. Where children might have sporadic discomfort, adults encounter chronic, persistent pain and significant joint stiffness that substantially impacts daily functioning. The progressive nature of the condition becomes increasingly apparent, with years of abnormal bone connections causing increased joint degeneration, potential arthritis development, and more limited treatment options. While children can often benefit from conservative interventions like physical therapy, adults typically require more aggressive management strategies, including advanced pain management techniques and surgical interventions aimed at restoring mobility and reducing chronic discomfort.

Additional reading

Understanding the condition's unique evolution from childhood to maturity is only the first step in a transforming journey for people entering the complex world of tarsal coalitions. This developmental bone issue is a powerful example of how our bodies change and adapt, showing the various ways medical challenges can evolve. Patients, families, and healthcare professionals can develop more comprehensive, personalised approaches to management and therapy by further investigating the complex distinctions between childhood and adult tarsal coalition experiences. For more information, this research paper provides greater insight: https://pubmed.ncbi.nlm.nih.gov/22541520/