Tarsal coalition

What is tarsal coalition?

A tarsal coalition is an abnormal connection between two or more tarsal bones in the foot. The tarsal bones are in the rear and midfoot. It is a condition that can either be inherited or caused by a genetic mutation. n. In about half of cases, both feet are affected.

There are three types of tarsal coalitions that are typically seen:

• Talocalcaneal (TC) coalition: Occurs between the talus and calcaneus
• Calcaneonavicular (CN) coalition: Occurs between the calcaneus (heel bone) and the navicular bone
• Talonavicular (TN) coalition: This is a less common type. Occurs between the talus and navicular bones

What are the signs and symptoms of tarsal coalition?

Many people with a tarsal coalition don't even know they have one, as they do not cause symptoms or any obvious foot deformity. Up to 75% of people with tarsal coalitions do not have any symptoms. However, symptoms can start to appear during growth spurts at 8 to 10 years of age (CN coalition) and at 12 to 14 years of age (TC coalition). Symptoms of tarsal coalition may include:

• pain
  • Pain usually occurs below the ankle, at the middle or back half of the foot.
  • The pain is typically made worse by higher levels of activity and may be accompanied by a limp.
  • In addition to pain, the child may experience muscle spasms in the affected lower leg.
• stiffness
• difficulty moving the foot
  • About 25% of people with a tarsal coalition have a rigid, flat foot.
  • A rigid, flat foot makes it difficult to walk on uneven surfaces. To make up for the foot's lack of motion, the patient may roll their ankle more than normal, which may result in ankle sprains.

How is tarsal coalition diagnosed?

A health-care provider will perform a physical exam of the foot. The patient will be asked to stand on their toes. This may reveal a flat arch that does not fully correct and there may also be decreased inward movement of the foot.

If a tarsal coalition is suspected, then X-rays are used to confirm the diagnosis and assess its extent. X-rays should be taken of both feet when standing, even if only one foot is painful. This is because sometimes the patient can have tarsal coalitions in both feet, yet only one foot is painful.

CT scans are sometimes used to confirm the diagnosis for definitive assessment and for surgical planning. These are only done after a physical assessment by an orthopaedic specialist. MRI is rarely recommended.

Talocalcaneal (TC) coalition

How is tarsal coalition treated?

Tarsal coalitions only require treatment if they are causing symptoms. About 75% of people with tarsal coalitions never need treatment. And of the 25% who do need treatment, less than half of those go on to have surgery (2%).

A high percentage of tarsal coalitions improve with conservative management which includes:

• Taking a break from high-impact activity (such as running and jumping) for 4 to 6 weeks.
• Immobilizing the foot using a temporary boot or cast for 4 to 6 weeks to take stress off the tarsal bones.
• Wearing arch supports, shoe inserts such as heel cups and wedges, and other types of non-hard plastic orthotics/insoles and supportive footwear may be recommended to help stabilize and support the foot.
• Stretching exercises of the calves and feet, range-of-motion exercises and soft tissue release/massage combined with other therapy, can improve your child's flexibility and stability. Strengthening of the small muscles (intrinsics) and global mover muscles (extrinsics) of the foot and ankle are recommended.
• Pain medications such as ibuprofen (e.g., Advil) or naproxen (e.g., Aleve) can reduce pain and swelling and should be taken 1 to 2 times per day for a short course of 4 to 6 weeks.

If the patient is still experiencing pain and/or function is not improving after the initial treatment strategies have been tried on a consistent basis for a period of 6-months, then your health-care provider may consider referral to orthopaedic surgery.

Surgery may include:

• Resection: a procedure where the tarsal coalition is removed and replaced with muscle or fatty tissue from another area of the body. The subtalar joint is otherwise healthy. This is the most common surgery for tarsal coalition as it preserves normal foot motion and successfully relieves symptoms in most patients who do not have signs of arthritis. However, it will not fully restore foot motion to normal.
• Deformity correction: additional procedures to improve the shape of the foot, typically a flatfoot.
• Fusion with or without deformity correction: an option for larger, more severe tarsal coalitions where the joint cartilage is no longer healthy. The goal of fusion is to limit the movement of painful joints and place the bones in the proper position.

At SickKids

All referrals for tarsal coalitions at SickKids require:

• Photos of the feet and ankles.
• X-rays: Radiographic evidence of a coalition with baseline bilateral standing/simulated weight-bearing foot and ankle AP/Lateral view radiographs. Oblique (medial)/standard external view radiographs and only if suspected after these first two order sets, consider completing Harris view radiographs.

References

Mosca, V. (2014). Principles and Management of Pediatric Foot and Ankle Deformities and Malformations (1st ed.). Wolters Kluwer Health

Lawing, C. (n.d.). Tarsal Coalition. OrthoInfo. https://orthoinfo.aaos.org/en/diseases--conditions/tarsal-coalition/

Bauer, J., & Martus, J. (n.d.). Tarsal Coalition. Pediatric Orthopaedic Society of North America. https://posna.org/physician-education/study-guide/tarsal-coaltion

Watts, E. (2026, February 21). Tarsal Coalition. Orthobullets. https://www.orthobullets.com/pediatrics/4068/tarsal-coalition