What is a Tarsal Coalition and how can it affect a Runner’s foot?

 In Lower Limb

A tarsal coalition is where two or more bones within the mid-foot or rear-foot are joined together. The connection can be osseous (bone), cartilaginous or fibrous. 90% of tarsal coalitions are either talocalcaneal (intra-articular) or calcaneonavicular (extra-articular) (Franson & Baravarian, 2004). They can cause pain, limited movement during walking and running and muscle spasm (Downey, 2011).

What are the Tarsal Bones?

The tarsal bones include the talus, calcaneus (heel bone), navicular, cuboid and cuneiform bones.

Causes of a Tarsal Coalition?

Most often a tarsal coalition occurs during fetal development resulting in the individual bones not forming properly (Foot Health Facts, 2017). There may be an acquired condition but these are less common (Franson et al., 2004). Less common causes are infection, arthritis or a previous injury to the area (Foot Health Facts, 2017).

How does a Tarsal Coalition cause pain while running?

The tarsal bones are extremely important in allowing the foot to be an adaptor and shock absorber by “unlocking” when a running foot initially contacts the ground. They should also then lock together as the heel is lifting off the ground so that the foot can become a “rigid” lever to allow efficient force generation from the foot and lower limb muscles.

What does this mean for runners?

If there is a block not allowing certain tarsal bones to function normally during the walking or running gait cycle this can cause an increase stress at the joint that is trying to move. This means that other surrounding joints may be affected due to compensation for the block. It can also affect muscles and tendons can also become overused as they are possibly placed at a mechanical disadvantage during movement.

Symptoms

A patient with a tarsal coalition may be symptomatic or asymptomatic. Symptoms don’t usually occur until after the tarsal bones begin to mature between the ages of 9 to 16 (Foot Health Facts, 2017). This can be because of the cartilaginous nature of the coalition until it begins to ossify and therefore further restrict motion (Franson et al., 2004).

Sometimes symptoms will not present themselves until even later in life especially if the patient is involved in repetitive activities such as long distance running. Symptoms can also show up after an injury such as an ankle sprain and a tarsal coalition should be considered especially if the ankle does not seem to be responding to normal treatment (Downey, 2011).

A list of symptoms may include (Foot Health Facts, 2017):

  • Pain while standing, walking and/or running
  • Tired or fatigued legs
  • Muscles spasms in the leg causing the foot to turn outwards when walking
  • Rigid Flat foot
  • Walking with a limp
  • Stiffness of the foot and ankle

Diagnosis

Diagnosis of Tarsal Coalition involves your clinician taking a thorough history of symptoms, past injury history, duration of discomfort, past treatments and conducting a thorough biomechanical examination of the foot and ankle to find possible restrictions of movement.

Ordering an x-ray, an MRI and/or CT scan is also of prime importance to confirm a coalition if it suspected, the type and to rule out other possible causes of pain.

Treatment

If a tarsal coalition is found as an incidental finding and no pain exists then treatment is not indicated (Downey, 2011).

If symptoms do exist then the primary goal of treatment is to improve a patient’s quality of life by reducing symptoms and restoring as much function as possible (Downey, 2011).   Conservative treatment is always considered first before considering surgery.

Some of the conservative treatments that are used include:

  • Correct running and casual footwear to help reduce load through affects joints
  • Shoe Modifications & additions such as padding and wedges to help as above
  • Physical Therapy may include soft tissue release and strengthening exercises
  • Orthotic devices can be beneficial in distributing the weight away from the joint and limiting motion at the joint.
  • Immobilisation by using a moon boot or casting may be used to rest and offload the affected area/s
  • Oral Medications such as non-steroidal anti-inflammatory drugs (NSAIDs) may be helpful in reducing pain and inflammation.
  • Steroid injections may be used to help decrease pain and inflammation.

Failing conservative treatment a referral to a foot and ankle surgeon is definitely required. This may also be done during the conservative management period so all options in terms are treatment are laid out clearly for the patient.

References

Downey, M. (2011). Keys To Treating Tarsal Coalitions | Podiatry Today. [online] Podiatrytoday.com. Available at: http://www.podiatrytoday.com/keys-treating-tarsal-coalitions [Accessed 23 Oct. 2017].

Foot Health Facts. 2017. Tarsal Coalitions. [ONLINE] Available at: https://www.foothealthfacts.org/conditions/tarsal-coalition. [Accessed 22 October 2017].

Franson, J. and Baravarian, B. (2004). How To Detect And Treat Tarsal Coalitions | Podiatry Today. [online] Podiatrytoday.com. Available at: http://www.podiatrytoday.com/article/3155 [Accessed 23 Oct. 2017].

Aleks Baruksopulo
SportsMed Podiatrist
BSc (Biomed), BHlthSc (Pod)

Featured in the Top 50 Physical Therapy Blog

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Showing 3 comments
  • Rachel
    Reply

    I have tarsal coalition in my right foot and love running. I’ve tried countless running shoes, inserts, etc.. over the years. Its been a real struggle find a running shoe that is suportive but not too heavy (and trust me, I’ve tried just about every shoe on the “best running shoes for overpronation” list out there). My favorite so far has been the Nike Lunarglide (minus the blisters I got with these shoes), and my least favorite has been any of the Brooks (they are supporitive but very heavy and unflattering). Any suggestions?

    • Brad Beer
      Reply

      Hi Rachel,

      Thank you for your question. Sorry to learn of your ongoing tarsal coalition struggles. I have asked our resident podiatrist to comment/provide his thoughts: will post once I receive them.

      Regards Brad Beer

      • Brad Beer
        Reply

        Hi Rachel plz see reply from our podiatrist below:

        thank you for your great enquiry. Tarsal coalitions can be tricky because they can cause a rigid type of flat foot that can put undue stress either directly at the site of the coalition or as a compensation either proximally (further up foot/ankle/leg) or distally (further down the foot). While running they often cause altered foot function leading to excessive, potentially rapid pronation (rolling in). So….I can see why you have had difficulty with shoes!
        What you have done so far is correct and unfortunately in a more complicated foot type like yours it does often involve a little bit of trial and error.
        In terms of trying to find a shoe that is going to help prevent injury it is unfortunately not as simple as matching an excessively pronating foot to an over-pronation running shoe. There is no strong evidence that this alone is going to reduce your injury rate.
        Your case of trial and error is a perfect example of what some running shoe researchers are suggesting to answer why injury rates have not changed over the years even though footwear technology has advanced significantly in terms of materials that aim to protect and understanding of foot biomechanics i.e. “we intuitively select a comfortable running shoe using our own comfort filter that allows us to stay in the preferred movement path”.1 What this means is that in your case by the sounds of it the Nike Lunar glides (mild stability shoe) have worked best for you because they are not interfering with the altered movement path created from the block of range of movement caused by the tarsal coalition. I hope this makes sense.
        The only caveat with this is that you may be experiencing a faster wear rate of your running shoes especially if your foot is excessively pronating and compressing the medial side of the midsole faster than the lateral side? In particular I find that with Nike (after selling them for 6 years in our specialty running shoe store) is that they feel most comfortable out of the box but tend to wear faster than other brands. This most likely has to do with the properties of the lunarlon midsole.
        Another running shoe brand technology that you may want to try which I find from experience lasts longer (on average) is Adidas boost. They are also light and responsive. Probably out of any major traditional brand Adidas seems to have embraced the philosophies of preferred movement path and less is more the most and as a result no longer have a great range of stability shoes. In your case they may be worth giving a trial. It is runner and shoe brand influenced but on average you should get 600 to 800km out of a pair of shoes. I do have some runners however getting a lot less than that (400 to 500km – most commonly in Nike) and just have to replace their shoes more regularly.
        So in summary to answer your question (sorry about the long winded response):
        1. Trial and error is part of the process especially in a difficult foot – comfort is key
        2. Don’t get too concerned about the type of shoe (i.e. Stability etc) in terms of injury prevention but concentrate on making sure all your other aspects of injury prevention are taken care of first especially strength, technique and programming. If you haven’t already read Brad’s book You Can Run Pain Free which details these aspects beautifully.
        3. Try rotating something like an Adidas Ultraboost (or similar Adidas if comfortable) into your running week with your Nike Lunar Glide. It is a good idea to do this in terms of wear but also potential for gathering strength from the shoe moving differently under foot.
        4. You may need to replace your shoes more often because of uneven compression caused from flatter, excessively pronating foot type.
        I hope this makes sense and please feel free to contact me if you have any further questions on shoes and in regards to supporting a foot with a tarsal coalition. FYI They are not a miracle cure and I try to avoid if possible but if a running patient is experiencing persistent pain from a tarsal coalition and surgery is not an option than a correctly made orthotic device can definitely be useful to help offload affected structure.
        Thank you again for your question and enjoy your running.
        Regards,
        Aleks Baruksopulo – POGO Podiatrist
        aleks@sportsmedpodiatry.com.au
        1 NIGG, B. M. et al. The Preferred Movement Path Paradigm: Influence of Running Shoes on Joint Movement. Med Sci Sports Exerc, v. 49, n. 8, p. 1641-1648, Aug 2017. ISSN 1530-0315. Disponível em: < https://www.ncbi.nlm.nih.gov/pubmed/28277405 >.

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