Patients with tarsal coalition will usually present with a rigid flatfoot (loss of inversion and eversion at the subtalar joint). Coalition is produced by a congenital fusion or failure of segmentation of two or more tarsal bones. The attachment may be fibrous, cartilaginous, or osseous. Tarsal coalition can be unilateral or bilateral and will often become symptomatic in early adolescence. The most common forms of tarsal coalition are calcaneonavicular and talocalcaneal.
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The patient will usually present with hindfoot pain, which may radiate laterally because of peroneal muscle spasm. Symptoms are exacerbated by sports, and young athletes can present with frequent ankle sprains. There is a familial component. Pes planus is usually present in both weight bearing and non–weightbearing positions. There is usually a loss of subtalar motion, and passive attempts at joint motion may produce pain.
Anteroposterior, lateral, and oblique radiographs should be obtained, but they may not always clearly identify the disorder. The oblique view often identifies the calcaneonavicular coalition. Computed tomography (CT) is the gold standard for diagnosis of tarsal coalition. Even patients with obvious calcaneonavicular coalition on plain radiographs should have a CT scan to rule out a second coalition.
Coalitions that are asymptomatic (the majority) do not need treatment. Nonoperative treatment for patients with pain consists of cast immobilization for a few weeks and foot orthotics. The symptoms will often return, necessitating surgery. Surgical excision of the coalition and soft tissue interposition to prevent reossification can be very effective.
Cavus foot is characterized by increased height of the medial longitudinal arch (high arch) and frequently hindfoot varus. It can be classified as physiologic or neuromuscular. Most patients with physiologic cavus foot are asymptomatic. A thorough neurologic examination on all patients with a cavus foot is important. Patients with painful high arches have a high risk of neurologic (tethered cord) and neuromuscular disease, and there is a strong association with Charcot-Marie-Tooth disease, a familial neuropathy. The underlying disorder should be treated first. Nonoperative treatment using orthotics is usually not helpful. Progressive, symptomatic cavus foot will likely need surgical reconstruction.
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Kohler disease (tarsal navicular) and Freiberg disease (headof the second metatarsal) are uncommon and due to avascular necrosis. Patients will present with pain at the affected sitewith activity and weight bearing. Infection, fracture, and neoplasm should be excluded. Treatment consists of immobilization and activity restriction. The majority of the patients willimprove upon subsequent revascularization and re-formationof bone.
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Sever disease is a common cause of heel pain among active young people. The mean age of presentation for girls is about 9 years of age and for boys about 11 to 12 years. Approximately 60% of cases are bilateral. Sever disease is caused by the forces of the calf musculature through the Achilles tendon at the calcaneal apophysis, causing microfracture. As the child ages and the apophysis begins to close, the pain disappears.
The common presentation is a young athlete who developsheel pain with activity that decreases with rest. Swelling is rare,but limping may be associated with Sever disease. The childwill have pain to palpation of the posterior calcaneus and oftentight heel cords. Radiographs are rarely indicated, but with persistent pain they should be done to exclude infection or tumor.
Activity modification, icing, and anti-inflammatory medications can be helpful. A program designed to improve heel cord flexibility and overall ankle strength may decrease symptoms. Heel elevation using heel wedges or heel cups can be helpful.