CLINICALLY SPEAKING
A Rare Presentation of Foot Pain Bilateral Navicular–Medial Cuneiform Coalition David A. George, MBChB, BMedSc, MRCS(Eng)* Pinak S. Ray, MS, MCh(Orth), FRCS(Orth)* Julian Livingstone, BSc, DPodM, FFPM RCPS(Glasg)* In this case report, we discuss a rare tarsal coalition occurring bilaterally between the navicular and the medial cuneiform in a 15-year-old girl and highlight the management of such cases. (J Am Podiatr Med Assoc 105(2): 181-184, 2015)
Tarsal coalitions are a well-documented cause of foot pain, with talocalcaneal and calcaneonavicular synostoses being the most common in the literature. We report on a case of bilateral navicular–medial cuneiform coalition occurring in a 15-year-old girl. We describe the etiology, the clinical and radiographic findings, and the treatment modalities available.
History A 15-year-old girl was referred in October 2012 to the Podiatry Clinic at Barnet Hospital (Barnet, England) from the Pediatric Department. She had a 4-year history of pain in the midarch region of both feet, increasing in severity during physical activity. She had been previously seen by the primary care podiatric medicine department. She stated that the pain improved when she wore a new pair of more rigid shoes, but once she wore the soles down to a comfortable position, the pain recurred, despite orthoses. She was otherwise fit and well and did not experience any swelling of her joints or aches and pains in other areas. On inspection, she had good arches bilaterally, and the results of Jack’s test (Hubscher’s maneuver) were normal; the arch increased and the hindfoot inverted on going on tiptoe. The neutral calcaneal stance was essentially normal, but she had a subtle cavus foot, as described by Manoli and Graham,1 with progressive valgus tendencies of the hindfoot on Coleman block testing. Her ankle had full range *Department of Trauma and Orthopaedic Surgery, Barnet and Chase Farm Hospitals, Royal Free London NHS Foundation Trust, England. Corresponding author: David A. George, MBChB, BMedSc, MRCS(Eng), Barnet Hospital, Wellhouse Lane, Barnet, Hertfordshire, EN5 3DJ, United Kingdom. (E-mail: [email protected])
of movement, with tenderness along the medial aspect of her ankle joint. However, there was clinical limitation in her midfoot, and midtarsal and subtalar motion seemed normal. The movement of her first metatarsophalangeal joint was more than 608 in dorsiflexion and 408 in plantarflexion. Clinically, the plantar aponeurosis and Achilles tendon were assessed as tight. Silfverskio¨ld testing showed limited dorsiflexion of the first toe and ankle with the knee fully extended, compared with the knee flexed.2 The neurologic examination was unremarkable.
Investigations Weightbearing dorsoplantar and lateral plain radiographs and oblique lateral views were obtained at the time of the first consultation. The calcaneal inclination angles and the calcaneal–first metatarsal angle were calculated as normal (Fig. 1).3 In addition, these radiographs demonstrated irregularities between the navicular and the medial cuneiform, a bar on the plantar aspect of the joint, consistent with a coalition (Figs. 2 and 3). A subsequent magnetic resonance image (MRI) of her left foot showed evidence of attempted coalition between the navicular and the medial cuneiform (Fig. 4), and the short tau inversion recovery sequence demonstrated increased signal in the head, neck, and posteromedial aspect of the talar dome inferiorly (Fig. 5), suggesting a stress reaction. The right foot MRI further identified an incomplete coalition and evidence of a stress reaction with edema on the short tau inversion recovery sequence. There was no evidence of arthropathy in the subtalar joint, indicating that this was likely a stress reaction.
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Figure 1. Weightbearing radiographs illustrating the calcaneal inclination angles (CIAs), calcaneal–first metatarsal angle (C1MA), and talocalcaneal angles (TCAs). Right: CIA, 22.78; C1MA, 23.68; and TCA, 17.28. Left: CIA, 27.58; C1MA, 23.78; and TCA, 16.28.
Management The various management options were discussed with the patient and her family. Conservative measures were chosen and were successful in reducing the patient’s pain associated with the bilateral coalition, which had been present for 3 years. Initial podiatric medical management in primary care had involved an ethyl vinyl acetate–
molded orthosis with a forefoot and rearfoot varus post. However, after the investigations this was changed to a Vasyli Howard Dananberg orthotic device, allowing the first ray to plantarflex and the rearfoot to evert, decompressing the subtalar joint.1 This was combined with patient education about plantar aponeurosis and Achilles eccentric stretches. Two years after diagnosis and fitting of the
Figure 2. Weightbearing radiographs (lateral,
oblique, and dorsoplantar) of left and right feet and ankles illustrating the coalition between the navicular and the medial cuneiform bones (red circles).
182
Figure 3. Plain lateral radiographs of the left foot and
ankle illustrating the coalition (red circle) and the associated surrounding anatomy.
March/April 2015 Vol 105 No 2 Journal of the American Podiatric Medical Association
Figure 4. Magnetic resonance image of the left foot
demonstrating the coalition between the navicular and the medial cuneiform (red circle). orthotic device, the patient was pain free with all physical activities. On examination, she no longer had tenderness, and she had full range of pain-free movement of her ankle, subtalar, and midtarsal joints bilaterally.
Discussion This case is an example of a rare coalition occurring between the navicular and the medial cuneiform and, to our knowledge, the first to be described bilaterally.4-6 Tarsal coalition is a condition characterized by the osseous, cartilaginous, or fibrous union between two tarsal bones, typically talocalcaneal, calcaneonavicular, and talonavicular.7-9 Development of a coalition is typically congenital, inherited in an autosomal dominant manner; the tarsal bones share a common embryologic origin and fail to completely separate.10 However, coalitions can also be acquired secondary to degenerative joint diseases, inflammatory arthritis, infection, and clubfoot deformities.9 This case is of particular interest in that all of the clinical tests undertaken to confirm hindfoot rigidity associated with the tarsal coalition were normal. As exemplified in this case, a variety of radiologic modalities to confirm diagnosis can be used. Initial plain radiographs identified a bar on the lateral film extending from the apex of the medial cuneiform to the navicular, without obvious altered navicular morphologic features (Fig. 2). In calcaneonavicular
Figure 5. Magnetic resonance image of the left foot
demonstrating edema of the talus secondary to the coalition, causing the misdistribution of forces (red circle). and talocalcaneal coalitions, there is high sensitivity and specificity because plain radiographs (dorsoplantar, oblique, and lateral) are diagnostic in most cases.11 However, fibrous and cartilaginous coalitions are infrequently recognized by plain radiography, and when this is the case, computed tomography and MRI are adopted.12 Additional features include differentiating osseous from nonosseous coalitions, illustrating the extent of joint involvement, and identifying secondary degenerative changes.8 We used MRIs in this case to reveal bone marrow edema on the talus (Fig. 5), evidence of abnormal loading and a severe stress reaction on the head and neck of the talus. The pain experienced by the patient was, therefore, not at the site of the coalition but at the talus secondary to the altered biomechanics of the medial arch. Other reports have associated the pain experienced by their patients to be secondary to the weakness of the cartilaginous bridges relative to the weightbearing force over the naviculocuneiform joint.13 As demonstrated by this case, conservative therapy consisted of a combination of orthoses for the feet, changes in physical activities, analgesia (specifically, nonsteroidal anti-inflammatory medication), and patient education.9 The tarsal coalition in this patient blocked dorsiflexion of the first ray, resulting in less pronation of the subtalar joint at the point of heel
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strike, and subsequent plantarflexion of the first ray. Allowing the first ray to plantarflex with the Vasyli Howard Dananberg orthosis resulted in decompression of the subtalar joint, allowing pronation, and relieved the pain that was associated with the bone edema on the talus as demonstrated by the MRI. Root et al14 described loss of midfoot motion leading to increased subtalar supination. The previous use of a varus posted (ethyl vinyl acetate–molded) orthosis failed to decompress the hindfoot, hence not allowing adequate shock absorption. Using the Vasyli Howard Dananberg orthotic device with a first metatarsal cutout allowed for eversion of the rearfoot at heel contact14 and decompressed the stressed joints, which in this case was the subtalar joint and not the actual coalition. The coalition blocked motion, leading to pain in the surrounding joints, and by allowing for more motion with use of the Vasyli Howard Dananberg orthosis rather than a varus posted orthosis, the stresses on the surrounding bones were relieved.15 If conservative measures had failed, surgical options may have included resection of the coalition with or without free-fat interposition or navicular–medial cuneiform fusions.5 Saxena and Erickson 16 demonstrated surgical excision of coalitions to have a favorable outcome regarding return to activity compared with nonsurgical management; however, this was described for more common coalitions.
Conclusions We presented a case of a 15-year-old girl with a 4year history of bilateral foot pain. Clinical examination revealed essentially a normal foot, and a pathologic abnormality was revealed only after radiologic investigation. Investigations identified a rare coalition between the navicular–medial cuneiform occurring bilaterally. Treated conservatively, she soon returned to her active lifestyle. This case demonstrates the importance in diagnosis, through variable imaging modalities, to adequately tailor treatment appropriately and relieve patient symptoms.
184
Financial Disclosure: None reported. Conflict of Interest: None reported.
References 1. MANOLI A II, GRAHAM B: The subtle cavus foot: ‘‘the underpronator.’’ Foot Ankle Int 26: 256, 2005. 2. SILFVERSKIOLD N: Reduction of the uncrossed two-joint muscles of the leg to one-joint muscles in spastic conditions. Acta Chir Scand 56: 315, 1924. 3. MURLEY GS, MENZ HB, LANDORF KB: A protocol for classifying normal- and flat-arched foot posture for research studies using clinical and radiographic measurements. J Foot Ankle Res 2: 22, 2009. 4. KERNBACH KJ: Tarsal coalitions: aetiology, diagnosis, imaging, and stigmata. Clin Podiatr Med Surg 27: 105, 2010. 5. ROSS JR, DOBBS MB: Isolated navicular-medial cuneiform tarsal coalition revisited: a case report. J Pediatr Orthop 31: e85, 2011. 6. VATSKY S, TOWBIN R: Isolated non-osseous navicularmedial cuneiform tarsal coalition. Appl Radiol Dec (suppl): 12, 2012. 7. MIKI T, YAMAMURO T, IIDA H, ET AL: Naviculo-cuneiform coalition: a report of two cases. Clin Orthop Relat Res 196: 256, 1985. 8. NEWMAN JS, NEWBERG AH: Congenital tarsal coalition: multimodality evaluation with emphasis on CT and MR imaging. Radiographics 20: 321, 2000. 9. BOHNE WH: Tarsal coalition. Curr Opin Pediatr 13: 29, 2001. 10. FOPMA E, MACNICOL MF: Tarsal coalition. Curr Orthop 16: 65, 2002. 11. CRIM JR, KJELDSBERG KM: Radiographic diagnosis of tarsal coalition. AJR Am J Roentgenol 182: 323, 2004. 12. NALABOFF KM, Schweitzer ME: MRI of tarsal coalition: frequency, distribution, and innovative signs. Bull NYU Hosp Jt Dis 66: 14, 2008. 13. SATO K, SUGIURA S: Naviculo-cuneiform coalition: report of three cases. Nihon Seikeigeka Gakkai Zasshi 64: 1, 1990. 14. ROOT ML, ORIEN WP, WEED JH: Clinical Biomechanics: Normal and Abnormal Function of the Foot, Vol 2, p 345, Clinical Biomechanics Corp, Los Angeles, 1977. 15. VASYLI - HOWARD DANANBERG. VASYLI Medical website. Available at: http://www.vasylimedical.com/products/ product_howard_dananberg.html. Accessed December 21, 2012. 16. SAXENA A, ERICKSON S: Tarsal coalitions: activity levels with and without surgery. JAPMA 3: 259, 2003.
March/April 2015 Vol 105 No 2 Journal of the American Podiatric Medical Association
A Rare Presentation of Foot Pain Bilateral Navicular–Medial Cuneiform Coalition David A. George, MBChB, BMedSc, MRCS(Eng)* Pinak S. Ray, MS, MCh(Orth), FRCS(Orth)* Julian Livingstone, BSc, DPodM, FFPM RCPS(Glasg)* In this case report, we discuss a rare tarsal coalition occurring bilaterally between the navicular and the medial cuneiform in a 15-year-old girl and highlight the management of such cases. (J Am Podiatr Med Assoc 105(2): 181-184, 2015)
Tarsal coalitions are a well-documented cause of foot pain, with talocalcaneal and calcaneonavicular synostoses being the most common in the literature. We report on a case of bilateral navicular–medial cuneiform coalition occurring in a 15-year-old girl. We describe the etiology, the clinical and radiographic findings, and the treatment modalities available.
History A 15-year-old girl was referred in October 2012 to the Podiatry Clinic at Barnet Hospital (Barnet, England) from the Pediatric Department. She had a 4-year history of pain in the midarch region of both feet, increasing in severity during physical activity. She had been previously seen by the primary care podiatric medicine department. She stated that the pain improved when she wore a new pair of more rigid shoes, but once she wore the soles down to a comfortable position, the pain recurred, despite orthoses. She was otherwise fit and well and did not experience any swelling of her joints or aches and pains in other areas. On inspection, she had good arches bilaterally, and the results of Jack’s test (Hubscher’s maneuver) were normal; the arch increased and the hindfoot inverted on going on tiptoe. The neutral calcaneal stance was essentially normal, but she had a subtle cavus foot, as described by Manoli and Graham,1 with progressive valgus tendencies of the hindfoot on Coleman block testing. Her ankle had full range *Department of Trauma and Orthopaedic Surgery, Barnet and Chase Farm Hospitals, Royal Free London NHS Foundation Trust, England. Corresponding author: David A. George, MBChB, BMedSc, MRCS(Eng), Barnet Hospital, Wellhouse Lane, Barnet, Hertfordshire, EN5 3DJ, United Kingdom. (E-mail: [email protected])
of movement, with tenderness along the medial aspect of her ankle joint. However, there was clinical limitation in her midfoot, and midtarsal and subtalar motion seemed normal. The movement of her first metatarsophalangeal joint was more than 608 in dorsiflexion and 408 in plantarflexion. Clinically, the plantar aponeurosis and Achilles tendon were assessed as tight. Silfverskio¨ld testing showed limited dorsiflexion of the first toe and ankle with the knee fully extended, compared with the knee flexed.2 The neurologic examination was unremarkable.
Investigations Weightbearing dorsoplantar and lateral plain radiographs and oblique lateral views were obtained at the time of the first consultation. The calcaneal inclination angles and the calcaneal–first metatarsal angle were calculated as normal (Fig. 1).3 In addition, these radiographs demonstrated irregularities between the navicular and the medial cuneiform, a bar on the plantar aspect of the joint, consistent with a coalition (Figs. 2 and 3). A subsequent magnetic resonance image (MRI) of her left foot showed evidence of attempted coalition between the navicular and the medial cuneiform (Fig. 4), and the short tau inversion recovery sequence demonstrated increased signal in the head, neck, and posteromedial aspect of the talar dome inferiorly (Fig. 5), suggesting a stress reaction. The right foot MRI further identified an incomplete coalition and evidence of a stress reaction with edema on the short tau inversion recovery sequence. There was no evidence of arthropathy in the subtalar joint, indicating that this was likely a stress reaction.
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Figure 1. Weightbearing radiographs illustrating the calcaneal inclination angles (CIAs), calcaneal–first metatarsal angle (C1MA), and talocalcaneal angles (TCAs). Right: CIA, 22.78; C1MA, 23.68; and TCA, 17.28. Left: CIA, 27.58; C1MA, 23.78; and TCA, 16.28.
Management The various management options were discussed with the patient and her family. Conservative measures were chosen and were successful in reducing the patient’s pain associated with the bilateral coalition, which had been present for 3 years. Initial podiatric medical management in primary care had involved an ethyl vinyl acetate–
molded orthosis with a forefoot and rearfoot varus post. However, after the investigations this was changed to a Vasyli Howard Dananberg orthotic device, allowing the first ray to plantarflex and the rearfoot to evert, decompressing the subtalar joint.1 This was combined with patient education about plantar aponeurosis and Achilles eccentric stretches. Two years after diagnosis and fitting of the
Figure 2. Weightbearing radiographs (lateral,
oblique, and dorsoplantar) of left and right feet and ankles illustrating the coalition between the navicular and the medial cuneiform bones (red circles).
182
Figure 3. Plain lateral radiographs of the left foot and
ankle illustrating the coalition (red circle) and the associated surrounding anatomy.
March/April 2015 Vol 105 No 2 Journal of the American Podiatric Medical Association
Figure 4. Magnetic resonance image of the left foot
demonstrating the coalition between the navicular and the medial cuneiform (red circle). orthotic device, the patient was pain free with all physical activities. On examination, she no longer had tenderness, and she had full range of pain-free movement of her ankle, subtalar, and midtarsal joints bilaterally.
Discussion This case is an example of a rare coalition occurring between the navicular and the medial cuneiform and, to our knowledge, the first to be described bilaterally.4-6 Tarsal coalition is a condition characterized by the osseous, cartilaginous, or fibrous union between two tarsal bones, typically talocalcaneal, calcaneonavicular, and talonavicular.7-9 Development of a coalition is typically congenital, inherited in an autosomal dominant manner; the tarsal bones share a common embryologic origin and fail to completely separate.10 However, coalitions can also be acquired secondary to degenerative joint diseases, inflammatory arthritis, infection, and clubfoot deformities.9 This case is of particular interest in that all of the clinical tests undertaken to confirm hindfoot rigidity associated with the tarsal coalition were normal. As exemplified in this case, a variety of radiologic modalities to confirm diagnosis can be used. Initial plain radiographs identified a bar on the lateral film extending from the apex of the medial cuneiform to the navicular, without obvious altered navicular morphologic features (Fig. 2). In calcaneonavicular
Figure 5. Magnetic resonance image of the left foot
demonstrating edema of the talus secondary to the coalition, causing the misdistribution of forces (red circle). and talocalcaneal coalitions, there is high sensitivity and specificity because plain radiographs (dorsoplantar, oblique, and lateral) are diagnostic in most cases.11 However, fibrous and cartilaginous coalitions are infrequently recognized by plain radiography, and when this is the case, computed tomography and MRI are adopted.12 Additional features include differentiating osseous from nonosseous coalitions, illustrating the extent of joint involvement, and identifying secondary degenerative changes.8 We used MRIs in this case to reveal bone marrow edema on the talus (Fig. 5), evidence of abnormal loading and a severe stress reaction on the head and neck of the talus. The pain experienced by the patient was, therefore, not at the site of the coalition but at the talus secondary to the altered biomechanics of the medial arch. Other reports have associated the pain experienced by their patients to be secondary to the weakness of the cartilaginous bridges relative to the weightbearing force over the naviculocuneiform joint.13 As demonstrated by this case, conservative therapy consisted of a combination of orthoses for the feet, changes in physical activities, analgesia (specifically, nonsteroidal anti-inflammatory medication), and patient education.9 The tarsal coalition in this patient blocked dorsiflexion of the first ray, resulting in less pronation of the subtalar joint at the point of heel
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strike, and subsequent plantarflexion of the first ray. Allowing the first ray to plantarflex with the Vasyli Howard Dananberg orthosis resulted in decompression of the subtalar joint, allowing pronation, and relieved the pain that was associated with the bone edema on the talus as demonstrated by the MRI. Root et al14 described loss of midfoot motion leading to increased subtalar supination. The previous use of a varus posted (ethyl vinyl acetate–molded) orthosis failed to decompress the hindfoot, hence not allowing adequate shock absorption. Using the Vasyli Howard Dananberg orthotic device with a first metatarsal cutout allowed for eversion of the rearfoot at heel contact14 and decompressed the stressed joints, which in this case was the subtalar joint and not the actual coalition. The coalition blocked motion, leading to pain in the surrounding joints, and by allowing for more motion with use of the Vasyli Howard Dananberg orthosis rather than a varus posted orthosis, the stresses on the surrounding bones were relieved.15 If conservative measures had failed, surgical options may have included resection of the coalition with or without free-fat interposition or navicular–medial cuneiform fusions.5 Saxena and Erickson 16 demonstrated surgical excision of coalitions to have a favorable outcome regarding return to activity compared with nonsurgical management; however, this was described for more common coalitions.
Conclusions We presented a case of a 15-year-old girl with a 4year history of bilateral foot pain. Clinical examination revealed essentially a normal foot, and a pathologic abnormality was revealed only after radiologic investigation. Investigations identified a rare coalition between the navicular–medial cuneiform occurring bilaterally. Treated conservatively, she soon returned to her active lifestyle. This case demonstrates the importance in diagnosis, through variable imaging modalities, to adequately tailor treatment appropriately and relieve patient symptoms.
184
Financial Disclosure: None reported. Conflict of Interest: None reported.
References 1. MANOLI A II, GRAHAM B: The subtle cavus foot: ‘‘the underpronator.’’ Foot Ankle Int 26: 256, 2005. 2. SILFVERSKIOLD N: Reduction of the uncrossed two-joint muscles of the leg to one-joint muscles in spastic conditions. Acta Chir Scand 56: 315, 1924. 3. MURLEY GS, MENZ HB, LANDORF KB: A protocol for classifying normal- and flat-arched foot posture for research studies using clinical and radiographic measurements. J Foot Ankle Res 2: 22, 2009. 4. KERNBACH KJ: Tarsal coalitions: aetiology, diagnosis, imaging, and stigmata. Clin Podiatr Med Surg 27: 105, 2010. 5. ROSS JR, DOBBS MB: Isolated navicular-medial cuneiform tarsal coalition revisited: a case report. J Pediatr Orthop 31: e85, 2011. 6. VATSKY S, TOWBIN R: Isolated non-osseous navicularmedial cuneiform tarsal coalition. Appl Radiol Dec (suppl): 12, 2012. 7. MIKI T, YAMAMURO T, IIDA H, ET AL: Naviculo-cuneiform coalition: a report of two cases. Clin Orthop Relat Res 196: 256, 1985. 8. NEWMAN JS, NEWBERG AH: Congenital tarsal coalition: multimodality evaluation with emphasis on CT and MR imaging. Radiographics 20: 321, 2000. 9. BOHNE WH: Tarsal coalition. Curr Opin Pediatr 13: 29, 2001. 10. FOPMA E, MACNICOL MF: Tarsal coalition. Curr Orthop 16: 65, 2002. 11. CRIM JR, KJELDSBERG KM: Radiographic diagnosis of tarsal coalition. AJR Am J Roentgenol 182: 323, 2004. 12. NALABOFF KM, Schweitzer ME: MRI of tarsal coalition: frequency, distribution, and innovative signs. Bull NYU Hosp Jt Dis 66: 14, 2008. 13. SATO K, SUGIURA S: Naviculo-cuneiform coalition: report of three cases. Nihon Seikeigeka Gakkai Zasshi 64: 1, 1990. 14. ROOT ML, ORIEN WP, WEED JH: Clinical Biomechanics: Normal and Abnormal Function of the Foot, Vol 2, p 345, Clinical Biomechanics Corp, Los Angeles, 1977. 15. VASYLI - HOWARD DANANBERG. VASYLI Medical website. Available at: http://www.vasylimedical.com/products/ product_howard_dananberg.html. Accessed December 21, 2012. 16. SAXENA A, ERICKSON S: Tarsal coalitions: activity levels with and without surgery. JAPMA 3: 259, 2003.
March/April 2015 Vol 105 No 2 Journal of the American Podiatric Medical Association
