13 Years Old with Ankle Pain: Meet James

James: First Diagnosed with Tarsal Coalition at 13 years old

James is 13 years old, very active and participates in a wide range of sporting activities at school, his favourite being basketball. He is currently playing games or training at least 5 times per week. We first met James a couple of months ago when he came in with his dad primarily because of some ongoing discomfort and pain in both feet. The pain was reported to be present on and off for the past 2 months. James also had occasional knee pain that he attributed to long days playing sports. James’ dad decided to bring him in because James was getting frustrated and upset that he couldn’t play full games without his achy feet holding him back and affecting his performance.

James’ symptoms included:

• Dull general ache around the top of the ankle that he described as being inside the ankle
• Ache present both with sport and after long walks
• Occasional sharp twinge in the rearfoot during sports
• Occasional knee pain related to lots of training and activity
• Feet felt a little stiffer which he attributed to inadequate stretching

James had a consultation with one of our expert biomechanical Podiatrists. We specialise in sports medicine, sport-related injuries and kids foot care. We carried out a thorough biomechanical examination on James which included examining his:

• Palpation around the heels and painful structures
• Range of motion at all the joints of the foot, ankle, knee and hip
• Gait (walking) assessment with shoes and without, on the ground and on the treadmill
• Foot posture
• Footwear assessment
• Muscle strength

Our main clinical findings was that James had very flat feet with almost no arch profile. His posterior tibial tendon was weakened and damaged, with pain on palpation and resistance. We were able to localise his pain to around the region of the talus although couldn’t elicit any sharp pain on palpation. His pronated foot posture was placing a lot of tension through his medial knee surfaces, accounting for the pain. His foot type with minimal support from footwear appears to have contributed to the overuse and damage to his posterior tibial tendon. He had some limited movement through his subtalar joint, though general movement at the axis was still sufficient.

We wanted to rule out stress fractures, any arthritic changes and any signs of a tarsal coalition, so referred James for some radiographic imaging. 

Diagnosis: Talocalcaneal Tarsal Coalition

Radiographs showed that James had the signs of a tarsal coalition at his talocalcaneal joint. A tarsal coalition describes an abnormal connection between the tarsal bones, which can involve varying combinations of tarsal bones. The coalitions can be bony, fibrous or cartilaginous. James had a bony coalition.

Treatment

Studies have shown that while not all tarsal coalitions are symptomatic, when they do become symptomatic, the symptoms may not be permanent. There are then two main categories of treatment: Conservative and Surgical treatment.

Tarsal Coalition Case Study 2Conservative treatment focuses on improving the patient’s quality of life through alleviating pain and discomfort. Surgical treatment typically involves resecting or fusing the affected tarsal bones. Seeing as James was only 13 years old, his pain was not severe, and he had only been symptomatic for 2 months, we presented the options to his dad and he decided to try the conservative route first in the hopes of avoiding surgery. 

We started with a change in footwear to pairs of joggers that gave James maximum stability on his feet

Orthotics were then prescribed to reduce the pressure on the affected tarsal bones limit their movement to reduce his pain and aches. Because the bones will continue to fuse, it is important that we keep the foot in the best possible alignment to get the best positioning and outcome for the fused bones

We talked James through any modifications he needed for his daily activities, with alternatives that minimise his discomfort

Anti-inflammatories and physical therapy are also adjuncts to conservative management of a juvenile tarsal coalition. We’ll be reviewing James in another two weeks. At this stage, all looks positive with the orthotics working to unload the painful joint and reduce symptoms. While conservative treatment doesn’t ‘fix’ the issue, in this case it can greatly improve the quality of life of a patient without undergoing surgery. If James’ symptoms persist or worsen, we’ll refer him to the orthopedic surgeon for investigation.