Slide 036 — Painful flatfoot onset in adolescence: Tarsal coalition

Clean FRCS notes with inline figures

Painful flatfoot onset in adolescence: Tarsal coalition

Clinical photograph

•Bilateral flatfoot with reduced medial foot arch

•Medial bulge → middle facet coalition

•From the back, hindfoot valgus with too many toe sign positive on right side

Diagnosis: pes planus

•Check/perform differentiate if it is flexible or rigid

•Ddx for painful flatfoot in child

•Tarsal coalition

•Accessory navicular

•Painful flexible flatfoot (tight Achilles)

•JIA

Causes of flatfoot in general:

•Unilateral vs bilateral vs rigid

•IDNNM cause

Assessment:

•Hx: Onset of symptoms, site of pain, trauma, footwear

Examination

•Exclude obvious syndromic or neurological causes

•Deformity (hindfoot valgus, forefoot abduction, rigid flatfeet)

•Tenderness (microfracture of coalition interface, ossification of previously fibrous or cartilaginous coalition, chondral injury, peroneal spasm, subfibular impingement, increase stress in other joints → hindfoot joint degeneration) (CN lateral pain at sinus tarsi, TC medial pain)

•Painful inversion against resistance (peroneal spasm)

•Limited subtalar movement. Reverse Coleman block to assess subtalar rigidity

•PTT function

•Examine contralateral side (50% bilateral)

•General exam: Associated with fibular hemimelia/ PFFD, carpal coalition, Apert syndrome

•CN vs TC coalition

•CN

•- More common, present earlier

•- Less stiff

•- lateral side pain

•- More responsive to resection

- Anteater nose sign on oblique XR

**Fig 2.** Radiograph / imaging - tarsal coalition radiographtop left

•TC

•- Less common

•- Present late

•- Medial side pain

•- C sign and anterior beak on lateral XR, coalition in harris view

Xray:

•CN: oblique view showed anteater sign

•TC: lateral view showed C sign= subtalar and middle facet coalition, talus neck periosteal traction spur. Harris view may also show coalition

•CT/ MRI to look for size and location of bony/ fibrous connection, r/o additional coalitions (5%)

Treatment:

•Conservative (if rigid flatfoot, arch support/ orthosis mold at current position to prevent deterioration eg UCBL) (walking cast boot) (temporary immobilization with casting)

•OT: Resection of coalition vs fusion

Myerson:

•Traditionally 50% is regarded as a contraindication for resection. Most important aspect of treatment is to realign the foot and ankle regardless of fusion or resection

•CN: excision via Olliers approach/sinus tarsi approach, EDB interposition +/- correct deformity and TA release

•TC: bony union > 50% → fusion, <50% → excision + interposition (split FHL graft, fat)

•Medial incision between FDL and PT

•Salvage: triple arthrodesis + deformity correction in rigid FF for older patient + OA

Indications for fusion:

•1. Malalignment

•2. >50%

•3. Degen

•4. Older

•AD – high level of penetrance

•NOG (Noggin) gene

•Bilateral in 50%

•Failure of mesenchymal segmentation

Ddx for flatfoot:

•Unilateral TDNNM

•Post traumatic

•Degenerative

•Charcot (neuroinflammatory)

•Neuromuscular (polio)

•Bilateral IDNNM

•Ligamentous laxity

•RA (inflammatory)

•Neuroinflammatory

•Neuromuscular (spastic diplegic, spina bifida)

•Both

•Idiopathic

•PTTD

•Congenital vertical talus

•Tarsal coalition

What does peroneal spasm mean?

•Peroneal spasm is a protective mechanism to reduce pain

•If no peroneal spasm, you know subtalar joint is okay (Lui)

Canadian army foot study

•1/5 have flat foot

•67% asx

•25% sx with flexible flat foot + tight TA

•8% sx with rigid (accessory navicular, tarsal coalition, congenital vertical talus)

•Wagner JBJS 1989

•Flexible flatfoot randomized to control, corrective shoes, Helfet heel cups, UCBL – improvement not related to orthosis. Increase laxity, more improvement.

#	lvl	marL	indent	logical	original note line
1	0	0	0	0	Painful flatfoot onset in adolescence: Tarsal coalition
2	0	None	None	0	Describe clinical photo:
3	0	171450	-171450	1	Bilateral flatfoot with reduced medial foot arch
4	0	171450	-171450	1	Medial bulge → middle facet coalition
5	0	171450	-171450	1	From the back, hindfoot valgus with too many toe sign positive on right side
6	0	None	None	0	Diagnosis: pes planus
7	0	None	None	0	Need to differentiate if it is flexible or rigid
8	0	None	None	0	Ddx for painful flatfoot in child
9	0	171450	-171450	1	Tarsal coalition
10	0	171450	-171450	1	Accessory navicular
11	0	171450	-171450	1	Painful flexible flatfoot (tight Achilles)
12	0	171450	-171450	1	JIA
13	0	None	None	0	Causes of flatfoot in general:
14	0	None	None	0	Unilateral vs bilateral vs rigid
15	0	None	None	0	IDNNM cause
16	0	None	None	0	Assessment:
17	0	None	None	0	Hx: Onset of symptoms, site of pain, trauma, footwear
18	0	None	None	0	PE:
19	1	171450	-171450	1	Exclude obvious syndromic or neurological causes
20	1	171450	-171450	1	Deformity (hindfoot valgus, forefoot abduction, rigid flatfeet)
21	1	171450	-171450	1	Tenderness (microfracture of coalition interface, ossification of previously fibrous or cartilaginous coalition, chondral injury, peroneal spasm, subfibular impingement, increase stress in other joints → hindfoot joint degeneration) (CN lateral pain at sinus tarsi, TC medial pain)
22	1	171450	-171450	1	Painful inversion against resistance (peroneal spasm)
23	1	171450	-171450	1	Limited subtalar movement. Reverse Coleman block to assess subtalar rigidity
24	0	171450	-171450	1	PTT function
25	0	171450	-171450	1	Examine contralateral side (50% bilateral)
26	0	171450	-171450	1	General exam: Associated with fibular hemimelia/ PFFD, carpal coalition, Apert syndrome
27	0	0	0	0	CN vs TC coalition
28	0	0	0	0	CN
29	0	0	0	0	- More common, present earlier
30	0	0	0	0	- Less stiff
31	0	0	0	0	- lateral side pain
32	0	0	0	0	- More responsive to resection
33	0	0	0	0	- Anteater nose sign on oblique XR
34	0	0	0	0	TC
35	0	0	0	0	- Less common
36	0	0	0	0	- Present late
37	0	0	0	0	- Medial side pain
38	0	0	0	0	- C sign and anterior beak on lateral XR, coalition in harris view
39	0	None	None	0	Xray:
40	0	171450	-171450	1	CN: oblique view showed anteater sign
41	0	171450	-171450	1	TC: lateral view showed C sign= subtalar and middle facet coalition, talus neck periosteal traction spur. Harris view may also show coalition
42	0	0	0	0	CT/ MRI to look for size and location of bony/ fibrous connection, r/o additional coalitions (5%)
43	0	None	None	0	Treatment:
44	0	171450	-171450	1	Conservative (if rigid flatfoot, arch support/ orthosis mold at current position to prevent deterioration eg UCBL) (walking cast boot) (temporary immobilization with casting)
45	0	171450	-171450	1	OT: Resection of coalition vs fusion
46	1	457200	0	1	Myerson:
47	1	457200	0	1	Traditionally 50% is regarded as a contraindication for resection. Most important aspect of treatment is to realign the foot and ankle regardless of fusion or resection
48	1	628650	-171450	2	CN: excision via Olliers approach/sinus tarsi approach, EDB interposition +/- correct deformity and TA release
49	1	628650	-171450	2	TC: bony union > 50% → fusion, <50% → excision + interposition (split FHL graft, fat)
50	2	1085850	-171450	3	Medial incision between FDL and PT
51	1	628650	-171450	2	Salvage: triple arthrodesis + deformity correction in rigid FF for older patient + OA
52	0	0	0	0	Indications for fusion:
53	0	0	0	0	1. Malalignment
54	0	0	0	0	2. >50%
55	0	None	None	0	3. Degen
56	0	None	None	0	4. Older
57	0	None	None	0	=============================
58	0	None	None	0	AD – high level of penetrance
59	0	None	None	0	NOG (Noggin) gene
60	0	None	None	0	Bilateral in 50%
61	0	None	None	0	Failure of mesenchymal segmentation
62	0	None	None	0	Ddx for flatfoot:
63	0	None	None	0	Unilateral TDNNM
64	1	None	None	1	Post traumatic
65	1	None	None	1	Degenerative
66	1	None	None	1	Charcot (neuroinflammatory)
67	1	None	None	1	Neuromuscular (polio)
68	0	None	None	0	Bilateral IDNNM
69	1	None	None	1	Ligamentous laxity
70	1	None	None	1	RA (inflammatory)
71	1	None	None	1	Degenerative
72	1	None	None	1	Neuroinflammatory
73	1	None	None	1	Neuromuscular (spastic diplegic, spina bifida)
74	0	None	None	0	Both
75	1	None	None	1	Idiopathic
76	1	None	None	1	PTTD
77	1	None	None	1	Congenital vertical talus
78	1	None	None	1	Tarsal coalition
79	0	None	None	0	What does peroneal spasm mean?
80	0	None	None	0	Peroneal spasm is a protective mechanism to reduce pain
81	0	None	None	0	If no peroneal spasm, you know subtalar joint is okay (Lui)
82	0	None	None	0	Canadian army foot study
83	1	None	None	1	1/5 have flat foot
84	1	None	None	1	67% asx
85	1	None	None	1	25% sx with flexible flat foot + tight TA
86	1	None	None	1	8% sx with rigid (accessory navicular, tarsal coalition, congenital vertical talus)
87	0	None	None	0	Wagner JBJS 1989
88	0	None	None	0	Flexible flatfoot randomized to control, corrective shoes, Helfet heel cups, UCBL – improvement not related to orthosis. Increase laxity, more improvement.

#	semantic level	section?	rewritten line
1	0		Painful flatfoot onset in adolescence: Tarsal coalition
2	0	yes	Clinical photograph
3	1		Bilateral flatfoot with reduced medial foot arch
4	1		Medial bulge → middle facet coalition
5	1		From the back, hindfoot valgus with too many toe sign positive on right side
6	0	yes	Diagnosis: pes planus
7	1		Check/perform differentiate if it is flexible or rigid
8	1		Ddx for painful flatfoot in child
9	1		Tarsal coalition
10	1		Accessory navicular
11	1		Painful flexible flatfoot (tight Achilles)
12	1		JIA
13	0	yes	Causes of flatfoot in general:
14	1		Unilateral vs bilateral vs rigid
15	1		IDNNM cause
16	0	yes	Assessment:
17	1		Hx: Onset of symptoms, site of pain, trauma, footwear
18	0	yes	Examination
19	1		Exclude obvious syndromic or neurological causes
20	1		Deformity (hindfoot valgus, forefoot abduction, rigid flatfeet)
21	1		Tenderness (microfracture of coalition interface, ossification of previously fibrous or cartilaginous coalition, chondral injury, peroneal spasm, subfibular impingement, increase stress in other joints → hindfoot joint degeneration) (CN lateral pain at sinus tarsi, TC medial pain)
22	1		Painful inversion against resistance (peroneal spasm)
23	1		Limited subtalar movement. Reverse Coleman block to assess subtalar rigidity
24	1		PTT function
25	1		Examine contralateral side (50% bilateral)
26	1		General exam: Associated with fibular hemimelia/ PFFD, carpal coalition, Apert syndrome
27	1		CN vs TC coalition
28	1		CN
29	1		- More common, present earlier
30	1		- Less stiff
31	1		- lateral side pain
32	1		- More responsive to resection
33	0	yes	- Anteater nose sign on oblique XR
34	1		TC
35	1		- Less common
36	1		- Present late
37	1		- Medial side pain
38	1		- C sign and anterior beak on lateral XR, coalition in harris view
39	0	yes	Xray:
40	1		CN: oblique view showed anteater sign
41	1		TC: lateral view showed C sign= subtalar and middle facet coalition, talus neck periosteal traction spur. Harris view may also show coalition
42	1		CT/ MRI to look for size and location of bony/ fibrous connection, r/o additional coalitions (5%)
43	0	yes	Treatment:
44	1		Conservative (if rigid flatfoot, arch support/ orthosis mold at current position to prevent deterioration eg UCBL) (walking cast boot) (temporary immobilization with casting)
45	1		OT: Resection of coalition vs fusion
46	0	yes	Myerson:
47	1		Traditionally 50% is regarded as a contraindication for resection. Most important aspect of treatment is to realign the foot and ankle regardless of fusion or resection
48	2		CN: excision via Olliers approach/sinus tarsi approach, EDB interposition +/- correct deformity and TA release
49	2		TC: bony union > 50% → fusion, <50% → excision + interposition (split FHL graft, fat)
50	3		Medial incision between FDL and PT
51	2		Salvage: triple arthrodesis + deformity correction in rigid FF for older patient + OA
52	0	yes	Indications for fusion:
53	1		1. Malalignment
54	1		2. >50%
55	1		3. Degen
56	1		4. Older
57	0		——
58	1		AD – high level of penetrance
59	1		NOG (Noggin) gene
60	1		Bilateral in 50%
61	1		Failure of mesenchymal segmentation
62	0	yes	Ddx for flatfoot:
63	1		Unilateral TDNNM
64	1		Post traumatic
65	1		Degenerative
66	1		Charcot (neuroinflammatory)
67	1		Neuromuscular (polio)
68	1		Bilateral IDNNM
69	1		Ligamentous laxity
70	1		RA (inflammatory)
71	1		Neuroinflammatory
72	1		Neuromuscular (spastic diplegic, spina bifida)
73	1		Both
74	1		Idiopathic
75	1		PTTD
76	1		Congenital vertical talus
77	1		Tarsal coalition
78	0	yes	What does peroneal spasm mean?
79	1		Peroneal spasm is a protective mechanism to reduce pain
80	1		If no peroneal spasm, you know subtalar joint is okay (Lui)
81	0	yes	Canadian army foot study
82	1		1/5 have flat foot
83	1		67% asx
84	1		25% sx with flexible flat foot + tight TA
85	1		8% sx with rigid (accessory navicular, tarsal coalition, congenital vertical talus)
86	1		Wagner JBJS 1989
87	1		Flexible flatfoot randomized to control, corrective shoes, Helfet heel cups, UCBL – improvement not related to orthosis. Increase laxity, more improvement.

036. Painful flatfoot onset in adolescence: Tarsal coalition

Clean FRCS notes with inline figures

Painful flatfoot onset in adolescence: Tarsal coalition

Clinical photograph

Diagnosis: pes planus

Causes of flatfoot in general:

Assessment:

Examination

- Anteater nose sign on oblique XR

Xray:

Treatment:

Myerson:

Indications for fusion:

Ddx for flatfoot:

What does peroneal spasm mean?

Canadian army foot study

Direct Q&A

Bilateral flatfoot with reduced medial foot arch

Hx: Onset of symptoms, site of pain, trauma, footwear

Exclude obvious syndromic or neurological causes

TC

Peroneal spasm is a protective mechanism to reduce pain

1/5 have flat foot

Raw speaker-note hierarchy audit

Improved semantic hierarchy used for the study notes