John Flibotte, MS III
Gillian Lieberman, MD
May 2006
Evaluation of Pediatric Foot
Pain
John Flibotte, Harvard Medical School Year III
Gillian Lieberman, MD
John Flibotte, MS III
Gillian Lieberman, MD
Our Patient…
AP is a 10 year old boy with chronic R
foot pain
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John Flibotte, MS III
Gillian Lieberman, MD
Anatomy of the Foot
Manusov EG, et al. (1996), Part II
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John Flibotte, MS III
Gillian Lieberman, MD
DDX of Pediatric Foot Pain
Forefoot/ Midfoot
Foot Pain
Structural
Abnormality
•Overlapping/ Curly Toes
•Accessory Navicular
Infectious
•Osteomyelitis
Repetitive/
Acute Trauma
•Onychocryptosis
(Ingrown Nail)
•Hallux Valgus
•Turf Toe
Tumor/ Growth
•Bone Cysts
•Ewing’s Sarcoma
•Osteoid Osteoma
•Synovial Sarcoma
•Sesamoiditis
•Sesamoid Stress Fx
•Frieberg’s Disease (AVN
of second metatarsal
epiphysis)
•Stress Fracture
•Fracture
•Kohler’s Disease
(Ischemic Necrosis of
Navicular)
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John Flibotte, MS III
Gillian Lieberman, MD
DDX of Pediatric Foot Pain
Hindfoot Pain
Foot Pain
Structural
Abnormality
•Pes Planus (Flatfoot)
Infectious
•Osteomyelitis
•Flexible
•RigidÆ Tarsal
Coalition
•Os Trigonum Syndrome
Repetitive/
Acute Trauma
Tumor/ Growth
•Plantar Fasciitis
•Bone Cysts
•Calcaneal Apophysitis
(Sever’s Disease)
•Ewing’s Sarcoma
•Calcaneal Stress Fx
•Osteoid Osteoma
•Synovial Sarcoma
•Retrocalcaneal Bursitis
(Haghund’s Disease)
•Lisfranc Joint Sprain
•Ankle Sprain
•Osteochondritis
dessicans
•Fracture
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Manusov EG, et al. (1996), Parts I & II
John Flibotte, MS III
Gillian Lieberman, MD
Anatomy of the Calcaneus
http://education.yahoo.com/reference/gray/subjects/subject?id=63
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John Flibotte, MS III
Gillian Lieberman, MD
Anatomy of the Talus-1
Lateral View
Fibular Facet
Medial View
Tibial Facet
Navicular Facet
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http://www.maitrise-orthop.com/corpusmaitri/orthopaedic/mo80_laude/laude_us.shtml#1
John Flibotte, MS III
Gillian Lieberman, MD
Anatomy of the Talus-2
Inferior Aspect
Navicular Facet
Middle Articular Facet (for
sustentaculum tali)
Posterior Articular Facet
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http://www.maitrise-orthop.com/corpusmaitri/orthopaedic/mo80_laude/laude_us.shtml#1
John Flibotte, MS III
Gillian Lieberman, MD
Standard Views of the Foot
• Lateral
• Oblique
• Anteroposterior
----------------------------------------------------------One Special View: Harris Beath View
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John Flibotte, MS III
Gillian Lieberman, MD
Obtaining a Lateral View
http://www.latrobe.edu.au/podiatry/Radiology/patientpositioningxray.html
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John Flibotte, MS III
Gillian Lieberman, MD
Normal Lateral Radiograph of Foot
http://www.rad.washington.edu/RadAnat/FootLateral.html
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John Flibotte, MS III
Gillian Lieberman, MD
Normal Lateral Radiograph of Foot
http://www.rad.washington.edu/RadAnat/FootLateralLabelled.html
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John Flibotte, MS III
Gillian Lieberman, MD
Oblique Radiograph of Foot
http://www.latrobe.edu.au/podiatry/Radiology/patientpositioningxray.html
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John Flibotte, MS III
Gillian Lieberman, MD
Normal Oblique Radiograph of Foot
http://www.rad.washington.edu/RadAnat/FootOblique.html
http://www.rad.washington.edu/RadAnat/FootOblique 14
Labelled.html
John Flibotte, MS III
Gillian Lieberman, MD
AP View of the Foot
http://www.latrobe.edu.au/podiatry/Radiology/patientpositioningxray.html
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John Flibotte, MS III
Gillian Lieberman, MD
Normal AP Radiograph of the Foot
http://www.rad.washington.edu/RadAnat/FootAP.html
http://www.rad.washington.edu/RadAnat/FootAPLabelled.html 16
John Flibotte, MS III
Gillian Lieberman, MD
Obtaining the Harris Beath View
http://www.latrobe.edu.au/podiatry/Radiology/patientpositioningxray.html
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John Flibotte, MS III
Gillian Lieberman, MD
Our Patient’s Initial
Radiographs
John Flibotte, MS III
Gillian Lieberman, MD
Our Patient’s Lateral Views
Loss of Middle Facet Space
Narrowed Joint Space
Narrowed Joint Space
Loss of Foot Arch
Children’s Hospital Boston
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John Flibotte, MS III
Gillian Lieberman, MD
Our Patient’s Oblique Views
Normal
Appearance
Children’s Hospital Boston
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John Flibotte, MS III
Gillian Lieberman, MD
Patient’s Harris Beath Views
R
Loss of Talocalcaneal Joint
Space
Children’s Hospital Boston
L
Loss of Talocalcaneal Joint
Space
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John Flibotte, MS III
Gillian Lieberman, MD
Patient’s Coronal CT
Bilateral Bony Fusion
Children’s Hospital Boston
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John Flibotte, MS III
Gillian Lieberman, MD
Diagnosis:
Talocalcaneal coalition
John Flibotte, MS III
Gillian Lieberman, MD
Discussion of Coalition
• Results from abnormal differentiation and
segmentation of primitive mesenchyme with
resultant lack of joint formation
• Postulated autosomal dominant inheritance with
variable penetrance
• 50%-60% are Bilateral
• Prevalence 1-2%
• Can occur between any tarsal bone;
talocalcaneal and calcaneonavicular coalitions
are most common
Newman & Newberg (2000)
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John Flibotte, MS III
Gillian Lieberman, MD
Types of Coalition
• Osseous
• Fibrous
• Cartilaginous
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John Flibotte, MS III
Gillian Lieberman, MD
Pathogenesis of Coalition
Limitation of Normal Subtalar & Midfoot
Motion
Inflammation of Involved Joints
Irritation of Peroneal Tendon Crossing
Subtalar Joint
Peroneal Tendon Spasm
“Peroneal Spastic” Rigid Flatfoot
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Manusov EG, et al. (1996), Part II
John Flibotte, MS III
Gillian Lieberman, MD
Talocalcaneal Coalition-1
• Coalition between the talusÆ calcaneus
– Most commonly between middle facet of talus and
sustentaculum tali of calcaneus
• Represents 48% of all Tarsal Coalitions
• Typically become symptomatic in 8-12 y.o. children
• Imaging Modalities:
–
–
–
–
–
–
Difficult to see on standard views
May be suggested by loss of foot arch
Harris Beath View to demonstrate subtalar joint
May need fine-cut CT
May also be seen on MRI
If a bone scan is done, will show as area of increased uptake
Newman & Newberg (2000)
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John Flibotte, MS III
Gillian Lieberman, MD
Talocalcaneal Coalition-2
• Secondary Plain Film Signs:
–
–
–
–
–
Talar beak
Narrowing of the subtalar joint
Rounding of the lateral talar process
Lack of depiction of middle facets on lateral
C-sign
• Secondary Signs on CT:
– Talar beak
– Joint Narrowing
– Broadening and down-sloping of sustentaculum tali
Newman & Newberg (2000)
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John Flibotte, MS III
Gillian Lieberman, MD
Middle Facet on Lateral
• Short solid arrow:
middle facet
• Long solid arrow:
posterior facet
• Open arrow: lateral
process of talus
(anterior extent of
posterior facet)
• Normal= Open space
Companion Normal Case
Liu PT, et al. (2003)
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John Flibotte, MS III
Gillian Lieberman, MD
Absence of Middle Facet
• Curved arrow: talar
beak
• Long arrow: loss of
middle facet space
• Short arrows: C-sign
present
• Loss of posterior facet
space
Companion Coalition Patient Case
Liu PT, et al. (2003)
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John Flibotte, MS III
Gillian Lieberman, MD
Talar Beak
• Secondary to
impaired subtalar joint
motion
• Represents navicular
overriding the talus
• Periosteal elevation
occurs at site of
talonavicular ligament
• Osseous repair
results in talar beak
Companion Coalition Patient Case
Newman & Newberg (2000)
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John Flibotte, MS III
Gillian Lieberman, MD
C-Sign
• Results from bone
bridging between talar
dome and
sustentaculum tali
• Seen in osseous and
non-osseous coalition
• Varies based on
sustentaculum size
and orientation
Companion Coalition Patient Case
Newman & Newberg (2000)
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John Flibotte, MS III
Gillian Lieberman, MD
Another Patient with Coalition
9 year old girl with Chronic R foot
pain
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John Flibotte, MS III
Gillian Lieberman, MD
Our Patient 2 Bone Scan
Focal
Areas of
Increased
Tracer
Uptake
Children’s Hospital Boston
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John Flibotte, MS III
Gillian Lieberman, MD
Patient 2 Sagittal CT
R
L
Bony Fusion
Children’s Hospital Boston
Preserved Joint Space
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John Flibotte, MS III
Gillian Lieberman, MD
Calcaneonavicular Coalition
•
•
•
•
Coalition between calcaneusÆ navicular
Represents 43% of all Tarsal Coalitions
Typically become symptomatic in 12-16 yo children
Best Imaging Modality:
– Plain Film, 45 degree internal oblique
– May also be seen on CT, MRI, bone scan
• Ragiographic Signs:
– Bony Bar (seen with osseous coalition)
– Bones in close proximity, irregular surfaces, anteromedial
calcaneus is widened/ flattened (seen with fibrous or
cartilaginous coalition)
– Hypoplasia of the talus
– Anteater sign
Newman & Newberg (2000)
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John Flibotte, MS III
Gillian Lieberman, MD
“Anteater” Sign
Companion Coalition Patient Case
www.peeperandfriends.com
Newman & Newberg (2000)
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www.porpoiserecords.com
John Flibotte, MS III
Gillian Lieberman, MD
How did they come up with
that anteater sign?
John Flibotte, MS III
Gillian Lieberman, MD
“Anteater” Sign
Companion Coalition Patient Case
www.peeperandfriends.com
Newman & Newberg (2000)
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www.porpoiserecords.com
John Flibotte, MS III
Gillian Lieberman, MD
“Anteater” Sign
www.peeperandfriends.com
Newman & Newberg (2000)
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www.porpoiserecords.com
John Flibotte, MS III
Gillian Lieberman, MD
Performance of Secondary Signs
• The next slide shows the individual
performance of secondary signs evaluated
in a retrospective blinded study
• Table shows that individual stand alone
signs have a low sensitivity, but high
specificity
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John Flibotte, MS III
Gillian Lieberman, MD
Performance of Secondary Signs
42
Crim & Kjeldsberg (2004)
John Flibotte, MS III
Gillian Lieberman, MD
Combination of all Secondary Signs
• Evaluated both retrospectively and
prospectively by attending and resident
radiologists
• Results:
– Calcaneonavicular Coalition
• Attending (100% sens, 97% spec)
• Resident (80% sens, 98% spec)
– Talocalcaneal Coalition
• Sensitivity 100%
• Specificity 88%
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Crim & Kjeldsberg (2004)
John Flibotte, MS III
Gillian Lieberman, MD
Treatment
• Initially managed conservatively with
steroid injections, orthotics
• Surgery may be undertaken to separate
fused tarsal bones
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John Flibotte, MS III
Gillian Lieberman, MD
Conclusions
• Coalition is a frequent cause of pediatric foot
pain that may present in late childhood or early
adulthood
• There are many secondary signs of coalition that
can be seen on plain film radiographs
• The combination of multiple secondary signs is a
sensitive and specific way to screen for coalition
• CT & MRI may be needed to confirm existence
of coalition
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John Flibotte, MS III
Gillian Lieberman, MD
References
1.
2.
3.
4.
5.
6.
Newman JS, Newberg AH. “Congenital tarsal coalition: multimodality evaluation with emphasis
on CT and MR imaging.” Radiographics. 2000 Mar-Apr;20(2):321-32.
Liu PT, Roberts CC, Chivers FS, Kile TA, Claridge RJ, DeMartini JR, Kenrich RE, Freed LH.
"Absent middle facet": a sign on unenhanced radiography of subtalar joint coalition. AJR Am J
Roentgenol. 2003 Dec;181(6):1565-72.
Manusov EG, Lillegard WA, Raspa RF, Epperly TD.”Evaluation of pediatric foot problems: Part
I. The forefoot and the midfoot.” Am Fam Physician. 1996 Aug;54(2):592-606.
Manusov EG, Lillegard WA, Raspa RF, Epperly TD.”Evaluation of pediatric foot problems: Part
II. The hindfoot and the ankle.” Am Fam Physician. 1996 Sep 1;54(3):1012-26, 1031.
Crim JR, Kjeldsberg KM. “Radiographic diagnosis of tarsal coalition.” AJR Am J Roentgenol.
2004 Feb;182(2):323-8.
Websites:
http://education.yahoo.com/reference/gray/subjects/subject?id=63
http://www.maitrise-orthop.com/corpusmaitri/orthopaedic/mo80_laude/laude_us.shtml#1
http://www.latrobe.edu.au/podiatry/Radiology/patientpositioningxray.html
http://www.rad.washington.edu/RadAnat/FootLateral.htm
www.porpoiserecords.com
www.peeperandfriends.com
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John Flibotte, MS III
Gillian Lieberman, MD
Acknowledgements
With thanks to:
•
•
•
•
Muneeb Ahmed, MD
Larry Barbaras our Webmaster
Gillian Lieberman, MD
Pamela Lepkowski
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