CASE REPORT
Isolated Navicular-Medial Cuneiform Tarsal
Coalition Revisited: A Case Report
James R. Ross, MD* and Matthew B. Dobbs, MD*wz
Abstract: Tarsal coalitions between the navicular and the
cuneiforms occur infrequently when compared with the more
common talocalcaneal and calcaneonavicular coalitions. Iso-
lated cases of navicular-medial cuneiform coalitions have only
rarely been reported; however, the diagnosis is likely under-
recognized. Conservative management should be pursued
initially for symptomatic patients, followed by surgical options
for unresponsive cases. The few reports available recommend
treatment with navicular-medial cuneiform fusions, but long-
term follow-up is not available to assess outcome and it remains
unclear whether an isolated arthrodesis of the navicular-medial
cuneiform joint will in turn lead to differing biomechanics of
adjacent joints. We report a case of a patient with an isolated
navicular-medial cuneiform coalition, treated with resection and
free-fat interposition rather than arthrodesis. To our knowledge,
this is the first case of a navicular-medial cuneiform coalition
reported in a patient of North American ancestry. At 2 years
postoperatively, she is pain-free with all activities and has full
range of motion of her ankle and subtalar joints, and full
mobility at the navicular-medial cuneiform joint. This unique
method provided a successful solution to this difficult situation.
Key Words: tarsal, coalition, fat interposition, navicular, medial
cuneiform
(J Pediatr Orthop 2011;31:e85–e88)
T arsal coalitions have previously been reported pre-
dominately in Western countries, with talocalcaneal
and calcaneonavicular coalitions being the most com-
mon.1–3 Coalitions between the navicular and the cunei-
forms, on the other hand, occur less frequently and most
commonly as part of more widespread tarsal anomalies.1
Isolated cases of navicular-medial cuneiform coalitions
have only rarely been reported, but the diagnosis is likely
underrecognized. Pain in the medial aspect of the midfoot
with corresponding limitation of motion should raise the
suspicion for such a coalition. The few reports available
From the *Department of Orthopaedic Surgery, Washington University
School of Medicine, Euclid Ave; wDepartment of Orthopaedic
Surgery, Washington University School of Medicine, One Children’s
Place; and zSaint Louis Shriners Hospital for Children, St Louis,
MO.
None of the authors received financial support for this study.
The authors declare no conflict of interest.
Reprints: James R. Ross, MD, Department of Orthopaedic Surgery,
Washington University School of Medicine, Campus Box 8233, 660 S.
Euclid Ave, St Louis, MO 63110. E-mail: rossj@wudosis.wustl.edu.
Copyright r 2011 by Lippincott Williams & Wilkins
J Pediatr Orthop ! Volume 31, Number 8, December 2011
recommend treatment with navicular-medial cuneiform
fusions but long-term follow-up is not available to assess
outcome.4–6 In addition, it remains unclear whether an
isolated arthrodesis of the navicular-medial cuneiform
joint will in turn lead to differing biomechanics of
adjacent joints, and thus an increased risk of arthritis.
We present the case of a patient with an isolated
navicular-medial cuneiform coalition, treated with resec-
tion and free-fat interposition rather than arthrodesis. To
our knowledge, this form of treatment has not previously
been presented for this type of coalition and this is the
first reported case of a navicular-medial cuneiform
coalition in a patient of North American ancestry. The
patients in previous case reports were of either Japanese
or Hispanic descent.4–7 The parents of the patient were
informed that data concerning the case would be
submitted for publication and they consented.
CASE REPORT
A 9-year-old white female, in otherwise good general
health, presented with a 6-month history of left foot pain. She
denied any history of trauma and was not able to specifically
recall the onset. The pain was localized to the medial-plantar
aspect of her midfoot. The pain was described as aching and
nonradiating in nature, and worsened with athletic activities,
specifically gymnastics and soccer. Six months of physical
therapy emphasizing stretching, ice therapy, and posterior tibial
strengthening, and 6 weeks of boot immobilization followed by
shoe inserts with medial arch support had not alleviated
her pain.
Physical examination revealed normal neurological and
vascular findings in the lower extremity. No dermatologic
abnormalities were noted. Her gait was notable for a tendency
to weight bear on the lateral border of the foot with callosities
over the fifth metatarsal head. She had tenderness to palpation
over the medial aspect of the navicular-medial cuneiform joint.
Ankle and subtalar motion was painless and full. There was
noted loss of flexibility in the medial midfoot and passive range
of motion of the midfoot reproduced pain that was localized to
the navicular-medial cuneiform joint.
Anteroposterior and lateral radiographs revealed a
narrowed navicular-medial cuneiform joint space with irregu-
larity and sclerosis suggestive of a synostosis (Fig. 1). Computed
tomography was performed to further analyze the joint
irregularity and define the tarsal anatomy (Fig. 2). This allowed
further characterization of a fibro-osseous coalition along the
plantar aspect of the navicular-medial cuneiform joint. Sclerosis
and cystic changes were seen along the margins of the bone at
the site of the coalition. Approximately 25% of the joint space
was estimated to be involved. No evidence of a calcaneonavi-
cular or subtalar coalition was appreciated.
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Ross and Dobbs
FIGURE 1. Anteroposterior and lateral radiographs revealing a narrowed navicular-medial cuneiform joint space with irregularity
and sclerosis, and suggestion of synostosis (arrowheads).
As the patient had failed a 6-month trial of physical therapy
and activity modification, surgical intervention consisting of a
coalition resection with fat interposition was recommended in an
attempt to restore motion in the involved joint and relieve pain.
Cast immobilization was not recommended, as the patient had
diligently worn an immobilizing boot for 6 weeks without relief.
The procedure was performed with the patient in the supine
position. A tourniquet was used with Esmarch exsanguination. A
longitudinal incision was made medially along the left navicular-
medial cuneiform joint. The joint capsule was incised and care was
FIGURE 2. Computed tomography revealing a fibro-osseous
coalition along the plantar aspect of the navicular-medial
cuneiform joint (arrowheads). Sclerosis and cystic changes
were seen along the margins of the bone at the site of the
coalition. Approximately 25% to one third of the joint space
was estimated to be involved.
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J Pediatr Orthop ! Volume 31, Number 8, December 2011
taken to create and preserve capsular flaps during the arthrotomy.
Intraoperative findings confirmed the presence of an intra-articular
bony coalition in the form of a synostosis (Fig. 3). It occupied
25% of the plantar and medial aspect of the joint. The coalition
was resected in its entirety allowing full restoration of joint
motion. A separate incision was made along the medial aspect of
the Achilles tendon to harvest a free fat graft. Once adequate graft
was obtained, the free fat was placed as an interposition
arthroplasty at the site of the resected coalition, followed by
closure of the joint capsule. A below-the-knee plaster cast was
applied, and the patient was made nonweight bearing for 2 weeks.
Two weeks after the operation, the cast was removed and
the patient was allowed to advance weight bearing as tolerated in
a short leg walking cast. The cast was removed 4 weeks after the
index procedure and the patient was encouraged to advance with
activities using a walking boot. Physical therapy was initiated on
an outpatient basis at that time focused on range of motion and
gait training. One month later, the patient was back to light
activities in gymnastics, such as cartwheels. At 2 years post-
operatively, she is pain-free with all activities. She clinically has
full range of motion of her ankle and subtalar joints, and full
mobility at the navicular-medial cuneiform joint, which is equal
to the contralateral foot. Radiographs were obtained at both
intervals, showing maintenance of the navicular-medial cuneiform
joint space, with complete resolution of the coalition (Fig. 4).
DISCUSSION
Over the last 50 years, there has been an increase in
the amount literature that has focused on the more
common calcaneonavicular, talocalcaneal, and talonavi-
cular coalitions. There have been, however, few reports
on coalitions between the navicular and medial cuneiform
and no reports in patients of North American ancestry. It
is interesting to note that 7 of the original 11 patients
previously presented,4,5 before the study by Kumai,8 were
of Japanese descent. Two of the remaining patients were
of Hispanic descent from Hawaii.6,7
Before 1996, only 8 reports of navicular-medial
cuneiform coalitions were documented, with a total of 17
feet in 11 patients.4–7 Of these cases that were surgically
managed, the coalition, either a synchondrosis or
synostosis, was noted to be intra-articular and occupy a
portion of the joint surface. Kumai et al in 19968 reported
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J Pediatr Orthop ! Volume 31, Number 8, December 2011 Isolated Navicular-Medial Cuneiform Coalition

FIGURE 3. A, Intraoperative findings confirmed the presence of the coalition (C) between the navicular (N) and medial cuneiform
(MC) that was seen on previous imaging modalities, in the form of a synostosis. B and C, A Freer elevator is placed into the
navicular-medial cuneiform joint, demonstrating the inability to fully traverse the joint. D, Placement of the autologous free fat
graft into the area of the resected coalition.

a subset of 125 patients (198 feet) who were seen for all
types of tarsal coalitions over a 15-year period at a single
institution. Patients ranged in age from 5 to 80 years with
a mean of 31.2 years. Forty patients, with a total of 60
feet, were noted to have navicular-medial cuneiform
coalitions, giving a relative incidence of 30.3%. Many of
these were not diagnosed until adulthood, as the mean
age of symptomatic patients was 31.9 years and only 11 of
60 coalitions were diagnosed in patients aged < 20 years.
Some were incidental findings (25%), which raise the
question that the prevalence of navicular-medial cunei-
form coalitions may indeed be higher than generally
thought. Diagnosis of this disorder in adolescents may be
overlooked due to a low index of suspicion on the part of
the physician. In addition, many cases may not become
symptomatic until adulthood when arthritic changes
develop in the joint with the coalition and adjacent joints
thought to be secondary to pathologic motion.9

FIGURE 4. Anteroposterior and lateral radiographs showing preservation of the navicular-medial cuneiform joint space, 2 years
after surgical excision and fat graft interposition.

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Ross and Dobbs
In previous reports, treatment consisted of con-
servative measures, fusion, or simple coalition excision.
No previous reports document any soft tissue interposi-
tion at the time of navicular-cuneiform coalition resec-
tion. It is generally accepted that all patients deserve a
trial of conservative treatment focused on attempts to
decrease motion of the painful joint in an attempt to
alleviate symptoms. Various shoe modifications and
orthotic devices, along with rest, reduced workload, and
anti-inflammatory medications are reasonable options to
pursue to try and accomplish this goal. There has not
been a specific prospective study investigating clinical
results of nonoperative management for navicular-medial
cuneiform coalitions, although some believe this line of
treatment to be rarely effective in providing long-term
relief in patients with other tarsal coalitions.10 In the
study by Kumai et al,8 approximately half of the
symptomatic patients that were treated conservatively
showed a reduction or disappearance of their symptoms.
Arthrodesis of the involved joint, with supplementation
of iliac bone graft, was the most common surgery
performed on patients who had failed conservative
measures (11 of 14 feet). Sixty-four percent of these
patients had excellent results, 18% had good results, and
9% had poor results with short-term follow-up.
Arthrodesis of the navicular-medial cuneiform joint is
generally thought to have no significant impact on gait or
foot function, which makes it an attractive form of
treatment for recalcitrant pain in this area. However, a
recent study demonstrates significant motion present in the
normal navicular-medial cuneiform joint both during daily
activities and with strenuous physical exertion.11 In this
biomechanical study by Arndt et al,11 1.6-mm pins were
inserted into the tibia, fibula, and various tarsal, and
metatarsal bones of 4 volunteers. A camera motion analysis
system was used to capture kinematic data during running.
Segmental motion was determined and individual joint
rotations were calculated. The medial cuneiform-navicular
joint did not have any clear dominance of rotation in a
single plane; however, did show to have appreciable
motion. The mean sagittal, frontal, and tranverse rotations
were 7.1, 8.1, and 4.1 degrees, respectively. This is not
insignificant when compared with the same rotations
measured of the talonavicular joint (6.5, 13.5, and 8.7
degrees), suggesting that there is perhaps more motion in
the navicular-medial cuneiform joint than previously
appreciated. It is not unreasonable to assume that this
joint motion plays a role in overall foot mobility and that
fusion of this joint may lead to altered biomechanics in the
remaining joints of the foot with resulting increased wear
and the development of arthritic changes and pain. With
this in mind, coalition resection, rather than arthrodesis, to
preserve motion at the navicular-medial cuneiform joint,
may be a better treatment option.
In the study by Kumai et al,8 21% of the patients
(3 of 14) who failed conservative treatment underwent
navicular-medial cuneiform coalition resection, with 66%
excellent and 33% good results. The age of these patients
were not identified and there was no mention of any
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J Pediatr Orthop ! Volume 31, Number 8, December 2011
augmentation or tissue interposition to prevent reforma-
tion of the coalition. The authors of this study noted easy
gross detection of coalition, which seemed to spare the
dorsal region of the joint, which was also confirmed on
histologic examination. Interestingly, the similar pathology
was also noted in our case in that plantar one fourth of the
navicular-medial cuneiform joint was involved. Previous
reports have shown that fat interposition arthroplasty can
be used with success for coalition resections in other areas
of the foot.12,13 We used a modification to previously
described procedures, in that we used a local, autogenous
free fat graft from the pre-Achilles fat pad, rather than
from the gluteal or abdominal region.
In summary, isolated navicular-medial cuneiform
coalition is a rare condition for which there is no
consensus regarding treatment recommendations. We
present a case of isolated, unilateral navicular-medial
cuneiform in a 9-year-old female of North American
ancestry that was treated with resection and autogenous,
free fat graft interposition that resulted in complete pain
relief and full return to activities with 2 years of follow-up.
One must have a heightened awareness for this diagnosis
in a patient that presents with pain in the medial aspect of
the midfoot with corresponding limitation of motion.
Conservative management should be pursued initially for
symptomatic patients, followed by surgical options for
unresponsive cases. As it has been shown from biomecha-
nical studies that significant motion is present in the
normal navicular-medial cuneiform joint,11 an attempt at
coalition resection and joint preservation over an arthrod-
esis should be considered when treating patients surgically.
REFERENCES
1. Chambers CH. Congenital anomalies of the tarsal navicular with
particular reference to calcaneo-navicular coalition. Br J Radiol.
1950;23:580–586.
2. Lapidus P. Congenital fusion of the bones of the foot with a report
of a case of congenital astragaloscaphoid fusion. J Bone Joint Surg.
1932;14:888–894.
3. Gregersen HN. Naviculocuneiform coalition. J Bone Joint Surg Am.
1977;59:128–130.
4. Miki T, Yamamuro T, Iida H, et al. Naviculo-cuneiform coalition: a
report of two cases. Clin Orthop Relat Res. 1985;196:256–259.
5. Wiles S, Palladino SJ, Stavosky JW. Naviculocuneiform coalition.
J Am Podiatr Med Assoc. 1988;78:355–360.
6. Hynes RA, Romash MM. Bilateral symmetrical synchondrosis of
navicular first cuneiform joint presenting as a lytic lesion. Foot
Ankle. 1987;8:164–168.
7. Green MR, Yanklowitz B. Asymptomatic naviculocuneiform
synostosis with a ganglion cyst. J Foot Surg. 1992;31:272–275.
8. Kumai T, Tanaka Y, Takakura Y, et al. Isolated first naviculocunei-
form joint coalition. Foot Ankle Int. 1996;17:635–640.
9. Conway JJ, Cowell HR. Tarsal coalition: clinical significance and
roentgenographic demonstration. Radiology. 1969;92:799–811.
10. Zaw H, Calder JD. Tarsal coalitions. Foot Ankle Clin. 2010;15:
349–364.
11. Arndt A, Wolf P, Nester C, et al. Intrinsic foot kinematics measured
in vivo during the stance phase of slow running. J Biomech.
2007;40:2672–2678.
12. Olney BW, Asher MA. Excision of symptomatic coalition of the middle
facet of the talocalcaneal joint. J Bone Joint Surg Am. 1987;69:539–544.
13. Mubarak SJ, Patel PN, Upasani VV, et al. Calcaneonavicular
coalition: treatment by excision and fat graft. J Pediatr Orthop.
2009;29:418–426.
r 2011 Lippincott Williams & Wilkins