Bilateral Os Subtibiale and Talocalcaneal Coalitions in a College Soccer Player:

A Case Report
Joseph M. Bellapianta, MD
1
, James R. Andrews, MD
2
, Roger V. Ostrander, MD
2
1
Orthopaedic Surgeon, Plancher Orthopaedics and Sports Medicine, Cos Cob, CT
2
Orthopaedic Surgeon, The Andrews Institute, Gulf Breeze, FL
a r t i c l e i n f o
Level of Clinical Evidence: 4
Keywords:
ankle
fracture
impingement
subtalar motion
a b s t r a c t
An os subtibiale is an accessory bone separated from the distal medial tibia proper. Subtalar tarsal coalition is
a failure of joint formation between the talus and calcaneus during hindfoot maturation. The patient in this
case report has large bilateral os subtibiale and subtalar coalitions, which were undiagnosed throughout his
soccer career until recently when he began having anteriorlateral ankle pain. After failing conservative treat-
ment the patient underwent ankle arthroscopy, which revealed a fully separated, large articular portion of the
medial malleolus. The hypertrophic synovium and cartilage were debrided and the patient had a full recovery,
returning to soccer 8 weeks after surgery. Os subtibiale is a rare but well-described entity in the radiology and
orthopaedic liturature. To our knowledge, bilateral os subtibiale this large has not been described. In addition,
an os subtibiale with concomitant subtalar coalition has never been reported. This report will hopefully alert
clinicians about these 2 rare anatomic ndings and encourage them to use caution when evaluating suspected
fractures of the medial malleolus that could be functional os subtibiale ossicles. In addition, we hope to shed
some light on the complicated coupling of motion between the ankle and subtalar joint. These may have
developed together to allow more normal coupled motion between the ankle and subtalar joint in this high-
level college soccer player, and may be relevant to future reports or research in this area.
2011 by the American College of Foot and Ankle Surgeons. All rights reserved.
Os subtibiale is a rare, normal variant of the medial malleolus
where an articulating portion of the medial malleolus is a free-
oating ossicle of bone. The os subtibiale can vary in size and is
thought to be a failure of fusion of a secondary growth center. It was
rst described by Ptzner in 1896 (1) and has since been described in
isolated reports, including the ossicle being mistaken for a fracture
(26). The incidence of os subtibiale varies in the literature from
0.001% to 1.2% (7, 8).
Subtalar tarsal coalition is a failure of joint formation between the
talus and calcaneous during hindfoot maturation. Talocalcaneal coa-
lition is believed to be present in less than 1% of the general pop-
ulation with bilaterality occurring in roughly 22% to 60% of patients
(9). The actual prevalence may be much higher. The coalition
between tarsal bones can be composed of bone, cartilage, or brous
tissue (10). Decreased motion at this joint can lead to increased
motion at the surrounding joints and their supportive ligaments,
resulting in frequent ankle sprains as a common presenting symptom.
In the following case report, we present a case of the large bilateral
os subtibiale with concomitant bilateral subtalar tarsal coalition
identied in a high-level collegiate soccer player. These rare anatomic
ndings have only previously been described together in 1 report of
pediatric ball-and-socket ankle deformities. To our knowledge, these
are also the largest os subtibiale described in the literature.
Case Report
A 20-year-old man who progressed through elementary school,
high school, and 2 years of college soccer essentially asymptomatic
presented to our ofce with left anterolateral ankle pain. Symptoms
began approximately 6 months previously. He reported a vague
recollection of an ankle sprain in high school and was recently told
that he had a fracture of his ankle that did not heal.
On physical examination, the patients feet were normal appearing
without swelling, scars, or deformity. The forefoot and midfoot
examination was normal with good peroneal, anterior tibialis, and
posterior tibialis function bilaterally.
He had slightly prominent medial malleoli bilaterally. Upon repeat
examination of left medial malleolus, the ossicle was mobile and
clearly separate from the tibia proper. There was no discomfort with
palpation or mobilization of this ossicle. He did have pain with
Financial Disclosure: None reported.
Conict of Interest: None reported.
Address correspondence to: Joseph M. Bellapianta, MD, Orthopaedic Surgeon,
Plancher Orthopaedics and Sports Medicine, 31 River Road, Cos Cob, CT 06907.
E-mail address: Bellapianta1@gmail.com (J.M. Bellapianta).
1067-2516/$ - see front matter 2011 by the American College of Foot and Ankle Surgeons. All rights reserved.
doi:10.1053/j.jfas.2011.03.016
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery
j ournal homepage: www. j f as. org
The Journal of Foot & Ankle Surgery 50 (2011) 462465
Fig. 1. Lateral radiograph of the left ankle. Arrows show the C sign.
Fig. 2. Anterior to posterior radiograph of the left ankle. The arrow shows the os subtibiale.
Fig. 3. Mortise radiograph of the left ankle. The arrow shows the os subtibiale.
Fig. 4. Valgus stress radiographof theleft ankledemonstratingnormal medial anklestability.
J.M. Bellapianta et al. / The Journal of Foot & Ankle Surgery 50 (2011) 462465 463
palpation over the anterior talobular ligament and anterolateral
joint line. On examination of the right medial malleolus, the ossicle
was nontender, and no motion was appreciated. Normal ankle motion
was observed bilaterally; however, there was no subtalar motion
appreciated bilaterally.
Radiographs showed a C sign on the lateral viewof the hindfoot,
which is a C-shaped line formed by the medial outline of the talar
dome and the inferior outline of the sustentaculum tali (11). This is
suggestive of a subtalar coalition (Figure 1). Anteroposterior and
mortise views showed an unfused os subtibiale (Figures 2 and 3). A
stress view of the symptomatic left ankle showed a stable medial
ankle joint (Figure 4).
Computed tomography (CT) scans showed 50% bony and brous
fusion of bilateral subtalar joints involving predominantly the ante-
rior and middle facets (Figures 5 and 6) as well as clear views of
bilateral os subtibiale (Figures 7 and 8A and B). CT reconstructions are
shown in Figures 9A and B. By CT scan measurements, the right and
left os subtibiale ossicles were 20 14 mm, and 18 14 mm,
respectively.
The patient had conservative treatment for 6 months consisting of
several periods of rest, anti-inammatory medication, intermittent
ice, and stretching/strengthening with no consistent relief of his pain.
After failure of conservative treatment, the patient was taken to the
operating room for left ankle arthroscopy. The patient had anterior
debridement of hypertrophic synovium on the anterior capsule and
also in the space between the ossicle and the tibia proper. Minimal
cartilage debridement was also done in addition to debulking of an
anterolateral tibial bossing. This was felt to be more prominent
arthroscopically than on his lateral ankle x-ray. Arthroscopic pictures
are shown in Figure 10A and B. Eight weeks after his arthroscopic
debridement he was able to return as the starting forward for his
college soccer team.
Discussion
The os subtibiale in this case report are large, well-rounded acces-
sory bones separated fromthe medial tibia proper. The case presented
here is one of a high-level collegiate soccer player with both large os
subtibiale and rigid talocalcaneal coalitions. These 2 entities have not
been described together in this context. The association of a ball-and-
socket ankle joint has been described in the pediatric population
associated with os subtibiale and talocalcaneal coalition (12).
Various bony elements at the medial subtibial region have been
described and include accessory ossication centers, avulsion frac-
tures, and posttraumatic ossication (6). Calcications in the deltoid
ligament secondary to repetitive microtrauma are common in
Fig. 5. Axial CT images of bilateral ankles. The arrow highlights the talocalcaneal
coalitions.
Fig. 6. Coronal CT images of bilateral ankles. The arrow highlights the talocalcaneal
coalitions.
Fig. 8. Sagital CT scans of left (A) and right (B) ankles at the level of the os subtibial.
Arrows show the ossicles separated from the tibia proper.
Fig. 7. Coronal CT images of bilateral ankles at the level of the os subtibiale. Arrows show
the large ossicles articulating with the talus.
J.M. Bellapianta et al. / The Journal of Foot & Ankle Surgery 50 (2011) 462465 464
patients with a history of multiple ankle sprains. All os subtibiale
ossicles found during our literature search are much smaller, with
presumably less contribution to the talar articulation and function of
the ankle joint. Secondary ossication centers of the medial malleolus
are common in children (47% in girls, 17% in boys). They usually appear
in the eighth to ninth years and fuse by approximately age 11 (13).
It would be purely speculative to assume that one of these entities
led to the formation of the other, but perhaps this patients ability to
compensate for so long was because of the os subtibial. The varus and
valgus motion needed to compete on the soccer eld, which was lost
by the coalition, may have been made up for by the additional point of
articulation in his ankle between the os and the tibia proper. There is
a tightly coupled motion of these 2 joints around the talus, allowing
multiple degrees of freedom of motion (14). Perhaps the increased
inversion/eversion motion at the level of the ankle caused abnormal
forces anteriorlaterally, leading to the pain and wear seen
arthroscopically.
We have discussed with the patient the need for possible future
surgery. Given his limited condromalacia and his ability to function at
a high level for so long, we felt a less aggressive arthroscopic
debridement would be a reasonable rst line of surgical treatment.
References
1. Ptzner W. Die variationen im aufbau des fussskelets. Morphol Arb VI:245, 1896.
2. Lapidus PW. Os subtibiale. Inconsistent bone over the tip of the medial malleolus. J
Bone Joint Surg Am 15:766771, 1933.
3. Coral A. Os subtibiale mistaken for a recent fracture. Br Med J 292:15711572,
1986.
4. Bircher E. Neue falle von varietaten der handwurzel und des fubgelenkes. A) Os
trigonum traumaticum? B) Os subtibiale. Fortschr Rontgenstrahlen 26:8593,
1918.
5. Madhuri V, Poonnoose PM, Lurstep W. Accessory os subtibiale: a case report of
misdiagnosed fracture. Foot Ankle Online J 2(6):3, 2009.
6. Trolle D. De to accessoriske knogler: os subtibiale og os subbulare I relation til
diagnosen af malleolaer fracturer. Nord Med 25:247249, 1945.
7. Coral A. The radiology of skeletal elements in the subtibial region: incidence and
signicance. Skeletal Radiol 16(4):298303, 1987.
8. Stormont DM, Peterson HA. The relative incidence of tarsal coalition. Clin Orthop
181:2836, 1983.
9. Tsuruta T, Shiokawa Y, Van Ghillewe KV, Gryspeerdt SS, Baert AL, Dereymaeker GE.
Radiological study of the accessory skeletal elements in the foot and ankle. Nippon
Seikeigeka Gakkai Zasshi 55(4):357370, 1981.
10. Kent V. Tarsal coalition and painful atfoot. J Am Acad Orthop Surg 6(5):274281,
1998.
11. Lateur LM, Van Hoe LR, et al. Subtalar coalition: diagnosis with the C sign on lateral
radiographs of the ankle. Radiology 193(3):847851, 1994.
12. Takakura Y, Tanaka Y, Kumai T, Sugimoto K. Development of the ball-and-socket
ankle as assessed by radiograph and arthrography. J Bone Joint Surg (Br)
81(6):10011104, 1999.
13. Ogden JA, McCarthy SM. Radiology of post natal skeletal development. VIII. Distal
tibia and bula. Skeletal Radiol 10(4):209220, 1983.
14. Leardini A, Stagni R, OConnor JJ. Mobility of the subtalar joint in the intact ankle
complex. J Biomechanics 34(6):805809, 2001.
Fig. 10. Arthroscopic images captured during surgery. (A) Looking from the anteriorlateral
portal across the anterior ankle without distraction. The os subtibiale can be seen in the
distance. The arrow is pointing to the chondromalasia of the anteriorlateral talus. (B) A
closer look from the same portal with distraction and plantarexion of the ankle. The X
is on the os subtibiale.
Fig. 9. Three-dimensional reconstructions of the CT scan. Arrow in A shows the right os
subtibiale from posteriormedially. Arrows in B show the right and left ossicle respectively.
J.M. Bellapianta et al. / The Journal of Foot & Ankle Surgery 50 (2011) 462465 465