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The “Double Medial Malleolus”: A New Physical Finding in Talocalcaneal

Coalition

Article  in  Journal of Pediatric Orthopaedics · June 2016

DOI: 10.1097/BPO.0000000000000788

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 ORIGINAL ARTICLE
The “Double Medial Malleolus”: A New Physical Finding
in Talocalcaneal Coalition
Vanna Rocchi, DO,* Ming-Tung Huang, MD,w James D. Bomar, MPH,z
and Scott Mubarak, MDz
Purpose: It has been the observation of the senior author that
there is a bony fullness or “double medial malleolus” over the
middle facet as a consistent finding with most talocalcaneal
coalitions (TCC). To document this observation, we reviewed
records and radiographs in 3 patient groups.
Methods: Part 1: retrospective chart review was completed for
111 feet to determine the clinical presence of a palpable “double
medial malleolus.” Part 2: computed tomography (CT) scans for
evaluation of tarsal coalition or symptomatic flatfoot between
January 2006 and December 2014 were retrospectively reviewed
for the same cohort. Soft tissue thickness was measured as the
shortest distance between bone and skin surface at both the
medial malleolus and the middle facet/coalition. The volume of
the middle facet or coalition was measured at their midpoint.
These findings were compared among feet with TCC (n = 53),
calcaneonavicular coalition (CNC) (n = 20), and flatfoot
(n = 38).
Results: Part 1—clinical: from medical records, 38 feet (34%)
had documented record of a palpable medial prominence. Of the
feet reviewed with a “double medial malleolus,” all had TCC (no
false positives or false negatives). Clinical and CT prominence
demonstrated significant correlation (rs = 0.519, P = 0.001).
Part 2—radiographic: CT observation of “double medial
malleolus” is significantly associated with TCC (P < 0.001). CT
observation of double medial malleolus is 81% sensitive and
79% specific as a predictive test for TCC. The middle facet-to-
skin distance was significantly closer in those with TCC versus
controls (P < 0.001). The ratio was larger in patients with TCC
versus CNC (P = 0.006) or flatfeet (P < 0.001). Volume was
nearly twice the size in patients with TCC versus the controls
(P < 0.001).
Conclusions: TCCs have a bony prominence below the medial
malleolus on clinical exam and CT scan not present in flatfeet or
CNCs. This abnormal middle facet is almost twice the size of the
From the *Division of Orthopedic Surgery, Naval Medical Center San
Diego; zDivision of Orthopedic Surgery, Rady Children’s Hospital,
San Diego, CA; and wNational Cheng Kung University Hospital,
Tainan City, Taiwan, Republic of Taiwan.
This study was conducted at Rady Children’s Hospital, San Diego, CA.
None of the authors received financial support for this study.
The views expressed in this article are those of the authors and do not
reflect the official policy or position of the Department of the Navy,
Department of Defense, or the United States Government.
The authors declare no conflicts of interest.
Reprints: Scott Mubarak, MD, Division of Orthopedic Surgery, Rady
Children’s Hospital, 3030 Children’s Way, Suite 410, San Diego, CA
92123. E-mail: smubarak@rchsd.org.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop  Volume 00, Number 00, ’’ 2016
Copyright r 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
normal middle facet. Obesity or severe valgus may mask this
finding. If a palpable bony prominence is noted just below the
medial malleolus during examination of a painful foot with a
decrease in subtalar motion, the likely diagnosis is TCC. With
this added clinical finding, appropriate images can be ordered to
confirm the diagnosis of the latter. We advise CT scans with 3D
images for surgical planning. The primary finding for tarsal
coalitions in textbooks is decreased subtalar motion. This new
finding of a palpable enlarged medial prominence just below the
medial malleolus is highly associated with TCCs.
Level of Evidence: Level III.
Key Words: talocalcaneal coalition, double medial malleolus,
tarsal coalition
(J Pediatr Orthop 2016;00:000–000)
T alocalcaneal coalition (TCC) is among the most
common type of coalition, which is not infrequently
neglected.1–4 The modern diagnosis of TCC relies mainly
on imaging—radiographs, computed tomography (CT),
or MRI, with CT as the current gold standard for tarsal
coalition assessment.5 The clinical presentation and find-
ings, upon which physicians rely to make a diagnosis, are
limited in classic teaching. Commonly described signs of
TCC include decreased subtalar motion and pes
planovalgus deformity.4 In our experience, a bony prom-
inence plantar to the medial malleolus of the ankle has
been useful in finding patients with TCC. The purpose of
this study was to examine for the presence of the “double
medial malleolus” in patients with and without a TCC.
METHODS
After IRB approval, a list of 728 patients between
ages 5 and 19 was generated. All data in this study were
created between January 2006 and December 2014. In-
clusion criteria required patients to have symptomatic
flatfoot or tarsal coalition, who had obtained CT scans
for the evaluation of foot pain or stiffness. After our in-
clusion criteria were applied, 111 feet remained.
Part 1 of our study involved a retrospective chart
review to determine the clinical presence or absence of a
palpable “double medial malleolus.” Records reviewed
included preoperative history and physical, preoperative
progress notes, or the operative report. The double medial
malleolus was usually referred to as a tender prominence,
localizing distally to the medial malleolus. Often, the
www.pedorthopaedics.com | 1
Rocchi et al
operative report dictation revealed the incision was made
over a medial prominence. Many operative reports em-
phasized an incision over the TCC or the middle facet,
but these were only included if there was specific mention
of prominence or bump.
Part 2 involved critical retrospective evaluation of
CT scans. CT scans were evaluated and measurements
were obtained on various cuts. CT observation of a
“double medial malleolus” was made on all feet, and
judged prominence to be present or absent based on ap-
pearance of skin bulge seen on coronal imaging. Soft
tissue thickness was measured as the shortest distance
between bone and skin surface at both the medial mal-
leolus and the middle facet, or coalition on coronal slices,
demonstrated in Figure 1. The ratio of these measure-
ments was calculated. The depth of the middle facet or
coalition was measured at their midpoint. Vertical dis-
tance of the middle facet or coalition was identified as the
distance from the normal prominence of the medial talus
to the flexor hallucis longus groove. Length of the middle
facet or coalition was determined on sagittal imaging, at
its midpoint. All measurements were made on digital
radiographs using MergePACS measurement tools
(MergePACS 6.5.6; Merge Healthcare, Chicago, IL). A
total volume of the middle facet or coalition was then
calculated. These findings were compared among feet
with TCC (n = 53), calcaneonavicular coalition (CNC)
(n = 20), and flatfoot (n = 38). When observed, obesity
and valgus deformity were also reported. TCC types were
also separated into previously described groups.6 Com-
parisons were made among shingle, posterior, osseous,
and linear types.
We then correlated the documentation of clinical
prominence to the observation of a bump on advanced
imaging.
Basic descriptive statistics are reported. The
Shapiro-Wilk test of normality was used on all con-
tinuous data. Our data were found to be non-normally
distributed. The Kruskal-Wallis and the Mann-Whitney
tests were used to evaluate differences in continuous data
among our patient groupings. The w2 and Spearman
rho (rs) were used to evaluate differences in proportions
FIGURE 1. Radiographic evaluation: computed tomography measurements.
2 | www.pedorthopaedics.com
Copyright r 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Pediatr Orthop  Volume 00, Number 00, ’’ 2016
and correlations among categorical data. Statistical
significance was defined as P < 0.05. All statistical
analysis was conducted using SPSS (version 12; SPSS,
Chicago, IL).
RESULTS
Part 1 of our study investigated medical records
and found 38 feet (34%) that had documented record
of a palpable medial prominence. Thirty-two feet
were documented as having a palpable medial prom-
inence and 6 feet were documented as not having a
palpable medial prominence. Of the feet reviewed with a
“double medial malleolus,” all had TCC (no false pos-
itives or false negatives). Clinical and CT prominence
demonstrated significant correlation (rs = 0.519,
P = 0.001).
Part 2 evaluated the CT observation of a “double
medial malleolus” and found significant association with
TCC (P < 0.001). CT observation of double medial
malleolus is 81% sensitive and 79% specific as a pre-
dictive test for TCC.
There were 50 female and 61 male feet. Mean age
was 12.2 ± 2.6 with a range from 7.8 to 19 years old. The
distance from the medial malleolus to skin was sig-
nificantly less in females compared with males at
3.3 ± 2.6 mm versus 3.4 ± 0.9 mm (P < 0.001). This dif-
ference may appear small due to 1 female outlier
(16.4 mm). There was no statistical difference between
sexes with regard to middle facet-to-skin distance
(P = 0.392), ratio (P = 0.215), or volume (P = 0.101) in
patients with TCC.
When comparing coalition groups, we found that
the middle facet-to-skin distance measurement was sig-
nificantly less in those with TCC (mean: 8.2 ± 3.4 mm)
versus both CNC (mean: 11.4 ± 4.2 mm) and those
without coalition (mean: 10.2 ± 2.3 mm) (P < 0.001).
There was no significant difference between CNC and
those without coalition (P = 0.731).
The ratio comparing distance from skin-to-medial
malleolus and skin-to-middle facet was significantly larger in
patients with TCC (mean: 0.43 ± 0.16) versus CNC (mean:
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop  Volume 00, Number 00, ’’ 2016
FIGURE 2. Radiographic evaluation: Harris heel view. Left is normal with parallel joints. The right is a TC coalition, note that the
joints are no longer parallel and the middle facet is enlarged (white arrow).
0.33 ± 0.13) (P = 0.006) or none (mean: 0.32 ± 0.09)
(P < 0.001), indicating the middle facet is closer to the skin
surface. There was no significant difference between CNC
and those without coalition (P = 0.935).
The volume of the middle facet/coalition was cal-
culated to be almost twice as large in patients with TCC,
with average volume 6.7 ± 3.0 cm3 (95% CI, 5.9-7.5)
compared to CNC with average volume 3.7 ± 1.1 cm3
(95% CI, 3.2-4.2) or those without coalition 3.5 ± 1.2 cm3
(95% CI, 3.1-3.9) (P < 0.001). There was no statistical
difference identified in patients with CNC or those with-
out coalition (P = 0.561).
When evaluating differences among TCC types, we
found that posterior coalitions are more prominent than
the other types, with a skin-to-middle facet distance of
4.8 ± 1.5 mm, versus 7.7 ± 3.0 mm for osseous,
8.9 ± 2.9 mm for linear, and 10.1 ± 3.2 mm for shingle
types (Pr0.005). The ratio comparing distance from
skin-to-medial malleolus versus skin-to-middle facet/
coalition also found difference between TCC types.
Again, showing posterior coalitions as more prominent
(Pr0.001). Volume was statistically different between
groups with posterior coalitions being smaller than other
types. Mean posterior coalition volume was 4.2 ± 2.0 cm3
versus linear measuring 6.8 ± 3.0 cm3, osseous measuring
7.2 ± 2.5 cm3 and shingle-type measuring 8.2 ± 2.7 cm3
(Pr0.016).
DISCUSSION
Orthopaedic surgeons rely on physical exam findings
to help establish a diagnosis. To date, orthopaedic text-
books and journal articles document the primary clinical
finding for tarsal coalition to be decreased subtalar motion,
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
The Double Medial Malleolus
often in the setting of a symptomatic flatfoot.7–11 Whereas
valgus deformity is most commonly associated, varus de-
formity has also been described.12 Peroneal spasms are
occasionally present with TCC.10,11,13,14 Older review ar-
ticles make a brief mention of this submalleolar prom-
inence, but no studies to date have made a correlation with
imaging studies.8,11 No textbook specifically mentions a
submalleolar medial bony prominence.10,15–19
The physical exam of a painful foot, including
evaluation for and documentation of bony prominences,
may help establish a diagnosis before obtaining imaging
studies; however, they should be obtained for preoperative
planning. TCCs are hard to appreciate on standard
imaging and often appear normal.14,18 Standing lateral
views may suggest the finding, especially in the setting of
clinical suspicion. The C-sign is a reliable indicator of
TCC, which is seen when there is a confluence of the
subchondral bone of the talar dome with the posterior
edge of the middle facet coalition and the sustentaculum
tali.4,20–22 This was studied in detail by Moraleda and
colleagues. A complete C-sign is present in 14% of TCCs
and an even higher percent will have an incomplete C-sign,
but so will flexible flatfeet.20
Clinical suspicion must be present to obtain non-
standard radiographs that help diagnose a TCC, spe-
cifically, the Harris heel view.23 Harris views are
particularly useful for TCCs in that it can show the
abnormally enlarged relationship of the sustentaculum
tali to the adjacent talus facet22 with bridging of the
talocalcaneal joint (seen with osseous coalition).13
Harris views allow evaluation of the relationship be-
tween the subtalar joint and the middle facet and may
show a fusion.18 In normal feet, the joints appear par-
allel, whereas in feet with TCC, the middle facet is often
www.pedorthopaedics.com | 3
Rocchi et al J Pediatr Orthop  Volume 00, Number 00, ’’ 2016

FIGURE 3. A, Clinical evaluation—“Double medial malleolus”: black arrow indicates the medial malleolus, white arrow indicates
the submalleolar prominence. B, Clinical exam—Submalleolar prominence on lateral view: black arrow indicates the medial
malleolus, white arrow indicates the submalleolar prominence. C, 3D-CT highlighting talocalcaneal coalition

angled, and parallelism is lost23 (seen in Fig. 2). CT
studies may then be obtained to define the type and
extent of coalition to assist in preoperative planning for
TCC excision.
In our study, we found that TCCs have increased
bony prominence of the middle talocalcaneal facet below
the medial malleolus on clinical exam that is not present in
flexible flatfeet or CNCs. This finding was further sub-
stantiated by our CT studies. The abnormal middle facet
is almost twice the size of the normal middle facet and is
more prominent. Middle facet coalitions are reliably pal-
pable distal to the medial malleolus and are closer to the
skin than normal middle facets. Obesity or severe valgus
may mask this finding. Obesity increases the soft tissue
envelope, which decreases palpability of bony prom-
inences. Severe valgus directs the middle facet laterally,
away from the skin, increasing the skin-to-middle facet
distance, decreasing the ability to palpate bony prom-
inence. Posterior TCCs were shown to be more prominent
and easier to palpate than other types of TCCs. This may
be related to the location, as the volume was actually less
than other types in our study.
Limitations of this study include those inherent to all
retrospective reviews. Not all patients had a documented

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J Pediatr Orthop  Volume 00, Number 00, ’’ 2016
FIGURE 4. 3D-CT highlighting calcaneonavicular coalition.
record of our physical finding, so the sample size was
relatively small. Evaluation of CT scans was limited in
that the reviewer could see the absence or presence of a
coalition in each case; bias could have played a role in
observation of an overlying skin bump. In the future,
prospective evaluation of patients with foot pain doc-
umenting the physical exam findings of decreased subtalar
motion with the “double medial malleolus” and/or pal-
pable bump in the sinus tarsi combined with CT evalua-
tion will be helpful to confirm our physical exam
observation.
We feel that the findings of this study are most
relevant when applied to a physical assessment. There-
fore, when the orthopaedic surgeon examines a painful
foot, a careful evaluation of subtalar motion should be
performed with the foot positioned near neutral. In this
position the truncated talus is fixed in the ankle mortise.
If the physician notes a decrease in subtalar motion, the
next step is to palpate for bony prominences. A medial
bony prominence just below the medial malleolus (Fig. 3)
is suggestive of a TCC. If, however, there is a palpable
(often tender) bony ridge laterally in the distal sinus tarsi
a CNC is likely, often with limited plantarflexion24,25
(Fig. 4).
Following this clinical pathway, appropriate
standing AP and lateral films are useful to define the
coalition. We do advise CT scans with 3D reconstructed
images to define the size of the coalition, type, and for
surgical planning. Intraoperative CT scanning after the
resection of the TCC has been shown to alter surgical
decision making resulting in an improved ability to obtain
a complete resection.26
CONCLUSIONS
The primary finding for tarsal coalitions in text-
books is decreased subtalar motion. This new finding of a
palpable enlarged medial prominence just below the me-
dial malleolus is highly associated with TCCs.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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The Double Medial Malleolus
REFERENCES
1. Gantsoudes GD, Roocroft JH, Mubarak SJ. Treatment of
talocalcaneal coalitions. J Pediatr Orthop. 2012;32:301–307.
2. Kernbach KJ. Tarsal coalitions: etiology, diagnosis, imaging, and
stigmata. Clin Podiatr Med Surg. 2010;27:105–117.
3. Mahan ST, Spencer SA, Vezeridis PS, et al. Patient-reported
outcomes of tarsal coalitions treated with surgical excision.
J Pediatr Orthop. 2015;35:583–588.
4. Mosca VS. Subtalar coalition in pediatrics. Foot Ankle Clin.
2015;20:265–281.
5. Dare DM, Dodwell ER. Pediatric flatfoot: cause, epidemio-
logy, assessment, and treatment. Curr Opin Pediatr. 2014;26:93–100.
6. Rozansky A, Varley E, Moor M, et al. A radiologic classification of
talocalcaneal coalitions based on 3D reconstruction. J Child Orthop.
2010;4:129–135.
7. Cass AD, Camasta CA. A review of tarsal coalition and pes
planovalgus: clinical examination, diagnostic imaging, and surgical
planning. J Foot Ankle Surg. 2010;49:274–293.
8. Danielsson LG. Talo-calcaneal coalition treated with resection.
J Pediatr Orthop. 1987;7:513–517.
9. Khoshbin A, Law PW, Caspi L, et al. Long-term functional
outcomes of resected tarsal coalitions. Foot Ankle Int. 2013;34:
1370–1375.
10. Olney BW. Tarsal coalition. In: McCarthy JJ, Drennan JC, eds.
Drennan’s The Child’s Foot and Ankle. Philadelphia: Lippincott
Williams & Wilkins; 2009:160–173.
11. Wilde PH, Torode IP, Dickens DR, et al. Resection for symptomatic
talocalcaneal coalition. J Bone Joint Surg Br. 1994;76:797–801.
12. Stuecker RD, Bennett JT. Tarsal coalition presenting as a pes cavo-
varus deformity: report of three cases and review of the literature.
Foot Ankle. 1993;14:540–544.
13. Harris RI, Beath T. Etiology of peroneal spastic flat foot. J Bone
Joint Surg Br. 1948;30B:624–634.
14. Herzenberg JE, Goldner JL, Martinez S, et al. Computerized
tomography of talocalcaneal tarsal coalition: a clinical and anatomic
study. Foot Ankle. 1986;6:273–288.
15. Tachdjian MO. The foot and leg. In: Wickland EH, ed. Pediatric
Orthopedics Second Edition. Philadelphia: W. B. Saunders Com-
pany; 1990:2585–2592.
16. Canale ST, Beaty JH. The foot and leg. In: Canale ST, ed.
Campbell’s Operative Orthopedics, 11th ed. Philadelphia: Mosby
Elsevier; 2008:4606–4619.
17. Weinstein SL, Flynn JM. The foot. In: Weinstein SL, Flynn JM, eds.
Lovell and Winter’s Pediatric Orthopaedics, 7th ed. Philadelphia:
Lippincott Williams & Wilkins; 2013:1505–1509.
18. Staheli LT. Foot/tarsal coalition. In: Staheli L, ed. Fundamentals of
Pediatric Orthopedics, 4th ed. Philadelphia: Lippincott Williams &
Wilkins; 2007:179.
19. Mosca VS. Talocalcaneal tarsal coalition. In: Mosca V, ed.
Principles and Management of Pediatric Foot and Ankle Deformities
and Malformations. Philadelphia, PA: Wolters Kluwer; 2014:
101–104.
20. Moraleda L, Gantsoudes GD, Mubarak SJ. C sign: talocalcaneal
coalition or flatfoot deformity? J Pediatr Orthop. 2014;34:814–819.
21. Sakellariou A, Sallomi D, Janzen DL, et al. Talocalcaneal coalition.
Diagnosis with the C-sign on lateral radiographs of the ankle.
J Bone Joint Surg Br. 2000;82:574–578.
22. Crim J. Imaging of tarsal coalition. Radiol Clin North Am. 2008;
46:1017–1026. vi.
23. Kulik SA, Clanton TO. Tarsal coalition. Foot Ankle Int. 1996;
17:286–296.
24. Mubarak SJ, Patel PN, Upasani VV, et al. Calcaneonavicular
coalition: treatment by excision and fat graft. J Pediatr Orthop.
2009;29:418–426.
25. Upasani VV, Chambers RC, Mubarak SJ. Analysis of calcaneona-
vicular coalitions using multi-planar three-dimensional computed
tomography. J Child Orthop. 2008;2:301–307.
26. Kemppainen J, Pennock AT, Roocroft JH, et al. The use of
a portable CT scanner for the intraoperative assessment of
talocalcaneal coalition resections. J Pediatr Orthop. 2014;34:
559–564.
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