Time to discuss a clinical topic Section

Stiff feet and ankles – NHS or Private?

ankle pain post

A condition called COALITION

A recent enquiry dropped into my post bag. A woman contacted me on behalf of her partner. There seemed to be some frustration as he had received an NHS consultation and wanted to consider private care. It was clear from the information that his health was not tip top but he also had a rarer condition called a coalition. This is far removed from any political group you may have heard of, although the bony bond leaves the foot, and generally the ankle, stiff.

Private or NHS?

There is a pretty straight forward rule as far as I am concerned and that is if you have to pay for something without insurance cover there maybe no endgame; the cheque book might be left open.  Coalition can be fixed but like many complex foot conditions there is no assurance all will work well. The NHS may be the better place if you have the right surgeon.

Given that the ankle has two joints (actually three but let’s keep it simple). The foot bone is connected to the leg bone around a joint up and down movement (talus), and the heel bone (calcaneus) being connected to the ankle bone (talus) providing sideways and spiral movements. The two taken together make sure we can walk on even ground safely and smoothly.

A joint should have a space, but with coalition that space is taken up by a bridge of bone crossing the space, preventing movement. The bridge of bone is also called a ‘bar’ and depending where it develops, the joint affected can stop important movement. When the ankle complex is affected it has a knock on effect back up the leg, so the knee, hip and back seem to be affected because the smooth transmission of movement stalls.

There are 2 main types of bar affecting the ankle; talo-calcaneal coalition or the calcaneo-navicular coalition. The first is more difficult of the two coalitions to treat as the ankle won’t move much from side to side, or will be painful during activity. The stiffening effect means the mechanical efficiency around the ankle is reduced. Not all foot surgeons treat this problem as surgery is complex and recovery can be longer than usual.

Diagnosis is important as all ages can be affected from teenage upwards. Computerised scanning is important either by CT or MR scans. Conservative treatment will depend on how stiff the ankle has become and if other problems co-exist.

While I no longer undertake surgery for this problem, I do not mind seeing patients but would not mislead patients that my consultation would lead to direct intervention. Your surgeon should be trained in this type of surgery, have extensive foot and ankle experience and ideally be a member of the British Orthopaedic Foot and Ankle Society. Currently few podiatric surgeons are offering such treatment in England so a specialist foot orthopaedic surgeon is best depending upon the area you work in.

Often the only way to resolve the bar is to remove it as in the calcaneo-navicular bar or coalition, or to make the joint stiff by surgical restriction (fusion) depending how affected the joint is. Ankle injections should probably have been offered before surgery. There is a case for special orthoses to be considered which may help, but  examination is important to work out if this has any benefit.


The best aim:


  • correct diagnosis – confirmed by special x-ray
  • conservative care – injection / orthosis
  • Assessment of medical conditions to consider risks
  • surgery: talo-calcaneal coalition (better resolution) or the calcaneo-navicular coalition (more complex) because ankle joint stiffens completely and fixation materials can be a problem



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