[Coalition 18] Drunken Waiter Sign: Classic Indicator of Middle Facet Coalition

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The drunken waiter sign (also called the dysmorphic sustentaculum tali sign) is a hallmark imaging feature of a middle facet talocalcaneal coalition.

Normal appearance

• On coronal CT/MRI, the middle facet is oriented upward or horizontal.
  
  
• The sustentaculum tali is rectangular and brick-shaped on radiographs.
  
  

Abnormal appearance

• With coalition, the sustentaculum tali becomes dysmorphic.
  
  
• The middle facet shows a broad, downward medial slope rather than the normal horizontal orientation.
  
  
• This abnormal tilt produces the characteristic “drunken waiter” look—like a waiter struggling to hold a tray.
  
  

Clinical & imaging relevance

• Strongly associated with cartilaginous middle facet coalitions.
  
  
• Frequently accompanied by bone marrow edema, cystic change, and irregular subchondral margins at the coalition site.
  
  
• Serves as an important indirect imaging sign, prompting further evaluation with CT or MRI.
  
  

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