summary Calcaneovalgus Foot is a common acquired condition caused by intrauterine "packaging" seen in neonates that presents as a benign soft tissue contracture deformity of the foot characterized by hindfoot eversion and dorsiflexion. Diagnosis is made clinically with a calcaneovalgus foot deformity without congenital deformity or dislocation. Treatment is usually observation with passive stretching and possible casting as the condition resolves spontaneously in 3-6 months. Epidemiology Incidence mild form can occur in up to 40% of newborns estimated incidence of true deformity is 1 in 1,000 live births Demographics more common in females and first-born children Etiology Pathophysiology usually a positional deformity of the foot caused by intrauterine "packaging" Presentation Physical exam excessively dorsiflexed hindfoot that is passively correctable dorsal surface of foot can rest on anterior tibia looks similar to vertical talus differs on exam in that vertical talus has a rigid hindfoot equinus/valgus and rigid dorsiflexion through midfoot vertical talus also has mid-foot valgus, with a medial prominant talar head. Imaging Radiographs AP and lateral tibia used to determine presence of posteromedial bowing plantar flexion lateral radiographs useful to differentiate from congenital vertical talus if foot is sufficiently flexible to rule out congenital vertical talus, no radiographs are required before ossification of navicular at age 3, the first metatarsal is used as a proxy for the navicular on radiographic evaluation calcaneovalgus foot first metatarsal will line up with talus vertical talus the axis of the talus passes plantar to the 1st metatarsal (and navicular if visible yet) on both standard lateral and plantar flexion lateral radiographs Differential Conditions that should be differentiated posteromedial tibial bowing posteromedial bowing of the tibia is almost alway accompanied by some degree of calcaneovalgus foot deformity with the calcaneovalgus foot, apex of the deformity is at the ankle joint with posteromedial bowing of the tibia, apex is at the distal tibia congenital vertical talus (CVT) appears similar to calcaneovalgus foot clinically with CVT, the hindfoot is in equinus hindfoot is in calcaneus (dorsiflexion) in a calcaneovalgus foot with CVT, there is a midfoot dislocation through the talonavicular joint CVT is a rigid deformity calcaneovalgus is a flexible deformity paralytic foot deformity deformity is caused by spasticity of foot dorsiflexors (L4 and L5)/evertors (S1) weakness of plantar flexors (S1 and S2) /inverters (L5) this muscle imbalance can be caused by an L5 spinal bifida leading to a calcaneovalgus deformity Treatment Nonoperative observation & passive stretching exercises indications if foot can be plantar-flexed beyond neutral technique resolution may be expedited by stretching performed by parents outcomes typically resolves spontaneously by 3-6 months casting indications if foot cannot be plantar-flexed beyond neutral outcomes severity of initial deformity has no relation to final outcome Complications Leg Length Discrepancy LLD a possible sequela when calcaneovalgus foot is associated with posteromedial bowing of the tibia the most common surgery needed for posterior medial bowing is to address the LLD Flexible flatfoot deformity occurs several years after the resolution of the foot deformity