summary Foot Conditions are the most common deformity seen in Cerebral Palsy which are caused by lower extremity spasticity and can take several forms including equinus, hallux valgus, equinocavovarus, and equinoplanovalgus. Diagnosis is made clinically with presence of spasticity/contracture of the gastrocsoleus complex in equinus, presence of a spastic hallux valgus, and supination deformities of the midfoot and forefoot. Treatment is usually bracing and shoe modifications for mild and flexible conditions. Surgical management is indicated for progressive deformities that are not amenable to bracing. Etiology See Cerebral Palsy General Foot deformities are common in cerebral palsy and may take several forms including Equinus Hallux Valgus EquinoPlanoValgus EquinoCavovarus Equinus Epidemiology most common deformity in cerebral palsy Pathophysiology imbalance of ankle dorsiflexors and plantarflexors, resulting in plantar flexion of the hindfoot relative to the ankle, with normal mid- and forefoot alignment spasticity/contracture of the gastrocsoleus complex Presentation symptoms shoe fitting / wear and tear tripping secondary to poor foot clearance instability due to decreased base of support physical exam inspection forefoot callosities toe walking or absent heel strike during gait compensatory hyperextended knee with heel contact equinoplanovalgus in late stages motion evaluate degree of spacticity and total motion provacative tests Silfverskiold test improved ankle dorsiflexion with knee flexed = gastrocnemius tightness equivalent ankle dorsiflexion with knee flexion and extension= achilles tightness Imaging radiographs not required unless other pathology present (hindfoot malalignment) Treatment nonoperative serial manipulation and casting indications mild spasticity, dynamic, younger patients botulinum toxin A intramuscular injection into gastrocnemius indications mild spasticity, may delay need for surgery mechanism of action blocks presynaptic release of acetylcholine articulated or hinged AFO indications mild and passively correctible deformity with mild spasticity and no myostatic contractures. contraindication presence of excessive ankle dorsiflexion in midstance solid AFO indications mild to moderate foot deformities that are partially correctible with mild to moderate spasticity and with mild myostatic contractures contraindications excessive ankle dorsiflexion during midstance in heavy patients, >=12 years of age and significant rigid foot malalignment operative tendo-Achilles lengthening (TAL) versus gastrocnemius recession indications rarely indicated as an isolated procedure, except in hemiplegia TAL if Silfverskiöld test shows gastrocsoleus complex tightness gastrocnemius recession if Silfverskiöld test shows isolated gastrocnemius tightness Techniques Gastrocnemius recession approach posterior or posterior medial calf incision soft tissue dissect through subcutaneous tissues, identify sural nerve and retract from field dorsiflex foot and palpate aponeurosis incise fascia trasnversely or in U-fashion, should see noticable increase in foot dorsiflexion fascia may be sutured to underlying soleus muscle, sutured side-to-side, or left free immobilize with cast in neutral dorsiflexion outcomes requires less immobilization but higher recurrence rate compared to TAL Tendo-Achilles lengthening (TAL) approach percutaneous or open posterior longitudnal incision over Achilles tenodn soft tissue dissect through subcutaneous tissues avoiding neurovascular structures, identify tendon perform tenotomies in slide or z-lengthening fashion with foot dorsiflexed should see noticable increase in foot dorsiflexion immobilze in walking cast for 4-6 weeks Hallux Valgus Epidemiology most common in diplegics with equinus and planovalgus feet associated with equinovalgus and external tibial torsion Pathophysiology caused by combination of adductor hallucis overactivity and externally applied forces, such as inadequate clearance resulting from equinovalgus deformity, forcing the great toe into valgus. Presentation symptoms pain and difficulty wearing proper shoes physical exam inspection hallux lies underneath 2nd toe painful bunion/callosity over 1st MT head Imaging radiographs recommend views standard weight-bearing series findings increased HVA, IMA, DMMA, HVI Treatment nonoperative observation indications no pain or difficulty with footwear operative first metatarsophalangeal joint arthrodesis indications painful hallux valgus outcomes highest overall success rate compared to other surgeries in ambulatory and nonambulatory children with cerebral palsy recurrence rate is unacceptably high with the other procedures proximal phalanx (Akin) osteotomy indications hallux valgus with associated valgus interphalangeus Techniques EquinoPlanoValgus Epidemiology incidence common foot deformity seen with cerebral palsy (spastic diplegic and quadriplegic) location typically bilateral Pathophysiology equinus with pronation deformity pathomechanics due to comination of spastic peroneal muscles, weak posterior tibialis, spastic heel cord in ligamentous laxity foot creates lever arm dysfunction during gait leads to bearing weight on the medial border of the foot and talar head external rotation of the foot creates instability during push off Presentation symptoms painful callus over talar head secondary to weight-bearing shoe wear problems physical exam inspection typically bilaterally valgus heel deformity seen when viewing feet from posterior prominent talar head appreciated in the arch midfoot break occurs in attempt to keep foot plantigrade hallux valgus typically develops over time motion the hindfoot valgus deformity must be manually corrected first before testing for achilles contracture a valgus heel can mask an equinus contracture by allowing a shortened path for the achilles Imaging Radiographs recommended views weight-bearing AP radiographs of the ankles must be obtained to rule out ankle valgus as cause of deformity findings decrease in the calcaneal pitch negative talo-first metatarsal angle on lateral view uncovering of talar head Treatment Nonoperative bracing indications flexible deformities Operative bony and soft tissue procedures indications pain or pressure sores despite bracing soft tissue procedures tendo-Achilles lengthening peroneus brevis lengthening posterior tibial tendon advancement bony procedures calcaneal osteotomy lateral column lengthening (Evans procedure) Grice procedure subtalar arthroereisis Techniques calcaneal osteotomy and lateral lengthening approach incision along lateral border of calcaneus, avoiding sural nerve bone work medial slide osteotomy- oblique cut through calcaneus with posterior fragment slid medially and into varus lateral column lengthening- trasnverse osteotomy anterior to middle facet, trapezoidal bone graft interposed instrumentation percutaneous k-wires, cannulated screws or laterally-placed plate complications destabilized calcaneocuboid joint if accessed during lengthening Grice procedure approach sinus tarsi approach soft tissue fatty tissue removed sinus tarsi without violating joint capsule bone work calcaneus decorticated, joint manipulated into varus bone autograft sized and placed into graft bed, soft tissued sutured to hold graft in place outcomes does not interfere with tarsal bone growth subtalar arthroereisis approach lateral approach to subtalar joint bone work place polyethylene plug or staple laterally in subtalar joint outcomes stabilizes subtalar joint in correct alignment without fusion complications plug breakdown Complications overcorrection into varus most common complication sural nerve injury at risk during calcaneal osteotomy procedures overlengthening of lateral column results in a painful lateral forefoot secondary to overload EquinoCavoVarus Epidemiology more common in spastic hemiplegia Pathophysiology equinus deformity of the hindfoot coupled with supination deformities of the midfoot and forefoot pathomechanics invertors (posterior tibialis and/or anterior tibial tendons) overpower evertors (peroneal tendons) creates lever arm dysfunction during gait disrupts the second rocker by blocking ankle dorsiflexion and compromises stability function in midstance shortens the length of the plantar flexor muscles, compromising their ability to generate tension Presentation symptoms painful weight-bearing shoe wear issues physical exam inspection equinus contracture callosities on lateral border of foot and 5th metatarsal motion internal foot progression angle during gait foot drop if weakened tibial anterior supinated foot position during tibialis anterior activation (indicates main source of equinovarus) Imaging radiographs recommended views weight-bearing foot and ankle series findings metatarsal overlap increased calcaneal pitch Treatment nonoperative bracing indications supple deformity rarely successful and often worsens calluses and blisters operative soft tissue balancing tendo-Achilles lengthening and posterior tibial tendon muscular lengthening indications done in combination with SPLATT to address fixed equinus contracture split posterior tibial tendon transfer (SPOTT) indications passively correctable deformity between ages of 4 and 7 years split anterior tibialis tendon transfer (SPLATT) indications passively correctable deformity with spastic tibialis anterior muscle contraindications weak tibialis anterior and footdrop bony procedures calcaneal osteotomy indications done in combination with soft tissue balancing fixed varus hindfoot deformity arthrodesis indications done in combination with soft tissue balancing severe fixed deformity Technique split posterior tibial tendon transfer (SPOTT) approach medial 1- or 2-incisions centered over PT tendon at ankle, tendon sheath opened but flexor retinaculum not released lateral incision centered over peroneals, from lateral malleolus to base of 5th metatarsal soft tissue tendon split up to musculotendinous junction posterior portion re-routed posteriorly to tibia/fibula and anterior to neurovascular bundle tendon woven and sutured into peroneus brevis tendon cast applied with foot abducted and neutral flexion outcomes more consistent outcomes than with full tendon transfer split anterior tibialis tendon transfer (SPLATT) approach incision centered over tibial anterior tendon soft tissue tendon released from 1st metatarsal and split up to musculotendinous junction re-routed laterally under extensor retinaculum transosseous tunnel through cuboid, tendon sutures tied over button while foot in dorsiflexion calcaneal osteotomy approach lateral incision along border of calcaneus, avoid sural nerve branches bone work slide osteotomy- oblique cut through calcaneus posterior fragment slid laterally and into valgus closing wedge osteotomy- wedge taken from lateral cortex instrumentation two cannulated screws or staples for osteotomy fixation triple arthrodesis approach lateral incision along border of calcaneus avoiding sural nerve medial incision centered over talonavicular joint bone work subtalar joint accessed first to address hindfoot varus calcaneocuboid and talonavicular joints denuded of cartilage osteotomy may be required to fuse in slight valgus instrumentation percutaneous k-wires complications recurrence of deformity if soft tissues not balanced Complications Deformity recurrence failure to recognize and address all components