Updated: 12/27/2021

Cavovarus Foot in Pediatrics & Adults

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https://upload.orthobullets.com/topic/4063/images/Colman block test - flexible hindfoot - courtesy Miller_moved.png
https://upload.orthobullets.com/topic/4063/images/coleman block.jpg
https://upload.orthobullets.com/topic/4063/images/peek.jpg
https://upload.orthobullets.com/topic/4063/images/meary.jpg
https://upload.orthobullets.com/topic/4063/images/calcpitch.jpg
https://upload.orthobullets.com/topic/4063/images/talocalcaneal.jpg
https://upload.orthobullets.com/topic/4063/images/talonavicular.jpg
https://upload.orthobullets.com/topic/4063/images/sinustarsiseethrough.jpg
  • summary
    • Cavovarus Foot is a common condition that may be caused by a neurologic or traumatic disorder, seen in both the pediatric and adult population, that presents with a cavus arch and hindfoot varus.
    • Diagnosis is made clinically with the presence of a foot deformity characterized by cavus, hindfoot varus, plantarflexion of the 1st ray, and forefoot adduction. A coleman block test is useful to assess for the flexibility of the hindfoot deformity to assist with surgical planning. 
    • Treatment ranges from orthotics to operative soft tissue release and operative osteotomies depending on patient age and flexibility of the foot deformity.
  • Epidemiology
    • Demographics
      • seen in both pediatric and adult populations
    • Anatomic location
      • when bilateral often hereditary or congenital
  • Etiology
    • Deformity characterized by
      • cavus (elevated longitudinal arch)
      • plantarflexion of the 1st ray and forefoot pronation
      • hindfoot varus
      • forefoot adduction
    • Pathophysiology
      • neurologic
        • 67% due to a neurologic condition
        • diagnosis of neurologic condition is critical to render appropriate treatment
        • unilateral - rule out tethered spinal cord or spinal cord tumor
        • bilateral - most commonly due to Charcot-Marie-Tooth (CMT) disease
        • muscle imbalances generate deformity
          • weak tibialis anterior and peroneus brevis overpowered by strong peroneus longus and posterior tibialis
          • results in plantarflexed 1st ray and forefoot pronation with compensatory hindfoot varus
            • with the 1st metatarsal plantflexed and forefoot pronated, the medial forefoot strikes ground first
            • the subtalar joint supinates to bring the lateral forefoot to the ground and maintain three-point contact, resulting in hindfoot varus
            • while initially flexible, hindfoot varus can become rigid with time
      • idiopathic
        • usually subtle and bilateral
      • traumatic
        • talus fracture malunion
        • compartment syndrome
        • crush injury
    • Associated conditions
      • conditions which present with cavovarus foot
        • Charcot-Marie-Tooth disease
        • Cerebral palsy
        • Freidreich's ataxia
        • Spinal cord lesions
        • Polio
        • Amnitoic band syndrome (ABS)
      • conditions caused by the presense of cavovarus foot
        • see complications below
  • Presentation
    • History
      • recurrent ankle sprains and lateral ankle pain
        • peroneal tendon pathology
      • lateral foot pain
        • excessive weight bearing by the lateral foot due to deformity
        • can result in 5th metatarsal stress fractures
      • painful plantar calluses under 1st metatarsal head and 5th metatarsal head or base
      • plantar fasciitis
        • elevated medial arch, forefoot pronation and tight gastronemius lead to contracture of the plantar fascia
    • Physical exam
      • Coleman block test
        • evaluates flexibility of hindfoot deformity
        • technique
          • place 1" block under the lateral foot
          • eliminates contribution of the plantarflexed 1st ray and forefoot pronation to the hindfoot deformity
        • findings
          • flexible hindfoot will correct to neutral or valgus when block placed under lateral aspect of foot
          • rigid hindfoot will not correct to neutral
        • guides surgical treatment
          • flexible hindfoot deformities resolve with forefoot corrective procedures
          • rigid hindfoot deformities require corrective hindfoot osteotomy in addition to forefoot procedures
      • peek-a-boo heel
        • anterior standing examination shows varus heel "peeking" around the ankle
      • prominent first metatarsal fat pads
      • Silfverskiold test
        • check dorsiflexion with both knee flexion and knee extension
          • if tight only with knee extension, then gastrocnemius is tight
          • if tight also with knee flexion, then soleus is also tight
        • gastronemius tightness often present with cavovarus foot
      • altered gait
        • unstable base of support
        • increased double limb stance and decreased single limb stance
      • wasting of 1st dorsal interosseous muscle of the hand
        • suggestive of CMT
      • spine exam
        • scoliosis is suggestive of CMT
        • spinal dysraphism
  • Imaging
    • Radiographs
      • recommended views
        • standing anteroposterior (AP), lateral radiographs of the ankle
        • standing AP, lateral and oblique radiographs of the foot
      • findings
        • AP foot
          • talocalcaneal angle < 20° (nl 20-45°)
            • hindfoot varus
          • talonavicular overcoverage
            • talonavicular angle > 7° indicates forefoot adduction
          • metatarsal overlap
            • forefoot pronation
        • lateral foot
          • lateral talo-first metatarsal angle (Meary's angle) > 4° apex dorsal
            • break in Meary's line caused by plantarflexion of the 1st ray
          • calcaneal pitch or inclination angle > 30°
          • sinus tarsi see-through sign and double talar dome sign
            • due to external rotation of the ankle and hindfoot relative to the xray cassette, which is placed along the medial border of the adducted forefoot
          • bell-shaped cuboid
          • increased distance between base of 5th metatarsal and medial cuneiform
        • oblique foot
          • metatarsal stress fractures
          • calcaneonavicular coalitions
  • Studies
    • Electrodiagnostic Studies (EMG/NCS)
      • diagnostic algorithm for CMT generally dictates
        • a neurologic physical exam
        • electrodiagnostic studies
        • genetic testing
    • Genetic studies
      • used to confirm diagnosis after physical exam and electrodiagnostic studies
  • Treatment
    • Nonoperative
      • accomodative shoe wear
        • indications
          • rarely sufficient except in mild deformity
      • full-length semi-rigid insole orthotic with a depression for the first ray and a lateral wedge
        • indications
          • mild cavus foot deformity in adult (not indicated in children)
      • supramalleolar orthosis (SMO)
        • indications
          • more severe cavovarus deformity recalcitrant to shoewear accomodations
      • ankle foot orthosis (AFO)
        • indications
          • may be needed if equinus also present, resulting in equinocavovarus foot deformity
          • works best if equinus is a dynamic defomrity (not rigid)
      • lace-up ankle brace and/or high-top shoe or boots
        • indications
          • may consider in moderate deformities when patient does not tolerate the more rigid bracing with an SMO or AFO
    • Operative
      • soft tissue reconstruction
        • indications
          • failure of nonoperative treatment
        • performed with a combination of the following procedures
          • plantar release
            • indications
              • cavus deformity
            • technique
              • plantar fascia release
              • Steindler stripping (release short flexors off the calcaneus)
          • peroneus longus to brevis transfer
            • indications
              • plantar flexed first ray
            • technique
              • decreases plantarflexion force on first ray without weakening eversion
          • posterior tibial tendon transfer
            • indications
              • muscle imbalance
                • posterior tibialis typically is markedly stronger than evertors and maintains strength for a long time in most cavovarus feet
              • may consider transfer of posterior tibialis to dorsum of foot if severe dorsiflexion weakness of anterior tibialis
          • lengthening of gastrocnemius or tendoachilles (TAL)
            • indication
              • true ankle equinus
              • gastrocnemius recession produces less calf weakness and can be combined with plantar release simultaneously
              • TAL should be staged several weeks after plantar release
          • 1st metatarsal dorsiflexion osteotomy
            • indications
              • flexible hindfoot varus deformities (normal Coleman block test)
                • corrects the forefoot pronation driving the hindfoot deformity
          • lateral ankle ligament reconstruction (e.g. Broström ligament reconstruction)
            • indications
              • chronic ankle instability due to lignamentous incompetence following long-standing cavovarus
          • Jones transfer(s) of EHL to neck of 1st MT and lesser toe extensors to 2nd-5th MT necks
            • indication
              • toe clawing combined with cavus foot
              • performed if the indication is met and time permits
              • the modified Jones transfer for the hallux includes an IP joint fusion
      • lateralizing calcaneal valgus-producing osteotomy
        • indications
          • rigid hindfoot varus deformity (abnormal Coleman block test)
      • triple arthrodesis
        • indication
          • almost never indicated due to very poor long-term results
  • Complications
    • Ankle instability
      • standard lateral ankle ligament reconstruction will fail if cavovarus deformity is not concomitantly addressed
      • untreated can lead to varus ankle arthritis
    • Stress fractures
      • 5th metatarsal base (Jones fracture)
      • 4th metatarsal
      • navicular
      • medial malleolus
    • Hallux sesamoiditis
      • overload from plantarflexed 1st metatarsal head
    • Peroneal tendon pathology
      • tendonitis, tears, subluxation or dislocation
      • peroneus brevis most commonly involved
    • Plantar fasciitis
      • contracture of the plantar fascia results from elevated medial arch, forefoot pronation and tight gastronemius
  • Prognosis
    • Depends on
      • deformity severity
      • etiology
      • patient age
Technique Guides (4)
Flashcards (8)
Cards
1 of 8
Questions (17)

(SBQ18FA.9) A 39-year-old male presents with chronic bilateral foot pain and the radiographs shown in Figures A and B. All of the following are potential pathologies that may result directly from this condition EXCEPT:

QID: 211198
FIGURES:
1

Ankle instability

12%

(206/1766)

2

Fifth metatarsal fracture

12%

(211/1766)

3

Hallux valgus

55%

(971/1766)

4

Peroneal tendon subluxation

10%

(184/1766)

5

Plantar fasciitis

9%

(155/1766)

L 3 A

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(SBQ18FA.8) A 32-year-old male is diagnosed with a hereditary motor sensory neuropathy resulting from a partial duplication within the gene for peripheral myelin protein 22. In the setting of this disease, each of following characteristic deformities are accurately represented by the pathologic process responsible EXCEPT:

QID: 211187
1

Claw toes result from both strong extrinsic flexors and extensors overpowering atrophied lumbricals and interossei

12%

(226/1823)

2

First metatarsal plantarflexion is driven by the hypertrophic peroneus longus overpowering a weak tibialis anterior

12%

(224/1823)

3

First metatarsophalangeal joint hyperextension is driven by recruitment of the extensor hallucis longus in place of a weak tibialis anterior

22%

(404/1823)

4

Forefoot supination is driven by the relatively stronger peroneus longus indirectly overpowering a weak peroneus brevis

40%

(734/1823)

5

Hindfoot varus is driven by the preserved tibialis posterior overpowering a relatively weaker peroneus brevis

11%

(207/1823)

L 1 A

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(SBQ18FA.11) For which of the following pathologies would the orthotic shown in Figure A be most appropriate?

QID: 211220
FIGURES:
1

Hallus rigidus

3%

(49/1426)

2

Supple adult pes cavus

59%

(840/1426)

3

Mild midfoot arthritis

2%

(26/1426)

4

Pes planovalgus

25%

(353/1426)

5

Rigid pes cavovarus

11%

(152/1426)

L 3 A

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(SBQ18FA.10) Figure A is the radiograph of a 36-year-old female that presents with a high-steppage gait and claw toes. On genetic testing, she has duplication of the PMP gene on chromosome 17. Which of the following answers correctly identifies relative muscle strengths in this patient population?

QID: 211209
FIGURES:
1

Weak anterior tibialis and weak peroneus longus

28%

(483/1746)

2

Weak peroneus longus and weak brevis

4%

(75/1746)

3

Normal anterior tibialis and weak peroneus longus

8%

(142/1746)

4

Weak peroneus brevis and normal posterior tibialis

53%

(934/1746)

5

Normal peroneus longus and weak posterior tibialis

6%

(101/1746)

L 1 A

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(SBQ12FA.83) With a cavovarus foot, plantar flexion of the first ray is driven by a weak muscle "X" being overpowered by a strong muscle "Y". A tendon transfer to correct this involves transferring muscle "Y" to muscle "Z". Which muscles are represented by X, Y, and Z, respectively?

QID: 3890
1

X = Peroneus longus, Y = Tibialis anterior, Z = Peroneus brevis

16%

(227/1445)

2

X = Tibialis anterior, Y = Peroneus longus, Z = Peroneus brevis

68%

(985/1445)

3

X = Tibialis anterior, Y = Peroneus brevis, Z = Peroneus Longus

5%

(74/1445)

4

X = Peroneus brevis, Y = Peroneus longus, Z = Flexor digitorum longus

4%

(64/1445)

5

X = Posterior tibialis, Y = Peroneus brevis, Z = Flexor digitorum longus

5%

(69/1445)

L 1 C

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(SBQ12FA.52) A 34-year-old male undergoes cavus foot reconstruction after failed nonoperative treatment. During the procedure, you plan to correct the fixed deformity shown in figure A. Which surgical technique best addresses this deformity?

QID: 3859
FIGURES:
1

EHL transfer to the proximal phalanx

5%

(73/1579)

2

EHL transfer to the metatarsal neck

9%

(137/1579)

3

EHL transfer to the metatarsal neck with interphalangeal joint fusion

68%

(1078/1579)

4

FHB tenotomy

13%

(206/1579)

5

Metatarsal head resection

5%

(72/1579)

N/A C

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(OBQ09.32) What is the preferred orthotic device for a symptomatic adult foot deformity that is shown in Figure A, has no arthritis on radiographs, and responds to Coleman block testing as shown in Figure B?

QID: 2845
FIGURES:
1

Short walker boot

0%

(10/3457)

2

Accommodative custom orthotics

5%

(188/3457)

3

Lace up soft ankle brace

1%

(26/3457)

4

Medial hindfoot posting with arch support

17%

(592/3457)

5

Lateral hindfoot posting with recessed first ray

76%

(2621/3457)

L 2 B

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(OBQ04.90) An 18-year-old male presents with recurrent ankle sprains of the left ankle and painful callus underneath the 5th metatarsal. Standing examination is shown in Figures A and B. During Coleman block testing the hindfoot is positioned in 3 degrees of valgus. The peroneus brevis and anterior tibialis have 4/5 strength compared to 5/5 strength in peroneal longus, gastrocsoleus complex, and posterior tibialis. Using a semi-ridged orthotic with a recess for the head of the first ray and lateral hindfoot posting has failed to improve symptoms. Which of the following is most appropriate as one part of the surgical plan??

QID: 1195
FIGURES:
1

Peroneus brevis to longus transfer with medial calcaneal slide osteotomy

29%

(500/1723)

2

Triple arthrodesis

2%

(29/1723)

3

First ray dorsiflexion osteotomy with plantar fascia release

65%

(1128/1723)

4

Subtalar arthrodesis

1%

(16/1723)

5

First tarsometatarsal joint arthrodesis and metatarsophalangeal capsular release

2%

(37/1723)

L 3 C

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