Introduction Deformity characterized by cavus (elevated longitudinal arch) plantarflexion of the 1st ray and forefoot pronation hindfoot varus forefoot adduction Epidemiology seen in both pediatric and adult populations 67% due to a neurologic condition when bilateral often hereditary or congenital Pathophysiology neurologic diagnosis of neurologic condition is critical to render appropriate treatment unilateral - rule out tethered spinal cord or spinal cord tumor bilateral - most commonly 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 conditions caused by the presense of cavovarus foot see complications below Prognosis depends on deformity severity etiology patient age 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 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
Technique Guide 10/4/2016 Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Cavus Foot Reconstruction Orthobullets Team Pediatrics - Cavovarus Foot in Pediatrics & Adults Technique Guide 10/4/2016 Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Calcaneal Lengthening Osteotomy Deirdre Ryan Robert Kay Pediatrics - Cavovarus Foot in Pediatrics & Adults Technique Guide 10/4/2016 Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Midfoot Osteotomy Deirdre Ryan Robert Kay Pediatrics - Cavovarus Foot in Pediatrics & Adults Technique Guide 10/4/2016 Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Percutaneous Achilles Tendon Lengthening Orthobullets Team Pediatrics - Cavovarus Foot in Pediatrics & Adults
QUESTIONS 1 of 9 1 2 3 4 5 6 7 8 9 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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?? Review Topic QID: 1195 FIGURES: A B 1 Peroneus brevis to longus transfer with medial calcaneal slide osteotomy 32% (297/917) 2 Triple arthrodesis 2% (19/917) 3 First ray dorsiflexion osteotomy with plantar fascia release 60% (552/917) 4 Subtalar arthrodesis 2% (14/917) 5 First tarsometatarsal joint arthrodesis and metatarsophalangeal capsular release 3% (26/917) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 3 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? Review Topic QID: 2845 FIGURES: A B 1 Short walker boot 0% (9/2695) 2 Accommodative custom orthotics 5% (139/2695) 3 Lace up soft ankle brace 1% (15/2695) 4 Medial hindfoot posting with arch support 16% (442/2695) 5 Lateral hindfoot posting with recessed first ray 77% (2080/2695) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 5 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
Subtle Cavus Foot: Arthur Manoli, MD (CSFA #21, 2017) Pediatrics - Cavovarus Foot in Pediatrics & Adults - Treatment Consult Subtle Cavus Foot: Arthur Manoli, MD (CSFA #21, 2017) 5/15/2017 290 views Assessing Foot Flexibility: Part 1 (Intro & Subtalar Mobility - Dr. Vince Mosca Pediatrics - Cavovarus Foot in Pediatrics & Adults - Treatment Consult In the first segment about assessing foot flexibility, Vince Mosca, MD quickly c... 4/4/2015 1241 views Assessing Foot Flexibility: Part 2 (Toe Standing) - Dr. Vince Mosca Pediatrics - Cavovarus Foot in Pediatrics & Adults - Treatment Consult In the second segment about assessing foot flexibility, Vince Mosca, MD demonstr... 4/4/2015 467 views See More See Less
Cavus foot (C1879) Pediatrics - Cavovarus Foot in Pediatrics & Adults HPI - 12 yo with low lumbar spina bifida (L4-S1), who ambulates without any supports. Parents report a progressive cavus deformtiy more on the right than the left. They feel it is progressing rapidly. She has sensation to most of her foot, somewhat decreased on the lateral part of the dorsum of the foot, but normal in all toes and plantar surface. Complains of frequent ankle sprains. She has had de-tethering procedure 9 months ago, but parents feel it is still progressing. MRI scans and neurosurgical consult completed recently suggest no evidence of residual tethering. Failed bracing. Normal motor function on EMG of peroneals and tib ant and gastrocsoleus. Normal peroneal nerve and sural nerve conduction. How would you treat this patient? 4/18/2014 285 0 8