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 login to view 5 more bullets 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 login to view 2 more bullets findings login to view 2 more bullets guides surgical treatment login to view 2 more bullets 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 login to view 2 more bullets gastronemius tightness often present with cavovarus foot login to view 1 more bullet 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 login to view 6 more bullets lateral foot login to view 7 more bullets oblique foot login to view 2 more bullets 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 login to view 1 more bullet full-length semi-rigid insole orthotic with a depression for the first ray and a lateral wedge indications login to view 1 more bullet supramalleolar orthosis (SMO) indications login to view 1 more bullet ankle foot orthosis (AFO) indications login to view 2 more bullets lace-up ankle brace and/or high-top shoe or boots indications login to view 1 more bullet Operative soft tissue reconstruction indications login to view 1 more bullet performed with a combination of the following procedures login to view 33 more bullets lateralizing calcaneal valgus-producing osteotomy indications login to view 1 more bullet triple arthrodesis indication login to view 2 more bullets 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