summary Equinovarus Foot is an acquired foot deformity commonly seen in pediatric patients with cerebral palsy, spina bifida, and Duchenne Muscular Dystrophy that present with a equinovarus foot deformity. Diagnosis is made clinically with presence of an inverted heel with a supinated forefoot, often associated with pain and callous formation along the lateral border of the foot. Treatment ranges from bracing to tendon transfers to osteotomies depending on the underlying etiology, severity of deformity, and rigidity of contracture. Epidemiology Incidence common foot deformity seen with cerebral palsy (usually spastic hemiplegia) Duchenne muscular dystrophy residual clubfoot deformity spina bifida tibial deficiency (hemimelia) login to view 1 more bullet Etiology Pathophysiology pathomechanics imabalance of invertors and evertors (invertors overpower the evertors) relative overpull of login to view 3 more bullets example: in cerebral palsy login to view 4 more bullets foot deformity muscle imbalance overview Presentation Symptoms pain painful weight bearing over the lateral border of the foot instability during stance phase results in shortened single limb stance poor shoe and/or brace fitting and shoe wear problems Physical Exam inspection inverted heel (tibialis posterior typically implicated) supinated forefoot (tibialis anterior) callous and pain along lateral border intoeing gait (foot progression angle is more internal than knee progression angle) provocative tests active dorsiflexion of foot login to view 1 more bullet confusion test login to view 6 more bullets Coleman block test indications login to view 2 more bullets method login to view 2 more bullets manual manipulation of the hindfoot can be used to asses rigidity of the varus deformity login to view 1 more bullet Imaging Radiographs recommended views AP + lateral of foot findings forefoot adduction is seen on the AP radiograph the talus and calcaneus are more parallel than in typical feet one can often "look down" the sinus tarsi through a visual hole there the calcaneus looks foreshortened on the lateral view the metatarsals are often "stacked" on the lateral view (instead of being in line with one another) stress fractures along the fourth and/or fifth metatarsal bases can develop secondary to repetitive load along the lateral border of the foot. Studies Dynamic EMG may be useful in distinguishing whether tibialis anterior and/or tibialis posterior is/are causing the varus in CP Treatment Nonoperative ankle foot orthosis (AFO) helps provide stability for the foot and a more stable base of support during gait should have a "wrap around" hindfoot component of the brace to help control the varus and minimize pressure points serial casting indication login to view 1 more bullet botulinum toxin injection into tibialis posterior and/or gastrocnemius indication login to view 2 more bullets Operative gastrocnemius recession or tendoachilles lengtheing (TAL) for equinus indications login to view 3 more bullets split-posterior tibialis tendon transfer [SPOTT] or posterior tibial tendon lengthening (PTTL) indications login to view 4 more bullets technique login to view 5 more bullets outcomes login to view 1 more bullet split-anterior tibialis tendon transfer [SPLATT] indications login to view 2 more bullets technique login to view 2 more bullets calcaneal osteotomy indications login to view 1 more bullet technique login to view 3 more bullets Complication Overcorrection (resultant valgus deformity) increased risk in children who undergo surgery at younger age children with diplegia (as oppose to hemiplegia) Wound complications most common with calcaneal osteotomy lateral incision risk decreased by using absorbable suture Hardware Pressure sores/ulcers from buttons on bottom of foot (from SPLATT to cuboid) has led some surgeons to always transfer SPLATT to peroneus tertius or brevis