summary Equinovalgus Foot is an acquired foot deformity commonly seen in pediatric patients with cerebral palsy, spina bifida, or idiopathic flatfoot, that present with a equinovalgus foot deformity. Diagnosis is made clinically with presence of a valgus heel deformity with lateral calcaneal displacement and compensatory forefoot supination. Treatment ranges from bracing to surgical osteotomies and arthrodesis depending on the underlying etiology, severity of deformity, and rigidity of contracture. Epidemiology Incidence common foot deformity seen with idiopathic flatfoot (if the heel cord is tight) cerebral palsy (spastic diplegia and quadriplegia) spina bifida fibular hemimelia typically bilateral Etiology Pathophysiology primary deformities midfoot abduction hindfoot valgus equinus contracture secondary deformity forefoot supination muscle imbalances spasticity and/or overpull of login to view 2 more bullets weakness of login to view 2 more bullets pathomechanics results in lever arm dysfunction during gait login to view 1 more bullet patient is bearing weight on the medial border of the foot and possibly the talar head external rotation of the foot creates login to view 2 more bullets Presentation Symptoms pain difficulty with brace and/or shoe wear painful callus over talar head secondary to weightbearing Physical exam inspection and palpation valgus heel deformity with lateral calcaneal displacement login to view 1 more bullet prominent talar head login to view 1 more bullet midfoot break is common compensatory forefoot supination login to view 1 more bullet hallux valgus often develops over time the medial and lateral malleoli are palpated -- the lateral malleolus should be distal to the medial malleolus, unless there is ankle valgus motion flexibility of the deformity is checked the hindfoot valgus deformity is manually corrected (by inverting the hindfoot) in order to check for true ankle dorsiflexion and achilles contracture login to view 1 more bullet Imaging Radiographs recommended views weight-bearing AP and lateral foot x-rays weight-bearing AP radiographs of the ankles are obtained login to view 1 more bullet findings "talar sag" (talus tilted inferiorly) login to view 1 more bullet decrease in the calcaneal pitch login to view 1 more bullet Treatment Nonoperative bracing and physical therapy indications login to view 1 more bullet technique login to view 1 more bullet serial casting indications login to view 1 more bullet Operative calcaneal osteotomy with soft tissue procedure indications login to view 1 more bullet types login to view 1 more bullet fusions indications login to view 1 more bullet types login to view 4 more bullets subtalar arthroeresis indications login to view 1 more bullet Techniques Calcaneal osteotomy with soft tissue procedure soft tissue procedures gastrocnemius recession or achilles tendon lengthening for equinus peroneus brevis lengthening, if performing calcaneal lengtheing osteotomy bony procedures calcaneal osteotomy login to view 1 more bullet lateral column lengthening procedure login to view 4 more bullets medial calcaneal sliding osteotomy login to view 1 more bullet Grice procedure login to view 4 more bullets Complications Overcorrection (resultant varus deformity) most common complication more common in children with neuromuscular disease Recurrence more common if forefoot supination not corrected at time of primary surgery Sural nerve injury at risk during lateral calcaneal osteotomy approach Overlengthening of lateral column results in a painful lateral forefoot secondary to overload Wound dehiscence risk minimized by use of non-absorbable sutures