Updated: 6/15/2021

Calcaneovalgus Foot

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  • summary
    • Calcaneovalgus Foot is a common acquired condition caused by intrauterine "packaging" seen in neonates that presents as a benign soft tissue contracture deformity of the foot characterized by hindfoot eversion and dorsiflexion.
    • Diagnosis is made clinically with a calcaneovalgus foot deformity without congenital deformity or dislocation.
    • Treatment is usually observation with passive stretching and possible casting as the condition resolves spontaneously in 3-6 months. 
  • Epidemiology
    • Incidence
      • mild form can occur in up to 40% of newborns
      • estimated incidence of true deformity is 1 in 1,000 live births
    • Demographics
      • more common in females and first-born children
  • Etiology
    • Pathophysiology
      • usually a positional deformity of the foot caused by intrauterine "packaging"
  • Presentation
    • Physical exam
      • excessively dorsiflexed hindfoot that is passively correctable
      • dorsal surface of foot can rest on anterior tibia
      • looks similar to vertical talus
        • differs on exam in that vertical talus has a rigid hindfoot equinus/valgus and rigid dorsiflexion through midfoot
        • vertical talus also has mid-foot valgus, with a medial prominant talar head.
  • Imaging
    • Radiographs
      • AP and lateral tibia
        • used to determine presence of posteromedial bowing
      • plantar flexion lateral radiographs
        • useful to differentiate from congenital vertical talus
          • if foot is sufficiently flexible to rule out congenital vertical talus, no radiographs are required
        • before ossification of navicular at age 3, the first metatarsal is used as a proxy for the navicular on radiographic evaluation
          • calcaneovalgus foot
            • first metatarsal will line up with talus
          • vertical talus
            • the axis of the talus passes plantar to the 1st metatarsal (and navicular if visible yet) on both standard lateral and plantar flexion lateral radiographs
  • Differential
    • Conditions that should be differentiated
      • posteromedial tibial bowing
        • posteromedial bowing of the tibia is almost alway accompanied by some degree of calcaneovalgus foot deformity
        • with the calcaneovalgus foot, apex of the deformity is at the ankle joint
        • with posteromedial bowing of the tibia, apex is at the distal tibia
      • congenital vertical talus (CVT)
        • appears similar to calcaneovalgus foot clinically
        • with CVT, the hindfoot is in equinus
          • hindfoot is in calcaneus (dorsiflexion) in a calcaneovalgus foot
        • with CVT, there is a midfoot dislocation through the talonavicular joint
        • CVT is a rigid deformity
          • calcaneovalgus is a flexible deformity
      • paralytic foot deformity
        • deformity is caused by
          • spasticity of
            • foot dorsiflexors (L4 and L5)/evertors (S1)
          • weakness of
            • plantar flexors (S1 and S2) /inverters (L5)
          • this muscle imbalance can be caused by an L5 spinal bifida leading to a calcaneovalgus deformity
  • Treatment
    • Nonoperative
      • observation & passive stretching exercises
        • indications
          • if foot can be plantar-flexed beyond neutral
        • technique
          • resolution may be expedited by stretching performed by parents
        • outcomes
          • typically resolves spontaneously by 3-6 months
      • casting
        • indications
          • if foot cannot be plantar-flexed beyond neutral
        • outcomes
          • severity of initial deformity has no relation to final outcome
  • Complications
    • Leg Length Discrepancy
      • LLD a possible sequela when calcaneovalgus foot is associated with posteromedial bowing of the tibia
      • the most common surgery needed for posterior medial bowing is to address the LLD
    • Flexible flatfoot deformity
      • occurs several years after the resolution of the foot deformity
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