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  • A benign soft tissue contracture deformity of the foot characterized by hindfoot eversion and dorsiflexion
    • contracture without congenital deformity or dislocation is considered hallmark of disease  
  • Etiology
    • usually a positional deformity of the foot caused by intrauterine "packaging"
  • 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
  • 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.
  • 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 
  • 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
  • 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
  • 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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