25: Inverted Forefoot Deformities - Mahoney Flashcards
name 5 inverted forefoot deformities
forefoot varus forefoot supinatus metatarsus primus elevatus plantrflexed cuboid plantarflexed 5th metatarsal
define osseous forefoot varus
- Inverted position of plantar surface of all metatarsals (forefoot) relative to the plantar surface of the calcaneus (rearfoot) at the level of the STJ…
- With the STJ neutral and the MTJ locked (fully pronated)
- If all the metatarsals are inverted on the same plane, you cannot plantarflex the 1st metatarsal during examination
1st met higher than the 5th
forefoot varus
etiology of forefoot varus
- Inadequate valgus torsion of the head and neck of the talus (?)
- Normal fetal position of talar head and neck is varus rotation to the transverse plane.
- During normal development, there is a valgus rotation to the talar head and neck which creates a valgus curvature to the lesser tarsus. *** If this fails to occur, there is an inverted position of the forefoot to the rearfoot (ie, the forefoot is not perpendicular to the bisection of the heel).
most common cause of FF varus
lack of valgus rotation of the talar head
rule of compensation for FF varus
The heel will evert past vertical the same number of degrees as the FF varus deformity to get the medial aspect of the forefoot on the ground
Exists when there is no calcaneal eversion beyond the vertical available
uncompensated forefoot varus
However, most people will have adequate r.o.m. available at the MTJ or within the 1st ray’s r.o.m. to allow the forefoot to purchase the ground
RCSP rearfoot varus
RCSP forefoot varus
what does a compensated heel look like?
vertical heel
heel everted
If a forefoot varus is compensated by plantarflexing the first metatarsal, when seen in non-weightbearing neutral position …
metatarsals 2 through 5 will be in varus with the 1st metatarsal flexibly plantarflexed (can dorsiflex 1st metatarsal to the level of the 2nd metatarsal
The heel remains at vertical in RCSP (the STJ does not have to evert past vertical because the 1st metatarsal compensates by plantarflexing)
all the metatarsals are in
varus =
osseous forefoot
a 1st metatarsal that compensates to get the forefoot to the
ground will form a forefoot deformity known as a
flexible plantarflexed 1st ray with varus 2 through 5
what is the RCSP?
4 degrees of FF varus (rigid)
20 degrees of STJ inversion
4 degrees of STJ eversion
8 degrees of tibial varum
4 degrees inverted
- RF varus compensates before FF deformity
- this is the maximally pronated position and the FF varus is uncompensated
8° tibial varum - 4° eversion of STJ = 4° RF varus
To compensate for 4° of FFV, need to evert heel 4° past vertical
No more eversion of STJ is available
what pathologies associated with uncompensated forefoot varus?
- cavus foot type ***
- lateral foot strain ***
- callus sub 4th and 5h met heads and hallux
- corn dorsum 2nd toe
- functional equinus
describe partially compensated forefoot varus
The amount of STJ eversion is less than the amount of FF varus, but enough to position the heel in eversion in RCSP, but less than the amount of FF varus
Many feet will also compensate by plantarflexing the 1st metatarsal (metatarsals 2 through 5 are in varus and the 1st metatarsal is flexibly plantarflexed)
RCSP = ?
4 degrees of FF varus (rigid)
15 degrees of STJ inversion
4 degrees of STJ eversion
3 degrees of tibial varum
resting calcaneal stance position is 1 degree everted
This is the maximally pronated position which is less than the 4 degrees of FF varus so the FF varus is only partially compensated
Correct rearfoot deformity first
3° RF varus - 4° eversion of STJ = 0° of heel (heel vertical) with 1° of eversion left over
Need 4° of eversion past heel vertical to compensate, but only have 1° available
Therefore, RCSP is 1° valgus
foot type partially compensated FF varus
stable mild cavus
RCSP = ? compensation = ? 4 degrees of FF varus (rigid) 15 degrees of STJ inversion 6 degrees of STJ eversion 2 degrees of tibial varum
resting calcaneal stance position is 4 degrees everted
This is the maximally pronated position, so the 4 degrees of FF varus is totally compensated
Correct RF varus first
2° tibial varum - 6° of eversion of STJ = 0° of heel with 4° of eversion left over
Need 4° of eversion past heel vertical to compensate for 4° of FFV, so RCSP is 4° of valgus
pathology compensated forefoot varus
hypermobile flat foot, medial strain
A patient exhibits the following:Tibial stance of 3° varus, STJ eversion of 6°FF varus of 2°. This is an example of:
- compensated FF varus
- foot with a RCSP of 2 valgus
- Inverted position of the forefoot relative to the rearfoot at the level of the STJ
- an off weight-bearing plantarflexion force on the 1st metatarsal will result in a complete or partial reduction of the FF varus.
- Prior to the plantarflexion force, all the metatarsals are on the same inverted plane
forefoot supinatus
- soft tissue or positional abnormality
(unlike a forefoot that has metatarsals 2 through 5 on the same inverted plane with a flexibly plantarflexed 1st metatarsal)
With forefoot supinatus, all the metatarsals
are in varus and when you push down on the 1st
metatarsal, it …
plantarflexes
4 degrees of FF varus (rigid) 15 degrees STJ inversion 6 degrees STJ eversion 0 degrees of tibial varum 6 degrees of eversion in RCSP
2 degrees of excessive compensatory STJ pronation
- this is an abnormal amount of pronation
Correct RFV first
Next, correct for FFV
Since, the heel everts past 3°, it keeps moving until it reaches the end range of STJ eversion which is a RCSP of 6°
This is 2° more than is needed to correct the FFV of 4°
you can not develop forefoot supinatus unless …
your forefoot varus is greater than 3 degrees
The rearfoot overcompensates for a FF varus deformity, but only when the FF varus deformity is greater than 3° (the so-called “tipping point”)-in other words, will not develop a forefoot supinatus if the forefoot varus is 3° or less
This results in a soft tissue or positional varus position of the forefoot relative to the rearfoot which becomes stiff over time = forefoot supinatus
True FF varus always includes an osseous component, and possibly a soft tissue (supinatus) component
To detect if a soft tissue component is present …
press down on the 1st metatarsal head-if it moves, you have some component of soft tissue forefoot varus
Select all the correct answers pertaining to FF supinatus
A It is an osseous deformity similar to FF varus
B It contributes to the total amount of FF varus
C It usually forms when the rearfoot overcompensates for an osseous FF varus
DIt is not necessary to consider when posting the forefoot of an orthosis
B, C, D
what is metatarsus primus elevatus?
More dorsiflexion than plantarflexion of the 1st ray when measured with the STJ in neutral position
structural/osseous deformity
Total range of motion may be normal (10 mm), but dorsiflexion > plantarflexion of
1st ray
what is plantarflexed cuboid?
Cuboid is actually inverted on the calcaneus (which brings the 4th and 5th metatarsals closer to the ground), resulting in an inverted forefoot
4th and 5th metatarsals are plantarflexed more than the other metatarsals (relationship of 4 & 5 with the cuboid is normal).
The plantarflexed position of the 5th results in an inverted position of the forefoot
plantarflexed 5th metatarsal
it is natural for a kid to have flat feet until about …
6 years old
- We have learned that is natural for a child to be born with FF varus which is then corrected by valgus torque of the head and neck of the talus
- It usually takes up to 6 years for the forefoot varus deformity to correct itself and get the forefoot on the ground or parallel to the plantar surface of the heel
If we make an orthotic on a child under the age of 6 who still has FF varus, we …
we cannot cast them in the standard neutral position
If we do, we will make permanent the remaining amount of FF varus because we have prevented the medial forefoot from reaching the ground
So, after placing the foot in STJ neutral and locking the MTJ, we plantarflex the 1st metatarsal to the level of the 5th metatarsal to bring the forefoot to the ground and prevent a permanent FF varus from developing
Called rectus position casting
recuts position casting
after placing the foot in STJ neutral and locking the MTJ, we plantarflex the 1st metatarsal to the level of the 5th metatarsal to bring the forefoot to the ground and prevent a permanent FF varus from developing
