Cavus and flat foot

Question 1

CAVUS FOOT TYPE

Answer 1

pwards of 75% of cavus deformities
are believed to be of a neurologic
origin caused by an upper or lower
motor neuron lesion.
* The muscular imbalance produced by
these neuronal lesions often leads to
progressive debilitating deformities
requiring aggressive conservative and
surgical management.

Question 2

CAVUS FOOT TYPE
MUSCLE IMBALANCE

Answer 2

Progressive muscular atrophy/weakness to the
peroneus brevis that allows its unopposed
antagonistic counterpart, tibialis posterior, to
plantarflex the ankle joint and invert the
calcaneus at the subtalar joint.
* As the tibialis anterior weakens, the peroneus
longus pulls the first ray and forefoot into
plantarflexion and inversion.

Question 3

Digits become progressively retracted and clawed

Answer 3

nterior crural and intrinsic stabilizer muscle weakening
* Contractures develop at the MTPJs due to the
overpowering pull of the extensors while the long toe
flexors cause contractures at IPJs producing the classic
claw-toe deformity.
* Plantarflexion of the metatarsals due to retrograde
pressure from the clawed digits and shortening of the
plantar ligaments and fascia also contribute to the high
arched cavus appearance.

Question 4

CAVUS FOOT TYPE
CLINICAL EXAMINATION

Answer 4

neurologic testing
should be performed to rule out upper or lower
motor neuron lesions or cerebellar dysfunction.
* EMG/NCV
* The patient’s initial presenting history may be a
concern of painful sub-metatarsal calluses and/or
recurrent lateral ankle spraining and pain/instability

Question 5

WB and NWB evals to determine

Answer 5

flexible vs. non-flexible,
weakness, and laxity.

Question 6

Frontal plane assessment:

Answer 6

forefoot valgus & rearfoot varus

Question 7

Transverse plane:

Answer 7

metatarsus adductus.

Question 8

Sagittal plane:

Answer 8

anterior, posterior or combined cavus deformity

Question 9

CAVUS FOOT TYPE
CLINICAL EXAMINATION cint

Answer 9

Limited ankle ROM due to talar neck impingement (osseous
equinus) or due to the plantigrade forefoot requiring additional
ankle dorsiflexion during stance and gait (pseudoequinus).
* STJ ROM assessed to determine if the varus calcaneal position can
be reduced to neutral alignment.
* Coleman block tes

Question 10

Coleman Block Test

Answer 10

Placing the foot on a one-inch block with the first
ray hanging over the edge of the block.
* If the rearfoot varus deformity corrects to a more
neutral alignment, it is considered a positional type
of deformity (forefoot driven) versus a fixed
rearfoot deformity.

Question 11

Contractures to the

Answer 11

plantar ligaments, fascia
and intrinsic musculature produce the cavus
deformity, which typically becomes more rigid
over time.
* The forefoot may demonstrate medial, lateral
or globally plantarflexed metatarsals or rays in
the sagittal plane. T

Question 12

The digits are typically rigidly
extended at the MTPJs and flexed
at the IPJs due to

Answer 12

muscular
imbalances resulting in extensor
substitution during the swing
phase of gait.

Question 13

CAVUS FOOT TYPE
RADIOGRAPHIC EXAMINATION

Answer 13

The weightbearing lateral radiograph is the most
important veiw to document the degree and extent
of the cavus deformity.

Question 14

Meary’s Angle:

Answer 14

increased talar-metatarsal
declination angle

Question 15

Calcaneal inclination angle:

Answer 15

> than 30

Bullet-hole sinus tarsi
* Retracted non-purchasing digits

Question 16

CAVUS FOOT TYPE
RADIOGRAPHIC EXAMINATION (AP VIEW)

Answer 16

Transverse plane involvement at the mid and
forefoot levels.
* Adductus deformities of the metatarsals or
lesser tarsus are commonly observed.
Increased splaying of the first and fifth
metatarsals are also commonly observed.

Question 17

In lateral column types of anterior cavus
deformities…

Answer 17

pronatory joint
subluxations such as increased Kite’s and Cuboid
abduction angles are observed.

Question 18

CAVUS FOOT TYPE
CONSERVATIVE TREATMENT

Answer 18

supportive re-
alignment therapy with necessary protective
accommodation should be utilized.
* Appropriate brace, orthosis and shoe
management may buy time for progressive
neurologic cavus manifestations until surgical
intervention becomes necessary.

Question 19

Anterior Cavus Foot Type Classification

Answer 19

Midtarsal Joint Anterior Cavus
B. Lesser Tarsus Anterior Cavus
C. Tarso-Metatarsal Joint Anterior Cavus

Question 20

“Global” anterior cavus

Answer 20

all of the metatarsals are equally plantarflexed and lie on the same plane (perpendicular to the rearfoot).

Question 21

Lateral column cavus

Answer 21

greater degree of hyperdeclinationof the lateral column relative to the remaining forefoot.

Question 22

Medial column cavus

Answer 22

greater degree of hyperdeclinationof the medial column relative to the remaining forefoot.

Question 23

Compensation;ANTERIOR CAVUS

Answer 23

Ground reactive dorsiflexion of the hyperdeclinatedforefoot producing a posterior type of foot and limb imbalance with retraction of the lesser digits.
* Subsequent STJ pronation may occur secondary to the “pseudoequinus stress” produced.
* Lateral column cavus will cause compensatory STJ pronation due to the inverted forefoot and pseudoequinus stress. A posteromedial imbalance is produced with retraction of the 4th and 5th digits.

Question 24

ANTERIOR CAVUS
* Management

Answer 24

Appropriate cavus heel elevation wedges.
* This may be accomplished soley with the use of higher heeled shoewear for milder cases to negate the effects of the pseudoequinus stress.
* Moderate to severe anterior cavus deformities will require combination therapy of heel elevated shoewear with orthoses with appropriate sagittal plane posting.

Question 25

SPECIAL FUNCTIONAL STANCE TESTING
SWAY TESTING TECHNIQUE

Answer 25

TO HELP DETERMINE THE NATURE AND EXTENT OF FOOT AND
DIGITAL IMBALANCE AND DEFORMITY

Question 26

DIGITAL ASSESSMENT

Answer 26

POSITIONAL MALALIGNMENTS ASSOCIATED WITH FOOT IMBALANCE

Question 27

ANTERIOR CAVUS RELATED PATHOLOGY

Answer 27

Plantar fasciitis
* Retrocalcaneal heel pain
* Tarsal Tunnel Syndrome
* Posterior tibial tendon
dysfunction
* Neuromas
-splay foot

Question 28

POSTERIOR CAVUS

Answer 28

Congenital osseous deformity, calcaneus is elongated or a plaque of bone occurs on the plantar calcaneal tuberosity.
* Compensation occurs with STJ
supination and a forward shift of body balance creating an anterior type of imbalanc

Question 29

OSTERIOR CAVUS
* Management

Answer 29

produce a negative heeled environment.
* Place a test block wedge ahead of the heel and extending beneath the metatarsal heads.
* A negative heeled orthosis with a flat soled shoe or negative heeled
“Earth shoe” may be us

Question 30

TALIPES CALCANEOCAVUS (COMBINED CAVUS)

Answer 30

During stance, ground reactive force to the hyperdeclinatedforefoot and rearfoot will cause increased pressure to both the forefoot and rearfoot areas with associated pathology.

Question 31

• Managemen

Answer 31

provided with adequate
centroplantar foot support – reduce stress of “2-island” foot type.

Question 32

Medial Column

Answer 32

lateral forefoot valgus wedging in addition to the cavus heel elevation pads to counter the posterolateral imbalance during stance and gait.
*

Question 33

Lateral Column

Answer 33

medial forefoot varus posting and heel elevation to negate the compensatory posteromedial imbalance.