Pes Planus & Cavus Flashcards
The etiology of any cavus foot varies with the disease process, but all forms result from what?
muscle imbalance
What disease should you always suspect in every patient who presents with pes cavus?
Charcot-Marie-tooth disease
Which muscle groups are most often affected in CMT?
anterior and lateral compartment musculature
the foot deformities in CMT do not result from absolute weakness in teh motor units, but rather what?
relative imbalance of the failing foot intrinsics and preserved extrinsics
Which muscle in the lateral compartment is affected by CMT yet spared what other muscle?
PB is almost always affected but spares the PL
which muscle in the anterior compartment is affected by CMT yet spares a different anterior muscle?
EHL can be spared while the anterior tibialis is affected
explain the muscle imbalance behind equinus in CMT.
weak agonist: tibialis anterior
intact antagonist: triceps-surae
explain the muscle imbalance behind adduction and hindfood varus in CMT.
weak agonist: peroneus brevis
intact antagonist: tibialis posterior
explain the muscle imbalance behind plantarflexion of the first ray in CMT.
weak agonist: tibialis anterior
intact antagonist: peroneus longus
explain the muscle imbalance behind hallux claw toe in CMT.
weak agonist: foot intrinsics
intact antagonist: EHL and FHL
Which physical exam testing is used to see if a flatfoot is flexible or not?
Hubscher maneuver (toe test of jack) if flexible- medial arch should reform when hallux is dorsiflexed *can also have person stand on tiptoes to see if heel will go into varus
What is the Kidner procedure?
(for flatfoot tx- medial column procedure)
excise os tibiale externum and transpose TP to plantar aspect of navicular
Describe the Young procedure.
(for flatfoot tx- medial column procedure)
used to correct TN and/or NC fault in a flexible flatfoot with FF supinatus, wherein the TA is rerouted thru a keyhole slot in the navicular.
Describe the Lowman procedure.
TN arthrodesis combined with rerouting TA under the navicular and suturing it to teh spring ligament
Describe the Miller procedure.
navicular-medial cuneiform-1st met arthrodesis
Describe the hOke procedure.
navicular to 1st and 2nd cuneiform arthrodesis
Describe teh Cotton procedure.
dorsally-based opening wedge osteotomy of medial cuneiform, used to plantarflex the medial column
Describe the Evans procedure.
((for flatfoot tx- lateral column procedure)
opening osteotomy and insertion of bone graft about 1.5 cm proximal to CC joint
What physical exam testing can you use to test the flexibility of a cavus foot?
coleman block test
What soft tissue procedures can be useful for correction of a flexible pes cavus foot?
Steindler stripping
Hibbs suspension
STATT
What is the Hibbs suspension procedure?
the EDL tendon slips are detached from their insertion, combined, and reattached into into lateral cuneiform
What is the indication for HIbbs suspension procedure?
flexible cavus with claw toes secondary to extensor substitution phenomenon
what is the jones tenosuspension?
transfer of EHL to the 1st met head to treat a flexible plantarflexed 1st ray; must do a hallux IPJ joint fusion to prevent hallux cock up deformity
what is the STATT procedure?
(split Tibialis anterior tendon transfer)
TA is cut at its insertion proximally; then the lateral portion fo the TA is sutured to peroneus tertius
What is the Heyman procedure?
resecting the EDL from its distal insertion and reattaching the tendon to its respective met head
*digital fusion is required (similar to Jones tenosuspension)
what kind of symptoms may arise in the cavus foot due to poor shock absorption?
arch pain
intrinsic muscle fatigue
plantar fasciitis
what type of symptoms may arise in the cavus foot due to compensation for teh deformity by use of adjacent joint’s ROM?
extensor substitution hammertoes
ankle joint instability/arthritis
what type of symptoms may arise in the cavus foot due to overuse syndromes?
Achilles tendonitis/enthesopathy
plantar fasciitis
tarsal tunnel syndrome
What is the normal calcaneal inclination angle?
18-21 deg
What is the Cole procedure ?
(cavus correction- apex of deformity at midfoot )
dorsiflexory closing wedge osteotomy thru the entire midfoot
What is the name given to the procedure that is esentially a Cole procedure but performed at Lifranc’s joint?
Jahss
What is the Japas procedure?
“V” shaped osteotomy thru the apex of the midfoot (usually in navicular) to dorsiflex the midfoot
what are the historic bony osteotomies used to correct a cavus foot where the apex of deformity is in the midfoot?
cole osteotomy
Jahss
Japas
What procedure can be used to correct a rigid rearfoot varus?
Dwyer osteotomy- lateral closing wedge of the calcaneus
What is the koutsogiannis osteotomy?
(aka PCDO)- used to correct flatfoot
posterior calcaneal osteotomy with medial displacement of the calcaneus by 1cm
is the cyma line anteriorly or posteriorly displaced in a pronated foot?
anteriorly displaced
how does talar declination angle change in a pronated compared to a supinated foot?
increases in a flat foot
decreases in a high arch foot
what is a normal talocalcaneal angle (Kit’es angle)? how does it change with a pronated foot?
normal: ages 0-5: 35-50 deg
5-adult: 15-35 deg
*increased in STJ pronation
is the Cyma line anteriorly or posteriorly displaced in a supinated foot?
posteriorly displaced
what is the most efficient supinator in the foot?
tibialis posterior
*aso acts to decelerate internal rotation of the lower leg
what is a good PE test to assess the tibialis posterior?
single leg heel raise test
what is normal cuboid abduction angle? how does it change with pronation?
0-15 deg
*increases with pronation
what are some useful radiographic angles toe valuate a flatfoot?
calcaneal inclination angle talar declination angle 1st met declination angle cyma line cuboid abduction angle talonavicular congruity talocalcaneal angle cuboid declination angle
When determining planal dominance in a flatfoot, what radiographic changes will you see if you suspect transverse plane dominance?
- increased cuboid abduction angle
- increased talocalcaneal (Kite’s angle)
- decreased in the percentage of TN congruency
When determining planal dominance in a flatfoot, how would a dominant frontal plane deformity manifest as radiographically?
- widening of the lesser tarsal area on DP view
2, decrease in 1st met declination angle - decrease in height of sustentaculum tali
- increase in teh superimposition of lesser tarsal area on lateral view
When determining planal dominance in a flatfoot, how would a dominant sagital plane deformity manifest as radiographically?
- increased talar declination angle
- naviculo-cuneiform breach
- increased Meary’s angle (talometatarsal angle)
- decreased calcaneal inclination angle
what special radiographs could be helpful in evaluating pes valgus deformity?
- charger view (stress dorsiflexion lateral) - used to determine whether an osseous block of the ankle joint is present
- Harris beath view- helps rule out talocalcaneal coalition of the posterior and middle facets
What are some causes of rigid pes planovalgus?
vertical talus (convex pesplanovalgus) congential TN dislocation tarsal coalition/peroneal spastic flatfoot cerebral palsy spina bifida improper correction of clubfoot post-traumatic
Regarding tarsal coalitions, what is the difference between a bar and a bridge?
bar- extra-articular coalition that occurs outside a normal joint (Ex. calcaneonavicular bar)
bridge- intra-articular coalition that occurs at a normal joint site (Ex. talocalcaneal bridge)
What is the classification system used for tarsal coalitions?
Downey classification (Juvenile &Adult) Type 1- extra-articular coalition Type 2- intra-articular coalition A - no secondary arthritis B- secondary arthritis
Which tarsal coalition is most common?
talocalcaneal coalition- middle facet
in a tarsal coalition, you would expect limited ROM in which direction?
limited STJ inversion
eversion is more comfortable- that’s why they have flatfoot
What is the badgely procedure?
(for tarsal coalitions)
resection of coalition/ interposition of EDB placed into defect to prevent osseous union again
What is the treatment for Downey Juvenile 1a? 1b?
(extra-articular coalition w/ or w/o arthritis)
1a: resection w/ interposition of EDB
1b: triple arthrodesis
What is the treatment for Downey Juvenile 2a? 2b?
(intra-articular coalition w/ or w/o arthritis)
2a: resection w/ interposition of EDB; isolated/single/triple arthrodesis
2b: triple arthrodesis
What is the treatment for Downey Adult 1a/1b/2a/2b?
(extra-articular coalition w/ or w/o arthritis)
singe/triple arthrodesis (fusion bc adults don’t heal as well )
What special radiographic view can be used to rule out talocalcaneal coalition of the posterior and middle facets?
Harris and Beath views
