Tiffany's Foot and Ankle

Question 1

What is the Coleman block test?

Answer 1

Assesses hindfoot deformity flexibility in cavovarus foot. Place 1inch block under lateral foot. Eliminates plantarflexed 1st ray and forefoot pronation from contributing to hindfoot deformity.
- If flexible, hindfoot corrects. Correct forefoot only
- If not flexible, does not correct. Need to correct both hind and forefoot

Question 2

What is the peek-a-boo heel test?

Answer 2

Anterior standing exam. See if varus heel peeking around ankle

Question 3

How do you assess a cavovarus foot radiographically?

Answer 3

On AP
1. Talar-1st MT angle: forefoot adduction
2. Talonavicular angle: overcoverage
3. Talocalcaneal angle: hindfoot varus
Lateral
1. Meary’s (talar-1st MT angle): cavus
2. Calcaneal pitch: cavus
3. Medial cuneiform height
4. Sinus tarsi see-through sign

Question 4

What is the talonavicular angle?

Answer 4

On AP XR, demonstrates navicular coverage. Angle between
- Line connecting talus articular surface
- Line connecting navicular articular surface
Normal <7deg

Question 5

What is talonavicular uncoverage?

Answer 5

Look at talonavicular angle (normally <7deg)
Uncovered when navicular subluxed lateral on talus
Ex: forefoot abduction in planovalgus foot

Question 6

What is talonavicular overcoverage?

Answer 6

Look at talonavicular angle (normally <7deg)
Overcovered when navicular subluxed medial on talus
Ex: forefoot adduction in cavovarus foot

Question 7

What is the talar-1st MT angle on AP XR of the foot?

Answer 7

Axis of talus should be parallel to 1st MT axis
If not, there is either forefoot abduction or adduction

Question 8

What is Meary’s angle (lateral talar-1st MT angle)?

Answer 8

Angle between axis of talus and 1st MT on lateral XR
Normally angle = 0, meaning they are in line
If angle apex upwards, then pes cavus
If angle apex downwards, then pes planus

Question 9

What is calcaneal pitch?

Answer 9

On weight bearing XR. Angle between inferior border of calcaneus and horizontal
Normal = 20-30deg
Pes planus <20
Pes cavus >30

Question 10

What is medial cuneiform height?

Answer 10

On WB lateral foot XR, height of medial cuneiform from floor
Average = 2cm
Higher in cavus, lower in planus

Question 11

What are 3 radiographic methods of determining if a foot is in pes planus or cavus?

Answer 11

1. Meary’s (Talar-1st MT) angle
2. Calcaneal pitch
3. Medial cuneiform height

Question 12

What are 2 radiographic methods of determining if the forefoot is in abduction or adduction?

Answer 12

On AP XR
1. Talar-1st MT angle
2. Talonavicular angle

Question 13

What radiographic angle is used to determine hindfoot alignment?

Answer 13

On AP XR: talocalcaneal angle

Question 14

What is the sinus tarsi see-through sign?

Answer 14

Indicates hindfoot varus

Question 15

What is Charcot Marie Tooth (CMT)?

Answer 15

Hereditary motor sensory neuropathy causing cavovarus foot
Autosomal dominant, PMP 22 gene

Question 16

Describe the muscle imbalance in CMT (4)

Answer 16

1. Foot intrinsic (EHB, EDB) weakness causes claw toes
2. Weak tib ant, unopposed peroneus longus. Causes 1st ray plantarflexion (cavus and pronation)
   Compensatory hindfoot varus
3. Weak peroneal brevis, unopposed tib post. Hindfoot varus no longer compensatory now
4. Hand intrinsic weakness causes wasting

Question 17

What are the types of CMT?

Answer 17

Type 1: demyelinating: slow nerve conduction. Causes cavus foot
Type 2: Wallerian degeneration. Milder. Causes flaccid foot

Question 18

What is the clinical presentation of CMT? (6)

Answer 18

1. Cavovarus foot
2. Sensory deficits
3. Recurrent ankle sprains
4. Excessive lateral foot WB causing pain and 5th MT #
5. Calluses under MT heads and lateral border
6. Claw toes

Question 19

What is part of your physical exam for CMT? (7)

Answer 19

1. Neuro exam
2. Coleman block test
3. Peek-a-boo heel
4. Gait: steppage or unsteady
5. Drop foot
6. Silfverskiold
7. Hand: interosseous wasting

Question 20

What are orthopaedic manifestations of CMT other than in the foot and hands? (2)

Answer 20

1. Scoliosis
2. DDH

Question 21

What are orthotic options for cavovarus foot? (3)

Answer 21

1. Full-length semi-rigid insole w depression for 1st ray and lateral wedge. For mild deformity
2. Supramalleolar orthosis. For more severe deformity
3. AFO. If equinus is also present

Question 22

List the surgical soft tissue management options for cavovarus foot (5)

Answer 22

1. Plantar fascia release. Steindler stripping: release from calcaneus
2. Peroneus longus to brevis transfer
3. Posterior tibial tendon transfer to dorsum of medial cuneiform
4. Gastroc recession or TAL
5. Lateral ankle ligament reconstruction
6. Jones procedure

Question 23

What is the purpose of plantar fascia release in the management of CMT?

Answer 23

Indicated for cavus deformity
Steindler stripping: release fascia from calcaneus

Question 24

What is the purpose of a peroneus longus to brevis transfer in the management of cavovarus foot?

Answer 24

Indication: plantarflexed 1st ray
Transfer decreases plantarflexion force by peroneus longus
Restores eversion power

Question 25

List the bony procedures that could be performed in the management of CMT?

Answer 25

1. 1st MT dorsiflexion osteotomy. In kids, do medial cuneiform instead
2. Lateralizing calcaneal osteotomy
3. Triple arthrodesis

Question 26

What is the deformity seen in pes planus?

Answer 26

Hindfoot valgus
Decreased medial longitudinal arch
Forefoot abduction