Pes cavus dnbid


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Pes cavus dnbid

  1. 1. Physiotherapy Management of PesCavus<br />Dr. D. N. Bid [PT]<br />MPT, PGDSPT<br />Senior Lecturer<br />The Sarvajanik College of Physiotherapy, <br />Rampura, Surat -395 003 <br />
  2. 2. Synonyms for Cavus Foot<br />Anterior Equinus<br />Pes Cavo Varus<br />Contracted Foot<br />Talipes (Pes) Arcuatus<br />Talipes Plantaris<br />Schaffer Foot<br />Lotus Flower Foot<br />Bolt Foot<br />Claw Foot<br />Vault Foot<br />Hollow Foot<br />
  3. 3. What Is It?<br />Extraordinarily high plantar longitudinal arch<br />Arch fails to flatten out with WB<br />Forefoot is plantarflexed to rearfoot<br />Primarily sagittal plane deformity<br />
  4. 4. Etiology of Pes Cavus<br />Neurological<br />Congenital<br />Iatrogenic<br />Infection<br />Idiopathic<br />
  5. 5. Etiology <br />Neurological - # 1 cause; estimated at about 75%<br />Charcot Marie Tooth disease<br />Friedrich’s Ataxia<br />Roussy-Levy syndrome<br />Poliomyelitis<br />Cerebral Palsy<br />Dejerine-Sottas’s interstitial hypertrophic neuritis<br />
  6. 6. Etiology<br />Congenital<br />Spina Bifida<br />Talipes Equinovarus<br />Myelodysplasia<br />Clubfoot<br />Iatrogenic<br />Post surgery or trauma<br />Peroneal nerve injury<br />Weak anterior muscles<br />Overpowering posterior muscles<br />
  7. 7. Etiology<br />Infection<br />Syphillis<br />Poliomyelitis<br />Idiopathic<br />Must be considered<br />
  8. 8. Presenting Complaints<br />Pain and/or weakness<br />Discomfort and fatigue of the foot<br />Pain related to callus formation at the “ball” of the foot<br />Deformity<br />Trouble obtaining shoe gear <br />Ankle Joint instability<br />Lack of coordination<br />
  9. 9. Evaluation<br />Complete History<br />Include developmental, familial, and a good medical history<br />Neurological Exam<br />Evaluate motor & sensory systems, assess reflexes and coordination tests.<br />Musculoskeletal<br />check strength, ROM, DTR, rotational deformities (hips, knees, tibia, etc.)<br />
  10. 10. Evaluation<br />Biomechanical Exam<br />Include gait analysis<br />Wide based gait with short steps  neurological<br />High stepping  weak AJ DF<br />Kelikian push-up test: test for flexible or rigid digital deformities<br />Coleman Block Test<br />Assess ankle equinus<br />
  11. 11. Coleman Block Test<br />Pt. Stands with 1st ray hanging over the edge<br />If RF is vertical or pronated, then RF is compensating for a rigidly PF 1st ray<br />As a compensation, RF inverts when FF is on the ground<br />RF is 2° deformity<br />
  12. 12. BiomechanicsRearfoot Varus<br /><ul><li>Block Test
  13. 13. FF hanging off an edge
  14. 14. Bisected Calcaneus is vertical
  15. 15. STJ is Compensating
  16. 16. No rearfoot frontal plane component
  17. 17. Bisected Calcaneus is in varus
  18. 18. STJ is partially Compensated or uncompensated
  19. 19. Rearfoot frontal plane component </li></li></ul><li>BiomechanicsRearfoot Varus<br />Partial or Uncompensated<br />Tibial Varum<br />Compensated<br />
  20. 20. Other Diagnostic Tests<br />Electromyography (EMG)<br />Nerve conduction velocity<br />Muscle biopsy<br />Nerve biopsy<br />Blood Tests<br />Blood smear shows acanthocytosis (Bassen-Kornzweig syndrome)<br />
  21. 21. Radiographs<br />AP<br />Evaluate transverse plane deformities<br />Metatarsus adductus<br />Kite’s Angle <br />T-N articulation <br />AP Ankle<br />deformity may not be at foot; ankle in varus<br />
  22. 22. Metatarsus Adductus Angle<br /><ul><li>Is formed by a line perpendicular to the bisection of the lesser tarsus and a line representing the lesser metatarsus
  23. 23. The lesser metatarsus is represented by the bisection of the dorsal longitudinal axis of the shaft of the second metatarsal
  24. 24. Normal MA is less than 21o
  25. 25. As the foot becomes more adducted, this angle increases and a greater chance exists for abductus deformity at the first MPJ joint</li></li></ul><li>Talocalcaneal Angle (Kite’s Angle)<br />Is formed by the bisection of the longitudinal axis of the rearfoot and head and neck of the talus<br />Normal is 15-30o and 75% of talus head articluates with the navicular<br />Supination is 16o or less and greater than 75 % articulation<br />
  26. 26. Radiographs<br />Lateral <br />Evaluate:<br />Calcaneal inclination angle <br />Talar declination angle<br />Meary’s angle<br />Hibb’s angle<br />Metatarsal declination angle <br />Evaluate sinus tarsi and cyma line <br />
  27. 27. Calcaneal Inclination Angle<br />Best angle - changes little with supination or pronation<br />Inferior pitch of calcaneus to WB surface of calcaneus to 5th metatarsal head<br />Normal: 24.5°<br />Moderate pes cavus: 31°- 40°<br />Severe pes cavus : > 40° <br />
  28. 28. Calcaneal Inclination Angle<br />
  29. 29. Talar Declination Angle<br />Is formed by the weight bearing surface of the foot and the bisection of the head and neck of the talus<br />Normal is 21o<br />
  30. 30. Meary’s Angle<br />Talometatarsal angle<br />Bisection of talus intersects with bisection of the 1st met.<br />Normal: lines should be parallel<br />Abnormal: > 4° <br />Intersects at apex of the deformity<br />
  31. 31. Hibb’s Angle<br />long axis of calcaneus as it intersects with bisection of the 1st met.<br />Intersects at apex of the deformity<br />Represented by angle A<br />
  32. 32. PesCavusClassification<br /><ul><li>Anterior Can be
  33. 33. Posterior Structural(Rigid)
  34. 34. Combined Positional(Flexible)</li></li></ul><li>Anterior Cavus Foot<br />Sagittal plane deformity<br />Excessive PF of FF on RF<br />Metatarsal Cavus (apex at Lisfranc’s joint)<br />Lesser Tarsal Cavus<br />Forefoot Cavus (apex at Chopart’s joint)<br />Combined Cavus Foot (2 or more listed above)<br />
  35. 35. Anterior Cavus Foot<br />Local = PF of 1st ray only<br />Global = entire FF is PF<br />Differentiating these two is important in determining proper surgical procedure <br />
  36. 36. Anterior Cavus Foot<br />C.I.A. < 30°<br />Meary’s angle > 10°<br />Meary’s angle intersects at base of 1st metatarsal or Lisfranc’s joint<br />
  37. 37. Rigid Anterior CavusCompensation<br /><ul><li>Pseudoequinus
  38. 38. Functional limitation of AJ dorsiflexion caused by premature use of the AJ motion to compensate for pure sagittal plane anterior pes cavus deformity
  39. 39. No STJ compensation</li></li></ul><li>Flexible Anterior CavusCompensation<br />FF dorsiflexion at midfoot with WB forces<br />Plantar buckling at MPJs<br />Retraction of toes at MPJs<br />
  40. 40. Posterior Cavus Foot<br />Primarily STJ deformity<br />Less common than anterior pes cavus<br />C.I.A. > 30°<br />Meary’s angle < 10°<br />Meary’s angle intersects proximal to Chopart’s joint<br />
  41. 41. Posterior CavusCompensation<br /><ul><li>Sagittal plane</li></ul>A) Flexible:<br /><ul><li>Plantarflexion Comp.
  42. 42. No change in CIA</li></ul>B) Rigid:<br /><ul><li>FF plantarflexion Comp.
  43. 43. Decreased CIA</li></li></ul><li>Combined Cavus Foot<br />Anterior and Posterior components<br /> C.I.A., talar declination angle, & met. declination angle<br />
  44. 44. Combined Cavus Foot<br />Primary Anterior<br />C.I.A. ~ 30°<br />Meary’s angle intersects at N-C joint<br />Primary Posterior<br />C.I.A. > 30°<br />Talar varus<br />Meary’s angle intersects at Chopart’s joint<br />
  45. 45. Pes Cavus Rearfoot Varus<br />Functional FF deformity with a rigid RF varus<br />Coleman Block test used to determine if RF varus is 1° or 2° deformity<br />
  46. 46. Treatment Goals<br />Correct the deformity<br />Relieve pain<br />Maintain a balanced foot<br />
  47. 47. Principles of Treatment<br />Underlying etiology MUST be determined<br />The plane of the deformity is critical<br />Cavus foot requires multilevel correction<br />ie. Digits, Lisfranc’s joint, Midfoot, Rearfoot<br />
  48. 48. Non Operative Treatment<br />Indications: mild pes cavus or when surgery is contraindicated<br />Shoe modifications and inserts<br />build up shoe<br />AFO<br />Physical Therapy<br />Stretching<br />
  49. 49. Surgical Correction<br />Soft tissue procedures<br />indicated for flexible deformities<br />often used in conjunction with osseous procedures<br />Osseous procedures<br />
  50. 50. Surgical Treatment Classification<br />Type I – Mild Pes Cavus<br />Flexible, may appear normal w/ WB<br />Tylomas and metatarsalgia<br />Contracted digits w/ extensor substitution<br />Surgery:<br />MPJ release<br />PIPJ fusions<br />Hibbs procedure<br />Other soft tissue releases<br />
  51. 51. Surgical Classification<br />Type II – Moderate Pes Cavus<br />More rigid and more evident clinically <br />Primarily sagittal plane deformity<br />Hammertoes, tylomas, metatarsalgia <br />Surgery:<br />DFWO of 1st metatarsal<br />Dwyer calcaneal osteotomy<br />Digital procedures<br />
  52. 52. Surgical Classification<br />Type III – Severe Pes Cavus<br />Marked rigid deformity<br />Gait abnormalities<br />Multiplanar<br />Surgery:<br />Major tarsal fusions or osteotomies<br />Digital procedures<br />Triple arthrodesis<br />
  53. 53. Soft Tissue Procedures<br />Plantar Fascia Release<br />Steindler Stripping<br />Garceau & Brahms<br />Tendon Transfers<br />Jones<br />Hibbs<br />STATT<br />PT Tendon Transfer<br />PL Tendon Transfer<br />
  54. 54. Pes CavusTreatment<br /><ul><li>Early deformity
  55. 55. plantar release
  56. 56. indicated in pt <10 y/o with signif pf of 1st ray
  57. 57. plantar medial release
  58. 58. indicated for rigid hindfoot w/fixed varus angulation
  59. 59. plantar release w/medial tarsal structures
  60. 60. tendon transfers
  61. 61. indicated for supple inversion deformity w/ weak evertor
  62. 62. lateral transfer of Tib Ant T to midtarsal area along 3rd ray</li></li></ul><li>S.T. Procedures<br />Steindler Stripping: release plantar fascia, abductor hallucis, FDB, abductor digiti quinti, and often the quadratus plantae muscle attachment to the heel<br />Garceau & Brahms: selective plantar muscle denervation. Resect motor branches of medial and plantar nerve. Historical procedure<br />
  63. 63. Tendon Transfers<br />Jones Suspension: transfer EHL from the hallux to the 1st metatarsal<br />indications: flexible PF 1st ray, weak Tib. Ant., helps DF ankle to  met declination angle<br />Hibbs Suspension: transfer EDL from each toe out to the midfoot (lateral cuneiform or cuboid)<br />indications: flexible anterior cavus, flexible claw toes, pts. with extensor substitution, pts. with weak tib. Ant./ EDL /EHL<br />
  64. 64. Hibbs Suspension<br />
  65. 65. Split Tibialis Anterior Tendon Transfer (STATT)<br /><ul><li>Split Tib. Ant. in half. Lateral half is transferred to insert with the peroneus tertius, lat. cuneiform, or cuboid.
  66. 66. Indications: weak anterior m., swing phase supination</li></li></ul><li>Tendon Transfers<br />Posterior Tibial Tendon Transfer: Very difficult. Out of phase transfer. Transfer Tib. Post. to dorsum of foot through EDL, peroneus tertius or Tib. Ant. tendon sheath.<br />Indications: weak anterior muscle group<br />TAL: only indication is spastic equinus<br />
  67. 67. Peroneus Longus Tendon Transfer/ Lengthening<br />PL Transfer: transfer PL to dorsum of lesser tarsus through EDL tendon sheath or split through Tib. Ant. & peroneus tertius sheaths.<br />STOP procedure: suture PL to PB<br />indications: flexible 1st ray, heel varus<br />PL Lengthening: decreases PF of 1st ray<br />Indications: flexible 1st ray, weak tibialis anterior m.<br />
  68. 68. Osseous Procedures<br />Digital Reduction<br />DFWO metatarsals<br />COLE<br />JAPAS<br />Dwyer<br />McElvenny-Caldwell<br />Triple Arthrodesis<br />
  69. 69. Digital Reduction<br />restore MPJ alignment<br />PIPJ arthrodesis<br />Extensor hood resection<br />Extensor tendon lengthening<br />flexor plate release<br />Fixate (K-wire)<br />
  70. 70. Metatarsal DFWO<br />Proximal metaphysis<br />dorsal distal to proximal plantar<br />maintain hinge if possible<br />fixation (screws or K-wires)<br />Indications:<br />local FF cavus<br />rigid PF 1st met<br />
  71. 71. COLE <br />DFWO at MTJ<br />base is dorsal & apex is proximal<br />often do plantar release also<br />preserves STJ & MTJ motion<br />indications:<br /> anterior cavus<br />
  72. 72. JAPAS<br />V shaped MTJ osteotomy with apex proximal<br />long incision, runs along EDL to the 3rd digit<br />maintains length<br />More normal looking foot<br />
  73. 73. JAPAS<br />
  74. 74. Dwyer<br />lateral closing wedge osteotomy<br />wider laterally than medially,  heel varus<br />Indications:<br />calcaneal varus<br />posterior cavus<br />non-reducible deformity<br />Contraindications:<br />reducible calcaneal varus 2° to PF 1st ray<br />Important to do Coleman Block test here<br />
  75. 75. Dwyer<br />
  76. 76. Dwyer<br />
  77. 77. McElvenny-Caldwell<br />Fuse 1st metatarsocuneiform navicular joints in a DF position<br />
  78. 78. Triple Arthrodesis<br />T-C, T-N, C-C<br />can correct all planal deformities<br />common for severe cases of pes cavus<br />Must decide the deformity 1st!<br />Adducted FF? Correct at MTJ<br />Sagittal plane deformity at MTJ? Cut wider wedge dorsally vs. plantarly<br />RF varus? Fix at STJ (cut wider laterally than medially)<br />
  79. 79. Triple Arthrodesis<br />
  80. 80. Triple Arthrodesis<br />
  81. 81. Pes Cavus<br /><ul><li>Disadvantages of midtarsal osteotomies
  82. 82. Stiffness
  83. 83. Non-unions
  84. 84. Under/over correction
  85. 85. Edema
  86. 86. Neurovascular compromise</li></li></ul><li>Important Points<br /><ul><li>ID etiology
  87. 87. ID apex of deformity
  88. 88. Determine from examination the appropriate correction technique.</li></li></ul><li>Physiotherapy Management<br />Pre-operatively<br />When practical the patient will be seen pre-operatively, and with consent, the following assessed:<br />Current functional levels<br />General health<br />Social / work / hobbies<br />Functional Range of Movement<br />Gait / mobility, including walking aids and orthoses<br />Post-operative expectations<br />Patient information leaflet issued<br />Post-operative management explained<br />
  89. 89. Post-operatively:<br />Always check the operation notes, and the post-operative instructions. Discuss any deviation from routine guidelines with the team concerned. This is very important as the patient may have had a combination of techniques which may affect weight-bearing status and progressions. <br />
  90. 90. Initial rehabilitation Phase:0-6 weeks<br />Goals:<br />To be safely and independently mobile with appropriate walking aid, adhering to weight bearing status<br />To be independent with home exercise programme as appropriate<br />To understand self management / monitoring, e.g. skin sensation, colour, swelling, temperature, circulation<br />
  91. 91. Restrictions<br />Ensure that weight bearing restrictions are adhered to:<br /> Standard RNOH pescavus surgery:<br />Full Plaster of Paris (POP) with ankle plantargrade for 2 weeks Non Weight Bearing (NWB) <br />POP changed at 2 weeks. Progress to Full Weight Bearing (FWB) in POP<br />POP removed at 6 weeks. May require aircast boot or other orthosis. FWB<br />If any other surgical techniques used ensure you check any restrictions with team as these may differ<br />Elevation <br />If sedentary employment, may be able to return to work from 4 weeks post-operatively, as long as provisions to elevate leg, and no complications<br />
  92. 92. Treatment:<br />Likely to be in POP<br />Pain-relief: Ensure adequate analgesia<br />Elevation: ensure elevating leg with foot higher than waist<br />Exercises: teach circulatory exercises<br />Education: teach how to monitor sensation, colour, circulation, temperature, swelling, and advise what to do if concerned<br />Mobility: ensure patient independent with transfers and mobility, including stairs if necessary<br />
  93. 93. On discharge from ward:<br />Independent and safe mobilising, including stairs if appropriate<br />Independent with transfers<br />Independent and safe with home exercise programme / monitoring<br /> Milestones to progress to next phase:<br />Out of POP. Team to refer to physiotherapy at 6 weeks from clinic.<br />Progression from NWB to FWB phase. Team to refer to physiotherapy if required to review safety of mobility / use of walking aids<br />Adequate analgesia<br />
  94. 94. Recovery rehabilitation phase:6 weeks – 12 weeks<br />Goals:<br />To be independently mobile out of aircast boot<br />To achieve full range of movement<br />To optimise normal movement<br />
  95. 95. Restrictions:<br /><ul><li>Ensure adherence to weight bearing status
  96. 96. No strengthening against resistance until at least 3 months post-operatively of tenodesis / any tendon transfers if performed
  97. 97. Do not stretch any tendon transfers / ligament reconstructions if performed. They will naturally lengthen over a 6 month period</li></li></ul><li>Treatment:<br />Pain relief<br />Advice / Education<br />Posture advice / education<br />Mobility: ensure safely and independently mobile adhering to appropriate weight bearing restrictions. Progress off walking aids as able once reaches FWB stage<br />Gait Re-education<br />Wean out of aircast boot once advised to do so, and provision of plaster shoe as appropriate, if patient unable to get into normal footwear<br />
  98. 98. Exercises: <br />Passive range of movement (PROM)<br />Active assisted range of movement (AAROM)<br />Active range of movement (AROM)<br />Strengthening exercises as appropriate<br />Core stability work<br />Balance / proprioception work once appropriate<br />Stretches of tight structures as appropriate (e.g. Achilles Tendon), not of tendon transfers / ligament reconstructions if performed<br />Review lower limb biomechanics. Address issues as appropriate<br />If tendon transfer performed, encourage isolation of transfer activation without overuse of other muscles. Biofeedback likely to be useful<br />Swelling Management<br />
  99. 99. Manual therapy:<br />Soft tissue techniques as appropriate<br />Joint mobilisations as appropriate ensuring awareness of osteotomy sites and those joints which may be fused, and therefore not appropriate to mobilise<br />Monitor sensation, swelling, colour, temperature, circulation<br />Orthotics if required via surgical team<br />Hydrotherapy if appropriate<br />Pacing advice as appropriate<br />
  100. 100. Milestones to progress to next phase:<br />Full range of movement<br />Independently mobilising out of aircast boot <br />Neutral foot position when weight bearing / mobilising<br />Tendon transfers activating if performed<br />
  101. 101. Failure to meet milestones:<br />Refer back to team / Discuss with team<br />Continue with outpatient physiotherapy if still progressing<br />
  102. 102. Intermediate Rehabilitation Phase12 weeks – 6 months<br />Goals:<br />Independently mobile unaided<br />Wearing normal footwear<br />Optimise normal movement<br />Grade 4 or 5 muscle strength around ankle (NB. This may vary if neurological cause for pescavus)<br />
  103. 103. Treatment<br /><ul><li>Further progression of the above treatment:
  104. 104. Pain relief
  105. 105. Advice / Education
  106. 106. Posture advice / education
  107. 107. Mobility: Progression of mobility and function
  108. 108. Gait Re-education</li></li></ul><li>Exercises:<br />Range of movement<br />Strengthening exercises as appropriate<br />Core stability work<br />Balance / proprioception work <br />Stretches of tight structures as appropriate (e.g. Achilles tendon), not of transfers / ligament reconstructions if performed.<br />Review lower limb biomechanics. Address issues as appropriate<br />If tendon transfer performed progress isolation of transfer activation without overuse of other muscles. Biofeedback likely to be useful<br />Swelling Management<br />
  109. 109. Manual therapy:<br />Soft tissue techniques as appropriate<br />Joint mobilisations as appropriate ensuring awareness of those which may be fused and therefore not appropriate to mobilise<br />Monitor sensation, swelling, colour, temperature, circulation<br />Orthotics if required via surgical team<br />Hydrotherapy if appropriate<br />Pacing advice as appropriate<br />
  110. 110. Milestones to progress to next phase:<br />Independently mobile unaided<br />Wearing normal footwear<br />Adequate analgesia<br />Tendon transfers to be activating if performed<br />
  111. 111. Failure to meet milestones:<br />Refer back to team / Discuss with team<br />Continue with outpatient physiotherapy if still progressing<br />
  112. 112. Final rehabilitation phase6 months – 1 year<br />Goals:<br />Return to gentle low-impact sports<br />Establish long term maintenance programme<br />Grade 5 muscle strength around ankle and grade 4 or 5 of tendon transfers if performed (NB. This may vary if neurological cause for pescavus)<br /> Treatment:<br />Mobility / function: Progression of mobility and function, increasing dynamic control with specific training to functional goals <br />Gait Re-education<br />
  113. 113. Exercises: <br />Progression of exercises including range of movement, strengthening, transfer activation, balance and proprioception, core stability<br />Swelling Management<br />Manual therapy<br />Soft tissue techniques as appropriate<br />Joint mobilisations as appropriate ensuring awareness of those which may be fused and therefore not appropriate to mobilise<br />Pacing advice <br />
  114. 114. Milestones for discharge<br /><ul><li>Independently mobile unaided
  115. 115. Appropriate patient-specific functional goals achieved
  116. 116. Independent with long term maintenance programme</li></li></ul><li>Failure to progress<br />If a patient is failing to progress, then consider the following:<br />
  117. 117.
  118. 118.
  119. 119.
  120. 120.
  121. 121.
  122. 122. Bibliography<br /><ul><li>Canale, S. Terry, M.D.. Campbell’s Operative Orthopaedics. Mosby. St. Louis, 1998.
  123. 123. Hansen, Sigvard, M.D.. Functional Reconstruction of the Foot and Ankle. Lippincott Williams & Wilkins. Philadelphia, 2000.
  124. 124. Jahass, Melvin, M.D.. Disorders of the Foot and Ankle, 2nd edition. W.B. Saunders Company. Philadelphia, 1991.
  125. 125. Kelikian, Armen. Operative Treatment of the Foot and Ankle. Appleton & Lange. Stamford, 1999.
  126. 126. McGlamry, E. Dalton, D.P.M.. Comprehensive Textbook of Foot Surgery. Lippincott Williams & Wilkins. Baltimore, 2001.</li></li></ul><li>Bibliography<br />Myerson, Mark, M.D. Foot and Ankle Disorders. W.B. Saunders Company. Philadelphia, 2000.<br />Resnick, Donald, M.D.. Bone and Joint Imaging, 2nd edition. W.B. Saunders Company. Philadelphia, 1996.<br />Sammarco, James, M.D., Taylor, Ross, M.D.. “Cavovarus Foot Treated with Combined Calcaneus and Metatarsal Osteotomies.” Foot & Ankle International. 22:1; 19-30. 2001.<br /> <br />
  127. 127. Thank You<br />For being so attentive…………………………..<br /><br />
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