This document discusses cavovarus foot deformity, which is characterized by an elevated medial longitudinal arch, plantarflexed first ray, pronated forefoot, and varus hindfoot. It covers the anatomy of the foot arches, epidemiology, etiology, evaluation, radiographic findings, and management. Cavovarus deformity can be caused by neurological conditions like Charcot-Marie-Tooth disease or be idiopathic. Evaluation involves physical exam, x-rays, and further studies if needed. Management is either non-operative with accommodative shoes or operative with soft tissue procedures for flexible deformities and bony procedures for rigid deformities. Common surgical techniques are described.

1. CAVUVARUS
FOOT
DEFORMITY
Presenter: Abdulrhman Alansser
PGY:2, KSMC, SA
Supervisor: Dr.Ali Aldosari

2. OUTLINE
v Anatomy
v Epidemiology
v Etiology
v Evaluation
v Radiological Findings
v Management
v Cases
v Discussion

3. ANATOMYOFTHEARCHES OF FOOT
v Two longitudinal arches:
Ø Medial longitudinal arch
Ø Lateral longitudinal arch
v Transverse arch:
Ø Anterior transverse arch
Ø Posterior transverse arch

4. v Supports body weight in upright posture
v Acts as a lever to propel the body forwards in walking,
running and jumping
v Acts as a shock absorber
v Concavity of the arches protects the soft tissues of the sole
against pressure
ARCHES FUNCTION

5. MEDIAL LONGITUDINAL ARCH
v Higher than lateral
v Composed of
Ø Calcaneous
Ø Talus
Ø Navicular
Ø 3 cuneiform
Ø 3 metatarsals
v Talar head is key stone of this arch

6. v Flatter than medial longitudinal arch
v Rests on the ground during standing
v It is made up of – calcaneous, cuboid, 2 lateral metatarsals
LATERAL LONGITUDINALARCH

7. v Runs from side to side
v It is formed by cuboid,
cuneiforms, bases of
metatarsals
v Medial and lateral parts of
longitudinal arch act as
pillars
v Tendons of fibularis longus
and tibialis posterior
TRANSVERSE ARCH

8. INTEGRITY OF BONYARCHES
v Maintained by
passive factors and
dynamic supports

9. PASSIVE FACTORS
v Shape of the united bones
v Four successive layers of fibrous tissue
bowstring the longitudinal arch:
Ø Plantar aponeurosis
Ø Long plantar ligament
Ø Plantar calcaneocuboid
(short plantar) ligament
Ø Plantar calcaneonavicular
(spring) ligament

10. DYNAMIC SUPPORTS
v Active bracing action of intrinsic muscles of foot
v Active and tonic contraction of muscles with long tendons
extending in to foot
Ø Flexor hallusis and digitorum longus – longitudinal arch
Ø Fibularis longus and tibialis posterior – transverse arch
v Plantar ligaments and plantar aponeurosis bear greatest stress and
important in maintaining arches

11. MECHANISM OF ARCH SUPPORT
v SHAPE OF BONES:
Ø Bones are wedge-shaped with the thin edge lying inferiorly
Ø This applies particularly to the bone occupying the center of the arch
“keystone” (Head of the Talus)

12. v SUSPENDING THE ARCH FROM ABOVE:
MECHANISM OF ARCH SUPPORT
Ø Medial longtitudinal arch: Tibialis anterior, Tibialis posterior, medial
ligament of ankle joint
Ø Lateral longtitudinal arch: Peroneus longus, Peroneus brevis
Ø Transverse arch: Peroneus longus

13. WHAT IS A CAVOVARUS?
v Cavovarus, the most frequent type of cavus foot
v Presents with:
Ø Elevated medial longitudinal arch (Cavus)
Ø First ray plantarflexion with
Ø Forefoot pronation and adduction
Ø And, if rigid, a fixed hindfoot varus

15. EPIDEMIOLOGY
§ Seen in both pediatric and adult
populations
§ 67% due to a neurologic
condition
§ When bilateral often hereditary
or congenital

16. ETIOLOGY
Neurological
Causes
Charcot Marie
Tooth disease
Friedrich’s
Ataxia
Roussy-Levy
syndrome
Poliomyelitis
Cerebral Palsy
Congenital
Spina Bifida
Talipes
Equinovarus
Myelodysplasia
Clubfoot
Iatrogenic
Post surgery or
trauma
Peroneal nerve
injury
Infection
Syphillis
Poliomyelitis
Idiopathic
In traumatic it could be a result of:
• Talus fracture malunion
• Compartment syndrome
• Crush injury

17. ETIOLOGY
v Neurological
Ø Unilateral: Rule out tethered spinal cord or spinal cord tumor
Ø Bilateral: Most commonly Charcot-Marie-Tooth (CMT) disease
v It occurs as muscle imbalances that generate the deformity:
Ø Weak tibialis anterior and peroneus brevis overpowered by strong peroneus
longus and posterior tibialis
Ø Results in plantarflexed 1st ray and forefoot pronation with
compensatory hindfoot varus
Ø While initially flexible, hindfoot varus can become rigid with time

18. EVALUATION
v HX:
Ø Recurrent ankle sprains and lateral ankle pain
§ Peroneal tendon pathology
Ø Lateral foot pain
§ Excessive weight bearing by the lateral foot due to deformity
§ Can result in 5th metatarsal stress fractures
Ø Painful plantar calluses under 1st metatarsal head and 5th metatarsal head or
base
Ø Plantar fasciitis
§ Elevated medial arch, forefoot pronation and tight gastronemius lead to
contracture of the plantar fascia

19. EVALUATION
v PX:
Ø Gait:
§ Ask child to walk, run, toe walk, heel walk, squat and stand, and hop on
each foot.
§ Look for unstable base of support
§ Increased double limb stance and decreased single limb stance
Ø Thigh Foot Angle:
§ Developmental cavovarus usually associated with external tibial torsion
that is usually appears after foot corrective surgery
§ Normal (up to +10-15°)

20. EVALUATION
v PX Cont.:
Ø Peek A Boo Heel:
§ Anterior standing examination shows varus
heel “peeking” around the ankle
Ø Silfverskiold Test:
§ Check dorsiflexion with both knee flexion and extension
• If tight only with knee extension >> Gastrocnemius is tight
• If tight with knee flexion and extension >> Gasto. + Soleus are tight

21. EVALUATION
v PX Cont.:
Ø Coleman Block Test
§ Evaluates flexibility of the hidfoot deformity
§ Used under the lateral forefoot
§ Eliminates contribution of the plantarflexed 1st ray and forefoot pronation
to the hindfoot deformity
• Flexible hindfoot will correct to neutral or valgus
• Rigid won’t!!
§ Hard to be performed in pediatrics

22. EVALUATION
v PX Cont.:
Ø Modified Coleman Block Test
§ 2.5-cm block is placed under the lateral 2–3 MT heads
§ The heel remains on the ground and the medial MT heads seek the
ground as the forefoot pronates off the block
§ Guides surgical treatment
• Flexible hindfoot deformities resolve with forefoot corrective
procedures
• Rigid hindfoot deformities require corrective hindfoot osteotomy in
addition to forefoot procedures

24. EVALUATION
v PX Cont.:
Ø Prominent first metatarsal fat pads
Ø Wasting of 1st dorsal interosseous muscle of the hand
§ Suggestive of CMT
Ø Spine exam:
§ Scoliosis is suggestive of CMT
Ø Hip examination:
§ Painful hip usually with CMT
• X-ray: Acetabular dysplasia

25. v AP (weight bearing):
Ø Talocalcaneal angle
§ < 20° (nl 20-45)° (hindfoot varus)
Ø Talonavicular coverage angle
§ Talonavicular angle > 7° (forefoot adduction)
Ø Metatarsal Overlap
§ Indicates forefoot pronation
RADIOGRAPHIC FINDINGS
Lines connecting the edges

26. v Lateral:
Ø Lateral Talo-First metatarsal angle (Meary's angle)
§ > 4° apex dorsal break in Meary's line caused by plantarflexion of the
1st ray
Ø Sinus tarsi see-through sign and double talar dome sign
Ø Calcaneal pitch or inclination angle > 30°
RADIOGRAPHIC FINDINGS

27. v Oblique:
Ø Metatarsal stress fractures
Ø Calcaneonavicular coalitions
RADIOGRAPHIC FINDINGS

28. Ø Electrodiagnostic Studies (EMG/NCS)
Ø Genetic studies
Ø e.g. In CMT disease its necessary to do:
§ Neurological physical examination
§ Electrodiagnostic studies
§ Genetic testing
FURTHER STUDIES

29. MANAGEMENT
v Nonoperative treatment:
Ø Accommodative shoe wear with over-the-counter soft arch
supports until neuromuscular workup is done—then operate
v Operative indications:
Ø Pain, gait instability, skin pressure injuries, and/or progressive
deformity
Ø Following completion of a neuromuscular workup, with treatment
of the underlying condition if treatment exists

30. MANAGEMENT
v Operative Management:
Ø Based on the Cavovarus Flexibility
§ Flexible: soft tissue procedures
§ Rigid: Bony procedures
Ø Age
§ Children: more flexible deformities (soft tissue procedures might be
enough)
§ Adults: often will require bony corrective procedures

31. COMMON SURGICAL TECHNIQUES
v Superficial plantar-medial release

32. COMMON SURGICAL TECHNIQUES
v Superficial plantar-medial release

34. COMMON SURGICAL TECHNIQUES
v Deep Medial Release (D-MR)

36. COMMON SURGICAL TECHNIQUES
v Gastrocnemius Recession (Strayer Procedure)

38. COMMON SURGICAL TECHNIQUES
v Percutaneous Tenotomies of the FHL & FDL
FHL

39. COMMON SURGICAL TECHNIQUES
v Percutaneous Tenotomies of the FHL & FDL
FDL

41. COMMON SURGICAL TECHNIQUES
v Mini-open double cut slide TAL

43. COMMON SURGICAL TECHNIQUES
v Peroneus Longus to Peroneus Brevis Transfer
Ø The most important tendon transfer for most cavovarus foot deformities

44. COMMON SURGICAL TECHNIQUES
v Peroneus Longus to Peroneus Brevis Transfer

48. REFERENCES
v Joseph, B., 2009. Paediatric Orthopaedics A SYSTEM OF DECISION
MAKING. 1st ed.
v Joseph, B., 2009. Paediatric Orthopaedics A SYSTEM OF DECISION MAKING.
1st ed.
v Orthobullets.com

49. THANK YOU