Is Subtle Cavovarus a Problem for Athletes?

Cavovarus or high-arched foot is a common foot deformity that occurs due to the disruption of the foot-driven equilibrium between the first metatarsal, fifth metatarsal, and the heel. This imbalance leads to an increase in the foot's normal plantar concavity. Cavovarus deformity ranges from a mild and flexible malalignment to a fixed, complex, and severe deformation. Subtle cavovarus foot, the mild form of the cavus foot, was first described by Manoli and colleagues.

Managing Cavovarus Feet in Diabetic Patients.

A cavovarus foot is characterized by exacerbated medial longitudinal arch (cavus), hindfoot varus, plantar flexed first ray, forefoot pronation (apparent supination), forefoot adduction, and claw toe deformities. It can be broadly divided as flexible and rigid and further classified based on the neurological and non-neurological causes. Diabetes associated peripheral neuropathy complicates individual bony deformities associated with cavovarus foot with early callus which can breakdown to ulceration rapidly. Based on the disease progression in neurological and non-neurological causes of cavovarus feet in patients with diabetic neuropathy, 3 stages of the disease and its management is described.

From second webspace syndrome to second cross over toe: Clinical and radiological findings following Weil osteotomy with no soft tissue procedure.

BACKGROUND: The second webspace syndrome (SWS) refers to the progressive divergence between 2nd and 3rd toes associated with pain at the second intermetatarsal space that can be confused with Morton's neuroma and treated as such without considering the underlying deformity. There is yet no consensus regarding the best treatment, from isolated soft tissue or bony procedures or a combination of both. The objective of this study was to describe the clinical characteristics of the disease, as well as to evaluate the radiological outcomes of patients with SWS treated with open Weil's osteotomy or distal metatarsal minimal invasive osteotomy (DMMO) of the second metatarsal, with main emphasis on medialization of the head in the anteroposterior plane in either procedure. METHODS: A retrospective study of all patients with SWS treated with Weil's medializing osteotomy (open and percutaneous) associated or not with other forefoot procedures, treated between 2012 and 2019, was performed. Radiological variables such as metatarsal-phalangeal angle (MTPA), percentage of metatarsal uncoverage of M2 with respect to its phalanx, intermetatarsal angle (M1, M2 and M3), length of second metatarsal and intermetatarsal distance M2 - M3 were measured and compared before and after surgery. RESULTS: Twenty-six patients were included, with a mean follow-up of 26 months. All patients presented divergence between the 2nd and 3rd toes, 75 % associated pain at the level of the second intermetatarsal space and two patients presented neuropathic symptoms. After surgery (nineteen open and seven DMMO), all patients rated their results as good or excellent, and the two patients with neuropathic symptoms had improvement in their symptoms. Regarding the radiological results, the percentage of subluxation of the second MTP decreased in a large percentage of the operated patients (from 43.3 % to 3.9 %) with statistical significance as well as the length of M2, IM angle between M1 - M2, IM distance between M2-M3 and the percentage of uncoverage of the second MTP (p < 0.001). CONCLUSION: Medial translation associated with open Weil osteotomy or DMMO seems to correct the muscle-ligament imbalance of the second metatarsophalangeal joint and restore normal radiographic measurements, especially in the coronal and sagittal plane, without the need for soft tissue procedures, as well as the resolution of associated neuropathic symptoms in some patients. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Mediciones de imágenes fotográficas del pie como una metodología no invasiva y válida en la exploración clínica / Measurements of the Foot Photo Images as a Non-Invasive and Valid Methodology in Clinical Examination

Introducción: La evaluación anatómica músculo esquelética por imagen en la exploración clínica del pie diabético es la fotografía digital que evalúa la morfología superficial. Objetivos: Validar la obtención de las imágenes fotográficas del pie, calcular las mediciones longitudinales, angulares y el índice del arco plantar, de las imágenes fotográficas del pie por fotogrametría, y basados en estas, categorizar la normalidad de la forma en sujetos sanos. Métodos: Estudio exploratorio en 30 individuos sanos evaluados en la Unidad clínica de pie diabético en la ciudad de Trujillo, mediante un prototipo de cámaras alrededor de un podoscopio y un software de análisis de imágenes. La imagen fotográfica fue evaluada por mediciones longitudinales, angulares y el índice del arco plantar. Resultados: Los pacientes evaluados tenían una edad media de 25,06+/-11,95 años, y predominaron las mujeres. La longitud total del pie y anchura del metatarso en el lado derecho fue de 226,55 ± 36,49 mm y 98,99 ± 22,71 mm respectivamente; y en el lado izquierdo fue de 229,81 ± 42,25 mm y 104,49 ± 16,84 mm respectivamente. El ángulo intermetatarsal del 1-2 rayo, ángulo intermetatarsal del 4-5 rayo y ángulo del retropié para el lado derecho fueron 14 ± 4º, 11 ± 3º y 2 ± 2º respectivamente; para el lado izquierdo 14 ± 3º, 9 ± 3º y 2 ± 2º respectivamente, y el índice plantar del arco derecho e izquierdo fueron 0,23 ± 0,2 y 0,22 ± 0,1 respectivamente. La variabilidad solo se presentó en el antepie en el 20 percent de los casos. Conclusiones: La obtención de las imágenes fotográficas del pie fueron válidas, las mediciones fueron menores o similares a otros estudios. La variabilidad de la normalidad solo se presentó en el antepie(AU)

Introduction: The musculoskeletal anatomical evaluation by imaging in the clinical examination of the diabetic foot is digital photography that assesses the superficial morphology. Objectives: To validate the obtaining of photographic images of the foot, to calculate the longitudinal and angular measurements and the index of the plantar arch, from the photographic images of the foot by photogrammetry, and to categorize the normality of the shape in healthy subjects, based on these photographic images. Methods: This an exploratory study in 30 healthy individuals evaluated at the Diabetic Foot Clinical Unit in Trujillo city, using a prototype of cameras around a podoscope and image analysis software. The photographic image was evaluated by longitudinal and angular measurements and the plantar arch index. Results: The patients evaluated had a mean age of 25.06+/-11.95 years, and women predominated. Total foot length and metatarsal width on the right side were 226.55 ± 36.49 mm and 98.99 ± 22.71 mm, respectively; and on the left side it was 229.81 ± 42.25 mm and 104.49 ± 16.84 mm, respectively. The 1st-2nd ray intermetatarsal angle, 4th-5th ray intermetatarsal angle and hindfoot angle for the right side were 14 ± 4º, 11 ± 3º and 2 ± 2º respectively; for the left side 14 ± 3º, 9 ± 3º and 2 ± 2º respectively, and the plantar index of the right and left arch were 0.23 ± 0.2 and 0.22 ± 0.1 respectively. Variability only occurred in the forefoot in 20 percent of cases. Conclusions: Obtaining of the photographic images of the foot was valid, measurements were smaller or similar to other studies. The variability of normality only appeared in the forefoot(AU)

Pediatric Forefoot Deformities.

This article explores different pediatric forefoot deformities including syndactyly, polydactyly, macrodactyly, curly toe, and congenital hallux varus. The epidemiology and genetic background are reviewed for each condition. Preferred treatment options and recommended surgical techniques are discussed with review of the current literature.

The Foot in Cerebral Palsy.

Children with cerebral palsy frequently develop foot deformities, most commonly equinus contractures, which can be managed with orthotics up to age 5 to 7 years. Plantar flexor lengthening, typically around this age, should be restricted to the offending muscle only, usually with a fascia release of the gastrocnemius. Equinovarus, mainly a problem in children with unilateral cerebral palsy, often responds to plantar flexor lengthening. If further tendon transfers are needed, they should be done when the child is older to avoid overcorrection. Planovalgus mostly improves spontaneously up to age 5 years. Surgical correction is best done in adolescence.

Calcaneal Osteotomies in the Treatment of Progressive Collapsing Foot Deformity. What are the Restrictions for the Holy Grail?

The progressive collapsing foot deformity is a complex three-dimensional deformity, including valgus malalignment of the heel. The medial displacement calcaneal osteotomy is an established surgical procedure reliably resulting in an efficient correction of the inframalleolar alignment. However, complications are common, including undercorrection of underlying deformity, progression of hindfoot osteoarthritis and/or deformity, and/or symptomatic hardware.

Surgical Management of Musculotendinous Balance in the Progressive Collapsing Foot Deformity: The Role of Peroneal and Gastrocnemius Contracture.

Surgical treatment of progressive collapsing foot deformity (PCFD) relies on understanding the dynamic and deforming musculotendinous structures that contribute to hindfoot valgus, forefoot abduction, forefoot varus, and collapse or hypermobility of the medial column. Equinus commonly is seen in PCFD and consideration should be given to isolated gastrocnemius or Achilles lengthening. Although transfer of the flexor digitorum longus tendon is performed in PCFD attributed to dysfunction and pathology of the posterior tibialis tendon (PTT), retention of PTT is an area for further research. The peroneus brevis, which contributes to hindfoot imbalance in chronic cases, is a possible component of tendon rebalancing.

Deformidades de los pies en niños / Foot deformities in children

Las alteraciones en los pies son una consulta frecuente en ortopedia pediátrica. La gran mayoría corresponde a condiciones que no constituyen patología y habitualmente no necesitan tratamiento, como el pie plano flexible. Por otro lado, existen deformidades patológicas que necesitarán un adecuado estudio y tratamiento. Según su morfología podemos clasificarlas en cavo-varo, plano-valgo y misceláneas. Su origen puede ser congénito o adquirido y de diversas etiologías, destacando el pie bot, metatarso varo, hallux valgus juvenil y aquellas secundarias a enfermedades neuromusculares, entre otras. Conocer la historia natural de cada deformidad nos permite decidir el momento más adecuado para cada tratamiento. Los antecedentes mórbidos y perinatales del paciente son muy importantes, así como el nivel de actividad física y/o deportiva. El examen físico debe incluir observar la marcha, extremidades inferiores, tobillo y pie. En el pie se debe analizar cada segmento por separado (antepié, mediopié y retropié) y las articulaciones respectivas. Es muy importante distinguir entre deformidades rígidas y flexibles. El tratamiento incluye la observación (condiciones benignas y autolimitadas), calzado adecuado, insertos plantares, órtesis, yesos correctores, cirugía de partes blandas y cirugía ósea; todo complementado por un adecuado programa de rehabilitación funcional y deportivo.

Foot disorders are a frequent cause of consultation in pediatric orthopaedics. The vast majority correspond to conditions that don't constitute pathology and usually don ́t need treatment, such as flexible flat foot. On the other hand, there are pathological deformities that will require a proper study and treatment. According to their morphology we can classify them in cavo-varus, plano-valgus and miscellaneous. Its origin can be congenital or acquired and due to various etiologies, highlighting clubfoot, metatarsus adductus, juvenile hallux valgus and those secondary to neuromuscular diseases, among others. Knowing the natural history of each deformity allows us to decide the most appropriate time for each treatment. Patient's morbility and perinatal history is very important, as well as their level of physical and/or sports activity. Physical exam should include gait obsevation, lower limbs, ankles and feet. In the foot, each segment should be analyzed separately (forefoot, midfoot and hindfoot) and their joints. It ́s very important to distinguish between rigid and flexible deformities. Treatments include observation (benign and self-limited conditions), adequate footwear, insoles, orthosis, corrective casting, soft tissue surgery and bone surgery; all complemented by an adequate functional and sports rehabilitation programs

Foot deformities in patients with diabetic mellitus (with and without peripheral neuropathy).

BACKGROUND: Diabetic peripheral neuropathy (DPN) is one of the most common complications in diabetes mellitus. It is the disorder that most commonly affects the feet of people with diabetes. The aim of the present study is to determine the relationship between DPN and the presence of deformities in the foot. MATERIAL AND METHODS: A descriptive observational study was conducted of 111 patients diagnosed with Diabetes Mellitus (DM) type 1 or 2. All participants were aged at least 18 years and were previously informed in detail about the aims and procedures of the study. RESULTS: Regarding the presence of DPN, the only significant relationships were found for the right foot with the deformity of the second toe (claw, hammer or mallet) (p = 0.017, OR 0.29 [0.10-0.83]) and for the left foot with the deformity of the second toe (p = 0.048; OR: 0.37 [0.14-1.01]), third toe (p = 0.012; OR: 0.29 [0.11-0.79]) and the presence of hallux extensus (p = 0.05; OR: 8.27 [1.05-64.98]). CONCLUSIONS: A significant number of foot deformities were observed among these patients with DM, regardless of the presence of DPN. These deformities should be carefully evaluated in order to determine the most appropriate treatment at an early stage, which will reduce the risk of ulceration. Although it should be use with caution to be transferrable to the general population with peripheral neuropathy.

Vulnerability of the foot's morphological structure to deformities caused by foot loading paradigm in school-aged children: a cross-sectional study.

The study aimed to assess the association between the key predictive foot structure variables and its loading paradigm in 625 school-aged children. Clinical appraisal relied primarily on having the plantar parts of their feet comprehensively assessed with Podoscan 2D Foot CAD, and a dynamometer platform, the research tools of choice widely acknowledged for their overall accuracy and reliability, with a view to determining the distribution of respective foot loads, as well as addressing both balance and gait issues. The Clarke's angle, Wejsflog index, length and width of the feet, regardless of gender, proved the key predictive variables for the foot-loading paradigm. Notably the Clarke's angle, construed the most sensitive variable in assessing flat-footedness, offered an extra added value in overall investigative effort. The actual design of the study protocol effectively complements a standard clinical assessment procedure, whereas by comprehensively addressing those variables, it is also believed to aid clinicians in gaining an extra, hands-on, diagnostic potential, so that any teenagers exposed to the highest risk of developing foot deformities could effectively be identified through pertinent screening tests, and consequently offered a task-oriented, therapeutic management, specifically aimed at preventing potential postural complaints in later life.

[Surgical treatment options of foot deformities caused by neuromuscular disorders].

Many neuromuscular diseases can lead to paresis and/or spasticity of the peripheral muscles. Due to an unbalance between agonists and antagonists deformities of the foot and ankle may develop. These deformities can often be handled by nonoperative measures but in some patients the effect is insufficient. In these cases, surgical treatment with tendon transfers, osteotomies or arthrodesis can lead to satisfying results. The purpose of this review is to create an overview of the treatment concepts and options for these diseases.

Discrepancy between true ankle dorsiflexion and gait kinematics and its association with severity of planovalgus foot deformity.

BACKGROUND: In planovalgus deformity with triceps contracture, a midfoot break happens, and ankle dorsiflexion (ADF) occurs at the mid-tarsal joint during gait. Results of standard 3D gait analysis may misinterpret the true ankle dorsiflexion because it recognizes the entire foot as a single rigid segment. We performed this study to investigate whether the severity of planovalgus deformity is associated with the discrepancy between the value of ADF evaluated by physical examination and 3-dimensional (3D) gait analysis. In addition, we aimed to identify the radiographic parameters associated with this discrepancy and their relationships. METHODS: Consecutive 40 patients with 65 limbs (mean age, 11.7 ± 5.5 years) with planovalgus foot deformity and triceps surae contracture were included. All patients underwent 3D gait analysis, and weightbearing anteroposterior (AP) and lateral (LAT) foot radiographs. ADF with knee extension was measured using a goniometer with the patient's foot in an inverted position. RESULTS: Twenty-one limbs underwent operation for planovalgus foot deformity, and 56 limbs underwent operation for equinus deformity. The difference between ADF on physical examination and ADF at initial contact on gait analysis was 17.5 ± 8.4°. Differences between ADF on physical examination and ADF at initial contact on gait analysis were significantly associated with the LAT talus-first metatarsal angle (p = 0.008) and calcaneal pitch angle (p = 0.006), but not associated with the AP talus-first metatarsal angle (p = 0.113), talonavicular coverage angle (p = 0.190), talocalcaneal angle (p = 0.946), and naviculocuboid overlap (p = 0.136). CONCLUSION: The discrepancy between ADF on physical examination and 3D gait analysis was associated with the severity of planovalgus deformity, which was evaluated on weightbearing LAT foot radiographs. Therefore, physicians should be cautious about interpreting results from 3D gait analysis and perform a careful physical examination to assess the degree of equinus deformity in patients with planovalgus foot deformity.

Foot and Ankle Musculoskeletal Imaging of Pediatric Patients With Cerebral Palsy.

OBJECTIVE. Any combination of abnormal positioning of the ankle, hindfoot, midfoot, and forefoot is possible in the context of cerebral palsy, but some patterns are more common than others. The purpose of this article is to discuss the radiographic manifestations and surgical management of the following common conditions: equinus, equinoplanovalgus, equinocavovarus, vertical talus, oblique talus, hallux valgus, and ankle valgus. CONCLUSION. CP is defined by abnormalities of the developing fetal or infant brain that result in permanent central motor dysfunction. Foot and ankle deformities are very common in the patients with CP, occurring in up to 93% of such patients as a result of underlying abnormal muscle tone, impaired motor control, and dynamic muscle imbalance. Radiologists must develop knowledge of the most common changes in alignment and basic techniques for correction to better recognize abnormalities and improve communication with orthopedic colleagues.

Podiatry alterations in Ehlers-Danlos syndrome. / Alteraciones podológicas en el síndrome de Ehlers-Danlos.

BACKGROUND AND OBJECTIVE: This paper aims to describe the type of foot and most frequent podiatric alterations, as well as the level of pain, disability, fatigue and alteration of quality of life in patients with Ehlers-Danlos syndrome (EDS). MATERIALS AND METHODS: Thirty-eight individuals with hypermobile or classic EDS participated. The percentage of pain in the foot and deformities was recorded, and several questionnaires were administered. The type of foot was classified according to the footprint and the Foot Posture Index. RESULTS: There was a high degree of pain, disability, intensity of fatigue and low quality of life in these patients. According to the footprint, 20% presented flat feet, 47% normal feet and 33% cavus feet. CONCLUSIONS: The participants in this study had a high percentage of foot problems related to high levels of pain and limited functionality in the feet. The quality of life of these patients appeared diminished. Foot types were observed according to the footprint and deformities similar to those of the general population.

Using the Biomechanical Examination to Guide Therapy.

In trying to explain the myriad of foot deformities and symptoms that have slow onset and/or are considered to be overuse syndromes, clinicians have been trying to develop quantitative examinations to describe the cause of the patient's problems and to better individualize treatment modalities. This type of examination is called a biomechanical examination. This article discusses some of the more common portions of a biomechanical examination of the foot and lower extremity. It will also point out some ways that the information from a biomechanical examination can be applied in clinically treating patients.

Talectomy as Part of Chronic Foot and Ankle Deformity Correction Procedure: A Retrospective Study.

Severe foot and ankle deformities can be associated with high complication rates and impaired quality of life in patients. Surgical correction using a talectomy procedure has previously been described in many lower extremity pathologies and is a powerful tool for the correction of severe foot and ankle deformity. This study aimed to describe the role of talectomy and the outcomes of this procedure in patients presenting with severe foot and ankle deformity. A review of 45 patients undergoing talectomy by a single surgeon was completed. Data extracted included the cause of deformity, history of infection, body mass index, and relevant comorbidities. Outcome measures of interest were minor or major complications and limb functionality at final follow-up. Statistical analysis was performed by using a Wilcoxon rank sum test and a Fisher exact test looking at variables affecting selected outcome measures. Limb salvage occurred in 38 of 45 patients (84.4%). Patients with an infection history had 89% lower odds of a functional limb at final follow-up (p = .0389). Six of 7 patients (85.7%) who ultimately underwent amputation had a history of prior infection. Women had 8.25 times higher odds of having a functional limb compared with men (p = .047). All 13 patients with major complications had neuropathy (p = .024). Patients with chronic lower extremity deformities can successfully be treated with a talectomy as a part of the reconstructive procedure. This is a challenging patient population that is associated with a high complication rate. Patients with a history of infection should be counseled on the possibility of requiring major amputation.

Foot Deformities in Women Are Associated with Wearing High-Heeled Shoes.

BACKGROUND The aim of this study was to assess the association between foot deformities and type of shoe regularly worn at work. MATERIAL AND METHODS We studied 150 employed women ages 30-40 years and divided them into 3 groups according to type of footwear worn: women in Group I wore flat-soled shoes, women in Group II wore mid-heeled shoes (heels 4.0±0.5 cm), and women in Group III wore high-heeled shoes (heels 10.0±0.5 cm). We used the CQ-ST podoscope for measurements. RESULTS We found significant differences in right foot γ angle between Groups I and III (p=0.033) and between Groups II and III (p=0.040). For the left foot, differences were noted between Groups I and III (p=0.012). Group III subjects had higher values of alpha angle compared to Group I (p=0.000) and Group II (p=0.000). Significant correlations were also found between specific type of footwear worn and the incidence of hallux valgus of the right foot (p=0.010) and left foot (p=0.000), and the varus deformity of the fifth toe (ß) of the left foot (p=0.015). CONCLUSIONS The feet of women wearing high-heeled shoes were significantly flatter transversely, with a more laterally flexed hallux, as compared to those wearing low-heeled or flat-soled shoes. Wearing high-heeled shoes was associated with higher incidence of hallux valgus. The incidence of varus deformity of the fifth toe was associated with wearing high-heeled shoes.

Structural, Dermal and Ungual Characteristics of the Foot in Patients with Type II Diabetes.

Background and Objectives: Diabetes is a chronic and metabolic disease, considered as an important public health problem. The objective of this study was to determine the prevalence of podiatric pathology in type II diabetic patients. Materials and Methods: An observational descriptive study of prevalence in the endocrinology service of Complexo Hospitalario Universitario A Coruña (CHUAC) (A Coruña-Spain) was carried out (n = 153). Type II diabetic patients included, of legal age who signed the informed consent. Sociodemographic variables were studied (age, sex, body mass index (BMI), smoking habit, alcohol consumption, family history), disease variables (time of evolution of diabetes, treatments, low-density lipoprotein (LDL), high-density lipoprotein (HDL), glucose), podiatric variables: measurement of the footprint, metatarsal and digital formula, nail, skin, hindfoot and forefoot alterations. The data collection was done in 2018 and the data analysis was carried out in 2019. Results: The patients with type II diabetes had greater age, obesity and arterial hypertension it compared to the general population. Diabetic patients had a higher prevalence of flat feet than the general population (71.2% vs. 20.7%, p < 0.001), with a predominance of normal foot according to the podoscope. The predominant podological pathology was the presence of claw toes (94.8%), followed by dermal (78.4%) and nail (71.9%) alterations, and the Hallux Valgus (66.0%). The Clarke angle and the Chippaux index showed a Kappa concordance index of 0.26 with the type of footprint measured with the podoscope. The Staheli index showed a Kappa index of 0.27 associated with an observed agreement of 54%. Conclusions: This study shows that foot problems continue to be prevalent in subjects with type II diabetes mellitus and for this reason, podiatry is essential in its treatment.

New Sagittal Plane Reference Parameters for Foot Deformity Correction Planning: The Vitruvian Foot.

Currently available methods for analysis and planning of post-traumatic or congenital deformity correction of the foot have some limitations. The aim of this retrospective study was to establish reference lines and angles (RLAs), and the resulting ratios, based on reproducible anatomic points on sagittal feet radiographs. The key starting point of our evaluation was the previously undescribed length and position of the talus joint line (TJL), from the border of the articular surface of the talus and the posterior process of talus. First, we calculated the relationships between the TJL and the axes of the foot, particularly the anatomic and mechanical lateral talometatarsal angle axes of the first metatarsal. Then, we assessed the relationships with the calcaneus, particularly the lateral heel angle. Finally, we calculated the parameters (angles and coefficients k) derived from the TJL and the foot-bearing points (foot quadrilateral). A total of 64 normal radiographs from 55 patients were analyzed. The values that resulted are as follows: anatomic lateral talometatarsal angle = 28.5° ± 4.5°, mechanical lateral talometatarsal angle = 23.6° ± 3.2°, lateral heel angle = 15.2° ± 3.4°, foot quadrilateral: abc = 144.6° ± 9.4°, bcd = 31.3° ± 2.6°, cda = 79.2° ± 9.8°, dab = 105.0° ± 8.3°, k1 = 3.09 ± 0.4, k2 = 3.77 ± 0.78, and k3 = 1.56 ± 0.24. Sagittal plane reference lines and angles are proposed, providing quantitative values for reference. These parameters have the potential to be easily implemented in foot deformity analysis and correction planning.