The Valgus Foot in Cerebral Palsy Equinovalgus – not Plano-Valgus

Alfred D. Grant, M.D.David Feldman, M.D.N Ot k M DNorman Otsuka, M.D.

THE PURPOSE OF THIS PRESENTATION IS TO STATE CLEARLY THAT

THE VALGUS FOOT SEEN IN THE CEREBRAL PALSY PATIENT IS NOT PLANO-VALGUS BUT EQUINOVALGUS.

This Distinction Is Critical To Understanding The Extent And Evolution Of The Deformity,

As Well As The Rational For Non-surgical And SurgicalAs Well As The Rational For Non surgical And Surgical Management

Three Types Of Feet That Appear Flat

PLANO-VALGUS

LOW ARCHED SUPPLE FOOT

PLANO VALGUS•

EQUINOVALGUS FOOT

THREE TYPES OF FEET THAT APPEAR FLATTHAT APPEAR FLAT

PLANO VALGUSPLANO-VALGUS (Classic Flat Foot)

•Dropped longitudinal medial arch•Post Tibial too weak to elevate arch •Weight is born on the medial foot •Callosities along the entire medial arch g•HEEL CORD NOT TIGHT•

THREE TYPES OF FEET THAT APPEAR FLAT

LOW ARCHED SUPPLE FOOTLOW ARCHED SUPPLE FOOT (Runners)

•Low medial arch, •When weight is born the arch is

elevated by Post Tibial muscle •No callosities are seen medially. y•HEEL CORD NOT TIGHT

THREE TYPES OF FEET THAT APPEAR FLATTHAT APPEAR FLAT

EQUINOVALGUS FOOTQ(Paralytic i.e. CP. Polio)

•Primary problem - TIGHT HEEL CORD (possperonei)peronei)

•TIGHT HEEL CORD (peronei) LIMITS DORSIFLEXION

•Post Tibial not excessively tight or spastic•Post Tibial not excessively tight or spastic•Foot forced in valgus to be plantar grade

REVIEWING THE CP LITERATURE 184 PAPERS WERE FOUNDREVIEWING THE CP LITERATURE - 184 PAPERS WERE FOUND DESCRIBING THE FOOT AS PLANO-VALGUS OR VALGUS,

NONE EQUINOVALGUS.

In Correcting The Foot, The Focus Was Uniformly On The Valgus

Although Adjunctively StatedAlthough Adjunctively Stated,Those That Achieved Lasting Correction

All Corrected Equinus (W k d Th C lf(Weakened The Calf

I.E. Botox, Lengthened The Heel Cord (Peronei) Or Released The Gastrocnemius)

The Equinovalgus Foot

ALL EQUINOVALGUS FEET HAVE A TIGHT HEEL CORD

ANKLE DORSIFLEXION LIMITED BY THE TIGHT HEEL CORD

Not Limited WithNot Limited With Plano-valgus Or Low Arched Feet

The Equinovalgus Foot

CLINICAL TEST FOR THE CLINICAL TEST FOR THE EQUINOVALGUS FOOT

ANKLE DORSIFLEXION LIMITED BY THE TIGHT HEEL CORD

1

EQUINUS EVIDENT WHEN HEEL HELD IN NEUTRAL TO SLIGHT VARUS

2IN NEUTRAL TO SLIGHT VARUS

CLINICAL TEST FOR THE EQUINOVALGUS FOOT’ con’t

THE LIMB CAN ONLY ACHIEVE A PLANTARGRADE POSITION IF PLANTARGRADE POSITION IF

THE FOOT IS IN VALGUS3

CLINICAL TEST FOR THE EQUINOVALGUS FOOT

THE LIMB CAN ONLY ACHIEVE A PLANTARGRADE POSITION IF PLANTARGRADE POSITION IF

THE FOOT IS IN VALGUS3

CLINICAL TEST FOR THE EQUINOVALGUS FOOT

THE LIMB CAN ONLY ACHIEVE A PLANTARGRADE POSITION IF PLANTARGRADE POSITION IF

THE FOOT IS IN VALGUS3

WHERE ELSE IS THERE DORSIFLEXIION?

Subtalar Joint Axis Is Downward And I M i P t i T A t iIn Moving Posterior To Anterior

INVERSION AND

EVERSION AND

EQUINUSAND

DORSIFLEXION

With Inversion (Varus) With Eversion (Valgus)With Inversion (Varus) Equinus Occurs

With Eversion (Valgus) Dorsiflexion Occurs

EQUINOVALGUS FOOT

Plantargrade Position Only Achieved By ThePlantargrade Position Only Achieved By The Foot Everting In to Valgus With Associated

DorsiflexionDorsiflexion

EQUINOVALGUS + CROUCH Compensatory Valgus Accentuated

If The Heel Cord Is Tight

Compensatory Valgus Accentuated

If The Heel Cord Is Tight (Equinus)

Additional Dorsiflexion Can Only Occur In The

Subtalar Joint

But

Subtalar Dorsiflexion Always Accompanied By Valgus**

Equinovalgus

**Rockerbottom With Mid Tarsal Break May Occur As WellRockerbottom With Mid Tarsal Break May Occur As Well

EQUINOVALGUS

SEVERITY VARIESSEVERITY VARIES

SEVEREMILD SEVEREMILD

FIXEDSUPPLEHEEL CORDS ALWAYS TIGHT

EQUINOVALGUS MILD AND SUPPLE to MODERATE AND SLIGHTLY STIFFMILD AND SUPPLE to MODERATE AND SLIGHTLY STIFF

HEEL EQUINUS AND VALGUSMILD MODERATEHEEL EQUINUS AND VALGUSMILD MODERATE

MIDFOOT VALGUS

FOREFOOT APPEARS PRONATED BUT

SUPPLE TO SLIGHTLY STIFFSUPPLE TO SLIGHTLY STIFF

SUPPLE SLIGHTLY STIFF

EQUINOVALGUS SEVERE +/- FIXED

HEEL EQUINUS AND VALGUS

SEVERE

HEEL EQUINUS AND VALGUS

MIDFOOT VALGUS

FOREFOOT APPEARSFOREFOOT APPEARS PRONATED

BUTSUPINATED TO HIND AND

HALLUX VALGUS

MIDFOOT - FIXED

FIXED

EVOLUTION OF SEVEREEVOLUTION OF SEVERE EQUINOVALGUS DEFORMITY

From Mild And Supple To Severe And Fixed

EVOLUTION OF SEVERE EQUINOVALGUS DEFORMITYEQUINOVALGUS DEFORMITY

1. Patient Rolls Over The Medial Side Of The Foot

23

2. Drives The Head Of The 1st

Metatarsal Up –

1

Accentuating The Entire Foot Pronation

3. Rolls Over The Medial Aspect Of The Hallux –Creating The Hallux Valgus

EVOLUTION OF SEVERE EQUINOVALGUS DEFORMITY

4. The Forefoot Is Less Pronated Th Mid A d Hi df t A d Fi d

56

Than Mid And Hindfoot And Fixed

5. Hind And Mid Foot Valgus Is Corrected To Neutral By Rotation

78

Corrected To Neutral By Rotation Around Subtalar Axis

6 When This Rotation Occurs The

4

6. When This Rotation Occurs The Fixed Forefoot Rotates Into Supination In Relation To The Neutral Hind And Mid FootNeutral Hind And Mid Foot

7. Elevation Of 1st Metatarsal Is The Main Cause Of This Supination

4. Pronated foot7. Head of the 1st metatarsal up8 Hallux valgus

p

8. Hallux valgus

Treatment StrategiesNon SurgicalNon-Surgical

Reduce Contractures – Stretching - Casts R d S ti it Bl k (B t t )Reduce Spasticity - Blocks (Botox etc.) Bracing

S i lSurgical

BRACING IS ABRACING IS A PROBLEM

Patients’ With A Spastic Calf Walk In EquinusPatients With A Spastic Calf Walk In Equinus Subtalar Neutral, Varus Or Valgus

Brace Is Needed To Gain And Maintain A Plantargrade Position

The AFO - Usually Has A Molded Scaphoid Arch Set At 90 Degrees Dorsiflexion The Heel And Subtalar Position Neutral

PROBLEM – The Equinovalgus Foot Cannot Achieve Plantar Grade Position In This Brace Subtalar Valgus And Pronation Needed

BRACING IS A PROBLEM

The AFO at 90 degree These Feet Cannot Achieve gsubtalar position set in

neutralPlantargrade Position In This

Brace

As The Foot Goes Into Valgus BRACING PROBLEM

gThe Talar Head “Slams” Against The Medial Wall

Of The Neutrally Positioned Brace

THE MEDIAL WALL AND THE MOLDED SCAPHOID ARCH PREVENT VALGUSPREVENT VALGUS

IRRITATION, CALLOUSITY AND PAIN OCCUR.

UNTREATED EQUINUS IS THE PROBLEM IN BRACING THE EQUINOVALGUS FOOT!THE EQUINOVALGUS FOOT!

SurgicalTreatmentSurgicalTreatment

THE MILD SUPPLE CP EQUINOVALGUS FOOT

Tight Heel Cords (And Possibly Spastic Peronei)Hindfoot, Forefoot And Midfoot Is Flexible.

EquinovalgusPost Heel Cord RxGood Dorsiflexion

Dropped Inner Arch

EquinovalgusPre Heel Cord RxPre Heel Cord Rx

Limited DorsiflexionPlantargrade Pronation

TREATMENTPrimarily Lengthening The Heel Cord (And Peronei) or

GastrocnemiusGastrocnemius

THE SEVERE EQUINOVALGUS FOOTVARYING STIFFNESS EQUINUS

CALF WEAKENING PROCEDURE

VALGUS MOSCA, GRICE GREEN. DENNYSON(Prominent Talar Head)

OS CALCIS OSTEOTOMY

DENNYSON

FIXED HEEL VALGUS OS CALCIS OSTEOTOMYSUBTALAR/TRIPLE FUSION

FOREFOOT SUPINATIONFIRST METATARSAL

ELEVATION FIXED

PLANTARFLEX FIRST METATARSAL MID TARSAL OSTEOTOMY

HALLUX VALGUS

CORRECT HALLUX VALGUS

THE SEVERE EQUINOVALGUS FOOTVARYING STIFFNESS

SPASTIC CONTRACTED HEEL CORD,

PERONEI

VALGUS SVALGUS(Prominent Talar Head)

FIXED HEEL VALGUS

TAL, STRAYER, LENGTHEN PERONEI

FIXED HEEL VALGUS

FOREFOOT SUPINATIONFIRST METATARSAL

ELEVATION FIXED

HALLUX VALGUS

THE SEVERE EQUINOVALGUS FOOTVARYING STIFFNESS

MOSCAEQUINUS MOSCALENGTHEN LATERAL COLUMNCorrect Choparts Subluxation

VALGUS(Prominent Talar

Head)

TIGHTEN MEDIAL STRUCTURESPlicate Spring Ligament,

Use Post & Ant Tibial Tendons For Added Medial SuppportHead)

FIXED HEEL VALGUS SUBTALAR (Extra Articular)

Added Medial Suppport

FOREFOOT SUPINATIONFIRST METATARSAL

SUBTALAR (Extra-Articular) Fusion)

GRICE GREEN – Sinus Tarsi GraftFIRST METATARSAL ELEVATION FIXED

GRICE GREEN Sinus Tarsi Graft

DENNYSON-S-T Graft + Screw Talar Neck To Calcaneus)

HALLUX VALGUS

THE SEVERE EQUINOVALGUS FOOTVARYING STIFFNESS

MOSCAEQUINUS

VALGUS

MOSCALENGTHEN LATERAL COLUMNCorrect Choparts Subluxation

VALGUS(Prominent Talar

Head)

TIGHTEN MEDIAL STRUCTURESPlicate Spring Ligament,

Use Post & Ant Tibial Tendons For Added Medial Suppport

FIXED HEEL VALGUS SUBTALAR (Extra Articular) Fusion)

Added Medial Suppport

FOREFOOT SUPINATIONFIRST METATARSAL

SUBTALAR (Extra-Articular) Fusion)

GRICE GREEN – Sinus Tarsi Graft

FIRST METATARSAL ELEVATION FIXED DENNYSON-S-T Graft + Screw

Talar Nec K To Calcaneus)

HALLUX VALGUSFAIL UNLESS EQUINUS AND SUPINATION CORRECTED

THE SEVERE EQUINOVALGUS FOOTVARYING STIFFNESS EQUINUS

VALGUS(Prominent Talar Head)

FIXED (Stiff)OS CALCIS

OSTEOTOMYFIXED (Stiff) HEEL VALGUS

OSTEOTOMY

SUBTALAR/TRIPLE FUSION

FOREFOOT SUPINATIONFIRST METATARSAL

ELEVATION FIXED

HALLUX VALGUS

ELEVATION FIXED

THE SEVERE EQUINOVALGUS FOOTVARYING STIFFNESS EQUINUS

VALGUS(Prominent Talar Head) PLANTARFLEX FIRST

METATARSALFIXED HEEL VALGUS

FOREFOOT

METATARSAL Osteotomy 1st Cuneiform, 1st Metatarsal Or Fuse 1st

Metatarsal Cuneiform JointFOREFOOT SUPINATION

First Metatarsal Elevation Fixed

Metatarsal Cuneiform Joint

MID TARSAL OSTEOTOMY

Elevation Fixed

HALLUX VALGUS

THE SEVERE EQUINOVALGUS FOOTVARYING STIFFNESS EQUINUS

FIXED HEEL VALGUS

VALGUS(Prominent Talar Head)

FIXED HEEL VALGUS

( )CORRECT HALLUX

VALGUSFuse IPJoint

FOREFOOT SUPINATIONFIRST METATARSAL

ELEVATION FIXED

HALLUX VALGUS

Failure 1

UNTREATED OR INADEQUATELY TREATED EQUINUS IS THE MAJOR CAUSE OF FAILURE WHEN TREATING

THE EQUINOVALGUS FOOT!THE EQUINOVALGUS FOOT!

DS Grice Further Experience WithDS Grice, Further Experience With Extraarticulatt Arthrodeses Of The Subtalar Joint, JBJS 1955 37A, pp. 246

FAILURES WERE DUE TO: • Failure To Correct The Equinus Deformityq y• Inadequate Placement Of The Calcaneus

Under The Talus

Failure 2 CROUCH Tight Heel Cord And HamstringsTight Heel Cord And Hamstrings

HEEL CORD ONLY

TAL ONLY INCREASES CROUCH

ONLY

TAL ONLY - INCREASES CROUCH –Correct Proximal Deformities And Imbalances (SEML)

Failure 3

ANKLE VALGUS CAN BEANKLE VALGUS CAN BE MISSED

AP X Of Th A klAP X-ray Of The Ankle Should Be Obtained Before

T ti S V lTreating Severe ValgusTRIPLE

ANKLE VALGUSANKLE VALGUS MISSED

Failure 4

If The Hind Foot Valgus And e d oo a gus dEversion Is Corrected

The Forefoot Supination Must Be Corrected (if fixed)Be Corrected (if fixed)

Weight Bearing On The Uncorrected Fixed Supinated Forefoot

Will Force The Hind Foot Back Into Eversion And Valgus

Even If Everything Else Is Properly y g p yCorrected

SPASTIC CONTRACTED

THE SEVERE EQUINOVALGUS FOOTVARYING STIFFNESS

HEEL CORD (+/-Peronei)

VALGUSVALGUSProminent Talar Head

ELONGATED MEDIAL COLUMN

FIXED HEEL VALGUS

FOREFOOT SUPINATIONFIRST METATARSAL

ELEVATION FIXED

HALLUX VALGUS

THE CP EQUINOVALGUS FOOT

SPASTIC CONTRACTED HEEL CORD

TAL, STRAYER

CORDMOSCA

LENGTHEN LATERAL COLUMNCORRECT CHOPARTS SUBLUXATION

TIGHTEN MEDIAL STRUCTURESVALGUS

USUAL Rx DIRECTION

PLICATE SPRING LIGAMENT, USE POST & ANT TIBIAL TEMDONS FOR ADDED MEDIAL SUPPPORT

EXTR-ARTICULAR FUSION-GRICE GREEN DENNYSON

VALGUS(Prominent Talar Head

Elongated Medial Column)

FIXED HEEL VALGUSOS CALCIS OSTEOTOMY

GRICE GREEN, DENNYSON

FOREFOOT SUPINATIONFIRST METATARSAL

ELEVATION FIXED

SUBTALAR/TRIPLE FUSION

PLANTARFLEX FIRST METATARSAL OSTEOTOMY 1st CUNEIFORM, FUSE

ELEVATION FIXED 1st METATARSAL CUNEIFORM JOINT

MID TARSAL OSTEOTOMY

HALLUX VALGUSCORRECT HALLUX VALGUS

FUSE IP JOINT

THE CP EQUINOVALGUS FOOT SPASTIC CONTRACTED

HEEL CORD, PeroneiTAL, STRAYERLengthen PeroneiHEEL CORD, Peronei

MOSCALENGTHEN LATERAL COLUMN

CORRECT CHOPARTS SUBLUXATIONTIGHTEN MEDIAL STRUCTURESVALGUS

DON’T FORGET!!

TIGHTEN MEDIAL STRUCTURESPLICATE SPRING LIGAMENT, USE POST & ANT

TIBIAL TEMDONS FOR ADDED MEDIAL SUPPPORT

EXTR-ARTICULAR FUSION-GRICE GREEN, DENNYSON

VALGUS(Prominent Talar Head

Elongated Medial Column)

FIXED HEEL VALGUSOS CALCIS OSTEOTOMY

SUBTALAR/TRIPLE FUSION

GRICE GREEN, DENNYSON

FOREFOOT SUPINATION

SUBTALAR/TRIPLE FUSION

PLANTARFLEX FIRST METATARSAL OSTEOTOMY 1st CUNEIFORM FUSEFOREFOOT SUPINATION

FIRST METATARSAL ELEVATION FIXEDOSTEOTOMY 1st CUNEIFORM, FUSE1st METATARSAL CUNEIFORM JOINT

MID TARSAL OSTEOTOMYHALLUX VALGUS

CORRECT HALLUX VALGUSFUSE IP JOINTFUSE IP JOINT

SUMMARY

ALL EQUINOVALGUS FEET HAVE A TIGHT HEEL CORD

UNTREATED OR INADEQUATELY TREATED EQUINUS IS THE MAJOR CAUSE OF FAILURE WHEN TREATING

THE EQUINOVALGUS FOOT!

TREATMENT OF THE SEVERE EQUINOVALGUS FOOT FAILS UNLESS EQUINUS AND SUPINATION CORRECTED

THANK YOU