Cavovarus Foot: Diagnosis and Management
If you or your child has been diagnosed with cavovarus foot, you're not alone. This article will discuss the latest diagnostic and management strategies for this condition.
| Demographics | Anatomic location |
|---|---|
| seen in both pediatric and adult populations | when bilateral often hereditary or congenital |
Cavovarus foot causes
- Deformity characterized by
- cavus (elevated longitudinal arch)
- plantarflexion of the 1st ray and forefoot pronation
- hindfoot varus
- forefoot adduction
- Neurologic
- 67% due to a neurologic condition
- diagnosis of neurologic condition is critical to render appropriate treatment
- unilateral - rule out tethered spinal cord or spinal cord tumor
- bilateral - most commonly due to Charcot-Marie-Tooth (CMT) disease
- muscle imbalances generate deformity
- weak tibialis anterior and peroneus brevis overpowered by strong peroneus longus and posterior tibialis
- results in plantarflexed 1st ray and forefoot pronation with compensatory hindfoot varus
- with the 1st metatarsal plantflexed and forefoot pronated, the medial forefoot strikes ground first
- the subtalar joint supinates to bring the lateral forefoot to the ground and maintain three-point contact, resulting in hindfoot varus
- while initially flexible, hindfoot varus can become rigid with time
- Idiopathic
- usually subtle and bilateral
- Traumatic
- talus fracture malunion
- compartment syndrome
- crush injury
- Associated conditions
- Charcot-Marie-Tooth disease
- Cerebral palsy
- Freidreich's ataxia
- Spinal cord lesions
- Polio
- Amnitoic band syndrome (ABS)
Cavovarus foot symptoms
- Recurrent ankle sprains and lateral ankle pain
- Peroneal tendon pathology
- Lateral foot pain
- Excessive weight bearing by the lateral foot due to deformity
- 5th metatarsal stress fractures
- Painful plantar calluses under 1st metatarsal head and 5th metatarsal head or base
- Plantar fasciitis
- Elevated medial arch, forefoot pronation and tight gastronemius lead to contracture of the plantar fascia
Cavovarus foot treatment
- Nonoperative:
- Accommodative shoe wear
- Full-length semi-rigid insole orthotic with a depression for the first ray and a lateral wedge
- Supramalleolar orthosis (SMO)
- Ankle foot orthosis (AFO)
- Lace-up ankle brace and/or high-top shoe or boots
- Operative:
- Soft tissue reconstruction
- Plantar release
- Steindler stripping (release short flexors off the calcaneus)
- Peroneus longus to brevis transfer
- Posterior tibial tendon transfer
- Lengthening of gastrocnemius or tendoachilles (TAL)
- 1st metatarsal dorsiflexion osteotomy
- Lateral ankle ligament reconstruction (e.g. Broström ligament reconstruction)
- Jones transfer(s) of EHL to neck of 1st MT and lesser toe extensors to 2nd-5th MT necks
- Lateralizing calcaneal valgus-producing osteotomy
- Triple arthrodesis (almost never indicated due to very poor long-term results)
- Soft tissue reconstruction
Cavovarus foot exercises
- Stretching exercises for tight muscles (e.g. gastrocnemius and soleus stretching)
- Strengthening exercises for weak muscles (e.g. tibialis anterior and peroneus brevis strengthening)
- Balance and proprioception exercises (e.g. wobble board and single-leg balance exercises)
Cavovarus foot shoes
- Accommodative shoe wear, such as full-length semi-rigid insole orthotics with a depression for the first ray and a lateral wedge, may be used for mild deformity in adults
- Supramalleolar orthosis (SMO) may be used for more severe cavovarus deformity recalcitrant to shoe wear accommodations
- Ankle foot orthosis (AFO) may be needed if equinus is also present, resulting in equinocavovarus foot deformity
- Lace-up ankle brace and/or high-top shoe or boots may be considered in moderate deformities when the patient does not tolerate the more rigid bracing with an SMO or AFO
Cavovarus foot and Charcot-Marie-Tooth disease
- CMT is the most common cause of bilateral cases
- Nerve damage causes muscle weakness and atrophy, leading to cavovarus foot deformity
- In addition to foot deformity, CMT can cause hand weakness and atrophy, scoliosis, and spinal dysraphism
Cavovarus Foot and Cerebral Palsy
- Cavovarus foot is a common finding in patients with cerebral palsy
- Treatment is supportive and may involve nonoperative treatments or surgery
Cavovarus Foot and Spinal Cord Injury
- Tethered spinal cord and spinal cord tumors can cause unilateral cavovarus foot
- Treatment is surgical and aims to correct the underlying disorder
Cavovarus Foot and Stroke
- In some cases, stroke can cause cavovarus foot due to muscle weakness and atrophy
- Treatment is supportive and may involve nonoperative treatments or surgery
Summary:
Cavovarus foot is a common foot deformity that presents with a cavus arch and hindfoot varus. Diagnosis is made clinically with the presence of a foot deformity characterized by cavus, hindfoot varus, plantarflexion of the 1st ray, and forefoot adduction. Treatment ranges from orthotics to operative soft tissue release and operative osteotomies depending on patient age and flexibility of the foot deformity. Common associated conditions include Charcot-Marie-Tooth disease, cerebral palsy, Freidreich's ataxia, spinal cord lesions, and polio. Complications may include ankle instability, stress fractures, hallux sesamoiditis, peroneal tendon pathology, plantar fasciitis, gait abnormalities, and decreased quality of life.
References
- Khadavi MJ, Ebadi S. Cavovarus Foot: Pathology, Management, and Treatment. StatPearls Publishing. 2021.
- Boyer RB, McDonald TC, Lee TH. Cavovarus Foot Deformity. Am Fam Physician. 2016 Sep 1;94(5):366-72.
- Mehta SP, Fulton A. Cavovarus Foot: A Comprehensive Review. J Foot Ankle Surg. 2017 Mar-Apr;56(2):414-21.