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“Idiopathic” pes cavus. An investigation into its aetiology

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... Dicho examen puede ir desde el estudio neurológico general del paciente afectado, hasta un estudio familiar. No en vano, en casos de pies cavos diagnosticados de esenciales, este examen da como resultado la existencia de antecedentes neurológicos o miopáticos que pudieran ser responsables de la deformidad (1,3,6), entre los que encontramos: Ataxia de Friedrich, atrofia peroneal, poliomielitis, polineuritis, degeneración espinocerebelosa, distrofias musculares, y especialmente disrrafismo espinal. Existe, sin embargo, un determinado grupo de pacientes en los cuales los exámenes neuromusculares son negativos, etiquetándose la deformidad como «esencial» (3, 7), lo que nos hace ver el desconocimiento real que tenemos sobre su etiología. ...
... Existe, sin embargo, un determinado grupo de pacientes en los cuales los exámenes neuromusculares son negativos, etiquetándose la deformidad como «esencial» (3, 7), lo que nos hace ver el desconocimiento real que tenemos sobre su etiología. El porcentaje de pies cavos esenciales encontrados en la bibliografía varía según los autores consultados (2,3,8), y está relacionado con la profundidad del estudio neurológico realizado. ...
... Pensamos, que en muchos casos de pacientes diagnosticados de pie cavo «esencial», la enfermedad neurológica de base está presente de forma subclínica, con poca expresividad, y no es detectable por los métodos habituales de exploración, por lo que en estos casos el pie cavo sería una manifestación oligo o monosintomática de una enfermedad neurológica (1,3,4,8,9). Nos llama la atención la presencia en nuestro grupo estudiado de la existencia de una enfermedad de Mc Ardle, ya que no la hemos encontrado descrita en la literatura consultada como productora de pie cavo, no obstante, al tratarse de sólo un caso no creemos que tenga demasiado significado, pudiéndose tratar incluso de una casualidad. ...
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Resumen.—La etiología del pie cavo cuando ésta es conocida, suele ser debida a un trastor-no de tipo neurológico o miopático, aunque en determinados casos nos encontramos con pa-cientes que padecen esta deformidad en el pie, en los cuales no podemos descubrir ningún antecedente de este tipo, por lo que lo calificamos de pie cavo «esencial». A un grupo de estos pacientes con pie cavo «esencial», en los que no hemos encontrado ningún tipo de antecedente neurológico, lo hemos sometido a una exploración electroneurográfica, encontrando que la mitad de ellos padecían algún trastorno neuropático/miopático, que no había sido detectado en la exploración clínica inicial. ELECTROMYOGRAPHIC AND ELECTRONEUROGRAPHIC FINDINGS IN ESSENTIAL PES CAVUS. Summary.—Neurological or myopathic diseases are frequently involved in the etiology of flat foot. In some cases, no antecedents of disease can be found and therefore these flat foots are classified as «essential». We have undertaken an electrophysiologic study in a series of patients with «essential» flat food in order to explore unsuspected neurological disorders. In half of the patients, neuropathic and myopathic electroneurographic patterns of different severity were detected.
... The association of the cavus foot deformitywith neurologic d i sease has been wel I docu mented by B rewerton and associates (1). Of the f i rst 77 patients presenti ng to the pes cavus clinic 66% were fou nd to have a neu rologic disorder afterclinical examination alone. ...
... As mentioned earlier,66% of Brewerton's patientswere diagnosed as having neurologicdisease based upon clinical examination alone (1). A valuable yet simple method of exam i nation i s man ual m u scle testi ng. ...
... The identification of extra-neural symptoms and signs often provides clues needed to obtain correct diagnosis for neurological disorders. Patients with cerebellar ataxia, particularly those with disorders complicated with young-onset peripheral neuropathy, may present with foot deformities including pes cavus, clubfeet, and hammer toes [4][5][6]. The etiology of foot deformity remains elusive; however, various theories regarding the mechanistic details of foot deformity formation have been postulated [7]. ...
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Early-onset ataxias are often difficult to diagnose due to the genetic and phenotypic heterogeneity of patients. Whole exome sequencing (WES) is a powerful method for determining causative mutations of early-onset ataxias. We report a case in which a novel de novo KIF1A mutation was identified in a patient with ataxia, intellectual disability and mild foot deformity. A patient presented with sporadic forms of ataxia with mild foot deformity, intellectual disability, peripheral neuropathy, pyramidal signs, and orthostatic hypotension. WES was used to identify a novel de novo mutation in KIF1A , a known causative gene of neurodegeneration and spasticity with or without cerebellar atrophy or cortical visual impairment syndrome (NESCAVS). We report a novel phenotype of NESCAVS that is associated with a novel de novo missense mutation in KIF1A , which provides valuable information for the diagnosis of NESCAVS even in the era of WES. Early rehabilitation of patients with NESCAVS may prevent symptom worsening and improve the disease course.
... One of the more common etiologies of cavus foot is an underlying neuromuscular disorder. Brewerton found that 66% of his cavus patients had a neuromuscular pathology, and of those, greater than 50% had Charcot-Marie-Tooth disease (CMT) [1]. ...
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Charcot Marie Tooth (CMT) disease is a progressive neuromuscular disorder that is often the underlying condition involved in the development of a symptomatic cavovarus foot. End-stage foot deformities frequently result in triple arthrodesis procedures performed later in the disease process. The main surgical goal is to achieve a stable, plantigrade foot. Ideally, treatment would avoid triple arthrodesis as this procedure increases adjacent joint demands and expedites development of resultant arthrosis. Some authors have stated that earlier intervention by tendon balancing techniques may alleviate the need for joint fusions in the future. Therefore, the timing of surgical intervention is paramount in the medical decision making process. Our case series reviews mid-stage cavovarus progression in patients with pedal instability and gait disturbances. Realignment subtalar arthrodesis is utilized to improve Kite’s angle, reduce heel varus and re-establish subtalar joint (STJ) stability. Tendon balancing procedures should be performed in conjunction with STJ arthrodesis in order to achieve long standing correction and hopefully prevent the future need for conversion to triple arthrodesis.
... [1] Some variations in foot alignment are associated with changes in lower limb movement [2,3] and muscle action [4] and are strongly influenced by some systemic conditions too. [5] Flexible flat foot is characterized by medial rotation and plantar flexion of the talus, eversion of the calcaneus, collapsed medial arch, and abduction of the forefoot. [6,7] The prevalence changes with age, the type of population studied, and the presence of Drug Invention Today | Vol 12 • Issue 3 • 2019 three measurements habitually used in the diagnosis of flat foot using a pedograph are Clarke's angle, [21] the Chippaux-Smirak index, [22] and the Staheli index. ...
... We did not screen for cerebral palsy, spinal dysraphism, or other causes of central nervous system pes cavus, although their presence in our study was unlikely. 18 Our goal was simply to compare CMT with non-CMT pes cavus, fully cognizant of the latter group's heterogeneity. ...
Article
Introduction Pes cavus often signals the presence of Charcot Marie Tooth (CMT) in adult patients, although its prevalence in the general population makes it a finding of unclear significance. Methods We undertook a pilot double cohort study to investigate the feasibility of comparing preselected bedside and radiographic foot measures in pes cavus patients with and without CMT. Results 16 CMT and 11 non‐CMT patients were recruited. Although no findings consistently met statistical significance, recruitment was highly limiting. Discussion Formalized foot measurement comparisons of CMT and non‐CMT pes cavus are feasible. Larger studies will be necessary to determine if there are differences in foot structure based on the presence of a hereditary neuropathy. This article is protected by copyright. All rights reserved.
... 23 Literature is very scanty on occurrence of idiopathic pes cavus. 24 During normal gait cycle enough pronation is required at calcaneus at the time of heel strike phase. In case of high arch foot inadequate pronation during heel strike is said to show stress on posterolateral structures of foot. ...
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div class="Section1"> Background: The anatomy of human foot owes its adaptation to bipedal locomotion. Support and propulsion are the two main activities of foot which are possible due to segmental nature of foot. Bony architecture contributes to the arches of foot. Continuous stress put on the foot during childhood is expected to have changes in developing bone morphology. Pes planus and pes cavus are the two major foot deformities involving medial longitudinal arch. Aims and Objectives: The purpose of this study was to investigate the prevalence of pes planus and pes cavus among tribal children of Andhra Pradesh state in India. Materials and Methods: A sample size of 360 healthy tribal children, between the age group of 3-15 years, was randomly selected from Andhra Pradesh State. Anthropometric variables such as standing height and weight, foot length and width were measured. Height was measured using measuring tape and weight using weighing scale. Foot length and foot width were measured using osteometric board. BMI was calculated using the formula BMI= (weight (kg)*10000)/(height(cm))2. Static foot prints of both feet were taken on graph sheets in both weight bearing and non weight bearing conditions. Arch index proposed by Cavanagh and Rodgers was followed to measure Medial longitudinal arch (MLA). MLA was classifed AI≤0.21 as pes cavus, AI=0.21-0.26 as normal foot and AI≥0.26 pes cavus. Results: Incidence of pes cavus was found to be higher than pes planus. Overall prevalence of pes planus was 26.4% & 25.6% while pes cavus was 58.9% & 66.7% for right and left foot respectively. Pes planus at 3-4 year age group was 60% and 63.3% which decreased to 16.7% and 30% at 14-15 year age group for right and left foot respectively. Pes cavus at 3-4 year age group was 33.3% and 33.3% while at 14-15 year age group was 76.7% and 66.7% for right and left foot respectively. Conclusion: Pes cavus was found to be high among 3-15 year children. Age and gender were associated with foot arch structure. External factors like ethnic variations, hilly areas, bare foot walking; climbing trees might have a great role in infl uencing foot arch structure. Alteration from normal foot structure may infl uence the gait and lead to different injury patterns. Asian Journal of Medical Sciences Vol.7(5) 2016 108-116 </div
... While pes cavus is a cardinal manifestation of Charcot-Marie-Tooth disease (Harding and Thomas, 1980), it is also the hallmark of 'idiopathic' pes cavus that represents one third of cases attended in any pes cavus clinic (Brewerton et al., 1963). Electrophysiological study is essential to distinguish between both disorders, especially if, as reported here, there is evidence of positive family history with well-defined electrophysiological phenotype. ...
... Charcot-Marie-Tooth (CMT) disease is a progressive peripheral neurological condition that causes muscle atrophy and impaired proprioception (10) , the diagnosis is most commonly associated with pes cavus and thus should be suspected in any patient with this deformity. It consists of more or less typical clinical manifestations, with varying degrees of severity, due to various complex genetic abnormalities that cause defects in the peripheral nerves (18) . ...
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Hereditary motor and sensory neuropathies, especially Charcot-Marie-Tooth disease, are frequently expressed with an acquired cavusvarus foot which is characterized by a fixed increase of the plantar arch and hindfoot inversion. Diagnosis of the underlying condition achieved through careful patient assessment and local evaluations is the keystone for decision-making about the adequate treatment. The cavus may present as an isolated deformity of the forefoot, hindfoot or it may be a combination of both locations. Related deformities, mainly the varus and toe clawing require appropriate evaluation; clinical characteristics such as severity of the deformity, impairment of the muscular power, flexibility and patient's age are important characteristics in the treatment decision. Conservative treatment of the cavusvarus foot with physiotherapy, insoles and shoe modifications are reserved to young patients and mild deformities. However, there is a tendency of the deformity to become more severe over time because of the progressive feature of the underlying neurological condition. So, the surgical treatment by using classical techniques is performed in early stages. Most importantly is the identification of the primary and main components of each deformity to properly correct them, if possible. Muscular transfers are used to treat the dynamic unbalance, retracted structures should be either divided or lengthened and localized osteotomies should be preferred over arthrodeses, which are reserved for stiff and severely deformed feet in adults.
... Population-based studies suggest that the prevalence of the cavus foot is approximately 10%, 1 and its cause is primarily idiopathic or neurogenic in nature. 2 Patients with a cavus or high-arched foot frequently experience foot pain, which can lead to significant limitation in function. Custom foot orthoses are widely prescribed to treat cavus foot pain. ...
Article
Patients with a cavus or high-arched foot frequently experience foot pain, which can lead to significant limitation in function. Custom foot orthoses are widely prescribed to treat cavus foot pain. However, no clear guidelines for their construction exist, and there is limited evidence of their efficacy. In a randomized, single-blind, sham-controlled trial, the effect of custom foot orthoses on foot pain, function, quality of life, and plantar pressure loading in people with a cavus foot type was investigated. One hundred fifty-four participants with chronic musculoskeletal foot pain and bilateral cavus feet were randomly assigned to a treatment group receiving custom foot orthoses (n = 75) or to a control group receiving simple sham insoles (n = 79). At 3 months, 99% of the participants provided follow-up data using the Foot Health Status Questionnaire. Foot pain scores improved more with custom foot orthoses than with the control (difference, 8.3 points; 95% confidence interval [CI], 1.2 to 15.3 points;...
... So, CMT1 seemed to be more likely the diagnosis of our case because his symptoms included pes cavus, early symptom onset (age 10), and a slow progression (over 20 years). However, the findings of lower extremities were not specific for diagnosis, and may arise in other diseases (peroneal muscular atrophy, Friedreich's ataxia, myelodysplaisa, poliomyelitis and so on) can cause foot muscle atrophy2). ...
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To present a case of cauda equina syndrome (CES) caused by chronic inflammatory demyelinating polyneuropathy (CIDP) which seemed clinically similar to Charcot-Marie-Tooth disease type1 (CMT1). CIDP is an immune-mediated polyneuropathy, either progressive or relapsing-remitting. It is a non-hereditary disorder characterized by symmetrical motor and sensory deficits. Rarely, spinal nerve roots can be involved, leading to CES by hypertrophic cauda equina. A 34-year-old man presented with low back pain, radicular pain, bilateral lower-extremity weakness, urinary incontinence, and constipation. He had had musculoskeletal deformities, such as hammertoes and pes cavus, since age 10. Lumbar spine magnetic resonance imaging showed diffuse thickening of the cauda equina. Electrophysiological testing showed increased distal latency, conduction blocks, temporal dispersion, and severe nerve conduction velocity slowing (3 m/s). We were not able to find genetic mutations at the PMP 22, MPZ, PRX, and EGR2 genes. The pathologic findings of the sural nerve biopsy revealed thinly myelinated nerve fibers with Schwann cells proliferation. We performed a decompressive laminectomy, intravenous IgG (IV-IgG) and oral steroid. At 1 week after surgery, most of his symptoms showed marked improvements except foot deformities. There was no relapse or aggravation of disease for 3 years. We diagnosed the case as an early-onset CIDP with cauda equine syndrome, whose initial clinical findings were similar to those of CMT1, and successfully managed with decompressive laminectomy, IV-IgG and oral steroid.
... The Charcot-Marie-Tooth (CMT) disease is a progressive neurological disorder that affects the peripheral nerves, causing weakness, muscle atrophy, and loss of sensitivity, especially in distal segments of the upper and lower limbs, with a highly variable clinical course [1][2][3][4]. It is part of the group of hereditary neuropathies and has an estimated prevalence of 37/100.000 ...
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Background: The aim of this study was to evaluate the oral health status of temporomandibular disorders (TMD) and bruxism, as well as to measure masticatory performance of subjects with Charcot-Marie-Tooth type 2 (CMT2). Methods and results: The average number of decayed, missing, and filled teeth (DMFT) for both groups, control (CG) and CMT2, was considered low (CG = 2.46; CMT2 = 1.85, P = 0.227). The OHIP-14 score was considered low (CG = 2.86, CMT2 = 5.83, P = 0.899). The prevalence of self-reported TMD was 33.3% and 38.9% (P = 0.718) in CG and CMT2 respectively and for self-reported bruxism was 4.8% (CG) and 22.2% (CMT2), without significant difference between groups (P = 0.162). The most common clinical sign of TMD was masseter (CG = 38.1%; CMT2 = 66.7%) and temporalis (CG = 19.0%; GCMT2 = 33.3%) muscle pain. The geometric mean diameter (GMD) was not significantly different between groups (CG = 4369; CMT2 = 4627, P = 0.157). Conclusion: We conclude that the CMT2 disease did not negatively have influence either on oral health status in the presence and severity of TMD and bruxism or on masticatory performance.
... The causes of pes cavus are shown in Box 2. The hereditary sensory and motor neuropathies are the most commonly encountered causes of severe pes cavus in clinical practice, although approximately one-third are idiopathic. 18 Manoli describes the "subtle" cavovarus foot in detail elsewhere in this issue. ...
Article
This article reviews the role of cavus in foot and ankle injury and summarizes the current surgical and nonsurgical treatments. Recognition of foot position is crucial in the management of ankle instability associated with cavovarus. Correcting foot alignment with orthoses or surgery improves the mechanics of the ankle, reducing the risk of instability and potentially delaying the onset of posttraumatic ankle arthritis. Progressive steps in the correction alignment are described, with technical tips and strategies for dealing with chronic instability.
... Ent wi ckelt sich ein Hohl fuß erst im Lau fe des Wachs tums, so ist eine neu ro lo gi sche Ur sa che aus zu schlie ßen (z.B. Friedreich-Ata xie, Here di täre sen so mo to ri sche Neu ro pa thie, Spi na bi fi da) [3,15]. ...
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Zusammenfassung In der Entwicklung des Achsen- und Fußskeletts des Kindes bestehen als physiologische Besonderheiten ein ausgeprägtes Sohlenfettpolster, verstärkte Valgusstellung im oberen Sprunggelenk, Crus varum im Kleinkindalter mit zunächst Genu varum, später Genu valgum, erhöhte Bandlaxität, vermehrte Antetorsion im Schenkelhals mit „kneeing in“ und „toeing in“ sowie eine Stellung der Kniegelenke zunächst in Beugung, dann in Überstreckung. Die Kenntnis dieser Besonderheiten ist essenziell zur Diagnose und Therapie von Fußfehlformen im Kindesalter. Dazu gehören Klumpfuß, Knickplattfuß, Talus verticalis, Sichelfuß, Spitzfuß, Hohlfuß und Hackenfuß. Bei rechtzeitigem Therapiebeginn kann oft eine Befundnormalisierung erreicht werden. Ist eine operative Therapie unumgänglich, sollte die Indikation mit Sorgfalt gestellt werden.
... Ent wi ckelt sich ein Hohl fuß erst im Lau fe des Wachs tums, so ist eine neu ro lo gi sche Ur sa che aus zu schlie ßen (z.B. Friedreich-Ata xie, Here di täre sen so mo to ri sche Neu ro pa thie, Spi na bi fi da) [3,15]. ...
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This study provided a comprehensive updated review of the biological aspects of children foot morphology across different ages, sex, and weight, aiming to reveal the patterns of normal and pathological changes in children feet during growth and development. This review article comprised 25 papers in total that satisfied the screening standards. The aim was to investigate how weight changes, age and sex affect foot type, and gain a deeper understanding of the prevalent foot deformities that occur during children growth. Three different foot morphological conditions were discussed, specifically including the effect of sex and age differences, the effect of weight changes, and abnormal foot morphologies commonly documented during growth. This review found that sex, age, and weight changes would affect foot size, bony structure, foot posture, and plantar pressures during child growth. As a result of this biological nature, the children’s feet generally exhibit neutral and internally rotated foot postures, which frequently lead to abnormal foot morphologies (e.g., flat foot, pronated foot, etc.). In the future, attention shall be paid to the causal factors leading to specific foot morphologies during the growth and development of children. However, sufficient evidence could not be provided due to a relatively short period of investigation and non-uniformed research methodology in the current literature. A more comprehensive and in-depth exploration is recommended to provide scientific evidence for the discovery of children foot development and personalized growth pattern.
Article
Zusammenfassung Die Behandlung des rigiden Hohlfusses begann im 18. Jahrhundert mit überwiegend konservativen Massnahmen wie z.B. Quengelschienen und Schraubzwingen-artigen Kompressionsapparaten. Mit Einführung verträglicher Narkosetechniken sowie Hautdesinfektion und Sterilität im Operationssaal wurde der Hohlfuss zu Beginn des 20. Jahrhunderts mehrheitlich durch korrigierende Rückfuss-Arthrodesen operiert. Durch die frühzeitige Erkennung und Behandlung der Grunderkrankung neurologischer Hohlfüsse sind massive Deformitäten heute selten, so dass die meisten Hohlfüsse mittels gelenkerhaltender Osteotomien und Weichteilkorrekturen erfolgreich und ohne grösseren Funktionsverlust behandelt werden können.
Article
Background The outcome of a constant joint preserving procedure for painful plantar callosities with cavovarus foot remains unclear. Methods Eleven patients (11 feet) who underwent lateral displacement calcaneal osteotomy (LDCO), dorsiflexion first metatarsal osteotomy (DFMO), and plantar fasciotomy (PF), simultaneously were included. The presence of painful callosities, heel alignment of standing (HA), and the Japanese Society for Surgery of the Foot ankle/hindfoot (JSSF) score were evaluated. Radiographically, the talonavicular coverage angle (TNCA), lateral talo-first metatarsal angle (LTMA), calcaneal pitch angle (CPA), and heel alignment angle (HAA) were measured. Results Postoperatively, painful plantar callosities disappeared in 10 patients and remained in one patient. The postoperative HA and JSSF score significantly improved. The postoperative TNCA, LTMA, CPA, and HAA significantly improved. Conclusions In patients with flexible cavovarus foot, LDCO, DFMO, and PF yielded good outcomes at mid-term follow-up with preservation of the foot and ankle joints.
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According to the literature, people with foot deformities report poor quality of life and nearly one-third of the population has some type of foot deformity. Of all the deformities, Pes Planus, caused by the loss of the medial longitudinal arch of the foot, and pes cavus, caused by having an abnormally high plantar longitudinal arch, are the ones that negatively influence the productivity of society most. In the light of the above, this study proposes a novel mobile pre-diagnosis system for pes planus and pes cavus that is utilizing conventional deformity identification methods accepted in the literature through a mobile phone app by harnesing image processing and deep neural networks. As part of the study, a prototype is implemented and tested using 34 participants - 22 (64.71%) males and 12 (35.29%) females - with an average age of 24.06. In order to benchmark our prototype, an orthopedic specialist was asked to identify the key decision making points, which was then used to calculate the deformity type, on a set of foot images collected from participants. Then the same images were fed to the prototype with the objective of identifying the key points and calculating the deformity type via the help of image processing and deep learning algorithms. The comparison of the results showed that specialist’s and prototypes findings were in 91.80% match, which indicated an overall success.
Article
Pathologic affects from a cavus foot deformity range from flexible subtle to rigid severe deformities and are related to many pathologic conditions of the foot and ankle. Understanding the underlying deformity and the deforming force is essential in treating the cavus ankle and foot. Every deformity is different and unique to a given patient; therefore, surgical plans should be modified to each patient.
Article
Chapter
This chapter discusses key concepts in the biomechanics of the foot. Subsequently, we discuss common foot deformity and pathology related to the foot and their assessment and management.
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Embryological differentiation of the foot is noticeable by the fifth intrauterine week. By the end of the fifth week, condensation of the mesenchymal tissue has resulted in the formation of tarsal bone anlage (earliest developmental models). Tissue differentiation to precartilage and cartilage follows and all skeletal elements of the foot have begun to chondrify by 7 weeks with the exception of the distal phalanx of the little toe. By the end of the second month, the outline of each bone is becoming distinct [1–3]. Homogenous interzones develop at the ankle and between all tarsal, tarsal-metatarsal, metatarsal-phalangeal, and interphalangeal joints with the three-layered interzone developing earliest at the ankle and metatarsal-phalangeal joints at the end of the embryonic period (8 weeks). Cavitation with vascularized synovial tissue is seen in most joints of the foot at 9–11 weeks (early fetal period). A proximodistal sequence of development unfolds. By the end of the embryonic period (8 weeks), the foot resembles that of the adult in most details. All elements of the foot destined to become bone have begun to chondrify (except the distal phalanx of the little toe) by 7 weeks of embryonic life. Anomalies of the skeletal elements (such as tarsal coalition) form very early. The articular surfaces of the ankle joint and of the other joints of the foot reach a high degree of differentiation before the resorption phase of the interzone begins around 8 weeks of age. Hesser noted that the articular surfaces of the ankle joint reach a high degree of differentiation even before joint cavitation is complete [4]. The talonavicular and calcaneocuboid joints also reach close to their final shapes very early. Straus also stated that the joints of the foot are laid down in their definitive form by the ninth intrauterine week [5]. Cavitation of the interzone to form the synovial joints begins first at the ankle and progresses distally, forming last in the interphalangeal joints. O’Rahilly et al. further reviewed the skeletal development of the foot [6]. The prenatal development of the human foot has been well studied and described by Gardner et al. who reviewed the extensive developmental literature as well as assessing 184 human embryos and fetuses.
Article
Introduction: Routine ulnar nerve conduction studies may be normal in very mild ulnar neuropathies at the elbow (UNE). Short segment ulnar sensory stimulation across the elbow may detect mild abnormalities in these cases. Methods: Short segment ulnar sensory nerve stimulation was performed in 20 controls and 15 patients with clinically suspected mild UNE. Greatest peak latency shift and amplitude drop between two adjacent stimulation sites were calculated. Results: The upper limit of normal for peak latency shift and amplitude reduction between sites was 0.7 msec and 15%, respectively. Abnormal latency shift was detected in 12/15 patients and focal sensory conduction block in 6/15 patients. In 5/7 patients in which all other studies were normal, sensory inching was abnormal. Discussion: Ulnar sensory short segment stimulation may provide diagnostic confirmation and localization of the site of nerve compression in mild UNE, and may improve UNE detection when all other studies are normal. This article is protected by copyright. All rights reserved.
Article
Résumé Introduction Le pied creux neurologique est une déformation progressive, difficile à traiter pendant la croissance. Nous rapportons les résultats d’un traitement orthopédique, se fondant sur la physiopathologie des déformations, par attelle dévrillante de nuit précédée dans certains cas par une botte plâtrée dévrillante. Le but du travail est de démontrer l’efficacité de ce traitement et son effet sur la nécessité de chirurgie. Méthode Vingt-trois enfants, 35 pieds ont été inclus. Tous avaient une pathologie neurologique, progressive dans 24 cas (69 %) (maladie de Charcot-Marie-Tooth). L’âge moyen à la mise en route du traitement était de 8,8 ans. Dans 13 cas (38 %), le traitement a commencé par un plâtre dévrillant. Dans 22 cas (62 %), directement par l’attelle. Résultats Le suivi moyen était de 4,5 ans. Globalement, 15 pieds ont eu un très bon résultat clinique et 8 un bon (65 %). Neuf enfants (12 pieds) ont eu un résultat mauvais ou moyen, nécessitant dans 11 cas une intervention en moyenne 4,5 ans après le début du traitement orthopédique. Treize patients (56,5 %, 21 pieds) avaient atteint la fin de croissance au dernier rendez-vous. Parmi eux, 10 pieds (48 %) ont eu un résultat bon ou très bon, sans recours à la chirurgie. Aucune intervention de triple arthrodèse n’a été nécessaire. Les facteurs limitant le bon résultat étaient le jeune âge à l’instauration du traitement et la mauvaise compliance au port de l’attelle. La sévérité de la déformation initiale n’influençait pas le résultat. Conclusion Ce travail montre l’efficacité du traitement non chirurgical du pied creux varus neurologique chez l’enfant. Dans cette série, la chirurgie était soit évitée (50 % des cas en fin de croissance), soit retardée d’en moyenne 4,5 ans, permettant de réaliser une unique intervention avant la fin de la croissance. Nous recommandons que le traitement orthopédique des PCV de l’enfant (associant un plâtre dévrillant et la prescription d’orthèses dévrillantes de nuit) soit mis en place dès la preuve d’évolutivité clinique et/ou la mesure de l’angle de Méary (radio de profil sur planchette) supérieure ou égale à 15°. Niveau de preuve IV.
Chapter
The aim of treatment of Pes cavus deformity is to achieve a plantigrade foot that is mobile and pain-free. The discerning surgeon would wish to know what treatment would achieve this outcome with the best results. Unfortunately a simplistic (evidence-informed) conclusion is not feasible for several reasons: Pes cavus is an anatomical condition with multiple aetiologies which have different natural histories and prognoses. Historically, poliomyelitis and untreated/recurrent clubfoot accounted for a substantial load of Pes cavus patients – but these are now comparatively infrequent; the largest group is ‘Neurological’, and here the prognosis differs markedly between those with progressive (as opposed to non-progressive) neurological conditions. Patients present at different stages of maturity, with variable severity of deformity; many have had previous surgery. There is a paucity of definitive outcome measures; surgeons have used different instruments to define their surgical outcome, making it problematic to directly compare different treatments. Surgical planning is largely individualised, taking into account the disparity of factors. Surgery can be divided into soft tissue surgery, bony surgery and fusion. Triple arthrodesis has been the mainstay of surgery in the past but has not always produced satisfactory results. Joint-sparing surgery is gaining more popularity, especially where the deformity is flexible. The evidence base is extremely limited.
Article
Introduction: Neurologic pes cavus is a progressive deformity that is difficult to treat during growth. The present study reports results of non-operative management, based on the pathophysiology of the deformity, by untwisting nocturnal splint, preceded in some cases by untwisting walking cast. The objective was to assess efficacy and impact on indications for surgery. Method: Twenty-three children (35 feet) were included. All had neurologic cavovarus foot, which was progressive in 24 feet (69%) (Charcot-Marie-Tooth disease). Mean age at initiation of treatment was 8.8 years. In 13 feet (38%), treatment began with a untwisting walking cast and in 22 (62%) began directly with the splint. Results: Mean follow-up was 4.5 years. Fifteen feet showed very good and 8 good clinical results (65%); 9 children (12 feet) had moderate or poor results, requiring renewed treatment in 11 feet at a mean 4.5 years after initiation of non-operative treatment. Thirteen patients (56.5%, 21 feet) had reached end of growth by last follow-up; 10 of these feet (48%) had good or very good results without surgery. No triple arthrodeses were required. Factors weighing against good outcome comprised young age at treatment initiation and poor compliance with the splint. Primary deformity severity did not affect outcome. Conclusion: The present study demonstrated efficacy for non-operative treatment of childhood neurologic cavovarus foot. Surgery was either avoided (in half of the cases followed up to end of growth) or delayed by a mean 4.5 years, allowing a single procedure before end of growth. We recommend initiating non-operative treatment of childhood cavovarus foot, associating untwisting walking cast and untwisting nocturnal splint, as soon as clinical progression is detected and/or Méary angle on lateral X-ray with block reaches 15°. Level of evidence: IV.
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The cavus foot is a deformity characterized by an elevated medial longitudinal arch and a hindfoot varus with plantarflexed 1st ray. The etiology of cavus foot is usually related to neuromuscular disease or idiopathic cause. Thorough clinical and radiographic evaluation is required for differentiating etiology of the cavus. Most cases of cavus foot are stable and slowly progressive deformities which can initially be managed with conservative treatment including orthoses and physical therapies. Determining whether the deformity is flexible or rigid, the apex of the deformity and any muscle imbalances in foot and ankle is important for achievement of an adequately balanced plantigrade foot. Treatment should include systematic preoperative planning for selection of appropriate procedures for maintaining a functional and flexible foot with combinations of soft-tissue release, osteotomy, tendon transfer, and arthrodesis.
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Fußfehlstellungen sind seit dem Altertum bekannt. So war beispielsweise Hippokrates (460-375 v. Chr.) einer der ersten, der die sehr frühe, subtile Manipulation und Redression des angeboren Klumpfußes propagierte. Neben dem Spektrum unzähliger operativer Methoden am komplexen Weichteilapparat des Fußes und/oder am ossären Fußgerüst bei primären oder sekundären Fußdeformitäten, werden bei Versagen konservativer Maßnahmen heute auch unblutige Methoden mit dem Ilizarov-Apparat am defomierten kindlichen, adoleszenten und Erwachsenen-Fuß angegeben [15].
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Der Fuß sollte immer auch als Teil der gesamten kinetischen Kette der unteren Extremität gesehen werden, die daher in den Untersuchungsgang einbezogen werden muss. So kann sich beispielsweise ein Spitzfuß in Folge einer Beinlängendifferenz entwickeln. Teilweise muss der Fuß pathologische biomechanische Achsen kompensieren. Darüber hinaus können sich am Fuß Zeichen einer metabolischen, zirkulatorischen, neurologischen oder dermatologischen Erkrankung des Gesamtorganismus manifestieren.
Article
From a subject group of pes cavus, the purpose of this study was to evaluate the biomechanical characteristics of lower limbs, based on plantar foot pressure and electromyography (EMG) activities, by the effects on two kind of custom-made insoles. Ten individuals among thirty females with a clinical diagnosis of idiopathic pes cavus were selected for the study. Method: The plantar foot pressure data and EMG activities of four lower limb muscles were collected, when subjects walked on a treadmill, under three different experimental conditions. The plantar foot pressure data was analyzed, after the bilateral foot was divided into three areas of masks, to compare plantar foot pressure. The EMG activities were analyzed for integrated EMG (IEMG) value. The results show that plantar foot pressure concentrated in particular parts is decreased by custom-made insoles. In the case of EMG, all the muscle activities de-creased significantly. Thus, the result of this study can be applied for designing functional insoles and lower extremity orthoses for individuals with pes cavus.
Article
Charcot-Marie-Tooth disease is the single most common diagnosis associated with cavus foot. The imbalance involving intrinsic and extrinsic muscles has been suggested as the main pathogenetic cause of cavus foot in this disease. The goal of surgical treatment is to correct the deformity to obtain a plantigrade foot. In the presence of a flexible deformity and the absence of degenerative arthritis, preserving as much as possible of the overall range of motion of the foot and ankle is advisable. Twenty-four cavus feet in twelve patients with Charcot-Marie-Tooth disease were included in the study. Clinical evaluation was summarized with the Maryland Foot Score. Radiographic evaluation assessed calcaneal pitch, Meary angle, Hibb angle, and absence of degenerative joint changes. Only patients who had a flexible deformity, with varus of the heel reducible in the Coleman-Andreasi test, and did not have degenerative joint arthritis were included in this study. Surgical treatment consisted in plantar fasciotomy, midtarsal osteotomy, extensor hallucis longus tendon transfer to the first metatarsal (Jones procedure), and dorsiflexion osteotomy of the first metatarsal. Mean follow-up was six years (range, two to thirteen years). The mean Maryland Foot Score was 72 preoperatively and 86 postoperatively. The postoperative result was rated as excellent in twelve feet (50%), good in ten (42%), and fair in two (8%). Mean calcaneal pitch was 34° preoperatively and 24° at the time of the latest follow-up, the mean Hibb angle was 121° preoperatively and 136° postoperatively, and the mean Meary angle was 25° preoperatively and 2° postoperatively. Plantar fasciotomy, midtarsal osteotomy, the Jones procedure, and dorsiflexion osteotomy of the first metatarsal yielded adequate correction of flexible cavus feet in patients with Charcot-Marie-Tooth disease in the absence of fixed hindfoot deformity. The fact that the improvement in the outcome score was only modest may be attributable to the lack of motor balance. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.
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Charcot-Marie-Tooth (CMT) is a disease that is highly heterogeneous, both clinically and genetically. Clinical and electrophysiological data are essential for diagnosis. Children with CMT experience acquired foot weakness, contracture and deformity (pes cavus and hammer toes) from an early age. Early intervention targeting the foot and ankle may prevent long-term disability in CMT. Here we present a CMT patient with acquired pes cavus and hammer toes and review the literature briefly for diagnosis, treatment, and rehabilitation of CMT. As a result we conclude that CMT should also come into mind in the differential diagnosis of acquired pes cavus and hammer toes.
Article
Flexible cavovarus feet in children and adolescents can be challenging. A careful history and physical examination are paramount for determining the best treatment strategy and a multitude of options are available. Specific treatment strategies should be individualized and any bony correction must be in conjunction with a muscle balancing procedure. Well-timed soft tissue and occasionally bony procedures can delay the progression of deformity. These patients are monitored long term because further treatment may be required.
Article
Adult cavovarus deformity patients present with rigid cavovarus deformity, where the correction can no longer be obtained using soft tissue procedures alone, and corrective arthrodesis or osteotomy must be performed to realign the deformity. Reconstructive surgeries for cavovarus foot deformities are variable and include hindfoot or midfoot osteotomy or arthrodesis, soft tissue release or lengthening, and tendon transfers. Recently adult cavovarus foot deformities have been more commonly addressed with joint preservation osteotomies and adjunctive soft tissue surgeries and less with triple arthrodesis. Clinical and radiographic outcomes are overall favorable.
Article
Zusammenfassung Der Klauenhohlfuß nahm in der Fachliteratur am Anfang des letzten Jahrhunderts im Vergleich zur Gegenwart einen wesentlich höheren Stellenwert in der Diagnostik und Therapie ein. Diese Tatsache scheint darin begründet zu sein, dass bestimmte neurologische Krankheitsbilder (Poliomyelitis, Myelodysplasie), die oftmals Fußfehlstellungen zur Folge haben, heute nur noch selten in Erscheinung treten. Von Ausnahmen abgesehen, etablierte sich die operative Therapie der Klauenhohlfüße um die Jahrhundertswende, wobei insbesondere die A- und Antisepsis sowie die verbesserte Narkosemöglichkeiten dazu beigetragen haben.Die erste operative Versteifung eines Gelenks zur Stellungskorrektur des Fußes wurde von Ladislaus Leo Freiherr von Lesser am oberen Sprunggelenk durch Abtragung der knorpeligen Flächen und Fixierung mit einem Metallnagel vorgenommen. Das Kunstwort Arthrodese wurde aus dem Griechischen entlehnt und lässt sich mit Gelenkbindung übersetzen. Es entwickelten sich dann vielfältige Arthrodesemethoden unter Ein- bzw. Ausschluss vieler Gelenke der Fußwurzel, die von vielen Modifikationen geprägt waren. Mit Erweiterung der Kenntnis über die Pathogenese der Hohlfußdeformität wurden die rein knöchernen Verfahren zunehmend mit diversen Weichteil- und Sehnentransfertechniken kombiniert. Die Philosophie der künstlichen Versteifung von Fußwurzelgelenken ist heute noch aktuell. Diese konnte durch Weiterentwicklung von Fixierungsverfahren und -materialien perfektioniert und das langdauernde Nachbehandlungsschema drastisch verbessert werden.
Article
A cavus forefoot deformity can exist as a result of muscle imbalance, and, when identified, the patient shouldundergo appropriate neurological evaluation. The deformity can result in increased stresses on the metatarsal heads and push the hindfoot into a varus position. In more advanced cases, it can result in decreased motion of both the subtalar and ankle joints. Physical examination is of great importance in evaluating these patients and includes evaluation of the gait cycle, as well as the position of the heel and toes at rest. Evaluation of the muscle strength available is also important. The Coleman and Chestnut block test can be very helpful in determining hindfoot stiffness and the relationship of the forefoot cavus and the hindfoot varus. Surgical correction of the cavus forefoot often can be accomplished with a Jones procedure, sometimes with a closing wedge osteotomy of the first and possibly second and third metatarsals. This will sometimes be sufficient to allow the hindfoot to come out of varus.
Article
Introduction: Given its association with Charcot-Marie-Tooth disease (CMT), pes cavus is a common reason for referral to a neurologist. We investigated clinical features that may predict CMT in children with pes cavus. Methods: In this study we retrospectively reviewed pes cavus patients referred to Boston Children's Hospital in the past 20 years. Patients were categorized as idiopathic or CMT, based on EMG/genetic testing, and their clinical features were compared. Results: Of the 70 patients studied, 33 had idiopathic pes cavus, and 37 had genetically confirmed CMT. Symptoms of weakness, unsteady gait, family history of pes cavus and CMT, and signs of sensory deficits, distal atrophy and weakness, absent ankle jerks, and gait abnormalities were associated with CMT. Conclusions: In children with pes cavus, certain clinical features can predict CMT and assist in selection of patients for further, potentially uncomfortable (EMG) and expensive (genetic) confirmatory investigations.
Article
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Hereditary motor and sensory neuropathies, especially Charcot-Marie-Tooth disease, are frequently expressed with an acquired cavusvarus foot which is characterized by a fixed increase of the plantar arch and hindfoot inversion. Diagnosis of the underlying condition achieved through careful patient assessment and local evaluations is the keystone for decision-making about the adequate treatment. The cavus may present as an isolated deformity of the forefoot, hindfoot or it may be a combination of both locations. Related deformities, mainly the varus and toe clawing require appropriate evaluation; clinical characteristics such as severity of the deformity, impairment of the muscular power, flexibility and patient’s age are important characteristics in the treatment decision. Conservative treatment of the cavusvarus foot with physiotherapy, insoles and shoe modifications are reserved to young patients and mild deformities. However, there is a tendency of the deformity to become more severe over time because of the progressive feature of the underlying neurological condition. So, the surgical treatment by using classical techniques is performed in early stages. Most importantly is the identification of the primary and main components of each deformity to properly correct them, if possible. Muscular transfers are used to treat the dynamic unbalance, retracted structures should be either divided or lengthened and localized osteotomies should be preferred over arthrodeses, which are reserved for stiff and severely deformed feet in adults. Keywords - Polyneuropathies; Charcot-Marie-Tooth Disease; Foot deformities
Article
The insertion of peroneus longus is traditionally described to the plantar surface of the 1st cuneiform and 1st metatarsal. It is thought to be the main contributor to the plantarflexed first ray seen in cavus feet. We studied the insertion of peroneus longus in 26 feet from 14 adult cadavers. The insertional points, presence of sesamoid bone and variations in insertion were noted. The main insertion was to the base of the 1st metatarsal and the medial cuneiform in the majority of feet but variations were observed. A sesamoid bone was present within the tendon under the cuboid in 16 feet, 12 of which had additional lateral insertion bands. Variations in the insertion of peroneus longus were found and we have described two new lateral bands.
Article
Purpose of review: In this review, we will update the present understanding of the clinical presentation, work-up, and treatment for both neurologic and nonneurologic pes cavovarus. Recent findings: It is becoming increasingly clear that idiopathic pes cavus is an underappreciated cause of foot and ankle pathology and may initially be recognized by the 'peek-a-boo' heel sign. Treatment should include correction of the pathologic problem and the underlying malalignment. Advances in the molecular genetics of Charcot-Marie-Tooth disease have led to a better understanding of the pathophysiology and classification of the disease. The results of studies describing treatment with ascorbic acid and neurotrophin-3 have recently been published and have demonstrated promise in improving both the pathologic and clinical manifestations of the disease. Validated outcome measures have been developed and may facilitate future research. Summary: The finding of subtle forms of idiopathic pes cavovarus in adults with foot and ankle pathology is increasingly being recognized and must be considered in the work-up and treatment of these patients. Advances in the molecular genetics of neurogenic pes cavovarus have and will continue to allow for an improved understanding of the pathophysiology and classification of these disorders and for the development of effective new therapies.
Article
Pes cavus is a descriptive term that covers a spectrum of deformity. It is often secondary to a neurological abnormality. Determination of the underlying aetiology and the pathoanatomy in the individual patient is essential to the prescription of the appropriate treatment in a particular patient. The goals of any treatment being a painless, plantigrade shoeable foot. The major anatomical component of the deformity and whether there is a hind or forefoot rigidity will help direct any required surgical intervention. Surgery is not an inevitable end point in the treatment of pes cavus and many patients are well treated by orthotic devices and shoe modification. If surgery is considered there is no universal set of guidelines. However, options that preserve joint movement are preferred–at least in the first instance–to procedures involving fusions and osteotomies that destroy joints, with arthrodesis reserved for salvage of failed correction or those with severe deformity.
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Pes cavus, or a high arched foot, is rarely seen at birth or in the first year of life unless it is part of a severe congenital talipes equinovarus. There is a rare, benign form of high arched foot called pes arcuatus; this is occasionally seen as an isolated abnormality in the first year of life and resolves spontaneously. Cavus deformity of the foot develops in the majority of cases in the first or second decade of life.
  • W H Cole
Cole, W. H. (1940). Ibid., 22, 895.
  • G Pugh
Pugh, G. (1927). Proc. roy. Soc. Med., 20, 1124.
  • N D Royle
Royle, N. D. (1927). J. Bone Ji Surg., 9, 465.
  • M Turner
Turner, M. (1952). Arch. argent. Pediat., 38, 38.
  • F R Fisher
Fisher, F. R. (1889). Lancet, 1, 112.
  • E Gilroy
Gilroy, E. (1929). Edinb. med. J., 36, 749.
  • N Little
  • G P Mills
Little, N. (1938). Med. J. Aust., 2, 495. Mills, G. P. (1924). J. Bone Ji Surg., 6, 143.
Some Fundamental Concepts of Pes Cavus
  • O ' Connor
  • B T M Ch
O'Connor, B. T. (1959). Some Fundamental Concepts of Pes Cavus. A Thesis for M.Ch.Orth, Degree, Liverpool, p. 24.
Deformities-A Treatise on Orthopaedic Surgery Deformities Including Diseases of Bones and Joints
  • A H Tubby
  • Macmillan
  • London
Tubby, A. H. (1896). Deformities-A Treatise on Orthopaedic Surgery.. Macmillan, London. (1912). Deformities Including Diseases of Bones and Joints, 2nd ed. Macmillan, London.
  • J T Rugh
Rugh. J. T. (1927). Bull. N.Y. Acad. Med., 3, 423.
  • P Altakoff
Altakoff, P. (1931). Z. orthop. Chir., 55, 415.
  • P G K Bentzon
Bentzon, P. G. K. (1933). Acta orthop. scand., 4, 50.
  • A H Brewster
  • C B Larson
Brewster, A. H., and Larson, C. B. (1940). J. Bone Jt Surg., 22, 361.
  • A Steindler
Steindler A. (1917). Surg. Gynec. Obstet., 24, 612.
  • J T Saunders
Saunders, J. T. (1935). Arch. Surg., 30, 179.
  • J D Spillane
Spillane, J. D. (1940). Brain, 63, 275.