Pes Cavus dnbid 2014 lecture

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physiotherapy

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Pes Cavus :

Pes Cavus Dr. D. N. Bid

PowerPoint Presentation:

In pes cavus the arch is higher than normal, and often there is also clawing of the toes. The close resemblance to deformities seen in neurological disorders where the intrinsic muscles are weak or paralyzed suggests that all forms of pes cavus are due to some type of muscle imbalance. There are rare congenital causes, such as arthrogryposis , but in the majority of cases pes cavus results from an acquired neuromuscular disorder : [see Box in next slide].

PowerPoint Presentation:

A specific abnormality can often be identified; hereditary motor and sensory neuropathies and spinal cord abnormalities (tethered cord syndrome, diastematomyelia ) are the commonest in Western countries but poliomyelitis is the most common cause worldwide. Occasionally the deformity follows trauma – burns or a compartment syndrome resulting in Volkmann’s contracture of the sole.

Pathology:

Pathology The toes are drawn up into a ‘clawed’ position, the metatarsal heads are forced down into the sole and the arch at the midfoot is accentuated. Often the heel is inverted and the soft tissues in the sole are tight. Under the prominent metatarsal heads callosities may form.

Clinical features:

Clinical features Patients usually present at the age of 8–10 years. Deformity may be noticed by the parents or the school doctor before there are any symptoms. There may be a past history of a spinal disorder, or a family history of neuromuscular defects. As a rule both feet are affected.

PowerPoint Presentation:

Pain may be felt under the metatarsal heads or over the toes where shoe pressure is most marked. Callosities appear at the same sites and walking tolerance is reduced. Enquire about symptoms of neurological disorders, such as muscle weakness and joint instability.

PowerPoint Presentation:

The overall cavus deformity is usually obvious; in addition the toes are often clawed and the heel may be varus . Closer inspection will show the components of the high arch; this is important because it leads to an understanding of the responsible deforming forces.

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Rang (1993) presented a tripod analogy that simplifies the problem. The foot is likened to a tripod of which the calcaneus , fifth metatarsal and first metatarsal form the legs. Combinations of deformities affecting one or more of these ‘legs’ produce the common types of high arch, namely plantaris , cavovarus , calcaneus and calcaneo-cavus (Fig. 21.17).

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The toes are held cocked up, with hyperextension at the MTP joints and flexion at the IP joints. There may be callosities under the metatarsal heads and corns on the toes. Early on the toe deformities are ‘mobile’ and can be corrected passively by pressure under the metatarsal heads; as the forefoot lifts, the toes flatten out automatically. Later the deformities become fixed, with the MTP joints permanently dislocated.

PowerPoint Presentation:

Mobility in the ankle and foot joints is important. In the cavo-varus foot, the heel is inverted. The block test (Coleman et al., 1984) is useful to check if the deformity is reversible (Fig. 21.18); if it is, this signifies that the subtalar joint is mobile. If the cavus deformity has been present for a long time, then movements of the ankle, subtalar and midtarsal joints are usually limited.

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A neurological examination is important to try to identify a reason for the deformity. Disorders such as hereditary sensory and motor neuropathy and Friedreich’s ataxia must always be excluded, and the spine should be examined for signs of dysraphism

Imaging:

Imaging Weightbearing x-rays of the foot contribute further to the assessment of the deformity and the state of the individual joints. On the lateral view, measurement of the calcaneal pitch and Meary’s angle help to determine the components of the high arch (Fig. 21.19).

PowerPoint Presentation:

In a normal foot the calcaneal pitch is between 10 and 30 degrees, whereas Meary’s angle , formed by the axes of the talus and first metatarsal, is zero, i.e. these axes are parallel. In a calcaneus deformity, the calcaneal pitch is increased; in a plantaris deformity, Meary’s lines meet at an angle.

PowerPoint Presentation:

MRI scans of the spine will exclude a structural disorder, especially if this is more common than polio as a cause of high-arched feet in the region.

Treatment:

Treatment Often no treatment is required; apart from the difficulty of fitting shoes, the patient has no complaints. Foot deformity : In general, patients need treatment only if they have symptoms. However, the problem with high-arched feet is that it is often a progressive disorder that becomes more difficult to treat when the deformities are fixed; therefore treatment should start before the feet become stiff.

PowerPoint Presentation:

Non-operative treatment in the form of custom-made shoes with moulded inserts may provide some relief but does not alter the deformity or influence its progression. Surgery is often needed and the type of procedure will depend on the child’s age, underlying cause, site and flexibility of the individual deformities and type of muscle imbalance.

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The aim of surgery is to provide a pain-free, plantigrade , supple but stable foot. The methods available are soft tissue releases, osteotomies and tendon transfers. However, the deformity first needs to be corrected before a tendon transfer is considered; additionally, the transfer only works if the joints are mobile.

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An equinus contracture is dealt with by lengthening of the tendo Achillis and posterior capsulotomies of the ankle and subtalar joints. The varus hindfoot , if shown to be reversible by Coleman’s block test , may benefit from a release of the plantar fascia (the tight fascia acts as a contracted windlass on weightbearing , accentuating the deformity).

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However, if the subtalar joint is stiff, then calcaneal osteotomy will be needed; two types are commonly used: (1) the lateral closing wedge (an opening wedge on the medial side is a comparable operation but is fraught with wound problems); (2) a lateral translation osteotomy .

PowerPoint Presentation:

Treatment of a calcaneo-cavus deformity (which is the least common type of high arch) differs according to the age of the child. In young children (who usually have a neurological problem) tendon transfers, e.g. transferring the tibialis anterior through the interosseous membrane to the calcaneum , may be combined with tenodesis of the ankle using the tendo Achillis (Banta et al., 1981).

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Older children may need crescentic calcaneal osteotomies , which will correct both varus and calcaneus deformities ( Samilson , 1976) or variations of a triple arthrodesis ( Cholmeley , 1953).

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Midfoot deformities are usually cavus ( plantarflexed first metatarsal) or plantaris ( plantarflexed first and fifth metatarsals). The Jones tendon transfer helps elevate the depressed first metatarsal by using the extensor hallucis longus tendon as a sling through the neck of the first metatarsal.

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Often the peroneus longus is overactive and is partly responsible for pulling the first metatarsal down; some balance is restored by dividing this tendon on the lateral side of the foot and attaching the proximal end to the peroneus brevis , thereby removing the deforming force and improving the power of eversion simultaneously.

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Occasionally the deformity affecting the first metatarsal is fixed, in which case a dorsal closing wedge osteotomy at the base of the metatarsal is needed. A plantaris deformity is treated along similar lines for the first ray, and combined with a plantar fascia release if the deformity is mobile, but basal metatarsal osteotomies or even a wedge resection and arthrodesis across the midfoot are needed for rigid deformities.

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In severe examples and in those who have either relapsed or who have responded poorly with soft tissue releases and osteotomies , salvage surgery in the form of a triple arthrodesis is recommended; it produces a stiff but plantigrade and pain-free foot.

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Clawed toes: Correction of a clawed first toe is by the Jones tendon transfer, which involves either a tenodesis or fusion of the IP joint. Clawing of the lesser toes is treated with a flexor tendon transfer to the extensor hood of each toe, and MTP joint capsulotomies if the toes are still passively correctable; however, if the deformities are fixed, proximal IP fusion is needed.

Physiotherapy:

Physiotherapy Suggested conservative management of patients with painful pes cavus typically involves strategies to reduce and redistribute plantar pressure loading, with use of foot orthoses and specialized cushioned footwear.

PowerPoint Presentation:

The orthoses for pes cavus needs to accomplish to several specific goals: •  Increasing plantar surface contact area The overload on the metatarsal heads is a result of limited plantar surface contact due to high arch and limited ankle-joint dorsiflexion . Increasing the plantar surface contact ensures the foot to bear more weight in the arch while the metatarsal heads bear less weight during activity.

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•  Resisting against excessive supination Lateral ankle stability and laterally deviated subtalar joint axis (STJ) are frequently associated with high-arched feet. This position results in an excessive supinator torque around the subtalar joint axis. 

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•  Resisting against recessive pronation and supination forces Rearfoot instability is caused by an extension of the laterally deviated subtalar axis. In flexible pes cavus , midtarsal flexibility complicates the later portion of the stance pgase of gait. The forefoot pathology produces midtarsal joint supination, that leads to excessive pronation of the rearfoot . Some pes cavus suffer from both lateral ankle instability at midstance and rearfoot pronation at late midstance . 

Ref::

Ref: 1. Apley’s Orthopedics 2. http://www.physio-pedia.com/Pes_cavus

Thanx 4 yr attention……………:

Thanx 4 yr attention……………

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