FussSprungg 16 (2018) 3—29

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Special issue review

Clinical and new aspects of the subtle cavus foot:

A review of an additional twelve year experience

Klinische und neue Aspekte des subtilen Pes cavus —

Eine Standortbestimmung nach weiteren 12 Jahren

a,b,c,∗ d

Arthur Manoli II , Brian Graham

a

Michigan International Foot and Ankle Center, Pontiac, MI, USA

b

Department of Orthopaedic Surgery, Wayne State University, Detroit, MI, USA

c

Michigan State University, East Lansing, MI, USA

d

Performance Zone, Auburn Hills, MI, USA

Received 19 November 2017; accepted 27 November 2017

Available online 15 December 2017

KEYWORDS Abstract

Pes cavus;

Background: The subtle cavus foot (SCF) and its associated conditions have become

Pes cavovarus;

increasing recognized over the past 12 years. Many of the commonly associated

Metatarsus adductus;

pathological conditions often cause considerable pain and disability, especially in

Coleman block;

sports and other high activity pursuits.

Gastrocnemius

Results/Conclusions: Accurate diagnosis of an underlying SCF is essential to the

understanding of why the many associated conditions develop and for their treat-

ment. As the bones of the foot and ankle gradually form into a cavovarus position

and the joints stiffen, often with a degree of metatarsus adductus, the presenting

pathology may be difficult to treat. The SCF may need to be treated either nonop-

eratively with specialized orthotic devices or operatively, along with the particular

associated condition(s), at the time of surgical repair.

Level of evidence: Level V, expert opinion.

SCHLÜSSELWÖRTER Zusammenfassung

Pes cavus;

Hintergrund: Der subtile Pes cavus (,,subtle cavus foot‘‘, SCF) ist eine in den

Pes cavovarus;

letzten 12 Jahren zunehmend anerkannte Entität. Viele der zahlreichen assoziierten

Metatarsus adductus;

Pathologien sind eine potenzielle Quelle für Schmerzen und Funktionseinschränkun-

Coleman block;

gen, insbesondere bei Sportlern und körperlich hochaktiven Personen.

Gastrocnemius

Ergebnisse, Schlussfolgerungen: Die akkurate klinische Diagnose eines subtilen Pes

cavus ist die Voraussetzung für das Verständnis und die Behandlung der assoziierten

Beschwerden. Mit zunehmender Ausprägung und Rigidität des Pes cavovarus und

oftmals auch der Entwicklung eines Metatarsus adductus wird die zugrunde liegende

Pathologie schwieriger zu therapieren. Die Therapie eines subtilen Pes cavus kann

konservativ, mit entsprechender Orthesen- und Einlagenversorgung oder operativ,

mit gleichzeitiger Korrektur begleitender Pathologien erfolgen.

∗

Corresponding author at: Michigan International Foot and Ankle Center, 44555 Woodward, Suite 503, Pontiac, MI, USA.

E-Mails: [email protected] (A. Manoli II), [email protected] (B. Graham). https://doi.org/10.1016/j.fuspru.2017.11.006

4 A. Manoli II, B. Graham

Introduction those with flatfeet with pronation [1]. An accurate

diagnosis of the correct foot posture is essential

In 2005 we published a review article describing the to providing the correct treatment for people with

subtle cavus foot (SCF) and its many associated con- foot complaints.

ditions [1]. Since then, there has been an increased Most of the statements in this review are related

awareness of this foot posture and the related to published works and are documented. The new

problems in the general orthopaedic community. and future concepts are observations and opinions

Additional review articles [2—5], and a symposium of the authors and are mostly illustrated. Future

[6] have been published, and even Instructional research will be necessary to corroborate these

Course Lectures on the topic have been offered ideas.

at the American Academy of Orthopaedic Surgeons

Annual Meetings [7].

Unfortunately, many other types of practitioners Recent sports medicine emphasis

have not kept pace with these recent devel-

opments. It is still not uncommon for patients Especially interesting to orthopaedic surgeons has

continue to appear for a consultation for SCF treat- been the increasing emphasis on correctly diagnos-

ment after they have been told that they are ing this type of foot posture in sports medicine.

‘‘overpronators.’’ Many practitioners continue to Here, the increased awareness of the presence of

believe that almost all foot pathology in athletes, the common high-arched foot has helped explain

especially in runners, is the result of having flat- many of the observed pathologies and undoubtedly

feet and having ‘‘overpronation [8]’’. We find that improved care. Multiple associated abnormalities

misdiagnosis continues and is especially common in can be treated at one time, [9] or close tempo-

running stores and in strip mall arch support sup- rally [10]. Foot-posture-changing osteotomies may

pliers where many uninitiated workers fit people be performed in cases of recurrence [11—15] or pro-

desiring to purchase running shoes and inserts. phylactically to prevent a recurrence after an initial

The patient is usually prescribed a pair of high procedure [16,17].

‘‘arch supports’’ (Fig. 1). In many cases these are It has been noticed that basketball players who

hard plastic-like supports. They actually stiffen the are of excessive height may be particularly prone

foot and tip it more laterally. These arch supports to stress fractures in the foot (navicular and fifth

often make the symptoms worse. When the patient metatarsal), and ankle instability [15]. It is possi-

states that they are worse, the supporting arch sup- ble that these players are not simply cases of the

ports are often made even higher. Eventually they SCF, but that they may actually be examples of

are discarded. Motion control shoes are commonly, what Hansen calls ‘‘too tall neuropathy,’’ making

erroneously prescribed, also. treatment particularly difficult without posture-

We have found that the true ‘‘overpronator’’ is, changing osteotomies [18].

in fact, a rather rare phenomenon. We actually see Sports medicine courses may now include at least

far more patients with symptoms from a SCF than a description of the SCF posture. During a recent

American Orthopaedic Foot and Ankle Society-

sponsored course, ‘‘Sports Injuries of the Foot and

Ankle’’ (Houston, TX, October, 2013), there were

1210 min of instruction [19]. Of this, 520 min (43%)

were devoted to topics that we feel are directly

related to the SCF, such as recurrent ankle sprains,

stress fractures of the foot and ankle, sesamoid

problems, etc. Additionally, 390 min (32%) were

devoted to indirectly related issues, posterior ankle

pathology, turf toe and syndesmosis injuries which

may be difficult to treat because of the tight triceps

surae complex which is almost universally present

with the SCF.

Therefore, a full three-quarters of the course

(75%) was devoted to problems associated with the

Fig. 1. Rigid three-quarter length foot orthotic erro-

SCF, either directly or indirectly. There was also a

neously fabricated for a very high-arched SCF. Such a

single, 10 min presentation, second from the last,

device further stiffens the already stiff foot and tips the

on the cavus foot in the athlete — when to do an

foot so that the patient walks on the lateral border even ‘‘

more than usual. osteotomy.’’ We feel it is important to continue to

Clinical and new aspects of the subtle cavus foot: A review of an additional twelve year experience 5

Fig. 2. (A) Fifteen year-old male with moderately severe SCF. Note the peek-a-boo heels bilaterally. The deformity

appears worse on the right foot than on the left foot. (B) Bilateral heel varus is confirmed, viewing from the rear. The

right foot has more heel varus than the right foot. Note the medial insertion of the Achilles tendon bilaterally. (C)

Enhanced Coleman block test for the left foot. The contralateral limb is rotated externally approximately 90 degrees.

Excellent correction of the heel varus into a normal heel valgus position is seen. This illustrates that the plantarflexed

first ray is responsible for the heel varus and that the heel joints are supple. Enhanced Coleman block test for the

right foot. The contralateral limb is rotated externally approximately 90 degrees. There is partial, yet incomplete

correction of the heel varus. This illustrates that plantarflexed first ray is partially responsible for the heel varus and

that the heel joints are stiff and fail to correct fully.

emphasize the importance of the SCF, as it probably (Fig. 2B). In the average, ‘‘normal’’ foot, approxi-

is the biggest causative problem in sports medicine mately 5 degrees of valgus is present when viewed

today. from the back. If there is less than this normal val-

gus (either less valgus, straight, or heel varus), the

heel can be considered to be in a functionally varus

Evaluation postion (Fig. 2C—D).

When seeing a patient, after the taking of a thor-

ough history, it is important to have them take off Peek-a-boo heel sign

their shoes and socks and, at least, roll up their

pant legs to the knee, or, preferably above. While The peek-a-boo sign was described by Manoli et al.

standing, alignment of the limbs is evaluated, look- in a 1993 article concerning reconstruction of the

ing for genu varum or valgus. The feet are looked lower extremity for the late sequelae of compart-

at from the front and one should note the foot pos- mental syndrome of the leg [20]. Since then it has

ture. If one can see the medial heel, we call it a proved to be invaluable as a screening sign for

‘‘peek-a-boo’’ heel (Fig. 2A). This is most often due evaluation of the cavovarus foot, especially the

to a cavovarus foot posture, although not always. subtle ones [21]. Using it, it is possible to diagnose

To confirm whether there is a truly a varus heel, the even minor degrees of heel varus. With experience,

patient is turned around and viewed from the rear one can quantatively compare both sides for minor

6 A. Manoli II, B. Graham

differences (Fig. 2A). This is confirmed when view- the hindfoot starts to stiffen up and the heel fails

ing from the rear (Fig. 2B). to correct fully with Coleman block testing.

We disagree with recent articles which state

that if a foot does not fully correct on the block

that it should be considered as one with ‘‘hindfoot

Coleman block test driven varus.’’ [4,5] As the major component of the

deformity is likely forefoot-driven and this portion

When an anatomically varus heel is diagnosed, it of the deformity improves with standing on the

is important to ALWAYS perform a Coleman block block, ‘‘not fully correcting’’ indicates that one is

test to fully understand the foot’s characteristics simply dealing with a hindfoot in the ‘‘rigid-stiff

[22]. When viewed from the rear, the patient stands ‘‘phase in Mosca’s scheme (Fig. 2D). We prefer

on a block of wood, similarly sized book or other to think of a ‘‘hindfoot-driven varus’’ foot as one

object, and drops the medial portion on the fore- which has its origins in hindfoot pathology and stiff-

foot (medial 3—4 toes and metatarsal heads), off ness as seen in old, malreduced talar and calcaneal

of the edge of the block (Fig. 2C—D). The observer, fractures and cavovarus deformities from late com-

seated behind the patient, watches to see if the partmental syndromes of the leg. Here, the deep

heel corrects to a normal valgus position. If the heel posterior muscular scarring and contracture cause

corrects to a normal position, it demonstrates that the equinovarus foot posture [20].

(1) the heel is supple and (2) that the planarflexed

first ray of the cavovarus foot is tipping (supinating)

the entire foot so that the heel is in varus (Fig. 2C). Enhanced Coleman block test

This is due to a change in the static ‘‘triangle of

support,’’ described by Cotton [23] or the ‘‘tripod We have noticed that it is possible to increase the

effect’’ [24]. Cotton also discussed Wiles’ work effectiveness of the normal Coleman block test

where the important plantarflexing action of the by having the patient stand with the contralat-

long peroneal muscle on the first ray, maintaining eral lower extremity rotated outwards (laterally) at

the medial longitudinal arch, was emphasized [25]. about a 90 degree angle to the block (Fig. 2C—D).

Accurate interpretation of the Coleman block This effectively turns the pelvis towards the con-

test is essential for treatment of the SCF. We agree talateral side and causes the ipsilateral limb, and

with Coleman and Mosca that the primary driver of talus, to internally rotate. With the foot held firmly

the heel varus in most cases is a plantarflexed first on the block, this gently forces the foot into maxi-

ray [22,24,26]. This is especially true in the SCF. mum possible eversion and one can see exactly how

Mosca has described a scenario where the supple and how much eversion of the hindfoot is

foot goes through developmental phases (Table 1) possible.

[24,26].

Here we see that the forefoot, primarily the

plantarflexed first ray, gradually stiffens and False peek-a-boo heel signs

becomes rigid. The hindfoot lags behind, but even-

tually stiffens, then becomes rigid. The older the We have found the peek-a-boo heel sign to be

patient, the more rigidity develops, eventually, extremely valuable as a tool to identify cases of SCF.

each area becomes rigid with little motion. We must emphasize that it is a SCREENING TOOL

Most of the SCF cases in clinical practice fall into ONLY, and that all people should be viewed from the

the middle three groups. In most cases, ‘‘forefoot- rear to confirm that they actually have heel varus,

driven, hindfoot varus’’ is the major component. or less valgus, than normal. There are numerous

With long-standing deformity the subtalar joint of conditions that can create a false positive peek-boo

Table 1 Flexibility scheme of the subtle cavus foot.

Forefoot (plantar flexed first ray) Hindfoot (eversion)

Flexible Flexible (subtalar joint corrects fully)

Stiff Flexible (subtalar joint corrects fully)

Rigid Flexible (subtalar joint corrects fully)

Rigid Stiff (subtalar joint does not correct fully)

Rigid Rigid (subtalar joint does not move)

Adapted from Mosca, VS: Principles and management of pediatric foot and ankle deformities and malformations, Philadelphia,

PA, Wolters Kluwer Health; 2014;67—70.

Clinical and new aspects of the subtle cavus foot: A review of an additional twelve year experience 7

heel sign. One can also encounter a false negative

peek-a-boo heel sign.

False positive peek-a-boo heel and

alignment signs

Heel cord and/or gastrocnemius tightness (false

positive)

Patients with extremely tight heel cords usually

stand with their feet rotated outwards (Fig. 3A).

In this position of lower extremity external rota-

tion, one can often see the heel more than usual,

resulting in a false positive peek-a-boo heel sign. To

properly evaluate these people, one should have

them stand with their feet facing straight ahead,

facing the examiner and turned away, even though

the patient may complain that it feels ‘‘funny’’ or

‘‘strange’’ to stand that way. The peek-a-boo heel

usually diminishes (Fig. 3B). Viewing from the rear

confirms the actual heel shape (Fig. 3C).

Heel cord tightness should then be evaluated

with the patient seated, checking the amount of

dorsiflexion, with the knee straight and bent (Sil-

verskoold test for gastrocnemius muscle versus heel

cord tightness). This has implications for lengthen-

ing of the triceps surae muscle unit when necessary.

Metatarsus adductus and metatarsus primus

varus (false positive)

Many cavovarus feet have an element of metatarsus

adductus. It is also possible to see just metatarsus

adductus without a heel deformity, presumably a

remnant of a childhood deformity that did not spon-

taneously correct. Some patients may even have an

everted hindfoot, a skewfoot.

Adductus of the forefoot can result in a false

positive peek-a-boo heel sign. In order for the

patient to stand and walk with their feet facing

straight ahead, they must externally rotate their

hips (Fig. 4A—B). The heel is then more visible

when viewed from the front. Checking the patient’s

heel posture from the rear, should eliminate any

confusion. We disagree with the recent statement

of Abbasian (reference) that metatarsus adductus

Fig. 3. (A) A female patient with tight Achilles tendons.

masks a peek-a-boo heel and causes a false negative

situation. False positive peek-a-boo heel signs are seen bilaterally,

as the patient must turn her feet outward to stand. (B)

Occasionally, patients with large hallux valgus

With the feet turned more forward, the peek-a-boo heel

deformities will also present with false posi-

is seen less. (C) When viewed from the rear, the patient

tive peek-a-boo heel deformities (Fig. 5A—B). We

actually has heel valgus.

believe that external rotation of the hip, from the

same mechanisms as seen above with metatarsus

adductus and/or tight heel cords, is responsible for Large peel pad (false positive)

this phenomenon. Some patients exhibit multiple Some people actually have a congenitally large heel

factors leading to false peek-a-boo heels, as seen pad. When standing, the pad bulges in all direc-

below. tions. Medial bulging can be seen when viewing

8 A. Manoli II, B. Graham

Fig. 5. (A) This male patient has a multitude of factors

producing false peek-a-boo heel signs. He has large heel

Fig. 4. (A) Metatarsus adductus producting peek-a-boo

pads, triangular heel pads, especially on the right foot,

heels as the patient externally rotates the hips to face

and metatarsus primus varus. (B) When viewed from the

the feet forward. (B) A more severe metatarsus adductus

rear, the heels are actually in valgus. Piezogenic papules

deformity. The patient has to greatly externally rotate

are seen bilaterally. These are common in people with

the hips to face the feet forward. This produces false

large heel pads (see text).

peek-a-boo heels in the so-affected feet.

from the front, causing a false positive peek-a-

Careful examination can accurately identify the

boo heel sign (Fig. 5A—B). Viewing from the rear

normal heel contour (Fig. 6B).

shows the semicircular bulging and, often, piezo-

genic papules, where heel pad fat bulges through

the superficial fibrous septa of the pad. Generally,

Medial bulging of foot (false negative)

these nodules are of little clinical importance [27].

Patients may present with medial bulging of the

foot near the arch area. As an example, a male with

Medially displaced, triangular heel pad (false long-standing Mueller—Weiss syndrome is shown.

positive) The triangularly-shaped tarsal navicular results in

Occasionally, some patients have a heel pad that heel varus [28] (Fig. 7A—C). Because of the medial

is somewhat unstable and it shifts medially. It swelling, no peek-a-boo heel is seen when viewed

assumes a triangular appearance, when seen from from the front (Fig. 7D).

the rear. The medial prominence can give the Occasionally, someone will present with a

appearance of a peek-a-boo heel (Fig. 5A—B). large abductor hallicus muscle mass. Such medial

swelling can block the view of a peek-a-boo heel.

Here, the view from the rear is most important

Medial swelling of the posterior heel (false

positive) for the diagnosis (Fig. 8A—B). This patient also

has Haglund’s process heel prominences, which can

On rare occasions, medial swelling of the poste-

cause confusion as to whether heel varus exists, as

rior heel, as seen in this patient with psoriatic

explained below.

arthritis, can present as a peek-boo heel (Fig. 6A).

Clinical and new aspects of the subtle cavus foot: A review of an additional twelve year experience 9

of patients with neurologically-caused cavus, so

extreme examples were illustrated. The SCF has

similar structural changes, but to a lesser degree.

It is believed that the primary deformity in the

SCF is a plantarflexed first ray. This leads to a

supinated forefoot. The lesser metatarsals align

with the first and the entire forefoot assumes an

equinus posture with varying degrees of metatar-

sus adductus. The lesser metatarsals are wavy,

rather than straight. The midfoot becomes convex

and ‘‘heaped-up’’ dorsolaterally. The foot may look

bean-shaped when viewed from above. The talar

head is aimed laterally at the talonavicular joint.

This position locks the Chopart’s joints, and the

hindfoot assumes a varus posture [30]. The plan-

tarflexed first ray prevents foot from everting when

standing and diminishes the shock absorbing effect

of normal subtalar eversion [31].

As Mosca and others have shown, these anatomic

variations tend to become stiffer with time. The

bones remodel and the joints no longer retain much

motion. The midfoot bones become more trape-

zoidal in shape, larger on the top and smaller on the

bottom, like the tapered bricks in an architectural

arch. The plantarflexed first ray tends to become

more plantarflexed with time, particularly if signif-

icant hindfoot equinus is present at the ankle. This

is due to an imbalance between the strong long per-

oneal muscle and its weak antagonist, the anterior

tibial muscle [25,32,33].

Fig. 6. (A) A young male patient with known psoriatic

arthritis and SCF. There is a small peek-a-boo heel seen on At the ankle, the ankle mortise is externally

the left when viewed from the front. Incidentally, there rotated. This is the ‘‘sagittal breech,’’ as described

is a sausage toe of the right fifth digit, commonly seen by Lloyd-Roberts et al. when they described the

in patients with psoriatic arthritis. (B) When viewed from deformities of clubfeet [29]. This can lead to a pos-

the rear, there is medial swelling of the left heel in the

terior appearing fibula when a lateral radiograph

retrocalcaneal area which makes it look like there is more

is taken. Some of this apparent position is surely

heel varus than there actually is.

due to the external rotation of the lower extremity

at the hip when a person with metatarsal adduc-

Large Haglund’s heel prominences (false tus stands with his feet facing forward. It has been

negative heel varus from the rear) called ‘‘artifactual’’ [30]. Recently. however, two

As seen in the above example (Figs. 9A—B, 10B, F), cross-sectional studies confirmed that the fibula

‘‘pump bumps’’ can be deceptive, especially vary actually was situated posteriorly in relation to the

large ones. These bumps make it appear that the normal ankle mortise and that the appearance was

heel varus is less than what actually exists. Ath- not just projectional and artifactual [34,35].

letes with shoewear that is tight in the heel counter,

as seen in soccer, ice hockey, figure skating, run-

ning and football, are particularly vulnerable to this

[29]. Accurate diagnosis is essential in this confus- Prevalence, epidemiology

ing situation.

The prevalence of the SCF in the general popula-

tion is unknown. We see a great many more people

Anatomic considerations with SCF than neurologically caused cavovarus foot

in our center where we see large numbers of gen-

The bony morphology of the cavus foot has been eral foot patients and athletes of all ages. In some

well-documented by Aminian and Sangeorzan [30]. university practices the numbers may be reversed

Their descriptions were based primarily on scans due to selection bias. In a neurologically-based

10 A. Manoli II, B. Graham

Fig. 7. (A) Standing anteroposterior radiograph of the left foot. The triangularly shaped navicular is indicative of long-

standing Mueller—Weiss syndrome. (B) The right foot. (C) A patient with Mueller—Weiss syndrome and SCF. Radiographs

are shown in (A)—(B). Note the bilateral heel varus and medial foot swelling. (D) Medial foot swelling masks the

peek-a-boo heels. Small fat pad bulges bilaterally suggests plantarflexed first rays.

referral practice, only 20% of the patients seen and it was rare that an etiology could be found [39].

were ‘‘non-neurological.’’ [36] In another footprint study Sachithanandam stud-

Epidemiological studies have shown consider- ied 1846 healthy people aged 16—65 years found

able variability in the numbers of non-neurological that 10% had high-arched feet, as assessed by static

cavus in the populations studied. González de Aledo footprints [40].

Linos found 16.3% cavus in 948 children, 60% hav- It has been estimated that 20—25% of the general

ing a strong familial history, with no cases of population has a cavovarus foot [30]. In a very ele-

‘‘secondary’’ cavus from neurological disease [37]. gant study in 2047 diabetic patients, Ledoux et al.,

Brewerton found 465 of 577 (81%) patients in a found 57% were in neutral, 19% were flat, and 24%

retrospective survey to have ‘‘idiopathic,’’ nonneu- were in cavus [41].

rological cavus and in a prospective study, 26 of 77 There is probably a bell-shaped curve in the gen-

(33.8%) patients had idiopathic cavus, of which 11 eral population with significant flatfeet and cavus

of 26 (42%) people had a family history of cavus feet on opposite ends of the curve [1]. SCF lays

[38]. between the ‘‘normal’’ portion of the curve and

In a footprint study, Yalcinkaya et al, found 11.7% the more extreme types, although there is con-

of 3511 children had a cavus posture of their feet, siderable variability even in the SCF group [2].

Clinical and new aspects of the subtle cavus foot: A review of an additional twelve year experience 11

Fig. 8. (A) 15 year-old female high school cross coun-

Fig. 9. (A) This is a patient with bilateral peek-a-

try runner with bilateral foot pain. The peek-a-boo heels

boo heels and first metatarsal fat pad bulges. (B) When

are hidden by a large abductor hallucis muscles. There

viewed from the rear, large Haglund’s process heel promi-

are bilateral fat pad bulges under the plantarflexed first

nences can make the varus heels appear to be in valgus.

rays. (B) Patient viewed from the rear. There is heel varus

bilaterally which is masked by a large abductor hallucis

selection bias, but the study does show that there

muscle when viewed from the front (A). Haglund’s pro-

are many people with this foot type and they need

cess heel prominences can make the varus heel appear

appropriate, individualized, treatment, not just the

to be in valgus. See also Fig. 9B.

traditional ‘‘give everyone an arch support for over-

pronation’’ dogmatic treatment.

Often there is a family history of high arches Although these people may function at a high

(Fig. 10A—H). level in early life and may even perform very well in

The important issue here is not the absolute athletics, the fact that these feet are stiff and the

number of people with cavovarus feet, but the lack of shock absorbability eventually negatively

fact that there are large numbers of people with effects their quality of life. Misdiagnosis by medi-

this foot posture. In our problem foot clinic, it cal and non-medical professionals, more often than

is not unusual to see a majority of patients in a not, leads to mistreatment and prolongation of the

day with subtle cavovarus. In a survey done in our symptoms. Fitting these people with motion con-

pedorthotic division, of 1115 patients seen in a year, trol shoes, and/or rigid, high-arched plastic arch

47% had neutral or flat feet and were prescribed supports can make their symptoms much worse.

accommodative orthotics, whereas 53% had cavo-

varus feet and were prescribed some type of cavus

foot orthosis [1]. The patients were referred for Associated conditions

orthotic treatment by eight members of the Ameri-

can Orthopaedic Foot and Ankle Society and others. In our first review (2005) we supplied a table listing

We realize that this number is very high due to the conditions that may be associated with the SCF.

12 A. Manoli II, B. Graham

Fig. 10. (A)—(D) This is a 65 year-old mother of siblings with SCF illustrated in (E)—(H). She has bilateral SCF with

bilateral peek-a-boo heels and fat pad bulges under the first metatarsal heads. (B) Rear view of the mother with

bilateral SCF seen in (A). In addition to varus heels, she has moderately-sized Haglund’s processes on both calcanei.

(C) This is the 66-year-old father of the siblings with SCF illustrated in (E)—(H). The patient has bilateral SCF with peek-

a-boo heels. The pen marks diagram the dorsal sensory nerves that are being compressed by the heaped up midfeet.

The patient had a dorsiflexion osteotomy of his right first metatarsal in the past, which improved the foot posture. (D)

The father of the siblings with SCF. He has heel varus on his left. The heel on the right has heel valgus due to having had

a dorsiflexion osteotomy of his first metatarsal in the past. (E) Photo of the 35-year-old daughter of the patients seen

in (A), taken when she was 19 years-old. Note the major peek-a-boo heels and mild metatarsus adductus. The patient

successfully played major college soccer using cavus foot orthotics. (F) This is the rear view of the patient in (E). She

had heel varus, a medially inserting Achilles tendon, and moderately-sized Haglund’s processes on her calcanei. (G)

Photo of the 32-year-old son of the patients seen in (A)—(D). He has large peek-a-boo heel bilaterally. (H) When viewed

from the rear, the patient in (G) has bilateral heel varus. He also has medially inserting Achilles tendons, bilaterally.

Clinical and new aspects of the subtle cavus foot: A review of an additional twelve year experience 13

Additional experience has allowed us to modify, and

add to, the original list of conditions and skeletal

abnormalities. An * indicates a condition added to

the initial list (Table 2).

Discussion of associated conditions

It is beyond the scope of this review to discuss

individually, in detail, all of the listed conditions.

Many of the conditions are related to the basic bony

anatomy of the SCF, and the fact that the foot

is tipped into varus. Many of the associations are

directly related to the SCF and some are indirectly

related, all being a result of the posture of the foot.

For many years researchers have tried to deter-

mine the cause of recurrent ankle sprains and

chronic instability. Diminished proprioception, mus-

cle imbalances, and walking on and increased

pressure on the lateral aspect of the foot, were

found [44,73—75]. Eventually it was found to be a

cavovarus foot that was implicated in most cases

[66,76].

The peroneal tendons are constantly on stretch

and working hard to straighten the foot, but the

plantarflexed first ray does not allow it. The dis-

tal fibula is larger than in the ‘‘normal’’ foot, it is

posteriorly situated, and has a shallower peroneal

grove. These tendons may sublux out of the fibu-

lar groove, dislocate, split, and stretch the superior

peroneal retinaculum. The varus posture of the foot

and a degree of metatarsus adductus pulls the per-

oneus brevis muscle distally, leading to a low-lying

muscle belly on the peroneus brevis tendon, seen

when a repair is performed. This low-lying mus-

Fig. 11. (A) Semi-coronal CT scan cut of a middle aged

cle belly has been implicated in development of male with very large, symptomatic peroneal tubercles,

tendon pathology behind the fibula, as it is a space- bilaterally. (B) Axial CT cuts of patient in Fig. 10(A).

occupying lesion in the peroneal tunnel and may

lead to stretching the superior peroneal retinacu-

lum [77]. (Fig. 17C). The bone of the fifth metatarsal base

On the calcaneus, the peroneal tubercle may be may be enlarged.

enlarged, and impinge on the peroneal tendons and Under the first metatarsal head the fat pad may

cause splits of the peroneals here (Fig. 11A—B). be squeezed and be viewed medially. A large callus

Palpation directly above or below the peroneal or bursa may also develop (Fig. 12). The sesamoids

tubercle can give the diagnosis. Tendon splits may under the head are overloaded, may fracture,

also develop behind the fibula or at the os perineum develop chondromalacia, stress fractures, or avas-

area. If an os peroneum is present, the peroneus cular necrosis. At the base of the first metatarsal

longus tendon may tear distally to this intratendi- there may be arthritis and a tarsometatarsal boss

nous bone, or the bone may fracture and the pieces (Fig. 17).

pull apart. A tight gastrocnemius muscle may lead to plan-

The plantarflexed first ray tips the entire foot tar fasciitis [78,79]. We have seen patients with

so the patient walks on the lateral border. They cavovarus who have plantar fibromatosis (Fig. 13).

can develop a callus under the head of the fifth The plantarflexed first ray results in the plane

metatarsal and/or the base. Calluses under first and of the bottom of the foot being even more

fifth metatarsal heads may be seen concurrently plantarflexed, which leads to the gastrocnemius

14 A. Manoli II, B. Graham

Table 2 Conditions associated with the subtle cavus foot.

Ankle instability [42—44]

*Plantarflexed first ray

Peroneal overdrive

Posterior fibula

Recurrent instability after a lateral ankle ligament Reconstruction

Subtalar instability

Peroneus brevis tendon split

Peroneus longus tendon split

Recurrent dislocation of the peroneal tendons

*Low-lying peroneus brevis muscle belly [2]

Enlarged peroneal tubercle (Fig. 11A—B)

Painful os peroneum syndrome, with/without fracture of os

Enlarged distal fibula

*Diminished fibular-Achilles distance posterolaterally [45]

*Medial insertion of Achilles tendon on calcaneus (Fig. 2B)

*Shallow peroneal groove on fibula

Jones fracture of the fifth metatarsal

Stress fracture of the base of the fourth metatarsal [46]

Callus under base of fifth metatarsal [24,26]

*Enlarged base of the fifth metatarsal

Calluses under first and fifth metatarsal heads

Concurrently (Fig. 17B)

*Callus or ulcer under head of fifth metatarsal

Sesamoid overload, chondromalacia, avascular

Necrosis

Fat pad displaced medially from under first metatarsal head (Fig. 8A)

*Bursa under first metatarsal head (Fig. 12)

*Prominent second-fifth metatarsal heads with overload *Metatarsalgia

*Clawed toes

Plantar fasciitis

*Plantar fibromatosis (Fig. 13)

*stress fracture of tarsal navicular (Fig. 14A—B)

Vertical stress fracture, medial malleolus

Metatarsus adductus with bean-shaped foot

Hallux valgus with metatarsus adductus [47]

*Convex, ‘‘heaped up’’ midfoot (Fig. 10C—D)

*Compression of dorsal sensory nerves of foot (Fig. 10C—D)

*Multiple metatarsal stress fractures with metatarsal adductus [48,49] (Figs. 15A—E, 16)

Midfoot arthritis

*First metatarsal base-medial cuneiform boss, possibly with arthritis (Fig. 17A)

*Fourth, fifth metatarsal base-cuboid arthritis (Fig. 18A—C)

*Heel varus [50—52]

Varus ankle arthritis [53]

*Lateral impingement lesion of the ankle [54—57]

*Medial impingement spurs of the ankle [58—68] (Fig. 19A—B, D)

*Medial osteochondritis dessicans, ankle (OCD) [59,62] (Fig. 19B, D)

*Haglund’s deformity [31,69,70] (Figs. 7, 8 and 10)

Varus total ankle positioning postoperatively [1,71]

Medial compartmental knee arthritis

Iliotibial band friction syndrome [31]

Stress fractures tibia, fibula (Fig. 19B, D)

Exertional compartmental syndrome of leg, foot

Tight gastrocnemius muscle

*Indirect gastrocnemius muscle tightness due to plantarflexed first ray [72]

*Persistent heel varus after talus [39], calcaneal fractures, Lisfranc joint injuries

*Persistent heel varus after hindfoot reconstructions

Reproduced and modified from Manoli 2nd A, Graham BG. The subtle cavus foot; ‘‘the underpronator,’’ a review. Foot Ankle Int. 2005;26(3):256—63.

Clinical and new aspects of the subtle cavus foot: A review of an additional twelve year experience 15

Fig. 12. This 57 year-old female had SCF and a large painful bursa under the first metatarsal head.

Fig. 13. (A—F) These are all middle-aged females with SCF. All of these patients had symptomatic plantar fibromatosis

as well.

16 A. Manoli II, B. Graham

muscle, being even tighter, indirectly [72]. To

obtain any ankle dorsiflexion, the gastrocnemius

muscle must lengthen even more than usual to

obtain normal ankle dorsiflexion, effectively mak-

ing it tighter. This very tight gastrocnemuis muscle

often leads to metatarsalgia and clawed lesser toes,

as the long toe extensors recruit to help dorsiflex

the ankle against the tight gastrocnemius muscle.

This tight muscle is probably a contributing factor

in the development of many of the stress fractures

of the foot seen in athletes (Fig. 14).

The walking and running on the lateral border of

the foot may lead to a Jones’ fracture of the fifth

metatarsal [80]. There can be a fracture of the base

of the fourth metetarsal [1,46].

We have seen a number of patients who develop

lateral foot pain which is caused by a fairly

consistent arthritis of the base of the fourth

metatarsal-cuboid joint. This can be diagnosed

by feeling spurs on the fourth metatarsal base

(Fig. 18A). Often these spurs are visible on the

oblique radiograph of the foot (Fig. 18B, C). Joint

narrowing is occasionally seen. Arthritis of the

base of the fifth metatarsal-cuboid joint is some-

times seen associated with the arthritis of the

fourth metatarsal-cuboid joint. A steroid injecton is

excellent treatment for this arthritis. Unimproved

symptoms may require surgical spur debridement.

As a result of walking on the lateral border the

foot patients frequently have a varus tipping of the

ankle. This can result in recurrent sprains of the

ankle [81]. The assymetrical loading of the ankle

can also result in a varus arthritis of the ankle [53].

For many years, the recurrent sprains were impli-

cated as the primary cause of the development of

the arthritis [82]. Our belief is that the assymetri-

cal varus loads from the SCF are the main cause of

both problems, and that the recurrent sprains prob-

ably are only a secondary causative factor in the

development of the arthritis, as discussed below.

It is surprising that even in very young patients,

especially those involved in running and jumping

sports or sports that require ankle dorsiflexion,

medial osteophytes may develop on the leading

edge of the talus and medial malleolus causing

impingement, pain, and limited ankle dorsiflexion

Fig. 14. (A) Bone scan shows uptake in the left tarsal

[58—68]. These impingement spurs are a consid-

navicular bone in a 15 year-old female gymnast with SCF.

erable cause of pain. The diagnosis is made by

(B) An MRI scan shows a typical navicular stress fracture.

palpating the talar spurs in front of the medial

The patient was treated with open reduction, internal

malleolus [61] and diagnosis is confirmed with an

fixation of the fracture.

oblique radiograph of the foot which shows the spur

on the talus and, occasionally, on both sides of the repaired (Fig. 19B, D). Occasionally, an occult stress

ankle [65,67] (Fig. 19A—D). We usually also obtain fracture of the medial malleolus may be discovered

a CT scan of the ankle, as the spurs many be asso- (Fig. 19B, C). We usually remove impingement the

ciated with an osteochondritis dessicans (OCD) of spurs with an open arthrotomy, [59—61,68] but oth-

the medial dome of the talus which may need to be ers remove them arthroscopically [62,63,65,83].

Clinical and new aspects of the subtle cavus foot: A review of an additional twelve year experience 17

Erroneous attempts to link associated but the major cause of all of the problems is the

conditions cavovarus foot posture.

Also, the peroneal tendons are constantly work-

ing to straighten the foot, but cannot, because of

Obviously, many of the associated conditions may

the plantarflexed first ray. These bony architecture

occur at the same time and independently because

abnormalities may lead to peroneal splits, sublux-

of the structural bony and soft tissue abnormalities

ations, and dislocations as discussed above.

of the SCF. This is an example of divergent biologic

phenomena, where different results may stem from

a single source [84].

Medial impingement spurs and stress

Despite this, people have been trying for decades

to infer causation between the associated condi- fractures

tions, and these erroneous attempts continue to

this very day [85]. If one considers the fact that Surely, medial impingement spurs at the ankle and

the associated conditions can occur independently stress fractures of the foot and ankle are both

of each other as a result of the root cause, the SCF, related to the cavovarus foot posture and occur can

then the causation problems are easily solved. independently. We have noticed an additional, pos-

Much of the confusion seems to be due to the sibly direct, association of the development stress

fact that the SCF was not readily apparent to fractures in the foot (lesser metatarsals, navicular)

the physicians or the basic science researchers with the common medial impingement spurs at the

when the causation projects were being done. ankle [59]. The prevalence of these problems occur-

The researchers probably were not used to looking ring together is unknown, but large medial spurs

for structural problems and the SCF, in partic- are often seen on the oblique radiographic views

ular, was difficult to identify, especially if they of the foot in association with foot stress fractures

were not used to seeing it. For example, the [65,67]. It appears, that in this particular situation,

link between recurrent ankle sprains and the SCF the impingement spurs may have an additional dor-

was not recognized until 1998 when Colville sug- siflexion blocking effect at the ankle, along with a

gested that a calcaneal osteotomy may be required tight gastrocnemius muscle, to increase the bend-

for patients with chronic lateral ankle instability ing forces through the foot to contribute to the

and hindfoot varus alignment in order to prevent development of the stress fractures [89]. If seen,

the ligament reconstruction from failing due to we recommend removal the impingement spurs at

mechanical malalignment [76]. The first study to the time of the stress fracture repair [9].

show an anatomic cause (heel varus) for recurrent

ankle sprains was by Van Bergeyk et al. in 2002

[81]. Interestingly, the peek-a-boo heel sign was Persistant heel varus after foot

first described in 1993 [20], and as a clinical sign fractures, reconstructions

in 1996 [21] but not widely recognized until after

2005 [1]. With the use of the peek-a-boo heel as a screening

For many years it has been noticed that there tool, we have noticed in recent years, that a

seems to be an association of lateral ankle instabil- repaired fractured foot often has a cavovarus pos-

ity and peroneal tendon pathology [40,55,70,86]. ture after a talar neck or body fracture, Lisfranc

This association continues to be studied to this day joint repairs, and calcaneal fractures. This may

[85]. Other commomly implied direct associations be quite concerning to the surgeon and patient,

to lateral ankle instability are varus arthritis of especially after repairs that were thought to be

the ankle [87] medial ankle spurs and impingement perfectly anatomic at the time of surgery.

[66], and OCD lesions of the medial talus [59,62,88]. When the patient is finally fully weightbearing

In all of these previous studies, the authors have one notices that a peek-a-boo heel is present and

attempted to find direct cause and effect relation- the foot is in cavovarus. Heel varus is confirmed

ships, suggesting that the ankle instability directly by viewing from the rear. Surprisingly, when com-

causes the other problems. Our belief is that it is paring the foot posture to the contralateral side,

the cavovarus foot posture, and a lifetime of walk- very often the other side also has a peek-a-boo

ing primarily on the lateral border of the foot, that heel and heel varus, also. This phenomenon is so

causes assymetrical loading in the ankle, leading to common that we wonder whether the SCF may

the recurrent sprains, ankle instability and ankle actually be more prone to sustaining these fractures

arthritic changes. There may be some direct wors- and injuries. Wong and Clare have found 57.6% of

ening of the arthritic conditions from the instability, high-energy talar fractures had a cavovarus foot on

18 A. Manoli II, B. Graham

the contralateral side [39]. Recently, Lisfranc joint possible for metatarsus adductus to exist with-

injuries were studied for the possibility of having out heel varus (pure metatarsus adductus) or even

a preexisting cavovarus foot, but the methodology with a valgus heel (a skewfoot). Despite the heel

was not particularly sensitive to finding an associa- position, the forefoot deformity often leads to

tion [90]. Elbow fractures in children have recently stress fractures of the bases of the metatarsals,

been studied and certain fractures have shown a most commonly seen in the fifth metatarsal, and

preexisting postural elbow anatomy [91]. sometimes in the other lesser metatarsal bases,

We have also noticed the phenomenon of resid- diminishing in frequency as one moves medially

ual cavovarus following reconstructive procedures [48,49]. Gastrocnemius tightness is probably at

of the foot and ankle after trauma. Patients least a partial contributor to the development of

may have persistent varus after hindfoot fusions these fractures, as the foot tends to break in half

and may require revisions, such as revision triple through the metatarsal bases as weight on the fore-

arthrodeses [92—94], or osteotomies through mal- foot is counteracted by the tight Achilles complex.

positioned pantalar fusions [93]. Almost universally, Additionally we believe that the medially pos-

the ipsilateral and contralateral cavovarus feet itioned first metatarsal head is a contributing factor

were not recognized before the initial reconstruc- in the development these base stress fractures. As

tive procedure [39]. It can probably be safely seen in Fig. 16B the normal metatarsal head posi-

assumed that the foot that was operatively treated tion is lateral to the axis of subtalar motion in the

had a similar position, although that cannot be def- normal foot so foot eversion is possible.

initely proven. In the SCF, the plantarflexed first ray has

In performing a number of these revisions, we a eversion-blocking effect on subtalar motion

have been impressed with the need to do a sec- (Fig. 16A). We believe that a more medial position

tioning of the posterior tibial tendon and often of the first metatarsal head in metatarsus adductus

a full medial release before redoing the revision (Fig. 16B) probably has a similar effect on block-

osteotomies. The need for an extensive medial ing eversion, as the head lies medial to the axis

release when initially reconstructing severely varus of eversion of the subtalar joint. The more medi-

ankles with arthritis has been shown [71]. ally its position, the more eversion is blocked [99]

Future directions should include a sophisticated (Fig. 16B).

preoperative look at the contralateral foot when We believe that feet with both a plantarflexed

repairing talus, calcaneal, and Lisfranc injuries first ray and a medially positioned first metatarsal

or when doing major hindfoot reconstructions. head from metatarsus adductus may be particularly

Studying the contalateral side for foot type and prone to the development of metatarsal stress frac-

characteristics gives clues that may require addi- tures in the lateral metatarsals.

tional decision-making. In the fracture repair

situation it makes sense to repair the bones to their

initial anatomical position, even if it is that of a SCF. Nonoperative treatment

Gastrocnemius lengthening may be useful in some

situations. In some cases, as seen with moderate Shoes

to severe hindfoot varus, a medial release may be

required initially. Sizing

In the reconstructive situation, after the frac- The SCF presents some unique challenges when

tures have healed, the cavovarus may be a clinical selecting footwear. The relative narrowness and

problem. This ‘‘residual cavovarus’’ may require low volume of the heel, coupled with a high vol-

medial releases, foot osteotomies (1st metatarsal ume, ‘‘heaped up’’ midfoot and adducted forefoot,

and/or heel osteotomies, talar [95,96] or calcaneal limits the number of options (Fig. 17A—B).

osteotomies for malunions [97]. Fusions (subtalar Years ago, many companies offered

arthrodesis) with or without body osteotomies fol- ‘‘combination last’’ shoes e.g. size 10, with a

lowing calcaneal fractures, may also be necessary C heel and EE forefoot width. These have been

[98]. discontinued. Now, many patients with SCF are

forced to compromise. Often, a patient presents

with a shoe that is too narrow and lacks the

Metatarsal stress fractures with appropriate volume to accommodate the mid and

metatarsus adductus forefoot.

A common complaint is, ‘‘If I buy them any wider,

The SCF often has an associated degree of metatar- my heels will slip.’’ This tends to cause or contribute

sus adductus (Fig. 15A—E). However, it is also to many of the forefoot complaints we see. The

Clinical and new aspects of the subtle cavus foot: A review of an additional twelve year experience 19

Fig. 15. (A) This is a 49-year-old female with SCF with a major metatarsus adductus component. There are multiple

metatarsal stress fractures. (B) The forefoot has collapsed through the metatarsal stress fractures on the left. (C)

The patient’s right foot. (D, E) Oblique radiographs of both feet illustrate the multiple metatarsal stress fractures and

‘‘wavy’’ shafts, worse in the most lateral metatarsals.

problem tends to be greater in the female popu- When fitting, it is also imperative to compare

lation. When questioned on shoe their shoe size, the ‘‘arch length’’ and ‘‘heel-to-toe’’ measurement.

they will claim that their athletic shoe is a 9 but Many SCF patients have shorter or clawed toes. This

their dress shoes are 7.5 or 8. Due to the lack of can cause their heel-to-toe number to be lower rel-

combination last shoes, they are forced into a shoe ative to their arch length. Usually, it is best practice

that can aggravate forefoot conditions in order to to defer to the greater number to better accom-

have it fit securely. modate the arch length. Having more volume and

20 A. Manoli II, B. Graham

st

Fig. 16. (A, B) Illustrated are the biomechanics of having a plantarflexed 1 ray (A) or forefoot metatarsus adductus

(B). In (A), the plantarflexed first ray blocks eversion around the axis of motion of the subtalar joint, resulting in a

varus positioning of the heel and a tendency to walk on the lateral border of the foot [99,104]. In (B), the heads of the

medial metatarsals lie medial to the axis of subtalar motion, blocking eversion of the foot when the forefoot is striking

the ground. This results in increased bending forces, particularly in the proximal lateral metatarsals. This is where

stress fractures commonly occur with metatarsus adductus [48]. (Drawning modified from: Mann, RA. Biomechanics of

the foot and ankle. in Surgery of the foot and ankle. St Louis: Mosby, Mann, RA, Coughlin, MJ (eds);1992:20 (Original

adapted from Inman, RE, Inman, VT: Bull Prosthet Res 1969;10:97).)

proper flex point of the shoe, usually overrides the on proper footwear, but, that scenario is as help-

extra heel-to-toe size in most cases. Lastly, many ful as telling a patient to ‘‘go to the drugstore and

companies have their own interpretation of sizing get something good.’’ Improper attention to detail

scales. Years ago, centimeter size was supposed to is one of the main reasons shoe and orthotic treat-

address this. Unfortunately, companies cannot even ment may often fail.

agree on what a centimeter is. For most SCF patients, we suggest a neutral,

We use measurement as a baseline, but visually cushioned shoe. Patients with a SCF do not need

and manually verify proper fit. Many patients leave a motion-control shoe with a high arch support.

our center with a shoe 1—1.5 sizes larger than what They are disserved by fitting them with this type

they listed on their intake paperwork [100—102]. of shoe, which just limits their foot’s eversion and

Many patients are stubborn and very defensive shock absorbability more.

about their shoe size. Some cases are vanity (‘‘I’ve

been a 6 narrow since high school!’’) and some are

financial (‘‘ I just bought these a year ago and they Disturbing shoe trends

were very expensive!). It is important to explain Unfortunately, we’ve observed some perplexing

that, like clothing, shoe size scales can be very inac- design ‘‘trends’’ in various athletic shoes over the

curate these days. They should be reminded that last few years. ‘‘Minimal shoes’’ and the accom-

foot shape can change and, usually, orthotics need panying ‘‘forefoot strike’’ style of running that is

more space in the shoe to function properly. Finally, promoted along with them, seems to be the most

we emphasize that no one is expecting them to common [103]. The lower heel height and reduced

throw out all of their shoes and replace them. But, back-to-front (ramp) angle, along with the relative

they do require one, properly fit shoe, that they will thinness of the soles can quickly cause symptoms in

wear as much as possible, to treat their symptoms. an otherwise healthy runner.

One can also get accused of ‘‘trying to sell a It is not uncommon for sedentary patients to join

shoe,’’ or of being ‘‘picky.’’ Very often a patient a ‘‘boot camp’’ style gym. They are told to forgo tra-

presents with an orthotic in an improper shoe. ditional athletic shoes, and get minimal style shoes

When asked how they were dispensed, the response to ‘‘strengthen their arches’’ or to ‘‘run and move

is often ‘‘they handed me the orthotics and told more naturally.’’ While this may work for some, the

me to get good shoes.’’ We understand that it is added stress on an already rigid SCF can cause more

not always easy to go into detail with every patient harm than good.

Clinical and new aspects of the subtle cavus foot: A review of an additional twelve year experience 21

be less problematic than a heavy shoe with rigid

medial posting. The relative lack of ‘‘pronation

control’’ and excess flexibility found in these shoes

may help to free up this foot allowing it to function

a bit more normally.

Another perplexing trend is ‘‘asymmetric’’ neu-

tral cushion shoes. Most of the major manufacturers

produce these. Taken literally, neutral cushion

should mean just that. A lower durometer (softer),

more cushioned sole that is as close to a mirror

image on both the medial and lateral aspects. Many

of the shoes labeled as neutral actually are any-

thing but. They often have a medial heel that is

both higher and firmer than the lateral heel. Sev-

eral models will have gel pods, chevron grooves or

flex wedges molded into the lateral hindfoot, essen-

tially making the shoe a varus wedge.

Since the lateral heel or ‘‘crash pad’’ is the area

of highest load on initial impact, we can only sur-

mise they are trying to reduce that impact with

softer materials. This can be observed by placing

an unused ‘‘neutral’’ shoe on a flat surface. When

viewed from behind, many of them have an obvious

varus tilt to them. This flaw not only induces inver-

sion, but it can also lead to extremely premature

lateral sole wear. We have seen many cases of shoes

that look almost new, yet under load, the crash pad

will deform excessively. Some are only a few weeks

old.

This design feature can also create inversion

Fig. 17. (A) This is a 35-year-old male with SCF has

instability, even on flat stable ground. Almost all

a large, symptomatic, first tarsometatarsal boss with

of the major companies are guilty of this in their

moderate arthritis. (B) This patient has a SCF, and symp-

st th neutral cushion runners. Interestingly, most compa-

tomatic calluses under the 1 and 5 metatarsal heads,

nies do not utilize this same design feature in their

a common feature.

trail running models. In fact, most trail runners are

the truest neutral shoes currently on the market.

From a morphology standpoint, having a rigid Is this is just a strange coincidence? We have posed

SCF foot and tight gastrocnemius, one already has this question to some company representatives and

excess forefoot overload. Instructing the patient to have yet to hear a logical explanation. Common

avoid or reduce heel strike moment can create a sense dictates that a trail shoe having a softer and

much greater load on the metatarsals and forefoot. lower lateral outsole could be very unstable on

Also, there is increased strain on the Achilles and uneven terrain.

calf caused by trying to maintain a plantarflexed Basketball shoes have also evolved, or devolved

foot while running. Achilles tendonosis, plantar a great deal in recent years. We are not sure if all

fasciitis, metatarsal stress reaction/fractures, syn- of the changes are for the better. Having a large

ovitis, sesamoiditis and shin splints are conditions patient population of both NBA and D-1 athletes,

we have found in patients that switch to these min- we have seen this first hand. Many high level play-

imalist shoes. ers have SCF foot. It is especially prominent in taller

 

There are some patients that make the mini- players (6 3 or greater) [15,18] and even more so

malist transition successfully. In most cases, they in athletes of European decent. Many of the popu-

avoided doing too much, too fast by easing into lar shoes have been made lighter, weaker and more

the shoes and technique slowly. We often see SCF flexible in firmness, support and sole thickness.

patients that have been erroneously fit initially with This appears to be market driven. Many athletes

heavier, more rigid, pronation-control shoes which feel these stripped down shoes make them quicker

can ‘‘lock up’’ the foot. Switching to a minimalist and increase their leaping ability. This belief is

shoe with success suggests that a minimal shoe may found mostly in guards and faster athletic forwards.

22 A. Manoli II, B. Graham

Fig. 18. (A) A middle-aged woman with SCF and degenerative arthritis of the fourth-fifth metatarsal-cuboid joint.

The spur is palpable and tender just distal to the extensor digitorum brevis muscle belly. (B) There is narrowing and

spurring at the fourth, fifth metatarsal-cuboid joint. (C) Another middle-aged woman patient with more advanced

fourth and fifth metatarsal-cuboid joint arthritis.

Conversely, many of the larger forwards and centers Anecdotally, we have observed what appears to be a

do not do well in these newer-type shoes. Often- high number of 5th metatarsal fractures, inversion

times they will gravitate to the older style high tops sprains and Achilles complications in recent years.

with thicker soles and more robust design. We would like to see companies offer a greater

Lowering the heel height and reducing the ramp selection of larger size and width basketball shoes.

angle is also a newer design feature. From the ath- The vast majority of brick and mortar retailers carry

lete’s perspective, the shoes feel lighter and less no larger than a size 13. This includes specialty

restrictive (also less support and cushion). From retailers that cater to the basketball market. We

a manufacturing perspective, it saves weight and recently treated an NBA player from out of town.

reduces cost, but at what expense? One company He needed to go to a size 14 or 15 to accommodate

rep told us the lower heel was to increase lateral the orthotic and address multiple forefoot and toe

ankle stability and reduce inversion sprains. While issues. We called 3 stores at a large mall that spe-

this theory is continues to be unproven, it may con- cialize in basketball shoes. 2 of the 3 stated they do

tribute to other injuries. not stock over size 13. But, they offered to ‘‘special

rd

The vast majority of athletes with SCF, have order’’ them. The 3 said they had a ‘‘few’’ pairs

equinus, and a tight gastrocnemius and peroneal over size 13.

muscles. We question if a reduced heel height and Many younger players continue to wear size 13

ramp angle is a beneficial platform for this defor- well into their career. Some prefer the snug fit

mity. Lowering the heel, even a few millimeters, for perceived performance issues. In many cases,

can preload the already tight Achilles thereby rob- limited financial resources and lack of selection

bing the ankle of additional degrees of dorsiflexion during their youth contributed to the problem. In

 

that it already lacks. Decreasing the outer sole many cases, players well over 6 5 will present with

thickness can also diminish the shoes ability to shoes that are much too small. Many will claim

dissipate shock, as well as affecting its torsional that they have been wearing size 13 since middle

stability. We believe that the added stresses would school. Clearly their body and foot size increased

have to transfer to the foot and lower extremities. a great deal, yet they continue to wear the same

Clinical and new aspects of the subtle cavus foot: A review of an additional twelve year experience 23

Fig. 19. (A) This 19-year-male had multiple conditions associated with a moderately severe. SCF. He had severe medial

ankle pain. There is medial impingement with a large talar spur and a large ‘‘kissing lesion’’ on the tibia, in the front

of the medial malleolus. (B) The patient also had a large osteochondritis dessicans of the medial talar dome and an

occult stress fracture of the medial malleolus. (C) Axial CT view of the medial malleolar stress fracture. It was not

seen on plain radiographs of the ankle or foot. (D) This patient is a very active 75-year-old female with SCF. She has

large medial impingement spurs and a large medial osteochondritis dessicans lesion.

st

sized shoe. We hope the manufacturers realize this the plantarflexed 1 ray, causing excessive pres-

and cater a bit more to the larger-sized tmarket sure. Grinding down a cleat that is located directly

st

segment. under the 1 MTP joint may be necessary. A pre-

fabricated or custom device with a padded cutout

st

Cleated footwear under the 1 MTP joint can also help.

There also appears to be a trend towards lighter Cleat condition is also important. In cases with

more flexible shoes for football, soccer and base- chronic ankle instability, a lot of focus is put on

ball. This is another area that would benefit from ankle bracing and taping, even heavy spat taping in

wider width or higher volume shoes. Many soccer football only to see excessive wear on the cleats

and football cleats barely will contain the foot and along the lateral aspect of the shoe, especially

may only accommodate a very reduced and com- under the heel. If the lateral cleats are worn, they

promised orthotic, if one will fit at all. In this case, should be replaced.

we prefer to utilize a low profile pre-fabricated or We have also had success utilizing a thin,

custom device, that is necessarily more rigid for lightweight graphite plate for turf toe and Lisfranc

strength. injuries. Graphite tends to have a much greater

Cleat placement can also contribute to cer- strength to thickness ratio compared to the older

tain conditions. We have treated several athletes metal or plastic shanks still on the market. In cases

with SCF for sesamoiditis or sesamoid stress frac- of turf toe, we sometimes use a graphite plate with

tures, where a cleat was placed directly under a Morton’s extension.

24 A. Manoli II, B. Graham

Orthotics forefoot-driven-hindfoot varus. We do not feel this

can be addressed in a ¾ length device, so a full-

Patients with SCF are the greatest number of length device is always utilized. Depending on the

‘‘failed orthotic’’ cases that we see. It is not uncom- degree of severity, we utilize a neutral 2 through

mon for patients to have been fitted with numerous 5 ramp under the lateral metatarsal heads, higher

orthotics by other practitioners before we see laterally. If more correction is required, then a lat-

them. Invariably these orthotics have high aches to eral wedge can also be used that starts under the

mirror the patient’s foot. Most of the time they are hindfoot and blend all the way to the midfoot.

made of hard, unyielding plastic materials. If the Usually the hindfoot is keep at neutral with a few

symptoms do not improve, the arch is then made millimeters of lift to reduce tension on the Achilles.

even higher. It is not unusual to see that a pad was It is not uncommon to see failed devices that have

also placed directly under or just proximal to the a varus heel wedge. This will lock the foot up and

plantarflexed first metatarsal head, producing what contribute to inversion instability.

we call a ‘‘crippler.’’ Unfortunately, we have seen The SCF is also prone to lateral column overload.

this pattern in too many patients to count and even If that exists, we utilize a cut out or relief under the

th

in professional athletes! head or the base of the 5 metatarsal. This area can

It is understandable for the patients to harbor be acutely sensitive to pressure from a high-flange

more than a strong reluctance to try another set or excess thickness in a previous orthotic device.

when the term ‘‘orthotic’’ is brought up. They have When cost is a factor, or the patient is reluc-

tried several pairs of both custom and over-the- tant to try a new orthotic due to poor results in

counter devices with no success, and, often, their the past, an over-the-counter CFO is now available,

®

symptoms got worse. We are disturbed by the latest the Archrival (DJO Global, Vista, CA). Designed for

fad where one stands on a digital scanner in a drug a mild SCF, this device can be modified for more

or big-box store and a computer reads the pressure severe SCF by adding additional posting under the

map and ‘‘custom fits’’ orthotics for them from a lateral metatarsals and possibly along the lateral

supplied group of approximate samples. Obviously, border of the device. This lower profile device also

it is impossible to obtain a three dimensional fit works well when space is limited e.g. cleats, skates

from a two dimensional scan, especially with a and casual dress shoes (see Disclosure).

limited supply of samples.

To imply that these orthotics are ‘‘custom fit’’ is

a deception. Surgical treatment

We are all aware of the numerous materials and

the casting method debate. Weight bearing verses Most patients are treated initially with custom or

non-weight bearing, semi-rigid verses rigid and 3/4 over-the-counter CFO inserts and a program of wall-

length verses full length. All practitioners develop pushup, gastrocnemius muscle stretches. If the

a comfort factor with specific tools and techniques. symptoms improve, this program is simply contin-

Change is extremely difficult. ued. We have seen good to excellent improvement

But, for the SCF, making them very rigid, with of many of the symptoms of the associated con-

a high medial arch often fails. Casting a SCF in ditions. If not improved after a period of 6—8

subtalar neutral, non-weight bearing, places the weeks, it is appropriate to discuss surgery with

patient’s medial arch will be at its greatest height. the patient [105]. Usually, the associated condi-

Making a rigid device that conforms to that shape, tion(s) is addressed, and discussion should also

keeps the foot in a locked up posture. In many include whether the underlying SCF should also be

cases, this results in failed treatment and non- addressed at the same time.

compliance. When deciding how to surgically treat a SCF, in

Our approach is to help ‘‘unlock’’ the foot with a the early stages, when the hindfoot is still supple

combination of semi-rigid materials and a different and corrects completely with a Coleman block test,

geometry, a cavus foot orthotic (CFO) [1,104,105]. one needs to only perform a procedure to allow the

We use a digital scan, in a weight bearing position, first ray to dorsiflex [22,24,26]. In younger patients,

on one of the many scanners available. Then we if the first ray can be passively dorsiflexed to the

lower the medial arch between 10 and 30 percent. level of the lesser metatarsal heads, a peroneus

If using plaster, a traditional arch fill can accomplish longus to brevis transfer can be done at the level of

similar results. the peroneal tubercle or just distal to it, on the lat-

We then create a large relief to accommodate eral surface of the calcaneus. If the plantarflexed

st

the plantarflexed 1 ray. The vast majority of first ray is stiff or rigid, which is the usual situation

these cases correct on the Coleman block and have in adults, a closing wedge, dorsiflexion osteotomy

Clinical and new aspects of the subtle cavus foot: A review of an additional twelve year experience 25

of the first metatarsal is performed. The osteotomy to obtain more correction. This has been called a

is fixed with a single screw, using a notch tech- ‘‘Combi’’ osteotomy. As the bones in the SCF are dif-

nique to avoid breaking the dorsal cortex [106]. If ferent in shape than in an average foot and it often

the foot does not fully correct, we plan to add a is difficult to obtain full correction of the varus

lateral shifting osteotomy at the time of surgery. heel into valgus, it is irresistible to try to use both

Others have had good results in just performing techniques at the same time. In fact, a bench test

a dorsiflexion osteotomy of the first ray even in of this very procedure has been published [111].

Charcot—Marie—Tooth cavovarus [107]. This article was a theoretical review of methods

We disagree with the suggestions of Maskill et al. to move the heel laterally for varus deformity. The

and Deben et al. that if the foot does not cor- study was very well done, however, with no clinical

rect fully on the Coleman block that it is one with correlation, this type of publication may be partic-

‘‘primary hindfoot-driven varus’’ [4,5]. Our view is ularly dangerous, as there are hazards in doing the

very different, as we believe that the component ‘‘Combi’’ approach.

that DOES correct on the block (the component We personally know of seven instances where

due to the plantarflexed first ray) is the primary patients have developed a dense tarsal tunnel syn-

deformity and the hindfoot is simply becoming sec- drome and tibial nerve palsy after the ‘‘Combi’’

ondarily stiff (as in Mosca’s scheme), so it does not approach, when a closing wedge osteotomy and a

fully correct [24,26]. In their review they stated lateral shift of the calcaneal tuberosity were done

that ‘‘All patients in the study were noted to have at the same time. These nerve palsy cases were

a residual (heel) varus deformity.’’ Only 86% of their seen by three different experienced colleagues

patients had a first metatarsal osteotomy at the of ours, all members of the AOFAS. Tarsal tun-

time of surgery, correcting the hindfoot first, then nel release, once the complication was diagnosed,

determining if they needed to dorsiflex the first ray provided inconsistent recovery of sensation on the

[5]. bottom of the foot.

Obviously, there are different philosophies about The reader of this article should be made aware

the order in which the correction should be planned of this potential complication of combining a clos-

and done. If one is unsure of what to do, the heel ing wedge osteotomy with a slide osteotomy at the

can be moved laterally as this is generally safe same time when lateralizing the heel. Doing either

[108]. Or, alternatively, a closing wedge osteotomy a closing wedge or a lateralizing osteotomy appears

of the heel can be done [77]. While this does to be safer, although a tibial nerve can still be

improve hindfoot alignment, and may improve hind- effected [112,113].

foot instability symptoms, it has little effect on We are unaware of any reports of tarsal tunnel

the rotational, pronation—supination position of syndrome following medialization of the heel for

the foot and many of the other associated con- excessive valgus positioning.

ditions. Other authors have just proceeded with

a combined forefoot and heel osteotomy, without

mention of performing the Coleman block test or Conclusions

mention of forefoot or hindfoot-driven cavus, in

the SCF and paralytic deformity with satisfactory Advances in the diagnosis of the SCF have led to

results [87,109,110]. numerous improvements in the identification of

There are two areas where one should be cau- the many associated conditions. Many patients may

tioned. It is important to not dorsiflex the first have a multitude of associated conditions. Accurate

metatarsal if the hindfoot does not correct at all identification of the SCF can help one understand

on the Coleman block test. We treated a patient why patients may develop these common patholog-

who had this done for sesamoid overload with a ical conditions, and should lead to more accurate

rigid hindfoot. Afterwards, he had considerable and improved treatment of the many problems. In

ankle symptoms as he constantly tried to internally addition to fixing the associated conditions, consid-

rotate his ankle, trying to get first ray down to the eration should be given to the correction of the SCF,

ground as his subtalar joint was fixed, This prob- either with specialized orthotic devices postopera-

lem was improved by adding a post under the first tively, or with surgical correction at the same time,

metatarsal head. If this was unsuccessful, a plan- to prevent recurrence.

tarflexing first metatarsal osteotomy could have Future directions should include a very sophis-

been tried. ticated look at the peek-a-boo heel variants, and

Finally, there has been a wave of enthusiasm a realization that many of the associated condi-

to combine the lateral sliding heel osteotomy with tions may occur independently of each other but

a closing wedge osteotomy of the heel in order as a result of the root cause, having a SCF.

26 A. Manoli II, B. Graham

In trauma, a detailed look at the contralateral bjsports-2015-095054, pii:bjsports-2015-095054

foot morphology preoperatively (the presence of [Epub ahead of print].

a SCF, tight gastrocnemius muscle, plantarflexed [9] Calcaterra C. Miguel Cabrera had surgery for

bone spurs. And for a stress fracture in his

first ray, varus heel, etc.) may provide the surgeon

foot. NBC Sports HardBall Talk 2014;(October).

with important information about the etiology of

http://hardballtalk.nbcsports.com/2014/10/24/

the fracture and what to expect postoperatively.

miguel-cabrera-had-surgery-for-bone-spurs-and-

When doing late reconstructions of foot fractures, if

for-a-stress-fracture-in-his-foot/.

varus persists because of an intrinsic morphological

[10] Bontemps T. Nets’ Lopez also had left ankle

cavovarus, a medial release of the hindfoot should

surgery. New York Post; March 22, 2014. http://

be considered along with the proposed osteotomies nypost.com/2014/03/22/nets-lopez-also-had-left-

and fusions. ankle-surgery/.

[11] Associated Press. Yao’s career in jeopardy. New

York Times; June 29, 2009. http://www.nytimes.

com/2009/06/30/sports/basketball/30sportsbriefs-

Conflict of interest

yao.html?ref=sports& r=2&.

[12] ESPN.com news services. Doctors to repair ankle

Dr. Manoli and Mr. Graham are the inventors and by reshaping Hill’s heel; Mar 17, 2003. http://a.

®

patent holders of the Arch Rival , and receive roy- espncdn.com/nba/news/2003/0317/1525121.html.

alties from DJO Global, Vista, CA, USA for its sale. [13] NBA.com, NBA encyclopedia, Playoff edition.

Walton, WT. http://www.nba.com/history/

players/walton bio.html.

[14] Stotts J. Breaking down Joel Embiid’s navicu-

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