summary Equinovalgus Foot is an acquired foot deformity commonly seen in pediatric patients with cerebral palsy, spina bifida, or idiopathic flatfoot, that present with a equinovalgus foot deformity. Diagnosis is made clinically with presence of a valgus heel deformity with lateral calcaneal displacement and compensatory forefoot supination. Treatment ranges from bracing to surgical osteotomies and arthrodesis depending on the underlying etiology, severity of deformity, and rigidity of contracture. Epidemiology Incidence common foot deformity seen with idiopathic flatfoot (if the heel cord is tight) cerebral palsy (spastic diplegia and quadriplegia) spina bifida fibular hemimelia typically bilateral Etiology Pathophysiology primary deformities midfoot abduction hindfoot valgus equinus contracture secondary deformity forefoot supination muscle imbalances spasticity and/or overpull of peroneals gastoc-soleus complex weakness of posterior tibialis anterior tibialis pathomechanics results in lever arm dysfunction during gait due to shortened lever arm and non-rigid lever patient is bearing weight on the medial border of the foot and possibly the talar head external rotation of the foot creates instability during push off external foot progression Presentation Symptoms pain difficulty with brace and/or shoe wear painful callus over talar head secondary to weightbearing Physical exam inspection and palpation valgus heel deformity with lateral calcaneal displacement seen when viewing feet from posterior prominent talar head appreciated in the medial hindfoot midfoot break is common compensatory forefoot supination is common (best appreciated when hindfoot valgus is corrected manually during physical exam) hallux valgus often develops over time the medial and lateral malleoli are palpated -- the lateral malleolus should be distal to the medial malleolus, unless there is ankle valgus motion flexibility of the deformity is checked the hindfoot valgus deformity is manually corrected (by inverting the hindfoot) in order to check for true ankle dorsiflexion and achilles contracture a valgus heel can mask an equinus contracture by allowing for dorsiflexion through the subtalar joint Imaging Radiographs recommended views weight-bearing AP and lateral foot x-rays weight-bearing AP radiographs of the ankles are obtained used to rule out ankle valgus if suspected clinically (based on palpation of the malleoli, as above) findings "talar sag" (talus tilted inferiorly) indicates collapse of the arch decrease in the calcaneal pitch due to heel cord tightness Treatment Nonoperative bracing and physical therapy indications flexible deformities technique ankle foot orthosis or supramalleolar orthosis -- should be fabricated with hindfoot in subtalar neutral serial casting indications often helpful for deformities recalcitrant to bracing, therapy and home program Operative calcaneal osteotomy with soft tissue procedure indications rigid deformities which have failed conservative treatment types calcaneal slide or calcaneal lengthening osteotomy fusions indications severe rigid deformities, particularly in the presence of severe midfoot breaks in limited ambulators types talonavicular fusion indicated if severe midfoot break in neuromuscular patients with low function subtalar fusion consider in severe valgus foot, though rarely needed subtalar arthroeresis indications poor outcomes and contraindicated Techniques Calcaneal osteotomy with soft tissue procedure soft tissue procedures gastrocnemius recession or achilles tendon lengthening for equinus peroneus brevis lengthening, if performing calcaneal lengtheing osteotomy bony procedures calcaneal osteotomy medial slide osteotomy or calcaneal lengthening osteotomy lateral column lengthening procedure performed most commonly through calcaneus trapezoidal bone graft medial reefing of medial structures may need to perform medial column osteotomy if fixed supination present after calcaneal osteotomy completed medial calcaneal sliding osteotomy calcaneus is slid 1/3 to 1/2 calcaneal diameter Grice procedure extra-articular subtalar arthrodesis via a lateral approach place bone graft in lateral subtalar joint to block valgus does not interfere with tarsal bone growth uncommonly performed currently Complications Overcorrection (resultant varus deformity) most common complication more common in children with neuromuscular disease Recurrence more common if forefoot supination not corrected at time of primary surgery Sural nerve injury at risk during lateral calcaneal osteotomy approach Overlengthening of lateral column results in a painful lateral forefoot secondary to overload Wound dehiscence risk minimized by use of non-absorbable sutures