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Cerebral Palsy - Foot Conditions

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Topic updated on 06/12/16 7:02pm
Introduction
  • See Cerebral Palsy General
  • Foot deformities are common in cerebral palsy and may take several forms including
    • Equinus (this topic)
    • Hallux Valgus (this topic)
    • Pes Valgus (this topic)
    • Equinovarus  
    • Cavus Foot & Hallux Clawing
Equinus
  • Epidemiology
    • most common deformity in cerebral palsy
  • Pathophysiology
    • weakness of tibialis anterior
    • spasticity/contracture of the gastrocnemius and/or soleus muscles 
  • Presentation
    • symptoms
      • shoe fitting / wear and tear
      • tripping secondary to poor foot clearance
      • instability due to limited base of support afforded by toe position
    • physical exam
      • inspection
        • forefoot callosities
        • toe walking or absent heel strike during gait
        • hyperextended knee with heel contact
      • provacative tests
        • Silverskiold test
          • diplegia: gastrocnemis is tight
          • hemiplegia: gastrocnemius AND soleus are tight
  • Treatment
    • nonoperative
      • serial manipulation and casting
        • indications
          • mild spasticity, dynamic, younger patients
      • botulinum toxin A intramuscular injection into gastrocnemius
        • indications
          • mild spasticity, delays need for surgery
      • hinged AFO
        • indications
          • hemiplegics
      • solid AFO 
        • indications
          • diplegics
    • pperative
      • tendo-Achilles lengthening (TAL)
        • indications
          • severe spasticity, failed conservative management
Hallux Valgus
  • Epidemiology
    • most common in diplegics with planovalgus feet
    • associated with equinovalgus and external tibial torsion
  • Pathophysiology
    • caused by combination of adductor hallucis overactivity and externally applied forces, such as inadequate clearance resulting from equinovalgus deformity, forcing the great toe into valgus.
  • Presentation
    • symptoms
      • pain and difficulty wearing proper shoes
    • physical Exam
      • inspection
        • painful bunion/callosity over 1st MT head
  • Treatment
    • nonoperative
      • observation
        • indications
          • no pain or difficulty with footwear
    • operative
      • first metatarsophalangeal joint arthrodesis
        • indications
          • painful hallux valgus
        • outcomes
          • has the highest overall success rate compared to other surgeries in ambulatory and nonambulatory children with cerebral palsy. 
          • the recurrence rate is unacceptably high with the other procedures 
      • proximal phalanx (Akin) osteotomy  
        • indications
          • hallux valgus with associated valgus interphalangeus
Pes Valgus 
  • Epidemiology
    • incidence
      • common foot deformity seen with 
        • cerebral palsy (spastic diplegic and quadriplegic) 
        • fibular hemimelia
    • body location
      • typically bilateral
  • Pathophysiology
    • deformities
      • midfoot abduction 
      • hindfoot valgus
      • equinus contracture
    • muscle imbalance 
      • spasticity of
        • peroneals
        • gastoc-soleus complex
      • weakness of
        • ligamentous laxity
        • posterior tibialis
        • anterior tibialis
    • pathomechanics
      • creates lever arm dysfunction during gait
      • leads to bearing weight on the medial border of the foot and talar head
      • external rotation of the foot creates instability during push off
  • Presentation
    • Symptoms
      • painful callus over talar head secondary to weightbearing
      • shoe wear problems
    • Physical exam
      • inspection
        • typically bilaterally
        • valgus heel deformity seen when viewing feet from posterior 
        • prominent talar head appreciated in the arch
        • compensatory midfoot supination often seen
          • midfoot break occurs in attempt to keep foot plantigrade 
        • hallux valgus typically develops over time
      • motion
        • the hindfoot valgus deformity must be manually corrected first before testing for achilles contracture
          • a valgus heel can mask an equinus contracture by allowing a shortened path for the achilles
  • Imaging
    • Radiographs 
      • recommended views
        • weight-bearing AP radiographs of the ankles must be obtained to rule out ankle valgus as cause of deformity
      • findings 
        • decrease in the calcaneal pitch
        • negative talo-first metatarsal angle on lateral view
  • Treatment
    • Nonoperative
      • bracing 
        • indications
          • flexible deformities
        • technique
          • ankle foot orthosis or supramalleolar orthosis
    • Operative
      • calcaneal osteotomy with soft tissue procedure
        • indications
          • pain or pressure sores despite bracing
      • subtalar arthroereisis
        • has been successful for spastic flatfeet in case series
        • technique
          • stabilizes subtalar joint in correct alignment without fusion
  • Techniques
    • Calcaneal osteotomy with soft tissue procedure
      • soft tissue procedures
        • achilles lengthening
        • peroneus brevis lengthening
      • bony procedures
        • calcaneal osteotomy  
          • medial slide osteotomy or calcaneal lengthening osteotomy
        • lateral column lengthening procedure
          • performed through calcaneus or cuboid
        • Grice procedure  
          • extra-articular subtalar arthrodesis via a lateral approach
          • place ICBG in lateral subtalar joint to block valgus
          • does not interfere with tarsal bone growth
        • subtalar arthroereisis 
  • Complications
    • Overcorrection (resultant varus deformity)
      • most common complication
    • Sural nerve injury
      • at risk during calcaneal osteotomy procedures
    • Overlengthening of lateral column 
      • results in a painful lateral forefoot secondary to overload
Equinovarus
  • See complete equinovarus  
Cavus Foot & Hallux Clawing
  • See complete cavus foot and hallux clawing

 

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