5 pathological foot types

calcaneal varus
An inversion deformity of the posterior portion of the body of the calcaneus due to an incomplete detrotation from its infantile position. Measured in relationship to the lower 1/3 of leg

forefoot varus
A congenitally fixed osseous deformity where the forefoot is inverted relative to the rearfoot, when the stj is in the neutral position and the mtj is fully pronated/locked. Measured in relationship to plane of the lesser mets,2-4

hallux limitus
A blockade of motion at the 1st mpj during walking resulting inability of the proximal portion to pass over the toes. Limitation of motion occurs on WB and can be normal off WB. Measured as less than 20 degrees of MPJ ROM on WB. Intrinsic- DF of the IPJ with medial roll off, inverted forefoot at propulsion, abducted gait, HAV deformity, and secondary active retrograde pronation, Extrinsics- flexion of the hip, neck, shoulder, and TM joint complications because it causes body to thrust forward.

plantarflexed 1st ray/

Equinus
Any restriction of motion at ankle joint that prevents the body from passing over the foot. This restriction can come from an osseous block, gastroc tightness or soleus tightness. Osseous- abrupt end Soft tissue- spongy or flexible end point

Deformity

forefoot valgus Rigid PF 1st ray- a congenital or acquired position of the 1st ray which the 1st met head is fixed below the plane of the lesser met heads. Flexible- similar condition, but can be easily moved back to or above that level by some force apply to plantar foot Rigid- with limited ROM in LMTJ, frontal plane compensation will take place via supination of STJ With the forefoot plantar to heel compensation will occur as a lack of DF at the ankle. Flexible- with no limitation of ROM in LMTJ, frontal plane compensation will take place via supination of LMTJ, and DF of the 1st ray and OMTJ. With the forefoot plantar to the heel, compensation will occur as DF of the OMTJ and the 1st ray. Both of these the 1st ray is plantar to the lateral forefoot plane and plantar to the WB heel. Uncompensated- heel wont touch ground

Full- from varus to vertical heel b/c the STJ is undergoing rapid pronation. Partial- limited STJ motion. Ex. 6 degrees of calcaneal varus but only 2 available for pronation. Also 1st ray will plantarflex to bring the medial forefoot to the ground. Differentiate from a rigid PF 1st ray by the lateral block test. Uncompensated- calcaneus and forefoot will remain inverted as there is no ROM of STJ available

Compensations

Full- STJ compensation requires the calcaneus to go beyond vertical into valgus, this allows the forefoot to contact the ground, it unlocks the distal structures and leads to forefoot hypermobility. Must differentiate from forefoot supinatus by loading the lateral column w/o no change, and looking at arch topography Ex. 5 degree forefoot varus will be fully compensated by 5 degrees of valgus heel. Uncompensated- no ROM available thus forefoot held in an inverted position with the heel vertical and creates excessive lateral contact throughout stance with late stance WB on IPJ of hallux. Full-severe HAV deformity, tyloma 2-4, heel pain, plantar fasciitis, PTTD, propulsive instability, back and postural complications, and medial knee pain. Flat arch morphology with no visible contours (pancake) Uncompensated-wearing out the lateral border and leading to callus of 5th mpj and 1st IPJ

Full- excessive stj pronation provides required 10 degrees of DF unlocking of distal structures. Sagittal plane PF of calcaneus and mtj collapse/break, lowering of the calcaneal inclination angle, collapse of the arch, very destructive compensation Partial- knee flexion or extension, premature heel lift, out-toe gait, short stride, toe walking in children Uncompensated- with no range of motion available at the ankle and mtj the heel will not make contact with the support surface.

Symptoms

Full- Pronation lasts to long in the cycle, amount of deformity related to lig laxity. Haglunds deformity, bunion and tailors bunion, hammer toes 4 & 5, tyloma 2,3,4, knee problems, postural symptoms-fatigue. Partial- high arch appearance, lesions plantar to 1st met, lateral heel, knee and postural symptoms Uncompensated- lateral foot problems

Problem- dorsiflexion of the 1st ray at propulsion, compensation causes foot symptoms and postural symptoms. Calluses on medial side of hallux IPJ Have difficulty propelling the body forward thus looking for compensations which leads to more severe deformities.

Rigid- high arch foot, hammer toes, heel pain, lateral ankle sprains, lateral knee and hip pain, impact shock to back, plantar lesions 1 & 5 met heads, sesamoiditis Flexible- hammer toes, heel and arch pain, medial knee and hip pain, postural symptoms, plantar lesions 2-4 met heads, HAV deformity, hallux limitus

Severe HAV deformity, corns and calluses, hammer toes, heel and arch pain, fatigue and postural symptoms, back pain. Uncompensated- the calcaneus will be small, digits will slow down plantarflexion and they become dorsiflexed so they walk on their met heads w/o heel contacting the ground

Radiograph

DP: Thickening of the 2nd met shaft, displaced sesamoids, cuneiform split, intact cyma line, pronated 5th ray Lateral: mild 1st ray elevatus, mild change in calcaneal inclination angle, intact cyma line

DP: broken cyma line, increased TC angle, thickening of 2nd met shaft, talar head escape, cuneiform split. Lateral: 1st ray elevatus, lowering of the calcaneal inclination angle, broken cyma line, ptosis of the midfoot Decelerate and limit stj pronation by supporting the forefoot deformity, expedite stj supination, control compensations at the mtj by creating a Forefoot varus post just proximal to met heads or if more severe extend to sulcus

Etiology- It can be restricted by, elevation of the first ray, long 1st met, DJD(all can be picked up on x-ray) however the etiology is somewhere proximally, high correlation with flat feet, ligamentous lax body types.

DP: broken cyma line, anterior. Lateral deviation of talus, adductus of the forefoot, Bi-partite sesamoids Lateral- broken cyma line, anterior. Increased calcaneal inclination angle, decreased talar declination angle, humped shape to tarsal region.

DP: broken cyma line, medial escape of talus abductus of the forefoot, less than 75% of the talar head articulates with the navicular Lateral- broken cyma line, decreased calcaneal inclination angle, increased talar declination angle, saddle shape to the tarsal region. Cuboid lowers and everts Fully compensated- (mild to moderate)- decelerate calcaneal eversion, control Pf of the distal portion of calcaneus, control abduction of forefoot, and control medial shift of tibia. Severe- use an accommodative device, raise the heel to decrease the demand on the mtj, use a proper lasted rocker shoe to assist in support, use of a SMO Partial- bring the support surface up to the heel to extend the heel WB period, balance abnormalities of the forefoot.

Treatments

Decelerate and limit stj pronation by controlling calcaneal eversion, expedite stj supination, control compensations at the mtj by creating a Rearfoot varus wedge/post with a 2-5 bar post and a 1st ray cutout to accomadate the PF 1st ray

For a nonarthritic joint or non painful joint orthotic with kinetic wedge/1st ray cutout/ bi-directional 1st ray cutout to induce plantarflexion and eversion of the 1st ray For an arthritic joint, painful joint, sesamoiditis want to create a mortons extension to prohibit extra motion at the joint.

Rigid- control calcaneal inversion, raise heel to reduce need to dorsiflex ankle, align plane of 1st ray with the plan of the lesser mets with bar or valgus post. Flexible- control calcaneal eversion, allow 1st ray stabilization by creating a cutout, support midtarsal joint, align plane of the 1st ray with the plane of the lesser mets. Ex. 5 degrees of rigid forefoot valgus would compensate by 5 degrees of varus in heel. Ex. 5 degrees of flexible forefoot valgus compensate by 5 degrees of valgus in heel

Forefoot supinatus- similar to forefoot varus but some major differences. a. Triplanar acquired soft tissue contracture of the forefoot in a supinated position around the LMTJ vs. an osseous etiology for forefoot varus b. caused by the rearfoot being pronated vs the opposite way around c. Causes by any pronatory force which drives the calcaneus past vertical which causes compensatory supination about the LMTJ. Ex. Equines, PTTD, external limb position d. Over time, the soft tissues will adapt to this position, holding the forefoot in a supinated position (via Davis law) e. Most of the time reducible if you load the lateral column and has a contour of the plantar surface of the foot vs. the opposite is true for forefoot varus f. Should assess the muscle strength of the posterior tibial tendon g. Orthotic tx- DO NOT POST THE FOREFOOT (dont want to make the varus deformity even worse, and dont want to create restriction of dorsiflexion of 1st mpj), RATHER CONTROL THE EXCESSIVE REARFOOT MOTION Forefoot valgus- An osseous deformity of the forefoot in which the plane of all the lesser met heads is everted relative to a bisection of the posterior aspect of the calcaneus. Measured with the stj in neutral and mtj maximally pronated. Sometimes used interchangeably with plantarflexed 1st ray.