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SUBTLE CAVUS IN SPORTS INJURIES

MICHAEL P. CLARE, MDFLORIDA ORTHOPAEDIC INSTITUTE

TAMPA, FL USA

NON-NEUROMUSCULAR ∅NORMAL VARIANT: 20-25% INCIDENCE

∅ LEDOUX, ET AL. FAI 24, 2003

∅ FOREFOOT-DRIVEN / MORE SUBTLE

NORMAL GAIT CYCLE∅HEELSTRIKE TO MIDSTANCE

∅HINDFOOT EVERSION

∅ CHOPART JOINTS UNLOCKED∅ AXES OF JOINTS PARALLEL

∅MIDFOOT FLEXIBLE / SUPPLE∅ SHOCK ABSORPTION MECHANISM

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NORMAL GAIT CYCLE∅ TERMINAL STANCE TO TOEOFF

∅HINDFOOT INVERSION∅ POSTERIOR TIBIAL TENDON

∅ CHOPART JOINTS LOCKED∅ AXES OF JOINTS NON-PARALLEL

∅MIDFOOT FIXED / RIGID∅ LEVER FOR FORWARD PROPULSION

HINDFOOT ALIGNMENT∅ INFLUENCE ON HINDFOOT MOTION

∅ AMINIAN & SANGEORZAN, FA CLIN 13, 2008

VALGUS NEUTRAL CAVUS

PATHOMECHANICS∅NO HINDFOOT EVERSION

∅ CHOPART JOINTS REMAIN LOCKED

∅NO SHOCK ABSORPTION

∅ CORONAL PLANE STRESSES ABSORBED BY ANKLE JOINT

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FOREFOOT-DRIVEN CAVUS

∅ PLANTARFLEXED 1ST RAY

∅ KICK-STAND EFFECT ON TRIPOD

∅HINDFOOT EVERSION BLOCKED

KICK-STAND EFFECT ON TRIPOD∅ KRAUSE, ET AL. JBJS 89-B, 2007

∅ VARUS THRUST THRU ANKLE JOINT

KICK-STAND EFFECT ON TRIPOD

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LATERAL COLUMN OVERLOAD

∅ COURTESY TC FITZGIBBONS, MD

ASSOCIATED SEQUELAE

∅ CHRONIC ANKLE INSTABILITY

∅ PERONEAL TENDON PATHOLOGY

∅ S-AD DISTAL TIBIAL STRESS FX

∅NAVICULAR STRESS FX

∅ACCELERATED ANKLE ARTHRITIS

ASSOCIATED SEQUELAE

∅ 5TH MT FX / JONES FX

∅ 4TH / 5TH MT STRESS FX

∅ 1ST / 5TH MT HEAD CALLOSITIES

∅ LATERAL COLUMN OVERLOAD

∅ SESAMOIDITIS

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STANDING EXAMINATION∅ VIEW BACK TO FRONT / FRONT TO BACK

∅ COURTESY TC FITZGIBBONS, MD

PEEK-A-BOO HEEL SIGN∅ BEALS & MANOLI, FOOT ANKLE 6, 1996

COLEMAN BLOCK TEST∅ COLEMAN & CHESNUT, CORR 123, 1977

∅ 3/4” BLOCK

∅ LEAVE 1ST RAY OFF BLOCK MEDIALLY

∅ASSESS HINDFOOT FROM BACK TO FRONT

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FOREFOOT-DRIVEN CAVUS

∅HINDFOOT FLEXIBLE / REDUCES TO NEUTRAL

∅ PLANTARFLEXED 1ST RAY CAUSING VARUS

HINDFOOT-DRIVEN CAVUS

∅HINDFOOT FIXED / DOES NOT REDUCE / RESIDUAL CAVUS

∅HINDFOOT CAUSING VARUS

TIBIOFIBULAR OVERLAP

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CALCANEAL PITCH ANGLE

MORE POSTERIOR FIBULA∅ SCRANTON, ET AL. FAI 25, 2004

MEARY’S ANGLE

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METATARSAL STACKING∅ FOREFOOT SUPINATION /

ADDUCTUS

TREATMENT∅MANOLI & GRAHAM, FAI 26,2005

∅HIGH FAILURE RATE / RECURRENCE IF CAVUSNOT ADDRESSED

CAVUS FOOT ORTHOTIC

∅ LATERAL HEEL & SOLE WEDGE

∅ 1ST MT HEAD RECESS

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ARCH RIVAL™∅ PREFABRICATED CAVUS ORTHOTIC

∅ COMBINED WITH PTX/BRACE/SURGERY FOR ASSOCIATED CONDITION

FOOT SCIENTIFIC-3™∅ PREFABRICATED CAVUS ORTHOTIC

CAVUS DEFORMITY CORRECTION

∅ INDIVIDUALIZE BASED ON DEFORMITY

∅ TREAT ASSOCIATED CONDITION

∅ CHILVERS & MANOLI, FA CLIN 13, 2008∅MANOLI & GRAHAM, FAI 26,2005∅ FORTIN, ET AL. FAI 23, 2002

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TEXTBOOK CAVUS CORRECTION

∅ P-LONGUS TRANSFER TO P-BREVIS∅ PF FORCE ON 1ST RAY / PL OVERDRIVE ∅ PRESERVE EVERSION STRENGTH

∅ DORSIFLEXION 1ST MT OSTEOTOMY∅ELIMINATES KICK-STAND EFFECT OF 1ST

RAY BLOCKING HINDFOOT EVERSION

∅ LATERALIZING CALCANEAL OSTEOTOMY∅ELIMINATES VARUS THRUST THRU ANKLE

SUBTLE CAVUS IN ATHLETES

∅ TREAT ASSOCIATED CONDITION

∅ CAVUS ORTHOTIC FOR ALL SPORTS

LIMIT CAVUS CORRECTION TO REVISION CASES IN ATHLETES

∅ FOREFOOT-DRIVEN: DORSIFLEXION 1ST MT OSTEOTOMY

∅HINDFOOT-DRIVEN: LATERALIZING CALCANEAL OSTEOTOMY

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CASE 1

CASE 1: HISTORY∅ 17M BASKETBALL PLAYER

∅ SEVERE ANKLE SPRAIN 7 MO AGO

∅ULTIMATELY DX: OSTEOCHONDRAL FX

∅ TX NON-OPERATIVELY

∅ STILL UNABLE TO PLAY / LOCKING SX

CASE 1: EXAM∅ STABLE LIGAMENTOUS ENDPOINT

∅ POINT TENDER ANTEROLATERAL JNT

∅ TENDER AT EXTREME ANKLE DF

∅ SUBTLE CAVUS ALIGNMENT

∅ CORRECTS ON COLEMAN BLOCK

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CASE 1

CASE 1

CASE 1

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CASE 1: DIAGNOSIS ?

∅OSTEOCHONDRAL FX / LOOSE BODY

∅ KISSING LESION OF VAN DIJK (FROM LOCKED HINDFOOT)

∅ SUBTLE CAVUS FOOT

CASE 1: TREATMENT

∅OPEN EXOSTECTOMY TIBIA / TALUS

∅ LOOSE BODY REMOVAL / MICRO-FX

∅ CAVUS ORTHOTIC FOR SPORTS

CASE 1

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CASE 1

CASE 1

CASE 1

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CASE 1

∅NWB X 4 WEEKS

∅ PTX / PROGRESSIVE WB

∅ CLEARED TO RETURN TO PLAY @ 4 MO

CASE 1: FINAL

CASE 2

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CASE 2

∅ 18F / D-1 COLLEGE SOCCER COMMIT

∅ 5TH MT FX TX NON-OP / BONE STIM

∅ RE-INJURY 2 WKS AFTER BEING CLEARED TO RESUME ACTIVITY

∅MINIMAL TRAUMA

CASE 2

CASE 2

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CASE 2: DIAGNOSIS

∅ ZONE 3 FX / RE-FRACTURE

∅ COMPETITIVE ATHLETE

∅ SUBTLE CAVUS / ADDUCTUS

CASE 2: TREATMENT

∅ORIF 5TH MT

∅ CAVUS ORTHOTIC FOR SPORTS

CASE 2

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CASE 2

CASE 2

∅ CAVUS ORTHOTIC

∅ CLEARED TO RETURN TO PLAY @ 4 MO

∅ CARBON/STEEL SHANK FOR CLEAT

CASE 2: AFTERMATH

∅MILD PAIN AT SCREW TIP / RUBBING ON SOCCER CLEAT

∅ “YOU NEED TO HAVE THE SCREW REMOVED NOW BEFORE MORE BONE GROWS OVER IT…”

∅ SCREW REMOVAL

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CASE 2: AFTERMATH∅ RE-FRACTURE WALKING ON CAMPUS

∅ REVISION ORIF

CASE 2: AFTERMATH

SUMMARY∅NON-NEUROMUSCULAR VARIANT

∅~20% INCIDENCE IN POPULATION

∅ COMPLEX PATHOMECHANICS

∅ PRODUCES VARUS ANKLE THRUST / LATERAL COLUMN OVERLOAD

∅MANY ASSOCIATED SEQUELAE

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SUMMARY

∅ COLEMAN BLOCK TEST

∅ TREATMENT OF ASSOCIATED CONDITION / CAVUS FOOT ORTHOTIC

∅ RESERVE CAVUS CORRECTION FOR REVISION CASES IN ATHLETES

∅ DF 1ST MT OSTEOTOMY (FF-D) / CALCANEAL OSTEOTOMY (HF-D)