Key Points

• Characterized by abnormally high medial longitudinal arch
• Often associated with underlying neurological conditions
• Can be flexible or rigid
• Usually progressive without treatment
• 80% cases have neurological etiology

Etiology

Neurological Causes (80%)

• Charcot-Marie-Tooth Disease (Most Common)
  • Progressive peripheral neuropathy
  • Presents in first decade
  • Autosomal dominant inheritance
• Other Neurological Conditions:
  • Spinal cord tumors
  • Spina bifida
  • Poliomyelitis
  • Friedrich's ataxia
  • Cerebral palsy
  • Syringomyelia

Non-neurological Causes (20%)

• Idiopathic (Most common non-neurological)
• Post-traumatic
• Residual clubfoot
• Burns/contractures
• Compartment syndrome sequelae

Pathoanatomy

• Primary Deformities:
  • Elevated medial longitudinal arch
  • Plantar fascia contracture
  • First ray plantarflexion
  • Hindfoot varus
• Muscle Imbalance:
  • Strong ankle plantar flexors
  • Weak ankle dorsiflexors
  • Intrinsic muscle wasting

Clinical Features

History Taking

• Key Questions:
  • Age of onset
  • Family history
  • Progression rate
  • Associated symptoms
  • Neurological symptoms
  • Impact on activities
• Common Complaints:
  • Lateral foot pain
  • Frequent ankle sprains
  • Shoe wear problems
  • Metatarsalgia
  • Callus formation
  • Gait instability

Physical Examination

• Foot Examination:
  • Coleman block test
  • Arch height assessment
  • First ray position/flexibility
  • Hindfoot alignment
  • Forefoot positioning
• Neurological Assessment:
  • Muscle strength testing
  • Sensory examination
  • Deep tendon reflexes
  • Muscle bulk/wasting
• Gait Analysis:
  • Walking pattern
  • Foot progression angle
  • Balance assessment
  • Lateral heel wear

Diagnosis & Assessment

Imaging Studies

• Weight-bearing Radiographs:
  • AP, lateral, hindfoot alignment views
  • Key measurements:
    • Meary's angle (> 5°)
    • Calcaneal pitch (> 30°)
    • Hibbs angle
    • First metatarsal angle
• Advanced Imaging:
  • CT scan:
    • 3D deformity assessment
    • Surgical planning
  • MRI:
    • Soft tissue evaluation
    • Neural structures

Neurological Workup

• Essential Tests:
  • EMG/NCV studies
  • Genetic testing (CMT)
  • Spinal MRI if indicated
  • Neurologist consultation

Management Approach

Conservative Treatment

• Orthotic Management:
  • Custom orthoses with:
    • Lateral posting
    • Metatarsal support
    • Arch support
  • AFO for neurological cases
• Physical Therapy:
  • Stretching exercises
  • Balance training
  • Muscle strengthening
  • Gait training
• Footwear Modifications:
  • High-topped shoes
  • Rocker bottom soles
  • Lateral sole wedges

Surgical Management

• Indications:
  • Failed conservative treatment
  • Progressive deformity
  • Chronic pain
  • Functional limitation
• Surgical Options:
  • Soft Tissue Procedures:
    • Plantar fascia release
    • Tendon transfers
    • Achilles lengthening
  • Bony Procedures:
    • First metatarsal osteotomy
    • Calcaneal osteotomy
    • Midfoot osteotomy
  • Complex Reconstruction:
    • Triple arthrodesis
    • Midfoot fusion
    • External fixation

Postoperative Care

• Phase 1 (0-6 weeks):
  • Non-weight bearing
  • Cast immobilization
  • Wound care
• Phase 2 (6-12 weeks):
  • Progressive weight bearing
  • ROM exercises
  • Orthotic fitting
• Phase 3 (3-6 months):
  • Strengthening
  • Gait training
  • Return to activities