The Plano Valgus Foot in Cerebral Palsy

History/Symptoms-Clinical exam features-Gait parameters-Radiographic features-Surgical technique-Evidence I. PATHOANATOMY-CLINICAL FEATURES: This is primarily a stance phase problem a. EQUINUS CONTRACTURE at the ankle because of a gastro-soleus contracture. b. Initial contact: mid foot or forefoot c. Collapse of the medial arch: i. Talus is in equinus, talo-navicular joint is subluxed ii. Os Calcis is in Valgus and has a decreased pitch iii. Secondary changes in Midfoot and forefoot: dorsal peri-talar subluxation iv. External Tibial Torsion and Hallux Valgus d. Prominence of the navicular tuberosity-Skin Callosities and pain e. Brace Intolerance II. ASSESSMENT a. GMFCS AND FMS b. Topography: unilateral, bilateral involvement c. Tone Disorder: Spastic, Dystonic, Mixed d. Gait parameters: i. Temporospatial: Stance phase prolonged ii. Ankle and foot kinematics: 1. Absence of the first Rocker 2. Curtailed Second Rocker 3. Early heel rise 4. Transfer of GRF onto forefoot 5. Poor third Rocker iii. Kinetic changes: Ankle dorsiflexor moment, reduced ankle power iv. Proximal level changes: flexed knee gait, incompetent PF-KE couple III. RADIOGRAPHY a. Weightbearing views only b. Antero-posterior and lateral views of the foot c. AP views of the Ankle d. CT for tibial torsion-if indicated IV. Management options: a. Tone management b. Orthoses c. Contracture management d. Skeletal stabilisation V. Surgical treatment a. Stabilisation of the hindfoot with extra-articular techniques b. Restoration of the talo-navicular alignment: restore the weight bearing competence of the medial column.