SUBTLE CAVUS IN SPORTS INJURIES MICHAEL P. CLARE, MD FLORIDA 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 1
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 VALGUS NEUTRAL CAVUS AMINIAN & SANGEORZAN, FA CLIN 13, 2008 PATHOMECHANICS NO HINDFOOT EVERSION CHOPART JOINTS REMAIN LOCKED NO SHOCK ABSORPTION CORONAL PLANE STRESSES ABSORBED BY ANKLE JOINT 2
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 3
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 4
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 BACK TO FRONT FROM 5
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 6
CALCANEAL PITCH ANGLE MORE POSTERIOR FIBULA SCRANTON, ET AL. FAI 25, 2004 MEARY S ANGLE 7
METATARSAL STACKING FOREFOOT SUPINATION / ADDUCTUS TREATMENT MANOLI & GRAHAM, FAI 26,2005 HIGH FAILURE RATE / RECURRENCE IF CAVUS NOT ADDRESSED CAVUS FOOT ORTHOTIC LATERAL HEEL & SOLE WEDGE 1ST MT HEAD RECESS 8
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 9
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 10
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 11
CASE 1 CASE 1 CASE 1 12
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 13
CASE 1 CASE 1 CASE 1 14
CASE 1 NWB X 4 WEEKS PTX / PROGRESSIVE WB CLEARED TO RETURN TO PLAY @ 4 MO CASE 1: FINAL CASE 2 15
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 16
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 17
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 18
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 19
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) 20