Osteopathic
Deformity or dysfunction? Osteopathic manipulation of the idiopathic cavus foot: A clinical suggestion.
PROBLEM
Foot deformities are often associated with gait abnormalities that may contribute to dysfunction or pathology. One such deformity, the high arched or idiopathic cavus foot, has been associated with peroneal tendonopathy,1 lateral ankle sprains and instability,2,3 ankle arthritis,4 metatarsalgia or fracture,5 and up the kinetic chain to the knee,6 hip,7 and back.8 Characterized by a high medial longitudinal arch, plantarflexed first ray, claw toes, and callous over the 5th metatarsal base, the cavus foot is considered a varus foot deformity involving both the rear- and forefoot.5,9,10. The cavus foot ranges in severity from clubfoot to mild variants referred to as pes cavus or subtle cavus foot, and can be fixed or flexible.5,9 The fixed or flexible nature of the deformity is determined by whether the rearfoot joints are grossly mobile enough to compensate for the varus deformities to place the foot in a plantigrade position.10,11,12 Fixed varus deformities, isolated or both rear- and forefoot combined, are also referred to as uncompensated, while the flexible type are referred to as compensated.
Cavus foot deformities may lead to gait abnormalities that generate local or more proximal leg symptoms and dys-function, and may require treatment.13,14 Limited evidence supports the use of orthotics in cases of idiopathic cavus feet.13,15,16 For many cases of idiopathic cavus foot, non-operative care including stretching, shoe modification, and foot orthotics have been recommended, but often been found to be inadequate.5,9 When non-operative care is not successful, a variety of surgical procedures can correct the bony cavus deformity.3,4,5,9,17
An idiopathic cavus foot may exist due to hypomobility of any combination of the many joints in the foot and ankle. Joint manipulation to the hypomobile foot or ankle joints, followed by soft tissue surgery and serial casting as described by Ponseti and Smoley,18 has become common in pediatric cases of idiopathic clubfoot. Compared to manipulation and surgical arthrodesis, the Ponseti and Smoley18 approach has resulted in greater parental satisfaction and ankle range-of-motion (ROM) outcomes.19 No known reports of joint manipulation changing the architecture of the idiopathic uncompensated varus foot in adults exist. This paper illustrates several osteopathic manipulations addressing specific joint hypomobility in the idiopathic cavus foot to demonstrate the importance of mobilizing specific hypomobile joints before determining that a fixed foot deformity exists and requires other treatment.
SOLUTION
Some cases of idiopathic cavus foot may be amenable to osteopathic manipulation, a term used here to refer to direct joint mobilization (grade I-V), and indirect mobilization via Strain Counterstrain. When specific joint mobility assessments of the foot and ankle joints indicate hypomobility, it is suggested that osteopathic manipulation be attempted. Clinically, the selection of appropriate techniques will depend on assessment of the individual. In this case, 5 techniques were applied: 1) high velocity low amplitude thrust (HVLAT) talocrural joint separation, 2) Strain Counterstrain (SCS) for the lateral calcaneus (LCA), 3) HVLAT of the navicular, 4) mobilizations with movement (MWM) of the cuboid, and 5) MWM of the first metatarsal phalangeal (MTP) joint.
Limited evidence exists to support some of these techniques, while other techniques have not been reported in the literature. Talocrural joint separation with HVLAT has been described20 and used to increase ankle dorsiflexion in cases of equinus21, diabetes22, plantar fasciitis23, and ankle sprains (Figure 1).24–27 Jones28introduced SCS and described the application SCS for the lateral calcaneus, though not specifically for increasing rearfoot eversion as in this case (Figure 2). A HVLAT applied to the dorsal navicular for increased mid-foot pronation has not been reported in the literature (Figure 3). Mobilizations with movement (MWM) were introduced by Mulligan,29 and ankle MWM have been reported to increase ankle dorsiflexion.30,31 Open chain manipulation of the cuboid with the ankle plantarflexed for ankle sprains has been reported, but closed chain MWM of the cuboid to increase pronation with midfoot plantarflexion has not been described (Figure 4).32 MWM of the MTP joint to increase dorsiflexion after heel-off during gait (Figure 5) has also not been reported in the literature.
Talocrural joint separation high velocity low amplitude thrust (HVLAT). With patient in supine, operator gently positions the ankle in slight dorsiflexion and grasps dorsal foot with both hands: thumbs on plantar aspect and 5th fingers over anterior talus. ...
Strain Counterstrain for the lateral calcaneus tender point (LCA). With patient in side lying and LCA monitored with the operator's right 3rd digit (inset), right hand directs force to the medial posterior calcaneus for 90 seconds while left hand supports ...
High velocity low amplitude thrust (HVLAT) applied to the dorsal navicular. With patient in hook lying, operator grasps medial metatarsals and pulls into dorsiflexion while left thumb rests on the superolateral border of the navicular. The operator applies ...
Mobilization with movement (MWM) of the cuboid. With patient seated, operators' thumbs deliver sustained pressure to the proximal medial cuboid to pronate the cuboid in frontal plane, as the patient plantarflexes at the ankle and mid-foot during a seated ...
Mobilization with movement (MWM) of the 1st metatarsal phalangeal joint. With patient seated, operator's thumb and 2nd proximal interphalangeal joint deliver sustained pressure on the distal aspect of the metatarsal head at an oblique angle to facilitate ...
USE IN PHYSICAL THERAPY
The subject is a 27-year-old woman who presented with bilateral idiopathic cavus feet. Both feet appeared to have uncompensated rear- and forefoot varus deformities such that her first rays were atypically not plantarflexed and she bore no weight on the medial side of her foot in standing and walking. The subject's mother, who reportedly has similar but less severe cavus feet, reported that the subject's feet had always appeared the same since beginning to walk at eight months old. The subject's parents sought medical intervention at two years of age to address her bow-legged and hyper-lordotic posture. The physician assured them, however, that any deformity would correct as she developed without treatment or orthoses. Although the subject always walked on the lateral border of both feet, she had no other medical issues other than an ankle sprain from a car accident when nine years old. She never limited her activities and as an adult has exercised four to five times per week. Over the past five years, however, the subject reported insidious low back pain and bilateral hip pain ranging in intensity from three to seven on a scale with ten being the worst pain. She also reported bilateral clicking heel pain and overall discomfort in both feet. Pain on her left side had progressed in the past year leading her to consult a physical therapist.
At the time of consultation, the subject stood on the lateral borders of both feet with uncompensated cavus feet apparent. Her bilateral hip, knee, and ankle ROM were grossly normal except ankle dorsiflexion at approximately 10 degrees, rearfoot eversion less than neutral, and first MTP dorsiflexion at approximately 45 degrees. Mobility testing of the talocrural, subtalar, midtarsal, and first MTP joints revealed bilateral hypomobility throughout. Her gait was marked by a loud impact upon heel-strikes with lateral weight bearing throughout the stance phase. Pronation of the subtalar and midtarsal joints were insufficient for her feet to achieve medial plantigrade.
It was agreed upon to attempt to reduce the cavus foot architecture with osteopathic manipulation, starting with her right foot. Mortise separation with HVLAT increased ankle dorsiflexion by approximately 5 degrees. Strain Counterstrain for LCA resulted in rearfoot eversion past neutral, but did not alter the cavus shape of her foot. The HVLAT to the navicular resulted in dramatic lowering of her medial foot to plantigrade in standing, though she exhibited minimal first toe weight bearing during the terminal stance phase of gait. Closed chain MWM of the cuboid was used to increase midtarsal joint pronation and enhance medial weight bearing in both standing and gait. Closed chain MWM of the first MTP joint to increase dorsiflexion in terminal stance was applied once medial weight bearing was achieved. The net result was normalized standing posture and gait (Figures 6 & 7).
Anterior view after the subject's 1st consultation. Prior to intervention, the subject stood on the lateral borders of her feet with uncompensated cavus apparent. After osteopathic manipulation as described in this case study, her right foot achieved ...
Posterior view after the subject's 1st consultation. Note the marked rearfoot varus alignment of the uncorrected left foot compared to the corrected right foot rearfoot alignment.
After the first consultation, a home exercise program was provided including ankle and hip stretching, active closed chain ankle and toe dorsiflexion, and unilateral bridging for hip strength. Between the first and second consultation, the subject experienced general leg soreness, periodic lateral ankle and medial knee pain after walking several blocks, increased pressure around the lateral malleolus, numbness and tingling at the distal lateral lower leg, and disruption of her balance experienced as a veering limp to the left and occasional trip on sidewalk cracks.
The manipulation sequence was repeated on her left foot at the second consultation, three weeks later, when her feet did not exhibit signs of cavus deformity (Figure 8), except for lateral claw toes due to residual soft tissue contracture (Figure 9). Her back, hip, knee, and heel pain were completely relieved. Her gait was normalized, and she reported quieter, more comfortable bilateral heel strike two weeks after the second consultation. However, occasional loss of balance to her left occurred when walking fast. Residual numbness and tingling extended from the anterior ankle proximally to the lower leg. In short, the apparent uncompensated cavus foot deformities were actually multi-joint hypomobility-related dysfunctions.
Posterior view after the subject's 2nd consultation. Note full weight bearing on the 1st metatarsal phalangeal joints of both feet after bilateral manipulation.
Anterior view of the subject's feet after 2nd consultation. Note residual lateral claw toes and lateral foot border hypertrophy (lateral view inset).
DISCUSSION
The foot and ankle complex includes many joints, all of which can become hypomobile independently or as a group. This case of idiopathic cavus foot corrected with osteopathic manipulation is presented to provoke the consideration of whether observed foot abnormalities are bony deformities or dysfunctional joint hypomobility. As in this case, some idiopathic cavus foot abnormalities may be corrected with osteopathic manipulation. The patient/client should be advised to prepare for potential post-treatment lower extremity discomfort. In cases of bilateral abnormalities, treatment of both feet on the same day can minimize asymmetry-related discomfort, although in this case scheduling precluded this approach. Before assuming the presence of immutable bony deformity that may require orthoses or surgery, clinicians are suggested to assess the specific joint mobility of all foot and ankle joints and mobilize if hypomobility is indicated.
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