Rotational Deformities

of the Rearfoot and Ankle:

Assessment Relative to Surgical Intervention

Andrew J. Meyr, DPM FACFAS

Associate Professor,
Amateur Physicist,
Department of Surgery,
TUSPM

Descartes said: All of science can be

explained by the concept of matter in
motion.
String theory; 11-26 dimensions!
Podiatric String Theory…
 Lecture Objectives
• Review how to “break down” complex
deformities into their individual components
– This is…how to “take the test”, not treat the
deformity.
– This is…what to do when you get “stuck” looking
at an x-ray.

– Everyone may not be able to get their heads around

everything, but they can at least get to a point where they
recognize what is wrong.
– Taking tests is easy…..patients are in a vacuum.
 Rotational Deformities
of the Rearfoot and Ankle
A Brief History of “Dimensions”:

-We (as surgeons) understand 3 planes…

-Transverse plane
-Sagittal plane
-Frontal plane

…but tend to think in only 2 dimensions;

…..and only one dimension at a time.

 This is something that you do
already on a daily basis…
 HAV is a triplanar
pathology that we
typically evaluate in
multiple planes:
Transverse plane
Sagittal plane
Frontal plane
 It’s a poor carpenter who
blames his tools….
 HAV is a triplanar
pathology that we
typically evaluate in
only 2-dimensions:
Transverse plane
Sagittal plane
Frontal plane
 It’s a poor carpenter who
blames his tools….
 HAV is a triplanar
pathology that we
typically evaluate in
only 2-dimensions:
Transverse plane
Sagittal plane
Frontal plane
 It’s a poor carpenter who
blames his tools….
 HAV is a triplanar
pathology that we
typically evaluate in
only 2-dimensions:
Transverse plane
Sagittal plane
Frontal plane
 It’s a poor carpenter who
blames his tools….
 HAV is a triplanar
pathology that we
typically evaluate in
only 2-dimensions:
Transverse plane
Sagittal plane
Frontal plane
Recognition and Recommendation
Simple Rule of 3:
For a given patient presentation, separately
break the deformity down into 3 planes:
1. Transverse plane
2. Sagittal plane
3. Frontal plane

1. Identify a plane
2. Recognize deformity
3. Recommend intervention
Recognition and Recommendation
• Flatfoot Deformity
– Stage II Deformity

• Cavus Foot Deformity

• Charcot Deformity
• Post-traumatic Deformity
 Identify: Transverse Plane
• Stage II Flatfoot Deformity:
– Radiographic: AP/DP Radiograph
– Clinical: Stance and gait examination
 Recognize: Transverse Plane
• AP Radiograph
– Kite’s Angle
Normal: ~19-23 degrees
Increases with pes planus
Decreases with cavus
 Recognize: Transverse Plane
• AP Radiograph
– Kite’s Angle
– Cuboid Abduction Angle
Normal: ~0-5 degrees
Increases with pes planus
Decreases with pes cavus
 Recognize: Transverse Plane
• AP Radiograph
– Kite’s Angle
– Cuboid Abduction Angle
– Talar Head Coverage
 Recognize: Transverse Plane
• AP Radiograph
– Kite’s Angle
– Cuboid Abduction Angle
– Talar Head Coverage
– Talo-First Met Angle
• AP Meary’s Angle?
 Recognize: Transverse Plane
• AP Radiograph
– Kite’s Angle
– Cuboid Abduction Angle
– Talar Head Coverage
– Talo-First Met Angle

• Stance/Gait (Flatfoot)
– “Too many toes” sign
– Abductory “twist”
 Recommend: Transverse Plane
• Surgical Options (Flatfoot):

– Evans calcaneal osteotomy

– CC Distraction arthrodesis
– PT Tendon advancement/repair/transfer

– Forefoot adductus correction

– HAV correction
 Identify: Sagittal Plane
• Stage II Flatfoot Deformity:
– Radiographic: Lateral Radiograph
– Clinical: Stance and gait examination
 Recognize: Sagittal Plane

• Calcaneal Inclination Angle Normal: ~19-23 degrees

Decreases with pes planus
Increases with pes cavus
 Recognize: Sagittal Plane

• Calcaneal Inclination Angle

• Talar Declination Angle Normal: ~19-23 degrees
Decreases with pes planus
 Recognize: Sagittal Plane

• Calcaneal Inclination Angle

• Talar Declination Angle
• Meary’s Angle Normal: Parallel
Talus is plantar with pes planus
Talus is dorsal with pes cavus
 Recognize: Sagittal Plane

• Calcaneal Inclination Angle

• Talar Declination Angle
• Meary’s Angle
• Medial column “break” or “fault”
 Recognize: Sagittal Plane
• Clinical Examination
(Flatfoot):

– Equinus testing

– Loss of medial column

arch height on stance

– Early heel-off gait

• “Bouncy” gait
 Recognize: Sagittal Plane
• Clinical Examination
(Flatfoot):
– Equinus testing
• Silfverskiöld test
• Pre-operative AND
intra-operative testing

– Loss of medial column

arch height on stance

– Early heel-off gait

 Silfverskiöld test
• Decreased ankle • Decreased ankle
dorsiflexion with knee dorsiflexion with knee
both extended and extended, but normal
flexed with knee flexed

• Gastroc-soleal equinus • Gastroc equinus

TAL Gastroc recession

 Silfverskiöld test
• Decreased ankle • Decreased ankle
dorsiflexion with knee dorsiflexion with knee
both extended and extended, but normal
flexed with knee flexed

• Gastroc-soleal equinus • Gastroc equinus

TAL Gastroc recession

Technique Tip:
Must internally rotate or adduct the foot, or else
you are simply pronating the subtalar joint
 Silfverskiöld test
• Decreased ankle • Decreased ankle
dorsiflexion with knee dorsiflexion with knee
both extended and extended, but normal
flexed with knee flexed

• Gastroc-soleal equinus • Gastroc equinus

TAL Gastroc recession

Technique Tip:
May be better served with a functional test of
equinus, rather than Silfverskiöld test.
 Silfverskiöld test
• Decreased ankle • Decreased ankle
dorsiflexion with knee dorsiflexion with knee
both extended and WARNING: extended, but norma l
flexed with knee flexed
If you don’t think that you have equinus,
always reassess intra-operatively after
• Gastroc-soleal equinus
your bone• work.
Gastroc equinus

TAL Gastroc recession

Technique Tip:
May be better served with a functional test of
equinus, rather than Silfverskiöld test.
Hubscher Maneuver

Provides some information about the

sagittal plane, but is more useful for
differentiation between
flexible and rigid deformities.
 Recommend: Sagittal Plane
• Surgical Options (Flatfoot):

– Gastroc vs. TAL

 Recommend: Sagittal Plane
• Surgical Options
(Flatfoot):
– Gastroc vs. TAL

– Cotton Osteotomy
– Medial column
arthrodesis
 Identify: Frontal Plane
• Stage II Flatfoot Deformity:
– Radiographic: Which views?
– Clinical: Stance and gait examination
 Recognize: Frontal Plane

• Cyma Line?: Anterior break

• Obliteration of the sinus tarsi?
• Metatarsal overlap?
• Medial column fault/break?
 Recognize: Frontal Plane

• Long Leg Calcaneal

Axial View:

– Frontal plane relationship of:

• Tibia to calcaneus
• Tibia to talus
• Talus to calcaneus
– Calcaneal strike position to long
axis of tibia
 Recognize: Frontal Plane

• Ankle Views:

– Frontal plane
relationship of:
• Tibia to talus

• Valgus or Varus
orientation
 Recognize: Frontal Plane

• Clinical Examination:
– Resting calcaneal stance
position (RCSP)
– Helbing’s sign
– Medial “bulge”
– Single/double heel rise
– Subtalar joint ROM
 Recognize: Frontal Plane

• Clinical Examination:
– Resting calcaneal stance
position (RCSP)
– Helbing’s sign
– Medial “bulge”
– Single/double heel rise
– Subtalar joint ROM
– Forefoot-to-Rearfoot
• Forefoot varus
• Rearfoot valgus
 Recommend: Frontal Plane
• Surgical Options:
– Trying to put the “foot
back under the leg”
 Recommend: Frontal Plane
• Surgical Options:
– Trying to put the “foot
back under the leg”

– Medial calcaneal slide

osteotomy
• Koutsogiannis
 Recommend: Frontal Plane
• Surgical Options:
– Trying to put the “foot
back under the leg”

– Medial calcaneal slide

osteotomy
• Koutsogiannis

– Subtalar Arthroeresis
 Recommend: Frontal Plane
• Surgical Options:
– Trying to put the “foot
back under the leg”

– Medial calcaneal slide

osteotomy
• Koutsogiannis

– Subtalar
Double Arthroeresis
Calcaneal Osteotomy?
Recognition and Recommendation
1. Identify a potential plane of deformity
1. Transverse plane (Abduction/Adduction)
2. Sagittal plane (Flexion/Extension)
3. Frontal plane (Valgus/Varus)

2. Recognize how to best define it

1. Radiographic assessment (which view for what plane?)
2. Clinical evaluation (any special tests?)

3. Recommend a surgical procedure to correct it

 Is that enough? Probably not…
• We should probably be doing a better job of assessing the
distal tibia-fibula in relation to the remainder of the leg:
Transverse plane: Sagittal plane: Frontal plane:

13-18 degrees external rotation Anterior Distal TibialAngle Lateral Distal TibialAngle

Images from Paley’s Principles of Deformity Correction text

 Is that even enough?
Again, probably not…
• We should probably be doing a better job
of assessing the remainder of the leg:

-Tibial Valgus/Varum
-Genu Valgum/Varum
-Internal/External Femoral Position
-Internal/External Hip Rotation…..
 Pes Cavus Deformity
• Forefoot-Driven • Forefoot-Driven
Flexible Rigid

• Rearfoot-Driven • Rearfoot-Driven
Flexible Rigid
 Pes Cavus Deformity
• Forefoot-Driven • Forefoot-Driven
Flexible Rigid
Forefoot versus Rearfoot?:
-Coleman Block Test

• Rearfoot-Driven • Rearfoot-Driven
Flexible Rigid
Flexible versus Rigid?:
-Physical Examination
Coleman Block Test
 Pes Cavus Deformity
• Forefoot-Driven • Forefoot-Driven
Flexible Rigid
Jones Dorsiflexory First
Tenosuspension Met Osteotomy

• Rearfoot-Driven • Rearfoot-Driven
Flexible Rigid
Dwyer Calcaneal Rearfoot
Osteotomy Arthodesis
• Please do not hesitate to
contact Andy if there is
anything at all that that he
can do for you:

AJMeyr@gmail.com

Hockney’s Mount Fuji and Flowers