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FOOT & ANKLE
Copyright © 1984 by the American Orthopaedic Foot and Ankle Society, Inc.

Varus and Valgus Foot in Cerebral Palsy and Its Management

Leon Root, MoO:

New York, New York

ABSTRACT muscles (Fig. 2).27 These explanations are rather sim-

Varus and valgus foot, often associated with equinus, are plistic and even though they may indeed be causative
common problems in cerebral palsy. These deformities factors, the attitude of the entire limb, i.e., the position
can interfere with standing or walking, aggravate shoe of the hip or knee, plays an important role in the
wear, and lead to painful calluses on pressure areas of development of foot deformity. Banks 2 has pointed out
the foot. The deformities are caused by a basic muscle that nine of 10 patients with equinus have some evi-
imbalance. If the posterior or anterior tibial muscles are
overactive, the foot will swing into varus. If the peroneal
muscles predominate, the foot assumes a valgus position.
However, the alignment of the hip and knee play an im-
portant role in the production of deformity.
Correction of the deformity must be preceded by as-
sessment of the deforming forces. In the younger child,
simple muscle releases weaken the overpowering mus-
cles and help restore muscle balance. In some instances,
muscle transfers, either whole or split, not only alleviate
the deforming force but also may provide needed support
for the weaker muscles. Once bone deformities are estab-
lished, they must be corrected either prior to or simulta-
neously with muscle procedures.
The purposes of this article is to outline the evaluation
of the deformity and the various soft tissue and bone
operations which can be performed to correct them in
order to obtain a satisfactory plantigrade foot.

Varus or valgus deformities of the foot in the cerebral

palsy patient assume greater importance as they inter- Fig. 1. Varus foot with posterior tibial spasticity.
fere either with ambulation or with wearing of shoes.
Often these attitudes, or deformities if they are fixed,
are associated with an equinus and may be related to
abnormal positions of the hip or knee. In order to
formulate a logical and successful program of treat-
ment, the interacting dynamics of the cause of the
deformities must be understood.
In general, it has been accepted that the varus foot
or equinovarus foot is caused by a predominance of
the posterior tibial muscle (PTM) (Fig. 1) over relatively
weaker or less spastic peroneal muscles which allows
the foot to be pulled into varus. The valgus or the
equinovalgus foot is caused by the opposite situation
in which spastic peroneals overpower weaker tibial

• Attending Orthopaedic Surgeon, The Hospital for Special Sur- Fig. 2. Severe valgus feet with peroneal spasticity. (Reprinted with
gery, and Clinical Professor of Surgery (Orthopaedics), Cornell Uni- permission from Samilson. R.L.: Orthopaedic Aspects of Cerebral
versity Medical College, New York, New York. Palsy. Philadelphia, J.B. Lippincott, 1975.)
174
Foot & AnklefVol. 4, No.4 VARUS AND VALGUS FOOT
dence of valgus of the foot, whereas equinovarus is
present in only one of 10 spastic patients. Bennet et
al.,5 in an evaluation of 230 children who had foot
surgery at The Hospital for Sick Children in Toronto,
noted that where foot deformity was present in hemi-
plegics, 94% had equino or equinovarus deformity, and
where foot deformity was present in the diplegic or
quadriplegic group, 64% had valgus deformities and
only 36% had varus deformities.
The hemiplegic patient walks with an internally ro-
tated attitude of the affected limb (often associated with
femoral anteversion), the knee comes to full extension
with stance, and the foot internally rotates which pro-
motes the equinovarus pattern of walking. On the other
hand, diplegic and quadriplegic patients stand in the
"crouched" position, with thighs adducted and internally
rotated, and knees flexed; together this produces a
functional genu valgus which in turn creates a valgus
force on the ankle and foot (Fig. 3).8,21 If the triceps
surae group is contracted, the valgus stress forces the
calcaneus to rotate laterally beneath the talus. Weight-
bearing accentuates the deformity, and subsequently
the peroneals contract and the PTM becomes stretched
and weakened. Bleck? believes that spasticity of the
Fig. 3. Functional valgus of the feet due to genu valgum and
adductor spasticity. (Reprinted with permission from Bleck, E.E.:
OrthopaediC Management of Cerebral Palsy. Philadelphia, W.B. Saun-
ders, 1979.)
175
peroneal muscles brings the axis of rotation of the
subtalar joint into horizontal alignment to such an extent
that the talus loses the support of the navicular bone
and its plantar ligaments, allowing it to plantarflex and
eventually to evert laterally. Bassett and Baker" feel
that it is the so-called "bow string" effect of the Achilles
tendon on the ankle and subtalar joint that forces the
calcaneus into the path of least resistance.
Keats and Kouten 16 state that the peroneals are
rarely overactive and that weakness of the anterior and
posterior tibial muscles associated with an innervational
overload to the triceps surae group causes pes valgus.
Bennet et al. 5 performed electromyographic studies on
the posterior tibial, anterior tibial, gastrocnemius, and
peroneal muscles. In five of the six patients with valgus
feet, no activity of the PTM was noted during gait, but
all six patients with varus feet had PTM activity. They
concluded that "nonfunctioning" of the PTM was an
essential factor in the etiology and progression of the
valgus foot. Perry and Hotter" noted that peroneal and
tibial muscles have a tendency to function continuously
in gait.
In summary, the varus or valgus foot which may be
associated with an equinus attitude of the ankle is
related to imbalance of the muscles of the foot. Whether
or not this imbalance is primary or secondary to the
position of the hips and knees may vary in different
patients. Although the PTM may appear to be "silent"
with the valgus foot, there is no indication that the
muscle itself is truly nonfunctional, and the reverse is
true with the peroneals.
TREATMENT AND MANAGEMENT
The valgus or varus foot requires treatment only if it
interferes with standing or walking or is severe enough
to hamper shoe wear. If the foot can be corrected to
neutral and held with a splint or brace, management is
simple. That is usually the case in the young child;
however, as the child grows, the deformity may become
fixed or so strong functionally that an external device
cannot maintain foot alignment. Once this occurs, sur-
gical intervention is necessary.
In the following discussion, It is assumed that con-
servative treatment with braces, splints, or therapy has
not been successful.
Varus
The varus or equinovarus foot is most often seen in
the hemiplegic patient but can occur in a diplegic or
quadriplegic patient. Examination should rule out the
presence of femoral anteversion or internal tibial torsion
which has the appearance of varus, but in reality the
foot itself is not involved. Since the deformity is often
functional, a simple test will help determine whether or
176
not the PTM is hyperactive in regard to the peroneals.
The patient is instructed to stand on his toes and, if
possible, walk on his toes. If the PTM is hyperactive,
the varus attitude is accentuated."
Pure varus of the foot is rare. The usual deformity is
an equinovarus. If the equinus component is significant,
simple tendoachillis lengthening (TAL) must be per-
formed. There are five surgical procedures utilized to
correct the overpull of the PTM. Two of these are
designed to weaken the muscle and thus remove or
release the deforming force; two are utilized not only
to remove the deforming force, but also to assist with
dorsiflexion of the ankle; and the fifth creates a poste-
rior sling.
The first two are simple lengthenings of the tendon
or an intramuscular tendon recession as advocated by
Frost and Ruda (Fig. 4).9 These procedures can be
safely combined with a TAL when necessary and are
most successful in the child under 6 years of age who
does not have a fixed deformity of the foot or ankle. I
prefer intramuscular tendon recession because it can
Fig. 4. Intramuscular posterior tibial tendon recession. (Reprinted
with permission from Frost, H.M., and Ruda, R.: Clin. Ortnop., 79:61,
1971.)
ROOT Foot & Ank/ejVol. 4, NO.4
be done through the same incision as the TAL; it does
not adhere to the tendon sheath beneath the medial
malleolus; and, if at a future time a transfer is indicated,
the tendon is intact and the muscle not excessively
weakened. Frost and Ruda9 reported on 29 feet in
which they performed intramuscular tendon recession
with only two recurrences. In 20 feet with standard "Z"
lengthenings, 50% were failures. Banks" combined the
TAL and intramuscular tendon recession with good
results in 20 of 24 feet.
Postoperatively, a short leg walking cast is applied
for 4 to 6 weeks (4 weeks for children under age 4 and
6 weeks for children over age 4). Splinting or bracing
is rarely necessary.
The second two procedures are designed to remove
the deforming force and to transfer the power of the
PTM to assist dorsiflexion. Anterior transposition of the
posterior tibial tendon from behind the medial malleolus
was described by Baker and HiII. 1 They reported on 27
of these procedures with a 6- to 26-month follow-up.
All feet had good correction of deformity and no recur-
rences were observed. My own experience with this
procedure has not been satisfactory. Bisla et al. 6 noted
only 20% improvement with this rerouting of the ten-
don, and in no case was complete correction of the
varus or equinus achieved.
Posterior tibial tendon (PTT) transfer through the
interosseous membrane into the dorsum of the foot
has been recommended as a means of not only remov-
ing the deforming force but also as a way of providing
dorsiflexion assistance during the swing phase of gait.
Perry et aJ. 19 advocate the PTT transfer if electromy-
ographic studies indicate that the muscle is active only
in the swing phase. If the PTM is active in both the
stance and swing phase, a simple lengthening is rec-
ommended. Table 1 summarized the reported studies
on PTT transfers. Except for Schneider and Balon"
and Turner and cooper." the results of transfers seem
to be overwhelmingly good. In fact, Williams3 1 states
emphatically that this is "one of the most successful
and reliable operations in cerebral palsy." One hundred
of these procedures in cerebral palsy patients have
been performed at The Hospital for Special Surgery
and I have reviewed 85 of them. 22 80% of the cases
were good to excellent and only 20% were poor. Fail-
ures fall into four categories: 1) unrecognized fixed
varus deformity, which cannot be corrected with a
tendon transfer and, thus, the varus attitude persists;
2) a simultaneous TAL, which can lead to calcaneus
deformity; 3) transplanting the tendon too far laterally,
which may lead to excessive valgus; and, 4) insecure
insertion of the tendon into bone, which allows it to
detach.
Whether or not the muscle becomes an active dor-
sifexor or not (this occurs in about 20% of the trans-
Foot & AnklejVol. 4, NO.4 VARUS AND VALGUS FOOT 177

TABLE 1
Posterior Tibial Tendon Transfer in Cerebral Palsy
No. of feet Good Fair Poor Valgus deformity
Bisla et al. (6)" 20 14 1 5 5
Schneider and Balon (26)" 29 6 5 18 9
Gritzk et al. (11) 15 12 3 1
Williams (31) 53 33 14 6
Turner and Cooper (30) 14 4 10 2
" Numbers in parentheses are references.
"Most of the poor results were due to lateral transfer of the posterior tibial tendon or to simultaneous tendo achillis lengthening.

fers), the PTT transfer removes a deforming force and

at least provides a tenodesis effect which helps to
reduce bracing. I prefer to wait until the child is 6 years
of age before undertaking this operation and have
found it successful even in young adults. Although
valgus may occur with growth, it rarely becomes severe
enough to warrant surgical correction.
The fifth choice, described by Kauter." is splitting
the posterior tibial tendon and transfer of the lateral
half to the peroneus brevis tendon (SPTT). Hensinger
and Kling12 presented the results of 29 SPTT, 20 of
which had simultaneously TAL with an average follow-
up of 8 years. They reported good results in all cases.
Green10 has been pleased with this procedure in his 16
cases.
An additional cause of the varus foot is an overactive
anterior tibial muscle which is associated with acquired
cerebral palsy.2.5 Hoffer at al. 13 have recommended
splitting the anterior tibial tendon (Fig. 5) and transfer-
ring the lateral half into the cuboid. He reported on 21
feet, only two of which had recurrent deformity. In four
feet splitting the anterior tibial tendon was done alone,
and in the other 17 feet TAL and muscle releases were
done simultaneously. This procedure is recommended
when electromyographic studies of the anterior tibial
muscle reveals the muscle to be overactive and non-
phasic.
In the older child or adolescent in whom heel varus Fig. 5. Split anterior tibial tendon transfer.
is fixed and the forefoot adducted, I have combined a
lateral closing calcaneal osteotomy with plantar tascio- Under 4 years of age, treatment should be conserv-
tomy and transfer of the PTT to the dorsum of the foot. ative. Many surgeons advocate early TAL because of
This combination is successful as long as the forefoot the "bow string effect." Although I have performed a
adduction can be passively corrected. When forefoot TAL for equinovalgus feet, I have rarely seen improve-
adduction is fixed, then a triple arthrodesis is necessary. ment with that procedure alone. However, if the equinus
cannot be controlled with brace/splint, a TAL should be
Valgus
performed.
The valgus foot can be extremely difficult to control Although it is tempting to lengthen the peroneal
and to correct. The equinovalgus attitude of the foot muscles, Bleck? and Keats and Kouten'" caution
diminishes standing balance and, if severe, causes the against indiscriminate lengthening because the foot can
patient to trip or fall. Large, often painful calluses can develop on opposite deformity. If necessary, only one
develop over the medial border of the foot, and hallux tendon should be lengthened.
valgus becomes pernicious (Fig. 6). The valgus foot will Peroneal tendon transfer for correction of pes valgus
accentuate knee flexion, decrease walking efficiency, has not been well accepted. Hoover and Frost" rec-
and eliminate normal pushoff and running. ommended anterior medial transfer of the peroneal
178
longus (PL) and peroneal brevis (PB) tendons for cor-
rection of the "rocker bottom" foot. samnson'" advises
transferring the PB to the mid foot if electromyographic
studies demonstrate it to be active only in stance phase.
Perry and Hotter'? recommended transferring either the
PB or the PL posteromedially to the insertion of the
PTT if either are active only during stance phase. Pre-
ferrably the PB should be transferred, but if the PL is
active in stance and is to be transferred, the PB tendon
should be attached to the stub of the PL. When both
tendons are active throughout gait, one is lengthened.
Bennet et al. 5 favor transfer of the PB to the PTT.
Silver has published the results of 100 opening
wedge osteotomies of the calcaneus for pes valgus. 28,29
He reports 80% good results with long-term follow-up.
Although this operation appears successful, the pro-
cedure has not gained general acceptance.
Fig. 6. Bunions with severe valgus feet. (Reprinted with permission
from Giannestras, N.J.: Flexible Valgus Foot: Foot Science. Philadel-
phia, W.B. Saunders, 1976.)
TABLE 2
Subtalar Arthrodesis in Cerebral Palsy
Feet
Keats and Kouten (16)8 63
Nakano and Schmitt (17) 85
Rosenthal and Candage (23)b 41
Barrasso et al. (3) 40
Ross and Lyne (24) 17
Bleck (7) 44
Banks 100
8 Numbers in parentheses are references.
b Screw fixation with bone graft.
C Pin fixation with bone graft.
ROOT Foot & Ankle/Vol. 4, NO.4
The Grice subtalar arthrodesis, with variations, has
been performed extensively for pes valgus deformities
in cerebral palsy. Reports vary from 80% good results
to 50% poor results. Table 2 summarized the major
series which have appeared in the literature. My own
experience with subtalar arthrodesis in cerebral palsy
has been favorable. Most of the failures are either due
to loss of position of the bone graft or nonunion (both
of which result in recurrence of the valgus) or overcor-
rection into varus. Banks" and more recently
Rosenthal'" and Barrasso et al., 3 has recommended
screw or pin fixation in order to maintain alignment and
fixation of the graft. Bleck? points out that the best
results with subtalar arthrodesis are in children over 7.
In the older child or young adult who has significant
valgus which interferes with weightbearing or becomes
painful, surgical correction can be obtained with a triple
arthrodesis. However, the triple arthrodesis for the pes
valgus foot is an extremely difficult operation. I recom-
mend that the foot be approached both laterally and
medially so that the talonavicular joint can be visualized.
Bleck? recommends reducing the talus with a bone
block as part of the triple arthrodesis.
Another etiology for pes valgus which is not often
appreciated is severe external tibial torsion. Patients
who walk with internal rotation of the thighs may have
a compensatory external rotation of the foot and leg.
This produces a valgus stress on the foot. If femoral
anteversion is corrected by osteotomy, the knee will be
straight but the foot will be in even greater external
rotation in relation to the knee. A triple arthrodesis in
this situation is futile because the problem is not the
foot but in the tibia. A supramalleolar tibial rotation
osteotomy can successfully correct the alignment.
I have not discussed the wheelchair or nonwalking
patient. Obviously, the ambulatory patient requires cor-
rection of deformity, but we should not ignore patients
in wheelchairs. If the varus or valgus foot interferes
with their ability to stand and transfer, or with their
ability to wear shoes, or if the foot is so deformed that
it becomes disturbing to the patient and to the family,
Follow-up Good to Fair to
average (years) excellent poor
4-5 61 2
7 88% 12%
2V2 73% 27%
11/2 38 2
11 5 12
? 22 22
? 86 14
Foot & Ankle/Vol. 4, No.4 VARUS AND VALGUS FOOT
then I would not hesitate to recommend surgical cor-
rection.
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