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Calcaneal Foot Deformity – Causes and Treatment

Calcaneal foot deformity (Pes calcaneus) is a foot condition where the foot is permanently dorsiflexed, causing the person to walk primarily on the heel.

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Things worth knowing about "Calcaneal Foot Deformity"

Calcaneal foot deformity (Pes calcaneus) is a foot condition where the foot is permanently dorsiflexed, causing the person to walk primarily on the heel.

What is Calcaneal Foot Deformity?

Calcaneal foot deformity, known medically as Pes calcaneus, is a structural foot condition in which the foot is fixed in a dorsiflexed position -- meaning the front of the foot is permanently pulled upward and the heel becomes the primary point of ground contact during walking. The foot cannot be fully plantarflexed (pointing downward), which significantly affects the normal gait pattern. The condition may affect one or both feet and can be present from birth or develop later in life.

Causes

Calcaneal foot deformity can arise from several different causes:

Congenital malposition: An abnormal position of the baby in the womb (e.g., breech presentation) can mechanically push the foot into an overextended position before birth.
Muscle weakness or paralysis: Weakness or paralysis of the calf muscles -- as seen in conditions such as spina bifida, myelomeningocele, or cerebral palsy -- leads to an imbalance in which the muscles that lift the foot overpower those that lower it.
Nerve damage: Injury to the peroneal nerve or other motor nerves can impair foot muscle function and contribute to a calcaneal foot posture.
Over-correction of clubfoot: Surgical or conservative overcorrection of a clubfoot (Pes equinovarus) can occasionally result in a calcaneal foot deformity.
Trauma: Injuries to the Achilles tendon or calf musculature may also predispose to a calcaneal foot position.

Symptoms

Common signs and symptoms of calcaneal foot deformity include:

Visible permanent dorsiflexion of the foot -- the top of the foot points clearly upward
Absent or severely reduced ability to point the foot downward (plantarflexion)
Walking predominantly on the heel (calcaneal gait)
Pressure sores and calluses on the heel
Pain in the heel area, particularly when walking
Reduced push-off strength during walking
In advanced cases: shortening of the anterior leg muscles and restricted joint mobility

Diagnosis

Diagnosis is typically made through a clinical examination in which the physician assesses the shape of the foot, the range of motion of the ankle joint, and the gait pattern. Additional investigations may include:

X-rays: To evaluate the bony structures and the angle of the calcaneus
Electromyography (EMG): To assess muscle function and nerve conduction
Gait analysis: For a detailed evaluation of movement patterns
MRI or ultrasound: If accompanying soft tissue changes or tendon damage are suspected

Treatment

Treatment depends on the severity of the deformity and its underlying cause.

Conservative Treatment

Physiotherapy: Strengthening of the calf muscles, stretching of shortened structures, and gait training
Orthoses and splints: Custom insoles or lower leg orthoses help stabilize the foot and correct the abnormal position
Serial casting: Particularly in newborns, progressive plaster casts can gradually correct the foot alignment

Surgical Treatment

In severe or treatment-resistant cases, surgical intervention may be required. Possible procedures include:

Tendon lengthening or tendon transfer to restore muscle balance
Bone-corrective procedures (osteotomies) of the calcaneus
Arthrodesis (surgical fusion) of the ankle joint in severe cases

Prognosis

The prognosis of calcaneal foot deformity depends strongly on the underlying cause and the timing of treatment. In congenital cases without an underlying neurological condition, the outlook is generally good with early intervention. When the deformity is neurogenic in origin, long-term management by a multidisciplinary team including orthopedics, neurology, and physiotherapy is essential.

References

Niethard, F. U., Pfeil, J., Biberthaler, P.: Duale Reihe Orthopaedie und Unfallchirurgie. Thieme Verlag, Stuttgart, 8th edition, 2017.
Staheli, L. T.: Fundamentals of Pediatric Orthopedics. Lippincott Williams and Wilkins, Philadelphia, 4th edition, 2008.
World Health Organization (WHO): International Classification of Functioning, Disability and Health (ICF). Geneva, 2001. Available at: https://www.who.int/classifications/icf/en/

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