Hallux valgus in equino-planovalgus foot deformity in children with cerebral palsy and its etiopathogenesis: a review (part 1)

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Abstract

BACKGROUND: Hallux valgus in children with cerebral palsy is an understudied problem. Treatment approaches are generally applied as a secondary measure, often after the child starts complaining at an older age following correction of contractures and other foot deformities. Moreover, there are no established methods for the early prevention or treatment of hallux valgus. Understanding the fundamental mechanisms of etiopathogenesis and biomechanical disturbances during gait is crucial for developing preventive and therapeutic strategies for this patient population.

AIM: To analyze international studies of foot deformities in children with cerebral palsy and compare these findings with biomechanical studies in patients with idiopathic hallux valgus without neurological pathology.

METHODS: Sixty-four scientific articles and publications retrieved from multiple databases without time restrictions were reviewed.

RESULTS: Equinoplanovalgus foot deformity is a major etiopathogenetic factor in the development of hallux valgus in children with cerebral palsy. Biomechanical alterations associated with hallux valgus are characterized by limited dorsiflexion of the hallux, excessive dorsiflexion of the first ray, restricted supination of the hindfoot and midfoot, and increased plantar flexion of the ankle joint during the terminal stance phase. In equinoplanovalgus deformity, excessive pronation of the hindfoot and midfoot cannot be compensated because of the limited range of motion of the midtarsal joint, causing restricted midfoot supination and the inability to activate the locking mechanisms of the midfoot and forefoot during terminal stance.

CONCLUSION: Any biomechanical disturbance within the complex multisegmental structure of the lower extremity that reduces hindfoot and midfoot supination, causes first ray eversion, and limits hallux dorsiflexion may contribute to deformity. The diversity of motor disorders, contracture patterns, and deformities in children with cerebral palsy indicates the need for further research aimed at identifying the specific factors involved in hallux valgus formation. Such findings may be beneficial for developing preventive and therapeutic strategies for early-stage deformities.

About the authors

Valery V. Umnov

H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery

Email: umnovvv@gmail.com
ORCID iD: 0000-0002-5721-8575
SPIN-code: 6824-5853

MD, PhD, Dr. Sci. (Medicine)

Russian Federation, Saint Petersburg

Dmitriy S. Zharkov

H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery

Author for correspondence.
Email: zds05@mail.ru
ORCID iD: 0000-0002-8027-1593

MD

Russian Federation, Saint Petersburg

Vladimir А. Novikov

H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery

Email: novikov.turner@gmail.com
ORCID iD: 0000-0002-3754-4090
SPIN-code: 2773-1027

MD, PhD, Cand. Sci. (Medicine)

Russian Federation, Saint Petersburg

Dmitriy V. Umnov

H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery

Email: dmitry.umnov@gmail.com
ORCID iD: 0000-0003-4293-1607
SPIN-code: 1376-7998

MD, PhD, Cand. Sci. (Medicine)

Russian Federation, Saint Petersburg

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Supplementary files

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2. Fig. 1. The effect of valgus forces in EPVFD, causing asymmetric loading of the growth plates of the distal and proximal phalanges of the hallux and the first metatarsal bone.

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3. Fig. 2. Results of pedobarographic studies demonstrating the pressure distribution and ground reaction force projection in patients with hallux valgus. “+,” study results indicating increased load in the designated area; “–,” study results indicating decreased load in the designated area.

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4. Fig. 3. Alignment of the midfoot and forefoot components during the terminal stance and preswing phases under normal conditions in the frontal (a) and sagittal (b) planes. The red line represents the ground reaction force vector. Supination of the calcaneus and abduction and dorsiflexion of the talus disrupt the alignment of the talonavicular and calcaneocuboid joint axes, thereby blocking motion around the axes of the midtarsal (Chopart) joint. The supinated position of the cuboid bone aggravates the flexion moment at the base of the first metatarsal relative to the base of the second metatarsal, counteracting the dorsiflexion moment caused by the ground reaction force.

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5. Fig. 4. Terminal stance and preswing phase position of the midfoot and forefoot components in the frontal (a) and sagittal (b) planes in the hallux valgus. The red line represents the ground reaction force vector. Inadequate supination of the hindfoot and midfoot impedes effective resistance to the dorsiflexion torque generated by the ground reaction force acting on the first ray, contributing to its inversion, dorsiflexion, adduction, and supination as well as instability of the medial cuneonavicular joint and the Chopart joint, thereby limiting dorsiflexion at the first metatarsophalangeal joint. Valgus deviation of the hallux may occur as a compensatory mechanism for restricted hallux dorsiflexion.

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