Forefoot valgus: A fixed structural defect in which the plantar aspect of the forefoot is everted on the frontal plane relative to the plantar aspect of the rearfoot; the calcaneum is vertical, the mid tarsal joints are locked and fully pronated

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McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc.

Fore foot types: Differences between forefoot varus and forefoot supinatus.

Certainly this can be a contraversial topic. Perhaps this will help clear up some questions.

Supination of the forefoot that develops with adult acquired flatfoot is defined as forefoot supinatus. This deformity is an acquired soft tissue adaptation in which the forefoot is inverted on the rearfoot. Forefoot supinatus is a reducible deformity. Forefoot supinatus can mimic, and often be mistaken for, a forefoot varus. A forefoot varus differs from forefoot supinatus in that a forefoot varus is a congenital osseous deformity that induces subtalar joint pronation, whereas forefoot supinatus is acquired and develops because of subtalar joint pronation (1).

A Forefoot Varus induces STJ pronation whereas a Forefoot Supinatus is created because of STJ pronation (2).

As the foot experiences increased subtalar joint (STJ) pronation moments during weightbearing activities (as in forefoot supinatus) , the medial metatarsal rays will be subjected to increased dorsiflexion moments and the lateral metatarsal rays will be subjected to decreased dorsiflexion moments. Over time, this increase in STJ pronation moments will tend to cause a lengthening of the plantar ligaments and medial fibers of the central component of the plantar aponeurosis and a shortening of the dorsal ligaments in the medial longitudinal arch. As a result, the influence of increased STJ pronation moments occurring over time during weightbearing activities will tend to cause the following (3):

1. An increase in inverted forefoot deformity.
2. A decrease in everted forefoot deformity.
3. A change in everted forefoot deformity to either a perpendicular forefoot to rearfoot relationship or to an inverted forefoot deformity.

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1. Clin Podiatr Med Surg. 2014 Jul;31(3):405-13. doi: 10.1016/j.cpm.2014.03.009. Forefoot supinatus. Evans EL1, Catanzariti AR2.

2. https://kenva.wordpress.com/…/…/forefoot-varus-or-supinatus/

3. http://www.podiatry-arena.com/podiatry-forum/showthread.php…

Forefoot Varus or Forefoot Supinatus?

Forefoot varus is a fixed, frontal plane deformity where the forefoot is inverted with respect to the rearfoot. Forefoot varus is normal in early childhood, but should not persist past 6 years of age (i.e. when developmental valgus rotation of forefoot on rearfoot is complete, and plantar aspects of fore- and rearfoot become parallel to, and on same plane as, one another (1)

Forefoot supinatus is the supination of the forefoot that develops with adult acquired flatfoot deformity. This is an acquired soft tissue adaptation in which the forefoot is inverted on the rearfoot. Forefoot supinatus is a reducible deformity. Forefoot supinatus can mimic, and often be mistaken for, a forefoot varus. (2)

A forefoot varus differs from forefoot supinatus in that a forefoot varus is a congenital osseous where a forefoot supinatus is acquired and develops because of subtalar joint pronation.

“Interestingly, only internal rotation of the hip was increased in subjects with FV – no differences were present in hip adduction and knee abduction between subjects with and without FV. The authors nevertheless conclude that FV causes significant changes in mechanics of proximal segments in the lower extremity and speculate that during high-speed weight-bearing tasks such as running, the effects of FV on proximal segments in the kinetic chain might be more pronounced.”

We wonder if the folks in this study had a true forefoot varus, or actually a forefoot supinatus (3).

The Gait Guys

1. Illustrated Dictionary of Podiatry and Foot Science by Jean Mooney © 2009 Elsevier Limited.

2. Evans EL1, Catanzariti AR2. Forefoot supinatus.
Clin Podiatr Med Surg. 2014 Jul;31(3):405-13. doi: 10.1016/j.cpm.2014.03.009.

3. Scattone Silva R1, Maciel CD2, Serrão FV3. The effects of forefoot varus on hip and knee kinematics during single-leg squat. Man Ther. 2015 Feb;20(1):79-83. doi: 10.1016/j.math.2014.07.001. Epub 2014 Jul 12.

Forefoot Valgus or Plantarflexed 1st ray?

Hmmm. That IS the question, isn’t it?

We remember that Forefoot valgus is a condition where the forefoot is everted with respect to the rearfoot.

With a plantar flexed 1st ray, the forefoot is actually in varus (ie inverted) and the the 1st ray is dropped (thus, plantar flexed).

If you look at the picture, you will see the entire forefoot is everted, thus we are  looking at a true forefoot valgus. The question here, is “does the 1st ray move into dorsiflexion”? This would be the difference between a flexible (plastic or rigid deformity and is a function of the rigidity of the subtalar and midtarsal joints as well as the flexibility of the 1st ray.

The literature states that forefoot valgus is the most commonly seen frontal plane deformity of the foot (McPoil 1988, Burns, 1977). We have not found this in clinical practice, but rather forefoot varus. This may be due to most folks seeing us have an issue, and more issues seem to be caused by rigid varus deformities, since they cause the knee to collapse inward.

It’s origin can be multifactorial, ranging from a congenital malformation of the calcaneocuboid joint (more on that joint here) with the absence of a calcanean process, which allows a greater degree of eversion (Bojsen-Moller 1979); over rotation of the talar neck (Sglaraato 1971), or association with a pes cavus foot in compensation to an inverted rearfoot and inflexibilty of the subtalar joint (Lutter 1981). Neuromuscular diseases are believed to cause as many as 95% of these deformities (Dwyer 1975).

The question is, what do we do with it?

  • we insure that the foots mechanics are the best they can be through manipulation and mobilization
  • make sure the joints proximal and distal to the foot are functioning properly
  • muscle test and strengthen weak muscles (think about the poor peroneals in these folks!)
  • make sure they are NOT in a motion control shoe; more flexible is better
  • Make sure their shoe has adequate room in the toe box
  • sometimes, we post the insole of the shoe (or orthotic) in valgus, especially with rigid deformities

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The Gait Guys. Often a valgus slant on a varus reality. Still bald. Still good looking. Improving your gait competency with each post.