Calcaneal Valgus: Symptoms, Types, Causes and Treatment

Calcaneal valgus is a complex foot deformity with significant impacts on comfort, function, and quality of life. Understanding its symptoms, different types, underlying causes, and the range of available treatments is vital for both patients and clinicians. This comprehensive article synthesizes current scientific knowledge to provide an accessible yet detailed overview of calcaneal valgus based on the latest research.

Symptoms of Calcaneal Valgus

Calcaneal valgus is more than just a visual misalignment of the heel. Its symptoms affect daily mobility and can lead to secondary complications if left untreated. Early recognition of the signs can make a substantial difference in outcomes, especially for children and adults who are active or have underlying health conditions.

Symptom	Description	Impact	Source(s)
Pain	Aching/discomfort in hindfoot	Limits activity	1,2,3
Callus	Thickened skin under talus	Indicates pressure	1
Ulceration	Skin breakdown	Risk of infection	1
Shoe wear	Excessive/uneven	Difficult footwear fit	1
Poor brace fit	Intolerance to braces	Hindrance to support	1,2
Gait changes	Altered walking pattern	Instability	3

Table 1: Key Symptoms

Recognizing the Signs

Pain is the most common presenting symptom, often described as aching or soreness in the hindfoot. This discomfort can become severe enough to limit walking, running, or even standing for extended periods. In children especially, pain may be reported during physical activity or after long periods on their feet 1,2,3.

Complications from Pressure

Calluses and even ulcerations may develop under the head of the plantar-flexed talus due to abnormal pressure distribution. These signs often indicate that the foot is not bearing weight correctly, leading to skin changes that can cause further discomfort or infection if not addressed 1.

Secondary Effects

Patients frequently struggle with excessive or uneven shoe wear. This not only signals the presence of deformity but also complicates daily life, as finding suitable footwear becomes challenging. Additionally, many individuals find that braces, which are often prescribed for support, are uncomfortable or intolerable because of the underlying deformity 1,2.

Functional Impact

The altered alignment affects walking, often resulting in a compensatory gait. This means that individuals may walk differently to avoid pain, further stressing other parts of the foot and lower limb and sometimes leading to additional issues such as instability or difficulty with balance 3.

Types of Calcaneal Valgus

Calcaneal valgus is not a one-size-fits-all diagnosis. It presents in various forms, each with distinct clinical and biomechanical characteristics. Understanding these types helps guide appropriate treatment and set realistic expectations for outcomes.

Type	Key Feature	Population/Presentation	Source(s)
Flexible Valgus	Correctable on manipulation	Common in children/adolescents	2,5
Rigid Valgus	Fixed, unyielding deformity	Often with tarsal coalition	2,3
Flatfoot-associated	Combined with arch collapse	Flatfoot in adults/children	1,3,5
Skewfoot	Hindfoot valgus, forefoot abduction	Severe pediatric cases	1

Table 2: Types of Calcaneal Valgus

Flexible vs. Rigid Valgus

Flexible calcaneal valgus is correctable by hand or when the patient is non–weight-bearing. It is most common in children and adolescents, often associated with flexible flatfoot. The deformity is not fixed, and early interventions can produce good results 2,5.

Rigid calcaneal valgus, on the other hand, remains uncorrected regardless of positioning or manipulation. It is frequently linked with underlying issues such as tarsal coalition (abnormal connections between foot bones) or neuromuscular disorders. This form is more resistant to conservative measures and may require surgical correction 2,3.

Flatfoot-Associated Valgus

Flatfoot (pes planus) often coexists with calcaneal valgus, especially in both pediatric and adult populations. In these cases, the heel is everted (turned outward), and the arch is collapsed. This combination can be especially symptomatic and may progress over time if not treated 1,3,5.

Skewfoot

In severe pediatric cases, skewfoot can develop. This complex deformity involves both hindfoot valgus and forefoot abduction (outward turning of the forefoot). The result is a significant misalignment that may require combined surgical approaches for correction 1.

Causes of Calcaneal Valgus

Understanding what leads to calcaneal valgus is essential for effective prevention and treatment. The etiology is multifactorial, involving a combination of biomechanical, congenital, and acquired factors.

Cause	Mechanism/Context	Typical Onset	Source(s)
Neuromuscular disorder	Muscle imbalance, spasticity	Childhood	1
Tarsal coalition	Abnormal bone connection	Adolescence	2
Congenital flatfoot	Inherited arch/heel alignment issues	Early life	1,5
Acquired flatfoot	Tendon dysfunction, ligament laxity	Adulthood	3
Arthritis	Joint degeneration	Older adults	3
Injury/Trauma	Direct damage, malunion	Any age	3

Table 3: Common Causes

Neuromuscular Disorders

A significant number of pediatric cases are secondary to neuromuscular conditions, such as cerebral palsy or muscular dystrophy. Muscle imbalances or spasticity can pull the heel into a valgus position, making the deformity both difficult to correct and prone to recurrence 1.

Tarsal Coalition

Abnormal connections between the bones of the hindfoot (talocalcaneal or calcaneonavicular coalition) can cause a rigid hindfoot valgus. The coalition restricts normal joint motion, leading to compensation elsewhere in the foot and persistent deformity 2.

Congenital and Acquired Flatfoot

In both children and adults, flatfoot is a common contributing factor. Congenital flatfoot arises from inherited structural differences, while acquired flatfoot in adults is frequently linked to dysfunction of the posterior tibial tendon or generalized ligament laxity 1,3,5.

Arthritis

Degenerative changes in the joints of the hindfoot, particularly the subtalar or talonavicular joints, can destabilize the normal alignment, resulting in valgus deformity. This is more common in older adults and is sometimes seen after failed previous treatments or long-standing deformity 3.

Injury and Trauma

Direct injury to the foot, especially fractures involving the calcaneus or subtalar joint, can heal in a misaligned position, leading to acquired calcaneal valgus. This is less common but important to recognize, as the deformity may not be correctable without surgery 3.

Treatment of Calcaneal Valgus

Treatment for calcaneal valgus is highly individualized, depending on age, severity, flexibility, and underlying cause. Both conservative and surgical options are available, with recent advances offering improved outcomes for even complex cases.

Treatment	Indication/Goal	Key Points	Source(s)
Conservative	Mild/flexible cases	Orthotics, PT, bracing	1,3
Calcaneal osteotomy	Moderate/severe or rigid deformity	Realign heel, restore function	1,2,3
Tendon lengthening	Tight Achilles/gastrocnemius	Often combined with osteotomy	2,3,5
Arthroereisis	Pediatric flexible flatfoot	Implant supports subtalar joint	5
Arthrodesis	Severe/arthritic or failed cases	Fusion for pain relief	2,3

Table 4: Treatment Approaches

Conservative Management

In mild or flexible cases, conservative therapy is the first-line treatment. This includes:

• Custom orthotic insoles to support the arch and correct heel alignment
• Physical therapy aimed at strengthening supporting muscles and improving flexibility
• Bracing for those who need additional support

However, conservative measures may fail to provide relief in more severe or rigid deformities, particularly when underlying structural abnormalities are present 1,3.

Surgical Options

Calcaneal Osteotomy

• This procedure involves cutting and realigning the heel bone to restore its normal axis. Variations include lateral column lengthening (Evans procedure), medial displacement, and Z-shaped osteotomies.
• Osteotomies are particularly effective for correcting moderate to severe valgus deformities, both in children and adults, and can be combined with other procedures to address complex cases 1,3,5.

Tendon Lengthening

• Tightness of the Achilles tendon or gastrocnemius muscle is often addressed during surgery to improve range of motion and prevent recurrence.
• This is frequently performed in conjunction with calcaneal osteotomy, especially in rigid deformities or those with associated flatfoot 2,3,5.

Arthroereisis

• In younger patients with flexible flatfoot, a small implant is placed in the subtalar joint to limit excessive motion and support realignment.
• When combined with calcaneal osteotomy, this technique yields good functional outcomes and improved alignment 5.

Arthrodesis (Joint Fusion)

• Reserved for severe cases with joint arthritis or failed prior interventions.
• While effective at relieving pain and correcting alignment, it sacrifices joint motion and can lead to increased stress on adjacent joints over time 2,3.

Special Considerations

• In cases involving tarsal coalition, surgical resection of the coalition may be attempted if the coalition is small and the deformity is minimal. For larger, unresectable coalitions with severe valgus, calcaneal osteotomy provides pain relief and restores function 2.
• Computer-based pre-operative planning using 3D imaging is increasingly valuable in predicting surgical outcomes and customizing correction to individual anatomy 4.
• Soft tissue balancing is crucial, especially in adult-acquired flatfoot, to maintain long-term correction and prevent recurrence 3.

Conclusion

Calcaneal valgus is a multifaceted foot deformity requiring careful evaluation and a personalized approach to management. Key takeaways include:

• Symptoms: Pain, callus formation, ulceration, abnormal shoe wear, and altered gait are common and can significantly impact daily life 1,2,3.
• Types: The condition ranges from flexible to rigid forms, with specific variants like flatfoot-associated valgus and skewfoot found in children 1,2,3,5.
• Causes: Etiology is diverse—neuromuscular disorders, tarsal coalition, congenital/acquired flatfoot, arthritis, and trauma all play roles 1,2,3,5.
• Treatment: Options span conservative care to complex surgery. Calcaneal osteotomy, often with adjunct procedures, is effective for significant deformities, while arthroereisis and arthrodesis are reserved for select cases 1,2,3,5.

By understanding the spectrum of calcaneal valgus, clinicians and patients can make informed choices, optimizing both function and quality of life.