Definition
- Dorsiflexed calcaneus combined with plantarflexed forefoot, producing a high arch
- Calcaneal pitch markedly increased, heel nearly vertical
Aetiology
- Weak or absent gastrocsoleus with preserved dorsiflexors
- Myelomeningocele at low lumbar and sacral levels
- Polio
- Iatrogenic after overlengthening of the tendo Achillis, often in CP
Pathology
- Unopposed tibialis anterior pulls the calcaneus into dorsiflexion
- Toe flexors and intrinsics plantarflex the forefoot
- Plantar fascia contracts and fixes the deformity
Clinical Features
- Weight borne on the heel, no push off
- Heel pad ulceration in the insensate foot
- Crouch gait in CP
- Difficulty with shoe and brace fitting
Investigations
- Standing lateral radiograph shows high calcaneal pitch
- MRI spine if the cause is unknown
- Muscle charting before tendon transfer
Management
- Ground reaction AFO in mild deformity
- Tibialis anterior transfer to the calcaneus through the interosseous membrane in spina bifida
- Plantar fascia release
- Crescentic calcaneal osteotomy with posterior displacement (Samilson) for fixed deformity
- Dorsiflexion osteotomy of the first metatarsal for fixed forefoot plantarflexion
- Triple arthrodesis as salvage, avoided in insensate feet
Complications
- Heel ulceration and osteomyelitis
- Recurrence with growth
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.