What Is Skew Foot?

Definition of skew foot

A skew foot is a congenital birth defect and is a rigid deformity that affects the formation and growth of the bones in the foot. This is also known as “Z”- foot, serpentine foot, or severe metatarsus adducts. Sometimes, skewed feet appear as a hook inward or have a “C” shaped appearance.1

Understanding foot anatomy

The foot supports the entire body's weight and facilitates locomotion. It is composed of 26 bones, 33 joints, and over 100 muscles, tendons, and ligaments.

The foot is divided into three major parts: the forefoot, midfoot, and hindfoot, which collectively provide stability and flexibility to the ankle joint.

The forefoot has the metatarsals, the cuboid and cuneiforms in the midfoot, and the talus and calcaneus in the hindfoot. The metatarsals help in weight-bearing during walking and running, whereas the phalanges assist with balance and propulsion.

The joints and ligaments, like the plantar fascia in the foot, provide stability and support the foot's arch.2

Function of foot arches

The arches of your foot hold up your weight. When you stand, these arches spread out your weight across the bones in your foot. Your weight shifts from the shin bone to the talus and then to the calcaneus that is present at the back of your foot. The lateral longitudinal arch supports your foot in carrying your weight and helps you complete the heel strike to toe-off phase easily.3

Function of ligaments and tendons in foot stability

The primary function of the foot ligaments is to stabilise the ankle and support the foot arches. Bones, ligaments and tendons form the arch. The arch gives shape and structure to your foot.

The tendon acts as a mechanical bridge between the bones and the joints and enables the transmission of muscle strength between them. It helps in the contraction of the muscle to complete the targeted movement. Different types of tendons reflect the morphology of the muscle and their specific function.4

Foot ligaments help support your body’s weight and absorb its impact with every step you take.

Patho-anatomy of the skewed foot

Forefoot

The first metatarsal is adducted and plantarflexed on the medial cuneiform with prominent adducts deformity of the forefoot.

Midfoot

The navicular bone may lie laterally displaced or dorsally subluxed to the talus.

Hindfoot

The tendo achilles is contracted and lies in the valgus with pronation and inward rotation of the talus.5

According to research,6 30 feet in 18 children diagnosed as a skew foot (Z-foot, serpentine foot) have been assessed, and the findings were:

  1. Idiopathic congenital (21 feet),
  2. Congenital, which is associated with other defects or systemic disease (8 feet),
  3. Acquired after manipulations for club foot treatment (1 foot)
  4. Neurogenic, which was not represented in the study.

7 feet required a surgical release to fix it, and 8 feet were corrected operatively. In cases where the surgery was delayed, palliative care was provided to the children whereas, when the foot was twisted (type 3) in the severely skewed foot, stopping the treatments made the foot go back to its normal shape.

Causes of skewed foot

Having a skew foot is normal, and it usually gets better as the children get older. However, in adults, it often occurs because of the weight that is spread out or an imbalance in the strength of the muscles. Also, wearing shoes that don't give good support or strain the foot can cause it. Sometimes, injuries or diseases that cause swelling can also cause a skewed foot.

Diagnosing skew foot

Radiographs

  • Anteroposterior view shows midtarsal joints are abducted, and metatarsals are adducted, giving the foot Z shape.
  • The mid-talar axis will be medial to the base of the first metatarsal.

The lateral view shows a reduction in calcaneal pitch and a plantar flexed talus.

Treatment options

The treatment depends upon the severity of the deformity and the age at which the condition is diagnosed.

Conservative approaches

In the initial stages, orthotic devices, supportive footwear and serial long-leg casting with hindfoot valgus moulding can be used. Supportive footwear is generally ineffective in changing the shape of the foot, but for some, it may prove to function.7

Physical therapy includes stretching, exercises to build strength, passive manipulation exercises, and the use of curve hypercorrective pads.

Surgical interventions

It is usually delayed until after the age of 6 years. Until then it is usually avoided because the deformity is in the forefoot, midfoot, and hindfoot which means that the entire foot has to be reconstructed for a functional relationship.

Opening wedge osteotomy of the calcaneus can be performed to correct mid-tarsal abduction deformity and to position the sustentaculum to elevate the neck of the talus.

Corrective procedures such as osteotomies and soft tissue release, where soft tissue release is combined with joint-sparing osteotomy, retain the flexibility of the foot and are efficacious and have appreciated efficacy in the treatment of parvovirus foot deformity in older children.

Correction of the proximal line of the Z.8

Subtalar joint capsulotomy, which restores the calcaneus bone.

Talonavicular arthrodesis corrects heel valgus by creating closed kinetic chain supination of the rearfoot with subtalar mobility (subtalar joint capsulotomy). Talonavicular arthrodesis also reduces the external rotation of the ankle.

Correction and straightening of digital Z-line:

The first metatarsal-medial cuneiform-navicular arthrodesis corrects the first ray metatarsus primus elevates and adducts and also hallux flexus and forefoot varus.

Plantar fascial release removes traction force between the forefoot and the hindfoot.

Cuneocuboid wedge osteotomy corrects forefoot adduction and varus deformity proximally and helps align the three sections of the foot.

Complications of skewed foot

Babies with skewed feet have a high chance of developing hip dysplasia (DDH). DDH is a condition where the hip socket is too shallow to hold the femur or the thigh bone in place. One leg might appear longer than the other with a hip hike.

Summary

A skew foot is a congenital condition where the foot appears twisted or turned compared to its normal alignment. You should consult with the healthcare provider and try not to delay treatment. Among adults, skewfoot is frequently associated with imbalances in muscle strength, improper weight distribution, or wearing shoes that don't provide adequate support. Conditions such as obesity, sedentary lifestyles, or injuries can lead to this foot misalignment.

This condition might lead to complications, including discomfort, altered walking patterns, or strain on other parts of the body. Additionally, infants displaying metatarsus adductus (an inward turning of the foot) might have an increased risk of developing hip problems like developmental dysplasia of the hip (DDH.

Early intervention, especially in childhood, is often beneficial to manage skewfoot. Treatments may include exercises, supportive footwear, or in severe cases, corrective surgery. Understanding the causes and seeking appropriate medical advice can help address skew foot-related issues and prevent potential complications, ensuring better foot health and mobility in the long run.

References

  1. Skewfoot [Internet]. [cited 2023 Dec 4]. Available from: https://www.stlouischildrens.org/conditions-treatments/skewfoot
  2. Foot anatomy 101: an overview of the structure and function of the foot - palmetto state podiatry [Internet]. 2023 [cited 2023 Dec 4]. Available from: https://www.palmettostatepodiatry.com/foot-anatomy-101-an-overview-of-the-structure-and-function-of-the-foot/
  3. Kenhub [Internet]. [cited 2023 Dec 4]. Arches of the foot. Available from: https://www.kenhub.com/en/library/anatomy/arches-of-the-foot
  4. Bordoni B, Black AC, Varacallo M. Anatomy, tendons. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 Dec 4]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK513237/
  5. Editor DT. Skew foot [Internet]. Wheeless’ Textbook of Orthopaedics. 2020 [cited 2023 Dec 4]. Available from: https://www.wheelessonline.com/bones/foot/skew-foot/
  6. Napiontek M, Jóźwiak M. [Skew foot--etiology, clinical appearance, management]. Chir Narzadow Ruchu Ortop Pol. 1994;59(5):461–70.
  7. Mousafeiris V, Dreyer MA, Thomas A. Pediatric foot alignment deformities. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 Dec 4]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK592393/
  8. Untitled [Internet]. [cited 2023 Dec 4]. Available from: https://www.hmpgloballearningnetwork.com/site/podiatry/surgical-pearls/pertinent-surgical-pearls-management-skew-foot-deformity-young-adult 
This content is purely informational and isn’t medical guidance. It shouldn’t replace professional medical counsel. Always consult your physician regarding treatment risks and benefits. See our editorial standards for more details.

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Bhashwati Deb Barma

Bachelor of Physiotherapy,M.S., Ramaiah Medical College, India

Bhashwati is a Physiotherapist with a firm grasp of Paediatric physiotherapy and is currently working with special children in the community.

She has 6 years of experience working in hospitals and non-profit organizations set up. As a writer by passion, she is putting up her practical and academic knowledge into her articles.

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