Does the Sagittal Radiographic Morphology of Subtalar Joint Affect the Alignment of Foot?

OBJECTIVES: The etiology of flatfoot and cavus foot is multicausal and controversial. So far, no literature reports the relationship between the sagittal morphology of subtalar joint and the alignment of foot. The purpose of this study was to explore whether the subtalar alignment would influence the configuration of foot. METHODS: From January 2017 to January 2020, we included 109 feet in the flatfoot group, 95 feet in the cavus group, and 104 feet in the control group in this retrospective comparative study. The Gissane angle and calcaneal posterior articular surface inclination angle represented the sagittal morphology of the subtalar joint. Meary's angle, calcaneal pitch angle, and talar pitch angle reflected the alignment of foot. They were measured in the weightbearing foot X-rays. The angles in different groups were compared via Mann-Whitney U test. We calculated the correlation between the sagittal alignment of subtalar joint and the alignment of foot using Spearman's correlation analysis. Interobserver and intraobserver reliability were calculated. RESULTS: The Gissane angle, calcaneal posterior articular surface inclination angle, Meary's angle, talar pitch angle, and calcaneal pitch angle were significantly different in the three groups. The Gissane angle had an excellent correlation with the Meary's angle (r = 0.850, p < 0.0001), and the talar pitch angle (r = -0.825, p < 0.0001), and a good correlation with the calcaneal pitch angle (r = 0.638, p < 0.0001). The calcaneal posterior articular surface inclination angle had an excellent correlation with the Meary's angle (r = -0.902, p < 0.001), and the talar pitch angle (r = 0.887, p < 0.0001), and a good correlation with the calcaneal pitch angle (r = -0.702, p < 0.0001). The interobserver and intraobserver reliability for all radiographic measurements was good to excellent. CONCLUSION: A subtalar joint with a larger Gissane angle and a more horizontal calcaneal posterior articular surface angle tended to have a higher foot arch and vice versa. The inspiration from this study was that the deformities of flatfoot and cavus foot may relate to the subtalar deformity.

Feasibility and safety of minimally invasive calcaneal osteotomy (MICO) through a medial approach: a case-control study.

INTRODUCTION: Minimally invasive calcaneal osteotomy (MICO) is already an established surgical procedure for correcting hindfoot deformities using a lateral approach. So far, no description of a medial approach for MICO has been published. MATERIAL AND METHODS: Between August 2022 and March 2023, 32 consecutive patients (MICO with medial approach, MMICO: n = 15; MICO with lateral approach, LMICO: n = 17) underwent MICO as part of complex reconstructive surgery of the foot and ankle with concomitant procedures. The amount of correction in the axial view of the calcaneus and consolidation rates were evaluated radiographically. Subjective satisfaction, stiffness of the subtalar joint, and pain level (numeric rating scale, NRS) at the level of the heel were assessed clinically. The last follow-up was at 6 months. RESULTS: All osteotomies consolidated within 6 months after surgery. Displacement of the tuber was 9 mm on average in either group. Relevant subtalar joint stiffness was detected in 5 MMICO and 6 LMICO patients. No relevant differences between the groups were detected for wound healing problems, nerve damage, heel pain or patient satisfaction. CONCLUSION: In this study lateral and medial approaches for MICO were performed. Similar degrees of correction and low complication rates were found in both groups. The medial approach for MICO is safe and can be beneficial regarding patient positioning and arrangement of the C­arm.

Cavus Foot Deformity with Calcaneonavicular and Medial Cuneiform-Navicular Coalition: A Case Series.

Tarsal coalitions have only very infrequently been observed in the context of cavus foot abnormalities. Recognizing this diagnosis could be crucial to effective cavus repair. We report tarsal coalitions observed in cavus deformity here. Between 2022 and 2023, the records of every patient treated by one of the authors for a varus deformity who was later determined to have either a unilateral or bilateral tarsal coalition were examined. Two patients with cavus deformities who were treated by one of the authors have either a unilateral or bilateral tarsal coalition. Three foot (medial cuneiform-navicular n = 1 and calcaneonavicular n = 2) with tarsal coalition were examined. All of these cases occurred in patients with idiopathic cavus deformity. Computed tomography scans were used to make a firm diagnosis for each patient. We advise surgeons to keep an awareness for this potential comorbid issue in all cavus foot abnormalities and to take advanced imaging into consideration. In these uncommon cases, the medial cuneiform-navicular and calcaneonavicular joints formed an osseous coalition with pes cavus deformity, which successfully resolved with conservative and surgical treatment, respectively. Level of Clinical Evidence: IV.

Toes Deformities in Cavovarus: How to Approach Them.

Sagittal lesser toe deformities (LTD) are the most common in cavus foot. They are mainly the result of muscular imbalance between intrinsic and extrinsic muscles. Surgery is the second-line treatment if medical treatment fails. The aim of the present study was to provide an update on classification and surgical management of LTD in cavus foot including percutaneous procedures with a special focus on sagittal deformities. Joint sparing procedures are preferred for reducible LTD, whereas lesser toe fusions are used for rigid one in association with tendon transfer or percutaneous procedures depending of surgeon's experience and patient's clinical examination.

Effects of plantar fascia stiffness on the internal mechanics of idiopathic pes cavus by finite element analysis: implications for metatarsalgia.

Metatarsalgia occurring in individuals with pes cavus is typically associated with abnormal loading patterns in the forefoot resulting from structural alterations. Simultaneously, the frequent overstress of the plantar fascia (PF) caused by the persistence of this foot deformity may further exacerbate the chronic pain induced by metatarsal overload. We aimed to investigate and quantify the effects of PF stiffness on the internal biomechanics of pes cavus using a computational modelling approach. A patient-specific finite element model of the foot-ankle complex using the actual three-dimensional geometry of idiopathic pes cavus bones and soft tissues was reconstructed. A sensitivity study was conducted to evaluate the effects of varying elastic modulus (0-700 MPa) of the PF on the metatarsal stress distribution, and force transmission through the metatarsophalangeal (MTP) and tarsometatarsal (TMT) joints in the pes cavus. The results indicated that variations in PF stiffness led to stress redistribution in the metatarsal region. Peak stress gradually reduced with decreasing stiffness until the PF was released, eventually resulting in a reduction of 22.39% compared to the reference value of 350 MPa. Furthermore, adjusting the PF stiffness to twice the reference value (700 MPa) increased the contact forces through the TMT and MTP joints by up to 23% and 116%, respectively. The reduction of PF stiffness alleviated focal metatarsal loading, and therefore, surgical fascia release can be considered to alleviate metatarsalgia in patients with pes cavus.

Republication of "Minimally Invasive Surgery Using the Circular External Fixator to Correct Neglected Severe Stiff Equinocavus Foot Deformities".

Background: Stiff equinocavus deformities of the foot are challenging to treat, often requiring extensive soft tissue dissection and bone removal. These procedures frequently yield suboptimal results and not infrequently amputation. Minimally invasive surgery using a circular external fixator potentially avoids the trauma to the soft tissue and may lead to improvement in outcomes and a lower amputation rate. The objective of this study was to evaluate the efficacy of minimally invasive surgery using a circular external fixator and limited soft tissue release to correct stiff equinocavus deformities. Methods: The treatment outcome of 29 patients (31 feet) with stiff equinocavus deformities of the foot and ankle treated with minimally invasive surgery and circular external fixation were reviewed after a mean follow-up period of 63 months. Patients' demographics and cause of the deformities were recorded. Weight bearing radiographs of the foot were compared pre and postoperatively. Results: Outcome was satisfactory (plantigrade foot with improvement/resolution of pain) in 21 of 31 extremities, fair in 6 of 31 extremities, and poor in 4 of 31 extremities. In the majority of patients, a significant improvement in the equinocavus deformities was achieved with a statistically significant improvement in calcaneus and navicular height. Two patients with Charcot-Marie-Tooth and severely insensate feet had a poor outcome, resulting in transtibial amputation. Conclusion: Minimally invasive surgery with gradual correction of neglected stiff equinocavus deformities using a modular circular external fixator is a reliable initial limb salvage strategy. Minimally invasive surgery and gradual correction of neglected severe stiff equinocavus deformities using the modular circular external fixator to gradually correct neglected severe stiff equinocavus deformities, is a safe initial limb salvage strategy which may simplify secondary procedures such as arthrodesis. Level of evidence: IV.

Type of Feet in a Mexican Population: Analysis of the Footprint Morphology and Literature Review / Tipos de pies en una Población Mexicana: Análisis de la Morfología de la Huella Plantar y Revisión de la Literatura

ABSTRACT There is no specific age when the vault of the feet is completely formed. The objective of this study was to analyze the footprint morphology and obtain the Chippaux-Smirak Index in a Mexican population to identify the type of feet and its prevalence. A database of images of the soles of both feet was analyzed. The database contained images of 1,014 persons between 2 and 73 years old from Guanajuato state, Mexico. Moreover, a literature review was performed to identify the type of feet in the Mexican population. It was observed that less than 17 % of the population have cavus foot (p= 0.018). Furthermore, less than 25 % of the population between 17 and 73 years have flatfoot 3 (p= 0.0079) in the left foot. Also, only nine articles related to the type of foot in the Mexican population were found, but most of them were performed on young population. The formation of the medial arc could be beyond the first decade of life and the relatively high prevalence of flatfoot in adult life should be studied. Finally, the results found can be useful for orthopedists, physiotherapists, clinicians, and parents who are concerned about the foot health of their children.

RESUMEN No hay una edad específica en la que la bóveda de los pies esté completamente formada. El objetivo de este estudio fue analizar la morfología de la huella de los pies y obtener el Índice de Chippaux-Smirak en una población mexicana para identificar el tipo de pie y su prevalencia. Se analizó una base de datos de imágenes de las plantas de ambos pies. La base de datos contenía imágenes de 1,014 personas de entre 2 y 73 años del estado de Guanajuato, México. Además, se realizó una revisión bibliográfica para identificar el tipo de pie en la población mexicana. Se observó que menos del 17 % de la población tiene pie cavo (p= 0,018). Además, menos del 25 % de la población entre 17 y 73 años tiene pie plano 3 (p= 0,0079) en el pie izquierdo. Además, se encontraron 9 artículos relacionados con el tipo de pie en población mexicana, pero la mayoría de ellos fueron desarrollados en población joven. La formación del arco medial podría estar más allá de la primera década de vida. Se encontró una prevalencia relativamente alta de pie plano en la vida adulta que debe ser estudiada. Finalmente, los resultados encontrados pueden ser útiles para ortopedistas, fisioterapeutas, médicos y padres preocupados por la salud de los pies de sus hijos.

Evaluation and Management of Cavus Foot in Adults: A Narrative Review.

OBJECTIVE: Cavus foot is a deformity defined by the abnormal elevation of the medial arch of the foot and is a common but challenging occurrence for foot and ankle surgeons. In this review, we mainly aim to provide a comprehensive evaluation of the treatment options available for cavus foot correction based on the current research and our experience and to highlight new technologies and future research directions. METHODS: Searches on the PubMed and Scopus databases were conducted using the search terms cavus foot, CMT (Charcot-Marie-Tooth), tendon-transfer, osteotomy, and adult. The studies were screened according to the inclusion and exclusion criteria, and the correction of cavus foot was analyzed based on the current research and our own experience. At the same time, 3D models were used to simulate different surgical methods for cavus foot correction. RESULTS: A total of 575 papers were identified and subsequently evaluated based on the title, abstract, and full text. A total of 84 articles were finally included in the review. The deformities involved in cavus foot are complex. Neuromuscular disorders are the main etiologies of cavus foot. Clinical evaluations including biomechanics, etiology, classification, pathophysiology and physical and radiological examinations should be conducted carefully in order to acquire a full understanding of cavus deformities. Soft-tissue release, tendon-transfer, and bony reconstruction are commonly used to correct cavus foot. Surgical plans need to be customized for different patients and usually involve a combination of multiple surgical procedures. A 3D simulation is helpful in that it allows us to gain a more intuitive understanding of various osteotomy methods. CONCLUSION: The treatment of cavus foot requires us to make personalized operation plans according to different patients based on the comprehensive evaluation of their deformities. A combination of soft-tissue and bony procedures is required. Bony procedures are indispensable for cavus correction. With the promotion of digital orthopedics around the world, we can use computer technology to design and implement cavus foot operations in the future.

Iatrogenic Lesion of the Lateral Plantar Artery following Plantar Fasciotomy for Cavus Foot Correction - A Case Report.

Introduction: The aim of this study was to report a patient with a iatrogenic lesion of the lateral plantar artery following plantar fasciotomy (PF) for cavus foot correction, an extremely rare complication. Case Report: A 13-year-old male patient with bilateral cavus foot was surgically treated at the right foot. At 36 days follow-up, after plaster cast removal, a massive soft plantar bulge was located on the medial aspect of the foot. Once suture stiches removal was performed, a huge blood collection was evacuated, and active bleeding observed. Contrast-enhanced angio-CT revealed a lesion of the lateral plantar artery. A vascular suture was performed. At 5 months follow-up, the patient was pain-free in his foot. Conclusion: Despite a iatrogenic lesion of the plantar vascular structures following PF is extremely rare, it is a potential complication to consider. Meticulous attention to surgical technique and careful inspection of the foot the day after surgery, before patient discharge, are recommended.

Cavus Foot Correction Using a Full Percutaneous Procedure: A Case Series.

Cavus foot is a tri-planar deformity that requires correction in several bones and soft tissue. Minimally invasive surgeries are less aggressive, faster and easier to recover from. Here, we describe the initial results of a technique for percutaneous cavus foot correction. The procedure consists of calcaneal dorsal/lateral closing wedge osteotomy (with fixation), cuboid, medial cuneiform and first metatarsal closing wedge osteotomy (without fixation), and plantar fascia and tibialis posterior tenotomy with the patient in the prone position. Immediate weight bearing is permitted. Twenty patients were selected to undergo the procedure. The mean follow-up was 4.2 months and mean age 42.3 years. Eight of the 20 patients were submitted to cuboid and first metatarsal osteotomy, and 12 (60%) only calcaneal osteotomy. The median time for complete bone healing was 2.2 months. No wound complications were observed. No cases of non-consolidation of the cuboid or first metatarsal osteotomies were detected. The most common complication was sural nerve paresthesia. This is the first description of cavus foot correction using a minimally invasive technique. Complete bone healing is obtained even with immediate weight bearing and without cuboid and first metatarsal fixation.

Factores de riesgo asociados a patologías musculoesqueléticas en deportistas con pie cavo anterior a través de estudios de baropodometría / Risk factors associated to musculoskeletal pathologies in athletes with cavus foot through baropodometric studies

Resumen: Introducción: El pie cavo es una patología musculoesquelética con un aumento del arco medial del pie. La etiología del pie cavo aún es incomprensible, está relacionada con afecciones neurológicas, enfermedad de Charcot-Marie-Tooth, ataxia de Friedreich y parálisis cerebral. El objetivo de esta investigación fue analizar la distribución de la presión plantar en atletas jóvenes con pie cavo. Material y métodos: Se reclutaron 83 atletas jóvenes de entre nueve y 20 años de edad, que presentaban patología de pie cavo. La masa y el promedio de altura fueron 56.9 ± 12.36 kg y 1.61 ± 0.10 m, respectivamente. La distribución de la presión plantar de los pies se registró durante condiciones estáticas. Se compararon las presiones del antepié y el retropié. Resultados: La distribución de la presión plantar se categorizó en tres grupos. En el primer grupo los participantes presentaron mayor presión en la parte anterior del pie; en el segundo grupo los atletas mostraron una presión similar en la región posterior y anterior de los pies y en el último los sujetos revelaron una mayor presión en el retropié. Para ser considerado en uno de los tres grupos, la diferencia de presión entre la parte posterior y anterior del pie se estableció en 16%. Conclusión: Muchos trastornos musculoesqueléticos en el cuerpo humano son de origen biomecánico y están relacionados con la anatomía del pie. El pie cavo es una patología con alta prevalencia en atletas y está relacionada con las fuerzas mecánicas sobre los pies en condiciones dinámicas.

Abstract: Introduction: The cavus foot is a musculoskeletal pathology with an increase of the medial arch of the concavity of the foot. The etiology of the cavus foot is still enigmatic, it is related with neurologic conditions, Charcot-Marie-Tooth disease, Friedreich's ataxia, and cerebral palsy. The aim of this research was to analyze the plantar pressure distribution of the feet on young athletes with cavus foot. Material and methods: Eighty-three young athletes between nine and 20 years old, that presented cavus feet pathology were recruited. The mass and height average were 56.9 ± 12.36 kg and 1.61 ± 0.10 m respectively. Plantar pressure distribution of the feet was recorded during static conditions. The hindfoot and forefoot pressure were compared in each foot. Results: The plantar pressure distribution were categorized in three groups. In the first group the participants presented higher pressure in the hindfoot than forefoot, in the second group, the athletes showed similar pressure in the posterior and anterior region of the feet and in the last one, the subjects revealed higher pressure in the forefoot. To be considered in one of the three groups, the difference of pressure between the posterior and anterior part of the foot was established at 16%. Conclusion: Many musculoskeletal disorders in the human body are biomechanical in origin and related with foot anatomy. The cavus foot is a pathology with high prevalence in athletes and it is related with the mechanical forces over the feet during dynamic conditions.

Pes Cavus Deformity: Anatomic, Functional Considerations, and Surgical Implications.

Pes cavus is a complicated, multiplanar deformity that requires a thorough understanding in order to provide the appropriate level of care. The foot and ankle surgeon should perform a comprehensive examination, including a neurologic evaluation, in the workup of this patient population. Understanding the cause of the patient's deformity is a critical step in predicting the disease course as well as the most acceptable form of treatment. The surgical correlation with the patient's pathologic anatomy requires an in-depth clinical evaluation, in addition to the radiographic findings, as the radiographic findings do not necessarily correlate with the patient's discomfort.

Neurologic Conditions Associated with Cavus Foot Deformity.

The cavus foot deformity is an often less understood deformity within the spectrum of foot and ankle conditions. The hallmark concern is the possibility of an underlying neurologic or neuromuscular disorder. Although a proportion of these deformities are idiopathic, a significant majority do correlate with an underlying disorder. The appropriate evaluation of this deformity, in coordination within the multidisciplinary scope of health care, allows for a timely diagnosis and understanding of the patient's condition. We provide an abbreviated survey of possible underlying etiologies for the patient with the cavus foot deformity as a reference to the foot and ankle surgeon.

Hallux and Lesser Digits Deformities Associated with Cavus Foot.

It is important to identify the level of the deformity or deformities. It is important to get the limb as close to anatomic alignment as possible. Many levels and multiple procedures may be involved with this reconstruction.

The Subtle Cavovarus Foot Deformity: The Nonneurologic Form of Cavus Foot Deformity.

Conditions of ankle instability, peroneal tendon tears, and stress fractures of the lateral metatarsals are commonly encountered in a clinical foot and ankle practice. Evaluation of the supporting foot structure is critical to prevent failure of index procedures. The prominence of the subtle cavus foot is now a recognized entity and must be properly diagnosed and addressed surgically.

Tendon Transfers and Their Role in Cavus Foot Deformity.

Management of the cavus foot is a difficult task for the foot and ankle surgeon. Tendon transfers have been a longstanding accepted treatment for the flexible cavus foot. Performing tendon transfers requires an in-depth understanding of the patient's medical history, factors leading to the development of deformity, as well as the deforming forces contributing to the deformity. Evaluation of the patient for rigid, progressive, and/or spastic deformities is critical to avoid postoperative complications. Educating the patient on postoperative rehabilitation, potential complications, and postoperative expectations is essential to ensure appropriate surgical outcomes.

The Cavovarus Ankle: Approaches to Ankle Instability and Inframalleolar Deformity.

Pathologic affects from a cavus foot deformity range from flexible subtle to rigid severe deformities and are related to many pathologic conditions of the foot and ankle. Understanding the underlying deformity and the deforming force is essential in treating the cavus ankle and foot. Every deformity is different and unique to a given patient; therefore, surgical plans should be modified to each patient.

Non-radiographic validity and reliability measures for assessing foot types: A systematic review.

BACKGROUND: Foot type classification is well recognized in clinical practice and orthopedic literature, a universally accepted classification or standardized measures to determine foot types are lacking. The objective of this study was to identify which non-radiographic assessment methods are considered valid and/or reliable for the classification of foot types. METHOD: A systematic database search was performed. Only cross-sectional studies that performed reliability and/or validity analysis of non-radiographic methods were included. To evaluate the risk of bias, the Critical Appraisal Tool (CAT) was used to evaluate the measurement properties of objective clinical methods. RESULTS: Twenty-six studies were included. The results of reliability and validity, in general, demonstrated high scores, but, inconsistencies were related to the variability of the measurements, heterogeneity of the methods used to determine reliability and validity, and lack of parameters for classifying foot types, which resulted in few elements to determine which method of foot type evaluation is valid and reliable. CONCLUSION: Given the Intraclass Correlation Coefficient and CAT results and the presence of normative values, the static measurements of the "Arch Height Index", "Foot Posture Index", and "Staheli Arch Index" can be suggested to classify foot types.

[Risk factors associated to musculoskeletal pathologies in athletes with cavus foot through baropodometric studies]. / Factores de riesgo asociados a patologías musculoesqueléticas en deportistas con pie cavo anterior a través de estudios de baropodometría.

INTRODUCTION: The cavus foot is a musculoskeletal pathology with an increase of the medial arch of the concavity of the foot. The etiology of the cavus foot is still enigmatic, it is related with neurologic conditions, Charcot-Marie-Tooth disease, Friedreich's ataxia, and cerebral palsy. The aim of this research was to analyze the plantar pressure distribution of the feet on young athletes with cavus foot. MATERIAL AND METHODS: Eighty-three young athletes between nine and 20 years old, that presented cavus feet pathology were recruited. The mass and height average were 56.9 ± 12.36 kg and 1.61 ± 0.10 m respectively. Plantar pressure distribution of the feet was recorded during static conditions. The hindfoot and forefoot pressure were compared in each foot. RESULTS: The plantar pressure distribution were categorized in three groups. In the first group the participants presented higher pressure in the hindfoot than forefoot, in the second group, the athletes showed similar pressure in the posterior and anterior region of the feet and in the last one, the subjects revealed higher pressure in the forefoot. To be considered in one of the three groups, the difference of pressure between the posterior and anterior part of the foot was established at 16%. CONCLUSION: Many musculoskeletal disorders in the human body are biomechanical in origin and related with foot anatomy. The cavus foot is a pathology with high prevalence in athletes and it is related with the mechanical forces over the feet during dynamic conditions.

INTRODUCCIÓN: El pie cavo es una patología musculoesquelética con un aumento del arco medial del pie. La etiología del pie cavo aún es incomprensible, está relacionada con afecciones neurológicas, enfermedad de Charcot-Marie-Tooth, ataxia de Friedreich y parálisis cerebral. El objetivo de esta investigación fue analizar la distribución de la presión plantar en atletas jóvenes con pie cavo. MATERIAL Y MÉTODOS: Se reclutaron 83 atletas jóvenes de entre nueve y 20 años de edad, que presentaban patología de pie cavo. La masa y el promedio de altura fueron 56.9 ± 12.36 kg y 1.61 ± 0.10 m, respectivamente. La distribución de la presión plantar de los pies se registró durante condiciones estáticas. Se compararon las presiones del antepié y el retropié. RESULTADOS: La distribución de la presión plantar se categorizó en tres grupos. En el primer grupo los participantes presentaron mayor presión en la parte anterior del pie; en el segundo grupo los atletas mostraron una presión similar en la región posterior y anterior de los pies y en el último los sujetos revelaron una mayor presión en el retropié. Para ser considerado en uno de los tres grupos, la diferencia de presión entre la parte posterior y anterior del pie se estableció en 16%. CONCLUSIÓN: Muchos trastornos musculoesqueléticos en el cuerpo humano son de origen biomecánico y están relacionados con la anatomía del pie. El pie cavo es una patología con alta prevalencia en atletas y está relacionada con las fuerzas mecánicas sobre los pies en condiciones dinámicas.

Longitudinal Evaluation of Calf MRI in a Patient with Charcot-Marie-Tooth Disease 2E：A Case Study / The Japanese Journal of Rehabilitation Medicine

We present a case report that a longitudinal calf MR evaluation was performed for a patient with Charcot-Marie-Tooth disease who underwent bilateral reconstructive foot surgeries. A 39 years-old female was referred to our department because of severe bilateral cavus foot deformities and difficulty to walk. On radiological findings, severe bilateral cavus foot deformities were confirmed. On MR findings, fatty infiltrations were detected in the wide range of bilateral lower leg compartments. Difficulty to walk aggravated despite of the conservative treatment, so bilateral reconstructive foot surgeries were performed. She acquired plantigrade and better walking function postoperatively. Two years after surgery, no recurrence of cavus foot deformity was observed, but claw toe deformities and fatty infiltrations were mildly progressing. Since CMT is slowly progressive, we need to conduct a careful follow-up.