Congenital Talipes Equinovarus

Congenital Talipes Equinovarus (Idiopathic Club-Foot)

• The foot is curved downwards and inwards.
• The ankle is in equinus.
• The heel is in varus.
• The forefoot is adducted, flexed, and supinated.
• The skin and soft tissues of the calf and the medial side of the foot are short and underdeveloped.
• Secondary growth changes occur in the bones and becomes permanent if the condition is uncorrected.
• The foot remains short, and the calf may remain thin even with treatment.
• The incidence of deformity is relatively common, around 1–3 per 1000 births.
• This affects boys twice as often as girls.
• Nearly half the cases occur bilaterally.
• A family history increases the risk by 20–30 times.
• The exact cause is unknown.
• Theories include chromosomal defect, arrested development in utero, or an embryonic event such as a vascular injury.
• Similar deformities occur in infants with myelomeningocele and arthrogryposis.

Clinical Features of Club-Foot

• Is usually obvious at birth.
• The foot is turned and twisted inwards.
• The sole faces posteromedially.
• The heel is small and high.
• Deep creases appear posteriorly and medially.
• A normal baby's foot dorsiflexes and everts until the toes almost touch the front of the leg.
• In club-foot, this movement meets resistance, becoming fixed in severe cases.
• Infants should be examined for associated disorders like congenital hip dislocation and spina bifida.

X-Rays and Club-Foot

• X-rays are unhelpful in newborns.
• Tarsal bones are incompletely ossified making anatomy difficult to define.
• The shape and position of tarsal ossific centres in older infants help assess treatment progress.
• Ultrasound of the hips is important to rule out dislocation in newborns with club-feet.

Club-Foot Treatment

• The aim is to produce and maintain a plantigrade, supple, and well-functioning foot.
• Ponseti's method is favored.
• Treatment should begin early, preferably within days of birth.
• This consists of repeated manipulation and adhesive strapping or plaster of Paris casts to maintain correction.
• Serial changes and manipulations are required in a clinic setting.
• Percutaneous tenotomy of the Achilles tendon may be needed.
• A strict splintage regime in de-rotation boots is followed until the child is 3 years old after correction.
• Relapse is most likely to occur in children with neuromuscular disorders.
• Resistant cases require surgery.
• Surgical objectives include releasing joint tethers, capsular/ligamentous contractures, and fibrotic bands.
• Lengthening tendons allow positioning of the foot without undue tension.
• Ilizarov-type external fixation with tensioned wires permits gradual repositioning of the foot and ankle in exceptional circumstances.
• Corrective osteotomies and fusions can salvage a deformed, stiff, and painful foot in adolescents.

Metatarsus Adductus

• Varies from a slightly curved forefoot to resembling a mild club-foot.
• Deformity occurs across the tarsometatarsal joints.
• Adduction happens at the midfoot (talonavicular joint) in club-foot.
• Most cases (90%) improve spontaneously.
• It can be managed non-operatively with serial corrective casts and straight-last shoes.
• Resistant forms may require abductor hallucis muscle release.

Flat-Foot (Pes Planovalgus)

• Occurs when the longitudinal arch collapses.
• The medial border of the foot is in contact (or nearly in contact) with the ground.
• The heel becomes valgus, and the foot pronates at the midfoot.
• Flat-foot can be normal and asymptomatic.
• The arch is not formed until 4–6 years of age.
• About 15% of the population has supple asymptomatic flat-feet.
• Flat-feet that are stiff and painful are seen in some conditions.

Congenital Vertical Talus (Congenital Convex Pes Valgus)

• Is a severe neonatal form where the arch is sometimes reversed, leading to a 'rocker-bottom' appearance.
• This is from plantar dislocation of the talus head from the navicular.
• It gives the appearance of a 'vertical' talus on lateral x-ray.
• Passive correction isn't possible, unlike usual flexible flat-foot forms.
• A lateral x-ray with the foot plantarflexed confirms diagnosis.
• Talus aligns with the first metatarsal in flexible flat-foot when the ankle is plantarflexed.
• The talus doesn't align with the first metatarsal in vertical talus.
• Treatment involves manipulation, serial casting, and (in resistant cases) open surgery.

Flat-Foot in Children and Adolescents

• This is a common complaint, often noted by parents.
• The foot turns outwards when weightbearing.
• The medial border of the foot is in contact with the ground.
• The heel becomes valgus (pes planovalgus).
• Two forms exist: flexible (most common) and rigid.
• Mobile ('flexible') flat-foot in toddlers is often a normal developmental stage that disappears.
• Stiff ('rigid') flat-foot requires examination for underlying abnormalities.
• These abnormalities include tarsal coalition, inflammatory joint conditions, or neurological disorders.

Clinical Assessment of Flat-Foot

• Common flexible flat-foot presents without symptoms; parents notice flat feet or shoe wear.
• Deformity becomes noticeable when the child stands.
• A 'Jack test' helps to check.
• Going up on toes inverts heels and medial arches and indicates flexibility.
• With the child seated, feet planted and the examiner dorsiflexing the great toe, the medial arch reappears.
• With dorsiflexion heel adopts a neutral position, and tibia rotates externally in the Jack test.
• Examine foot with child seated/lying.
• Check localized tenderness, ankle movement range, subtalar and midtarsal joints.
• A tight Achilles tendon may induce a compensatory flat-foot deformity.
• Teenagers sometimes present with a painful, rigid flat-foot.
• Peroneal and extensor tendons appear to be in spasm.
• These patients require further investigation for tarsal coalition, inflammatory arthritis, or neuromuscular disorder.
• A specific cause is not identified in many cases.
• The clinical assessment has a general examination for joint hypermobility and signs of associated conditions.

Imaging of Flat-Foot

• X-rays are unnecessary for asymptomatic, flexible flat-feet.
• Standing AP, lateral, and oblique views may help identify underlying disorders for painful/stiff flat-feet.
• CT scanning is the most reliable way of demonstrating tarsal coalitions.

Treatment of Flat-Foot

• Flexible flat-feet in children rarely require treatment.
• Reassurance to parents about self-correction over time is important.
• Medial arch supports/heel cups may help.
• Symptomatic mobile flat feet improve through surgery in exceptional cases.
• Lengthening the lateral side of the foot through an osteotomy may resolve the condition.
• Inserting a wedge of bone graft or a titanium implant in the sinus tarsi elevates the neck of talus.
• When conditions are due to neuromuscular disorders like poliomyelitis, splintage or operative correction and muscle rebalancing may be needed.

Flat-Foot in Adults

• It is important to ask whether the flat feet have been there since childhood.
• Constitutional flat-feet can start causing nagging pain after changing daily activities even if asymptomatic before.
• More recent deformities may be due to disorders such as rheumatoid arthritis or generalized muscular weakness.
• Advice on footwear and arch supports helps when there's no underlying abnormality
• Patients with painful, rigid flat-feet require robust splintage and treatment for generalized conditions such as rheumatoid arthritis.
• Unilateral flat-foot suggests tibialis posterior synovitis or rupture.
• Women in later midlife are often affected.
• Onset is insidious, affecting one foot much more than the other.
• Systemic factors include obesity, diabetes, corticosteroid medication, or past surgery.

Treatment of Flat Foot in Adults

• Should start before the tendon ruptures.
• Rest, anti-inflammatory medication, insole support, and ultrasound-guided steroid injections are treatment options.
• The tendon sheath may be decompressed and the synovium excised.
• Call for surgery is determined by failure to improve may call.
• The calcaneum may be osteotomized to shift the axis of weightbearing more medially.
• A ruptured tendon is sometimes reconstructed with a tendon graft.

Pes Cavus

• The foot is highly arched.
• Toes are drawn up into a 'clawed' position.
• Metatarsal heads are forced down into the sole.
• Deformities mirror neurological disorders, with weak/paralysed intrinsic muscles.
• All forms are due to muscle imbalance .
• Is often noticeable around age 8-10.
• There are often is a past history of spinal disorder and both feet are affected.

Symptoms of Pes Cavus

• Pain may be felt under the metatarsal heads or over the toes.
• Pressure from shoes causes callosities at pain sites.
• Walking tolerance is usually reduced.
• Neurological examination identifies disorders such as hereditary motor/sensory neuropathies and spinal cord abnormalities (tethered cord syndrome, syringomyelia).
• Poliomyelitis is also a significant cause in some parts of the world.

Treatment of Pes Cavus

• No treatment is often required otherwise fit difficulties fitting shoes.
• The patient has no complaints otherwise.
• Custom shoes with molded supports help patients with significant discomfort.
• The deformity or its progression, this doesn't alter
• A tendon re-balancing operation when sx persist and deformities are passively correctable:
• Long toe flexors are released and transplanted into the extensor expansions to pull the toes straight.
• The aim of surgery - a stable pain-free , supple but stable foot.

Hallux Valgus

• Is the commonest of foot deformities.
• In people never having worn shoes, the big toe is inline with the first metatarsal, retaining the slightly fan-shaped forefoot
• The hallux assumes a valgus position with habit of shoe wearing, but it is valgus only with excessive angulation is referred to.
• Splaying of the forefoot, with varus angulation predisposes to lateral angulation of the big toe in people who wear shoes.
• This metatarsus primus varus may be congenital, or it may result from muscle in the forefoot in elderly people.
• Hallux valgus is common in rheumatoid arthritis.
• Lateral deviation and rotation of the hallux, together with a medial prominence side of the head of the first metatarsal, a.k.a a bunion.
• Bursas overlying.
• Lateral deviation of the Hallux may lead to over crowding sometimes over-riding.

Hallux Valgus Commonality

• Hallux valgus is most common in women between 50-70 yrs. old;
• Is usually bilateral.
• Often there are no symptoms apart from the deformity.
• Possible factors for pain are shoe pressure on a large inflated bunion, splaying of the forefoot, associated deformities of the lesser toes or secondary osteoarthritis of the first metatarsophalageal joint.
• Use shoes encouraged with deep toe boxes, which are soft with low heels
• If this deformity is persistent tissue soft, it can be corrected rebalancing by a metatarsal osteotomy.

Painful Heel

• Traction 'apophysitis' (Sever's disease)
• Is a condition common in young boys, that isn't a disease, but a very mild traction injury
• Pain and tenderness in the tendo Achillis insertion
• The heel of the shoe should be raised and strenous activities restricted for a few weeks little and.
• Older girls young women often complain with painful bumps often
• Calcaneal bursitis with friction shoes with bursititis are prominence the back of heel
• Attention should be paid to footwear and padding use
• Should symptoms warranty prominence removal may it

Plantar Fasciitis

• Pain under the ball of the heel, or slightly forwards of this, is a complaint fairly common. In people primarily aged 30-60 years.
• Is worse on weight bearing and shows tenderness along the heel’ contact area.
• Shows the bone in X-rays , this is not casual-tive but associated..
• Plantar fasciitis is in patients with inflammatory disorders and gout.
• Treatment of cortisteriod anti-inflammatory drugs is a conservative a pad will offset healing. Bone conditions can also give pain in that area.
• Months to resolve with generally self limiting cases like tumours

Stress Fracture

• Second and third metatarsal bones are fracture.
• Is normal now.
• Seen in long adults bones, is fusiform show
• Some pattern of those occurs
• Treatment is reassurance and rest

Interdigital Nerve Compression (Morton's Metatarsalgia)

• Affects the forefoot with the woman stating "feel like a pebble'.
• Pressure gives a tingling sensation
• Click from Mulder squeezing pain and is a syndrome
• Steroid uses pad if not excision fails.