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Ankle Sprain
Osteochondritis Dissecans
Tuberculosis of the ankle and foot
Plantar Fascitiis
Calcaneal Bursitis
Morton's Neuroma
Freiberg's Disease
March Fracture
Hallux Valgus
Hallux Varus
Hallux Rigidus
Hammer toe
Mallet toe
Flat foot
Kohler's Disease
Metatarsus Varus
Congenital Clubfoot
Calcaneus Cavus
Morton's Syndrome

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  - refers to a partial or complete rupture of the ligaments of the ankle
  - most commonly affect the lateral collateral ligament
  - forcible inversion of the plantarflexed foot most commonly ruptures
    the anterior talofibular ligament; if force continues calcaneofibular 
    ligament is also torn
  - posterior talofibular ligament rarely injured except in severe 
    injuries causing complete dislocation
  - medial collateral ligament is rarely ruptured; severe abduction force
    will cause avulsion of the medial malleolus rather than rupture

  - Ankle sprains typically occur when the foot and ankle are plantar-
    flexed. The Anterior talofibular ligament (ATFL) is generally the 
    first structure injured with a combined inversion-plantar flexion 
    stress. The Calcaneofibular ligament (CFL) is the second structure 
    injured as the inversion stress increases. For the Posterior talo-
    fibular ligament (PTFL) to become injured, either inversion must 
    continue further or some posterior displacement of the talus must
    occur. Inversion in neutral dorsiflexion primarily stresses the CFL. 
    The deltoid ligament is injured with eversion stress. Addition of 
    any rotatory stress to the above or inversion in dorsiflexion leads
    to syndesmosis injury.

Classes of Injury:
When ligaments endure injury, the most common site along the 
ligament tends to be within the midsubstance of the ligament.
Tears which occur closer to the insertion are often accompanied by 
avulsion fractures. More violent forces will be associated with multi-
ligamentous injury or fractures of bones about the ankle mortise. 
Each ligament is graded separately. 

 GRADE 1 (mild) – minor ligamentous disruption with maintenance of 
                   integrity and no signs of instability.

 GRADE 2 (moderate) – near complete disruption with macroscopic 
                tearing and swelling. There is a moderate amount of 
                functional loss such as difficulty with toe-walking and 
                there is mild or moderate instability.

 GRADE 3 (severe) – complete ligamentous rupture with obvious 
               swelling, discoloration, and tenderness. There is 
               significant functional loss with limited range of motion
               due to swelling, limited weightbearing tolerance due 
               to pain, and reduced stability due to the ligamentous 

Clinical Presentation for typical ankle sprain:
  1. have history of forced inversion of plantarflexed foot
  2. swollen, painful, very tender anterolateral aspect
  3. severe discomfort and instability in walking
  4. tenderness well localized to anterior talofibular, occasionally 
      calcaneofibular ligament
  5. ecchymosis after a few days
  6. if mild, symptoms subside in a few days
  7. if have complete rupture, acute symptoms subside after several 
      weeks but may have residual swelling and discomfort for 
      months especially if foot was immobilized for an insufficient 
      period of time; this patient becomes predisposed to recurrent 
      sprains and chronic lateral instability

History and Physical Examination:
 - sensation of a tear or pop with a “rolling over” of the ankle are 
   highly suggestive of an ATFL or CFL tear
 - Anteriorly based pain and inability to bear weight following the 
   patient’s foot “getting stuck” while the leg continued to rotate 
   suggest sydesmosis injury.
 - Fibular head region is palpated to detect defects and tenderness 
   suggestive of fracture and for irritability of the peroneal nerve
 - Fibular shaft is percussed throughout its length to identify 
   possible fracture sites.
 - The distal tibia and fibula, and the talar dome region are similarly
   inspected for overt fracture.
 - Points of maximal tenderness are commonly elicited over the ATFL
   and CFL. Careful deep palpation underneath the distal lateral 
   malleolus can reveal a defect consistent with complete CFL
 - A complete sensory examination and light percussion over the 
   superficial nerves are important to identify stretch injuries which 
   can cause superimposed dyesthetic pain.
 - The anterior drawer test is the hallmark test for integrity of the 
   ATFL. The patient’s calf muscles should be relaxed and the foot 
   should be in approximately 10 degrees of plantarflexion.The 
   calcaneus is grasped firmly and drawn forward while the tibia is 
   pushed posteriorly with the other hand. Under normal conditions, 
   the translation of the talus is no more than 4mm. A drawer of more
   than 8mm is indicative of at least an ATFL tear.
 - The talar tilt test is more sensitive for CFL tears. The lower leg is 
   held firmly by one hand while applying an inversion stress to the 
   talus and calcaneus with the other hand. Separation of the surface 
   of the talus from the tibia is considered a positive test. The ankle 
   should be kept n neutral during this manuever, since plantarflexion
   stresses the ATFL.
 - The Clunk test is a gross assessment of mortise widening, as when 
   there is a tibiofibular ligament complex injury. Grasping the 
   calcaneus with one hand, and surrounding the distal third of the 
   tibia and fibula with the other, the examiner attempts to move the 
   talus from side to side. A “clunk” is felt as the talus hits the 
   tibia or fibula. Care must be taken not to allow inversion or 
   eversion to occur during this manuever or a false-positive result 
   will obtain.
  - A squeeze test can be helpful when there is true tibiofibular 
   diastasis due to complete syndesmosis injury. Proximal 
   compression of the tibia and fibula together produces pain at 
   the level of the interosseous membrane. Diastasis compromises 
   load bearing at the ankle joint severely and require surgical 
 - The eversion test assesses the integrity of the deltoid ligament 
   complex. The lower tibia is grasped in one hand and the heel in the
   other. If the tibiotalar joint widens medially with eversion stress, 
   the test is positive.
 - Occasionally “stress views” of the ankle are performed. For the Tilt
   stress, the angle between the talar dome and the plafond is 
   measured. As to the exact angle constituting a significant widening,
   lateral opening of more than 10 degrees suggest either CFL or ATFL 
   injury, while greater than 20 degrees is highly suggestive of a
   combined CFL and ATFL injury.

Types of Fracture associated with ankle sprains:

   1. Spiral fracture of the distal fibula
     - one of the most common fractures of the ankle region

   2. Jones fracture 
     - an avulsion fracture at the base of the fifth metatarsal 
      associated with inversion sprain and pulling of the peroneus 

   3. Osteochondral talar dome fractures
    - May follow almost any type of ankle injury and should be 
      considered in slow healing cases and where the region over 
      the talus is tender.

   4. Mortise disruption follows syndesmosis or deltoid ligament
     injury;  the ring of the mortise should immediately be inspected 
     for evidence of bimalleolar fractures.


Acute Phase
   - Icing and compressive wrapping of the injured site. Cryocuffs are 
     helpful in minimizing the amount of postinjury swelling.
   - Early mobilizationof the sprained but nonfractured ankle.
   - Use of elastic support, air stirrup splints, lace up braces, or 
     plastic-molded supports.
   - Casting of the uncomplicated sprain
   - Use of crutches when the gait is affected.
   - Ankle pumping and “writing the alphabet” with the feet

Sub-acute to Chronic Phase
   - strengthening of the evertors, invertors, plantarflexors, 
     dorsiflexors with elastic tubing, and then via heel raises and 
     partial squats 
   - hip abductor muscle strengthening
   - use of balance boards
   - Bicycle exercise to maintain or increase endurance. Then progress 
     to more dynamic training including slide board, figure of 8 running 
     drills and hexagon drills.
   - For severe types: immobilization by cast for 3-6 weeks
   - For severe ligamentous disruption: surgery is done

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 - the site for osteochondritis dissecans in the ankle foot is in the 
   talar dome

 - necrotic bone lies within inner or outer margin of the superior 
   aspect of the talus immediately beneath the articular cartilage

 - may be spontaneous; but may follow an inversion twisting injury 
   producing a minute subchondral fracture

 - symptoms mimics an ankle sprain but may be prolonged

 - may be treated conservatively through prolonged non-weight 
   bearing or surgically if prolonged immobilization not desired

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  - usually affect both foot and ankle together
  - initial manifestation usually  a synovitis of the ankle or 
    tarsal joint

  - may have two types of tuberculous involvement:
	1. disease of synovium or extrasynovial soft tissue which 
	    presents with early inflammatory findings
	2. localized central bone or osseus lession which presents
	     with late inflammatory findings

  - In infants the metatarsals are the most commonly involved bone
  - In children, the tarsal bones
  - In adults the ankle bones
  - In elderly the the talus is most commonly involved
  - usually insidious onset with effusion, periarticular soft tissue 
    swelling, limited ankle mobility, pain, limping, local warmth and 
  - surgery done to remove infected tissues; given anti-tuberculosis
  - arthrodesis done if have extensive ankle and subtalar destruction
  - in adults ankle is fused in 10 degrees of equinus

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  This consists of traction-induced microtears of the plantar fascia 
  and its associated structures at the insertion on the calcaneus. 
  Ordinarily, the fascia tightens passively with toe extension, creating 
  a stiffer midfoot with arch elevation. This “windlass effect” and the 
  transition from pronation to supination are critical for transforming 
  the foot from a deformable structure suited for surface accommo-
  dation and shock absorption to one that is rigid and suited for use 
  as a lever during the attempt to push off the ground. Limited ankle 
  dorsiflexion, excessive pronation, and a tight gastrocnemius-soleus
  complex all increase the chance of developing plantar fascitis because
  the prolonged pronation during the stance phase decreases the chances
  of achieving the rigid, closed, packed midtarsal joint needed to push 
  off the ground.

Signs and Symptoms:
  1. point of tenderness along the medial fascia
  2. inability to run
  3. a painful first step of the morning
  4. decreased plantarflexor flexibility and strength, 
      and functional pronation
  5. functional adaptations include attempted inversion to reduce 
     medial structure overload and in case of runners, forefoot 
     running with a choppy stride

Acute phase
  - PRICE principle and use of anti-inflammatory medications as 
  - Steroid injection into the calcaneal attachment
  - Arch supports
  - Counterforce taping 
  - Heel pads

Chronic Phase
  - alternative program such as rowing, swimming, or aqua running

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 - This is often develops in elderly patients with a calcified spur 
  subjecting the bursa to trauma after prolonged walking or running. 
  Evaluation the footwear often reveals poor shock-absorbing capacity.
  Selecting the appropriate walking or running shoes supplemented 
  with a heel cup is often enough to relieve the symptoms. Restoration
  of normal flexibility and strengthening of the foot intrinsic can help 
  prevent recurring symptoms. Athletes should be encouraged to change 
  running shoes every 200 to 300 miles owing to the midsole break-down 
  that occurs after this amount of wear.

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  Pain about the distal end of the foot at the metatarsophalangeal 

Etiology of pain:
  - congenital laxity with stretching of the transverse metatarsal 
    ligaments as in flatfeet
  - weakness of the intrinsic foot muscles specifically lost toe flexor
    strength resulting in dropping of the metatarsal heads
  - equinus deformity throws weight on metatarsal heads 
  - pes cavus
  - any degeneration of the MTP joint
  - metabolic factors such as gout
  - prolonged walking resulting in sprain of the transverse metatarsal
  - intermetatarsal bursitis due to a narrow toe box
  - any foot deformity that puts pressure on the metatarsals   

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   This represents the entrapment of interdigital nerves in the foot. 
   The structure most often implicated is the transverse metatarsal 
   ligament, but surrounding bursal structures may also cause local 

Signs and Symptoms:
  - neuromas more frequently found between the third and second 
  - patients complain of an aching forefoot, which at times lancinating 
    pain confined to the foot
  - exacerbated by wearing tight shoes, high heels, and athletic 
    activities requiring repetitive forefoot weightbearing
  - patients obtain almost immediate relief when they take their shoes
  - often prefer to walk barefoot

Physical Examination:
   - Grasping the foot in one hand and squeezing the metatarsals 
     together will reproduce the symptoms. The examiner must examine
     each metatarsal ray individually to be sure that the pain is not 
     coming directly from the shaft of the metatarsals.

   - Intermediate-to long term relief may be obtained with footwear 
     modification, orthotic inserts, and corticosteroid injection
   - For those who do not respond to conservative treatment, neuroma 
     excision may provide relief

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    An osteochondrosis of the metatarsal head is also known as 
 Kohler’s No. 2 disease, aseptic necrosis of the metatarsal head.
 It is characterized by the development of aseptic necrosis of the 
 metatarsal epiphysis during a period of rapid growth maturation
 during the second decade and before closure of the epiphyseal plate.
    - with repeated trauma of weight bearing, head of metatarsal 
      becomes malformed and shaft hypertrophies; joint incongruity 
      eventually leads to osteoarthritis
    - ischemic epiphyseal necrosis most commonly affect the second
      metatarsal although 3rd metatarsal may also be involved
    - occur in adolescents before they have complete epiphyseal 
      closure of the metatarsals
    - unknown etiology
    - manifest during active growth period at puberty with painful, 
      tender swelling of the soft tissues around the 2nd MTP joint 
      aggravated by weight bearing and toe movements; symptoms 
      subside in a  few weeks except for occasional twinges of pain 
      throughout the years
    - pain later recurs with excessive walking, trauma, or use of high-
      heeled shoes; toe then hyperextended at MTP
    - managed conservatively with initial immobilization by cast, 
      non-weight bearing through crutch ambulation, steroid injections,
      prescription of metatarsal bar or pad, avoidance of high-heeled 

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    - stress fracture of the metatarsal bone
    - presenting symptom is pain after e long walk or march: edema
      of dorsum of the foot: well localized tenderness over middle of 
      affected metatarsal
    - pathology: hairline fracture of the shaft of the 2nd or 3rd 
      metatarsals with no displacement of the fragments
    - manage by immobilization in cast for 3 weeks

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    - most common painful deformity of the big toe
    - pathologically defined as a lateral deviation of the proximal 
      phalanx on the 1st metatarsal
    - generally due to the forcing of a foot with a short 1st metatarsal 
      into pointed/high heeled shoes
    - other etiologic factors:
	1. heredity- individuals with congenital splay foot
	2. mechanical- pressure of narrow, pointed shoes
	3. osseous-wedging of medial cuneiform
	4. degenerative arthritis of first MTP joint
	5. flatfoot
    - management by conservative if mild; surgical if severe
    - 3 components of the “Bunion Complex”
	1. large toe angulates toward the second toe
 	2. medial portion of the 1st metatarsal head enlarges
  	3. bursa over the medial aspect of the joint becomes 
           inflamed and thick-walled
            - frequently found in women with broad feet with 
             flattened transverse arch in a foot

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   - large toe angulated at MTP joint toward the medial side
   - usually congenital
   - Hallux varus is a condition in which the big toe begins to deviate
     away from the midline of the foot. Hallux varus most commonly 
     develops after the failure of a previous bunion surgery. There are 
     other conditions that may lead to hallux varus including trauma, 
     removal of a sesamoid bone from the big toe joint and some 
     forms of arthritis.
   - The treatment of hallux varus depends on the severity of the 
     condition.If the deformity is mild and the toe remains flexible
     no treatment is required at all. If the toe begins to deviate 
     considerably and is becoming stiff then surgery is usually 
     required. Correction depends on the flexibility of both joints 
     of the big toe and whether or not arthritis is present. Often, 
     a tendon transfer is performed. Tendons are shifted around the 
     big toe to straighten it and maintain flexibility. One of the 
     more popular operations that surgeons use today is a specially 
     designed transfer of a tendon of the big toe designed by Dr.
     Myerson (called the extensor hallucis brevis transfer procedure). 

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   - 2nd most common painful problem of the toes
   - painful restricted motion of the big toe, particularly on MTP 
     dorsiflexion with eventual degenerative arthritis
   - usually starts in late childhood and adolescense but symptoms
     may appear later
   - predominantly affect females in adolescence; both sexes equally 
     affected in adulthood
   - manifest as pain in the big toe particularly when it is dorsiflexed 
     before push off: swelling and tenderness; in adults have 
     progressively increasing stiffness

             Treatment begins with anti-inflammatory medications to 
    control the inflammation of the degenerative arthritis.  Special
    shoes that reduce the amount of bend in the toe during walking 
    will also help the symptoms initially.  A rocker type sole allows
    the shoe to take some of the bending force, and may be 
    combined with a metal brace in the sole to limit the flexibility
    of the sole of the shoe and reduce the motion needed in the 
    MTP joint. Injection of cortisone into the joint may give temporary
    relief of symptoms. Surgery may be suggested if all else fails. 
    Several types of procedures are useful in this condition.

          	 In some cases, bone spurs form on the top of the joint
    and can bump together when the big toe bends upward, or 
    extends. This causes a problem when walking, because the big 
    toe needs to bend upward when the foot is behind the body, 
    getting ready to make the next step.  The constant irritation 
    when the bone spurs bump together leads to pain and difficulty
    walking. A cheilectomy is a procedure that simply removes the 
    bone spurs at the top of the joint so that they don't bump 
    together when the toe extends.  This allows the toe to bend 
    better and reduces the amount of pain with walking.  To perform 
    a cheilectomy, an incision is made along the top of the joint.  
    The bone spurs that are blocking the joint from extending are
    identified and removed - from both the bones that make up the 
    joint.  A little extra bone may be  taken off to ensure that nothing
    rubs when the hallux is raised.  The skin is closed and allowed to 

	Many surgeons favor an arthrodesis, or fusion, of the 
    MTP joint  to relieve the pain.  To fuse a joint means to allow the 
    two bones that come together for form a joint to grow together
    and become one bone. The joint between the two bones is 
    removed and the two bones are allowed to grow together - or 
    fuse.  This results in a joint than no longer moves.  A rocker-sole
    shoe is usually necessary following a fusion to improve the gait 
    following this type of procedure. To perform a fusion,  an incision
    is made into the MTP joint.  The joint surfaces of the MTP joint 
    are removed.  The two surfaces are then fixed with either a metal 
    pin or screw, with the toe turned slightly upward to allow for 
    walking.  The bones are allowed to grow together, or fuse. 
    The fusion
    usually takes about three months to become solid. 

	Some surgeons favor replacing the joint with an artificial 
    joint, similar to what is done in the knee or hip - only much 
    smaller.  In this procedure, one of the joint surfaces is removed 
    and replaced with a  plastic surface.  This procedure may relieve 
    the pain and preserve the joint motion.  The major drawback to 
    this procedure is that the artificial joint probably will not last a 
    lifetime and will require more operations later if it begins to fail. 
    This surgery can usually be done as an outpatient. The surgery 
    can be done using a general anesthetic (where you are put to 
    sleep) or some type of regional anesthetic.  A regional anesthetic
    is a type of anesthesia where the nerves going to only a portion 
    of the body are blocked.  Injection of medications similar to 
    novacaine is used to block the nerves for several hours.  This  
    type of anesthesia could be a spinal block (where the lower half 
    of the body is asleep) or a foot block (where only the foot is 

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  - fixed flexion deformity of the PIP joint without hyperextension of 
    the MTP 
  - any toe may be affected
  - most prevalent in the second toe
  - probably congenital as it is often bilateral and seen in other family
  - develop callus over flexed IP joint
  - Recommendation: Obtain shoes of larger size with roomier 
    "toe boxes" to decrease pressure on the toes. Consult a pediatric 
    surgeon for possible surgical straightening of one or more hammer
    toes if careful shoe selection does not relieve the discomfort

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     Many disorders can affect the joints in the toes, causing pain 
 and preventing the foot from functioning as it should. A mallet toe 
 occurs when the joint at the end of the toe can not straighten. 
 Excessive rubbing of the mallet toe against the top of the shoe 
 can lead to pain and the development of a corn. The tip of the toe
 is often turned down against the shoe causing pressure and

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   - a foot with depression or complete loss of the longitudinal arch
   - forefoot is in abduction and slight supination
   - navicular bone and head of talus are prominent on medial 
     aspect of the foot 
   - calcaneus is everted or in valgus
   - longitudinal arc is depressed
   - of two types:
	  a. hypermobile flatfoot – hereditary marked laxity of 
               ligaments with hypermobile midtarsal and subtalar 
               joints and short tendon of Achilles
          b. rigid flatfoot with tarsal anomalies – common type and 
              due to a bridge, consisting of bone , cartilage or fibrous
              tissue between the talus and os calcis or  between the
              navicular and the os calcis

 	2. Acquired
	    a. osseous – fracture or disease of the talus and os 
	    b. ligamentous – dislocations causing tear and 
               lengthening of plantar ligaments
            c. muscle imbalance – weak tibials and strong peronei 
               causing valgus deformity
            d. postural or static – internal tibial torsion, excessive 
               weight, muscle fatigue, faulty footwear, bad walking habits
            e. arthritis of tarsal joints

   - Characteristics of a congenital flat foot
  	1. calcaneovalgus foot 
 	2. heel is in valgus
 	3. talus points medially toward the other foot
	4. talus points downward
	5. navicular bone lies on the superior surface of the neck
                    of the talus instead of anterior to the head

   - characteristics of rigid flatfeet:
	1. calcaneovalgus foot 
	2. heel is in valgus
	3. talus points medially toward the other foot
	4. talus points downward
	5. navicular bone lies on the superior surface of the neck
                    of the talus instead of anterior to the head
  	6. forefoot abduction

   - treatment:
      1. prescription of arch support
      2. shoe modifications: scaphoid pad, thomas heel,
          extended medial counter, medial wedge (if with valgus 
      3. nonweight bearing exercises: performed in hot tub bath, 
         flex toes and curl over a washcloth until he is able to 
         pick it up with his toes, passively flex toes, actively adduct
         foot and then dorsiflex in medial direction 
       4. Weight bearing exercises: heel-to-toe walking, toes 
          pointing forward with weioght bearing on outer border 
          of foot, use supination board, walking or playing in sand
          ballet dancing encouraged
       5. Resistive exercises for flexion, adduction, inversion and 
          inversion with dorsiflexion
       6. if conservative management is unsuccessful then do 

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   - refers to an osteochondrosis of the tarsal navicular
   - usually occurs at 4-10 years of age with average of 5 years old
   - characterized by aseptic necrosis of the navicular bone
   - more common in boys
   - manifest as limping and foot pain; may have slight swelling and 
     tenderness over the navicular area
   - confirm by x-ray
   - managed conservatively with immobilization by cast for several
     weeks followed by shoe modification; if symptoms relieved may
     resume full activity; complete reossification usually occurs in 2 
     to 3 years

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   - components:
       1. forefoot (anterior segment) adduction
       2. lateral border of the foot is convex with the apex at the
           base of the 5th metatarsal
       3. heel in valgus
       4. internal tibial torsion
       5. sharp angulation of the medial border of the foot at the 
           tarsometatarsal joint
       6. 1st metatarsal more angulated than the 4 other metatarsals
       7. talus medially and anteriorly displaced in its relation to the 
       8. no equinus deformity

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   - primary deformities or components:
	1.eversion and adduction of the forefoot
	2. varus of the calcaneus (heel inversion)
	3. equinus (plantarflexion)
	4. internal tibial torsion

   - secondary deformities:
	1. contraction of the tissues on the medial side of the 
	2. underdeveloped evertor muscles on the lateral side
                  of the leg
	3. underdeveloped and contracted calf muscles

   - sequence of treatment for congenital clubfoot:
	1. Serial plaster casting (starting at birth to 4 mos.)
	2. Corrective surgery (if with no correction at 4 mos.)
	3. bracing/shoe correction

   - operative procedures used in congenital clubfoot:
	1. soft tissue release of medial border tissues and TA 
	2. tendon transfers
	3. osteotomy
	4. arthrodesis

   - other facts about the congenital clubfoot:
	1. more common in males
	2. due to defect in prenatal development

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   - usual cause is weakness of the gastrocsoleus
   - non-surgical treatment in a young child is ineffectual as long as 
     the gastrocsoleus is paralyzed or weak
   - surgical management usually involves tendon transfers
   - classification:
	1. global – forefoot is cavus, all metatarsals are 
                         plantarflexed, apex at chopart’s joint
	2. anterior cavus – only the first metatarsal is vertical
	3. posterior cavus – calcaneus is essentially vertical 
                         ( in excess of 30 degrees)
	4. midfoot cavus – apex is midtarsus posterior to the
                         metatarsal cuneiform joint but anterior to the 
                         tuberosity of the calcaneus

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   - essentially a broadened forefoot due to weakness of the 
     intermetatarsal ligaments associated with weakness of the 
     intrinsic muscles
   - transverse arch flattened
   - middle metatarsal bear more weight 
   - may have hammer toes
   - may have calluses over plantar surfaces of the head

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   - short 1st metatarsal so excessive weight borne by 2nd metatarsal
   - hereditary

   - syndrome consists of:
	1. excessively short 1st metatarsal which is hypermobile 
                 at its base
	2. posterior diplacement of the sesamoids
	3. thickening of the 2nd metatarsal shaft

  - treatment consists of building a “platform” under the first 
    metatarsal bone to assume weight
  - described by Dudley Morton

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