Positional Talipes

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Heel pain

Pain on dorsal and medial side of foot

Great toe pain

Forefoot pain

Children

Sevef's disease

Kohler's disease

Tight shoes and stockings, Ingrowing toe nail

Verruca pedis

Adolescents

Calcaneal exostosis; Bursitis

Cuneiform exostosis; Peroneal flat foot

Early hallux rigidus;

Bunion

Hallux valgus, nail problems

March fracture;

Freiberg's disease Pes cavus; Verruca pedis

Adults

Osteoarthritis

Rheumatoid arthritis

Hallux valgus and bunion

Hallux rigidus

Anterior metatarsalgia; Plantar neuroma Pes cavus

Gout, nail Rheumatoid problems arthritis;

Gout;

Verruca pedis; Tarsal tunnel syndrome

Table 13.2

Factors in flat foot

Factors in pes cavus

Infants

Children

Adults

'Normal foot' Vertical talus Knock knees Valgus heels

Neurological disturbance Torsional deformities of the tibia

In all age groups, this is due to muscle imbalance often from a neurological disorder, e.g. spastic diplegia, poliomyelitis, Friedreich's ataxia, peroneal muscle atrophy, spina bifida (usually occulta). Many cases are associated with varus heels

Adolescents Continuation of childhood factors

Peroneal flat foot

Continuation of childhood factors Overweight, excessive standing Degenerative processes

Peroneal MusclePositional TalipesTalipes Positional

13.1. Clubfoot (1): Talipes equinovarus:

In the untreated case there is (A) persisting varus of the heel. (B) atrophy of the calf muscles, (C) callus where the child walks on the lateral border of the foot. It is commoner in males, may be bilateral, and may be associated with other anomalies.

13.2. Club foot (2): The newborn child often holds the foot in plantarflexion and inversion, giving a false impression of deformity. First observe the child as it kicks to see if this position is maintained.

13.3. Club foot (3): If the child maintains the foot in the inverted position, support the leg and lightly scratch the side of the foot.

Plantarflexion Foot NewbornEverted Foot ChildEverted Foot Child

13.4. Club foot (4): In the normal foot the child will respond by dorsiflexion of the foot, eversion. and fanning of the toes. This reaction does not take place if the child has a talipes deformity.

13.5. Club foot (5): If the child does not respond in a normal fashion, gently dorsiflex the foot. In the normal child, the foot can be brought either into contact with the tibia or very close to it.

13.6. Club foot (6): (A) Note that in the less common talipes calcaneus deformity, the foot is held in a position of dorsiflexion. (B) Note that in the normal infant the foot can be plantarflexed to such a degree that the foot and tibia are in line.

Baby Passing Through Birth Canal

13.7. Radiographs: Anteroposterior view (1): Interpretation is difficult owing to the incompleteness of ossification. Centres for the talus, calcaneus, metatarsals, phalanges, and often the cuboid are present at birth. Begin by drawing a line through the long axis of the talus.

13.8. Radiographs: Anteroposterior view (2): This line normally passes through the first metatarsal, or lies along its medial edge. Note also that the axes of the middle three metatarsals are roughly parallel. Now draw a second line through the long axis of the calcaneus.

13.9. Radiographs: anteroposterior view (3): Note (A) the axial line of the calcaneus passes through or close to the fourth metatarsal. (B) The axes of the talus and calcaneus subtend an angle of 30-50°.

Clubfoot Talus Calcaneus ParallelAxial View First MetatarsalAxial View First Metatarsal

13.10. Radiographs: Anteroposterior view (4): In club foot, the previously described relations are altered owing to forefoot adduction. Note (A) the talar axis does not cut the first metatarsal; (B) the middle three metatarsal axes are not parallel; (C) the calcaneal axis does not strike the fourth metatarsal; (D) the angle between the talus and calcaneus is reduced.

13.11. Radiographs: Lateral (1): Draw

(A) axes through talus and calcaneus, and (B) tangents to the calcaneus and fifth metatarsal. Note that in the normal foot at birth that the talar axis passes below the first metatarsal (C); the interaxial angle (D) is 25-50°; the angle between the tangents (E) is 150-175°.

13.12. Radiographs: Lateral (2): In club foot, note (A) the talar and calcaneal axes are nearly parallel; (B) the angle of the tangents is less obtuse; (C) the talar axis does not pass below the first metatarsal. Geometric analysis of the type discussed on this page may be of help in the doubtful case and in assessing progress, and MRI scans are of particular value in determining talonavicular alignment.

Positional Talipes Birth

13.13. Appearance: Note the shape of the foot, and the presence of any obvious deformities, abnormal callus formation etc.

13.14. Weightbearing posture:

Examine the weightbearing foot from above, from behind and from the sides.

13.15. Palpation: Look for tenderness. Note any joint crepitus. Note any increase or decrease in skin temperature.

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