Pain on dorsal and medial side of foot
Great toe pain
Tight shoes and stockings, Ingrowing toe nail
Calcaneal exostosis; Bursitis
Cuneiform exostosis; Peroneal flat foot
Early hallux rigidus;
Hallux valgus, nail problems
Freiberg's disease Pes cavus; Verruca pedis
Hallux valgus and bunion
Anterior metatarsalgia; Plantar neuroma Pes cavus
Gout, nail Rheumatoid problems arthritis;
Verruca pedis; Tarsal tunnel syndrome
Factors in flat foot
Factors in pes cavus
'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
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.
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.
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°.
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.
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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