bearing position. At that time, one can problems in Family Practice determine whether the longitudinal arch is present, whether the heel is in proper alignment, and what the effect of weight-bearing is on the alignment Common Foot Deformities of the forefoot to the hindfoot. Additionally, one notes the alignment of the entire foot to the midline axis in Infancy and Childhood of the body. The foot is then ex­ amined in the nonweight-bearing posi­ G. Paul, MD Richard tion. Note whether any deformities are Boston, Massachusetts fixed or supple. For instance, fixed fiatfoot deformities of the foot will persist in the nonweight-bearing posi­ tion, whereas flexible fiatfoot condi­ The evaluation and management of common foot disorders are tions will disappear in the nonweight- presented. In addition to the routine history and physical bearing position and an arch will be examination, analysis of x-rays of the foot in the weight-bearing noted. Motion at the ankle (the tibial- position is vital. A method of interpreting these x-rays is presented. talar joint), subtalar (the talo-calcaneal The emphasis of the paper is upon distinguishing conditions joint), and the midtarsal (the com­ bined talonavicular and calcaneal- requiring surgical management from those readily treated in the cuboid joint) and forefoot joints is office. The office management of the latter deformities is presented then evaluated. This must include both in detail. passive and active motion. Any fixed The family physician daily sees necessary to know how long the foot deformities — that is, limitation of infants and youngsters with foot dis­ deformity has been present, whether it passive motion should be noted. orders. Whereas some conditions need is progressive or resolving, and if any Active motion is essential in determin­ prolonged or involved orthopedic associated sensory or motor deficit has ing that all muscle groups are present. In neuromuscular disorders producing management, many require simple been noted. If the youngster is old foot deformities, the examiner must therapeutic measures readily initiated enough to walk, then the child’s or the perform a complete muscle examina­ in the office. The practitioner who parent’s impression of the effect of tion of ali muscle groups in the foot. appreciates the basic rudiments of foot weight-bearing on the foot deformity Each muscle being tested must actively disorders — for instance, whether in- is important. Also of interest is the contract, initially moving the bone or toeing is due to intrinsic deformities of presence of this or similar deformities joint against gravity and then moving the foot or to torsional malalignment in other members of the family. the bone or joint against increasing of the lower extremities — is able to Having obtained this information one proceeds to the physical examina­ resistance. Thus, the muscle’s presence reassure the patient’s family and see and its strength are assessed. A thorough tion. Examination of the feet must that appropriate management is ini­ sensory examination likewise is neces­ include an examination of the entire tiated promptly. sary. Lastly, the examiner should ob­ This paper will attempt to assist the lower extremities and the spine, ideal­ serve the plantar surface of the foot physician in undertaking the evalua­ ly, the person should be examined in diapers or shorts so that the extremi­ for callosities or other signs of ab­ tion of common foot disorders. An normal pressure; the toes and dorsal ties and spine can be observed. See important diagnostic aid in evaluation surfaces of the feet likewise may show whether he stands normally with the of the foot is the interpretation of corns and other signs of pressure from spine straight and the pelvis level. One weight-bearing x-rays of the foot. This overlying shoewear. radiographic analysis will be presented should palpate the spine for any de­ initially, followed by a review of the fects of the spinous processes and then Radiographic Evaluation more common foot disorders. The observe spine motion to see that it is paper is not meant to be an exhaustive free and supple. The examiner should In addition to a careful clinical treatise of orthopedic foot disorders; place his hands upon the iliac crests to examination, accurate radiographic my purpose is to cover the more determine that the pelvis is level and studies of the feet are an essential common conditions seen in the busy that the legs are equal in length. Next, requirement in delineating foot dis­ practitioner’s office. examine the hips and knees to deter­ orders.1 For this, x-rays with the child mine that full motion and strength are in the weight-bearing position in both the A-P and lateral position are essen­ Clinical Examination present. Following this, the patient, assuming he is a walker, is then asked tial. The necessary films are easily Prior to examining the patient a to walk in his normal manner. In this secured in those subjects old enough detailed history is obtained. It is way the examiner can determine the to stand, and consist of A-P and lateral effect of the foot deformity upon his views of both feet and ankles taken in From the Department of Orthopedic Sur­ gery, Boston University, School of Med­ gait. the weight-bearing position. icine, Boston, Massachusetts. Requests for The examiner then proceeds to a Radiographs can be obtained even reprints should be addressed to Dr. G. Richard Paul, D epartm ent o f Orthopedic specific evaluation of the feet. They with very young infants by either Surgery, University Hospital, 75 East taping the feet to the radiographic Newton Street, Boston, Mass 021 18. are first examined in the weight­

537 THE JOURNAL OF FAMILY PRACTICE, VOL. 3, NO. 5, 1976 cassette, or by a parent or assistant talocalcaneal angle in the weight­ flexed at the ankle joint; calcaneus ~ holding the lower extremities in this bearing position, with the midtalar line the foot is dorsiflexed at the ankle simulated “weight-bearing” position. projecting far medial to the first joint, with the heel at a lower levei The radiologist can be helpful in posi­ metatarsal. Furthermore, there is a than the toes. Many combinations of tioning the child to obtain the neces­ greatly increased talocalcaneal angle these deformities can exist. The f0re sary views. in the lateral radiograph (Figure 5b), foot can have both angular deformity Radiographs in the A-P projection with the anterior aspect of the talus in two planes as well as rotational (Figure 1) of the normal foot show medial to the os calcis. The anterior deformity along its long axis. Supina- that the midtalar line (a line drawn projection of the midtalar axis points tion is inward rotation and pronation through the long axis of the talus) to the floor, far below the first meta­ is outward rotation along the long axis projects anteriorly through the longi­ tarsal; the midtalar and first metatarsal of the foot. tudinal axis of the first metatarsal; the axes, rather than forming a straight Congenital C lubfoot (Talipes Equi. midcalcaneal line (a line drawn through line as in the normal foot, show a novarus) the long axis of the calcaneus) projects distinct break or sag, usually at the In talipes equinovarus, the forefoot anteriorly through the longitudinal talonavicular joint. Additionally, the is adducted and inverted (and also axis of the fourth metatarsal. The forefoot appears to be laterally angu- internally rotated on its long axis, or angle formed by the midtalar and lated (abducted) and everted, features midcalcaneal line is referred to as the that can be appreciated on the x-rays. in supination), the hindfoot is likewise in varus, and the entire foot is plantar- A-P talocalcaneal angle and varies be­ Let us consider one additional de­ tween 15 to 35 degrees. formity, metatarsus adductus. Here flexed. Although a strong familial Similar axes should be determined the hindfoot has normal talar-calcaneal tendency exists, its exact genetic pat­ tern has yet to be established.3 It is with the lateral projection (Figure 2). relationships, but the forefoot is ad­ The midtalar line (a line through the ducted (angulated toward the midline distinctly more common in males than long axis of the talus) projects ante­ of the body) in relation to the longi­ females. It can be viewed as an in riorly through the midline of the first tudinal axis of the foot (Figure 6). utero failure of the normal develop­ metatarsal to form a straight line. The ment of soft tissues and muscles of the Congenital and Developmental De­ legs and feet, with the feet never angle formed by the midtalar line and formities of the Feet the calcaneal line (a line through the achieving their normal in utero move­ Common foot deformities, of both ments. The result is a very severely long axis of the calcaneus) is the congenital and developmental origin, lateral talocalcaneal angle and varies contracted and deformed foot with will be reviewed on an individual basis. deficient leg musculature. between 15 to 35 degrees. Addition­ While some of these are present at ally, the angle formed by the midshaft Congenital clubfoot must be diag­ birth,2 others develop at later stages of nosed at birth. Treatment will vary axis of the tibia and the midcalcaneal growth. line in the lateral projection is nor­ greatly depending upon the severity of First, a word on terminology. mally 20 degrees of dorsiflexion. the condition. This is one deformity Talipes is derived from the Latin talus Let us apply this analysis to several that should be followed by an ortho­ (ankle bone) and pes (foot) and is the of the basic foot deformities. Hindfoot pedic surgeon. A series of plaster casts, generic term used for foot deformities varus deformities (inversion at the reapplied at weekly or biweekly inter­ of congenital origin. Terms designating subtalar joint, which is an angular and vals, is usually the first step in correct­ acquired deformities of the foot are rotational deformity along multiple ing the various deformities of a club­ preceded by the word pes. The pri­ axes at the subtalar joint) produce a foot. The rationale of serial corrective mary deformities of the foot and ankle very typical radiographic pattern. The plaster casts is that the soft tissues can be described as follows (Table 1): A-P projection (Figure 3a) will show a producing the deformity are gradually reduced (less than ten degrees) talo­ varus — the heel is inverted (adduction stretched so that the bones can assume calcaneal angle with the midtalar line and rotational deformities at the talo­ their normal alignment. Bones grow in calcaneal joint) and the forefoot is projecting far lateral (in the region of response to the stress applied to them; inverted (adducted and supinated); the third or fourth metatarsal) to the without proper alignment, their sub­ valgus — the heel is everted (abduction first metatarsal. The lateral projection sequent growth will be abnormal. This and rotational deformity) and the (Figure 3b) likewise shows a greatly is the thesis behind the early correc­ forefoot is everted (abducted and pro- reduced talocalcaneal angle, with the tion of all foot deformities. Moreover, nated); equinus - the foot is plantar- midtalar line projecting far superior to although the soft tissues are con- the metatarsals. Additionally, the fore­ Table 1: Major Foot Positions and Deformities foot is adducted and inverted, de­ Joint M otion D efo rm ity formities readily visualized on the x- rays (Figure 4). Ankle Plantarflexion Equinus Flindfoot valgus (eversion at the Dorsiflexion Calcaneus subtalar joint, which is combined Subtalar Inversion (adduction and rotation) H in d fo o t varus angular and rotational deformity along (Talo-calcaneal joint) Eversion (abduction and rotation) H in d fo o t valgus several axes of the subtalar joint) Midtarsal Plantarflexion Cavus likewise produces very typical radio­ (Talo-navicular and Dorsiflexion graphs which contrast with the varus calcaneal-cuboid Lateral rotation Supination joints) Medial rotation Pronation deformity. Here the A-P radiograph A bduction Abductus (Figure 5a) shows a greatly increased A dduction Adductus

538 THE JOURNAL OF FAMILY PRACTICE, VOL. 3, NO. 5, 1976 Figure 2. Weight-Bearing Lateral View of Normal Foot Figure 1. Weight-Bearing AP V iew of Note how the anterior projection of the midtalar line extends through the first met­ Normal Foot atarsal, and that the midtalar and first metatarsal lines are colinear. Likewise, the The anterior projection of the mid­ midcalcaneal line bisects the m idtalar line to form an angle o f 1 5-35 degrees (the lateral talar line runs through the first TC angle). metatarsal, and the anterior projec­ tion of the midcalcaneal line extends through the fourth metatarsal. The bony reconstructive procedures rather greater correction at each cast change. angle they form is normally 15-35 degrees (TC angle). than by further soft tissue procedures. Once full correction has been attained, By this age the abnormal bone devel­ the youngster is held in a straight last opment has occurred, and one can shoe for one to two years. It is tracted and tight, they become only hope to restore proper alignment of important to perform repeat examina­ more contracted with time. Assuming the foot only by resecting portions of tions at three to six-month intervals to that the deformities of a clubfoot can the bones. Here one is really eliminat­ see that recurrence does not take place. be fully corrected by a series of plaster ing the multiple joints of the hindfoot casts, the youngster’s foot then re­ by fusing the four major bones of the Flat Feet (Pes Planus, Pes Planovalgus, quires special shoes with a bar inter­ hindfoot into one mass which has a or Pronated Feet) connecting them (Denis-Browne bar) normal appearance. Tendon transfers at this time will improve the muscle to hold the feet abducted, dorsiflexed This much less serious condition balance of the foot. Observation until and externally rotated. This device is usually has a favorable outcome. Here skeletal maturity is attained is neces­ used to maintain, not obtain, correc­ we see essentially a laxity of all the sary to see that the deformity does not tion of the foot deformity. Once the soft tissues of the foot. On examina­ recur.6 youngster is standing, he is placed in tion one notes a collapse of the longi­ special shoes with an outflare last, tudinal arch of the foot and rounding Metatarsus Adductus outer heel wedge, and a short leg brace of the medial border of the foot, with with an equinus stop, a device prevent­ In this deformity of the forefoot, the heel either in neutral position or in ing the ankle from drifting into plan- all five metatarsals are adducted slight valgus. Additionally, the fore­ tarflexion. (medially angulated toward the mid­ foot is usually abducted, everted, and Should serial plaster casts not attain line of the body) in relation to the pronated. Whereas the deformity is full correction or should a recurrence long axis of the hindfoot. The cause is present in the weight-bearing position, of the deformity develop, then release probably environmental (ie, intra­ there is no deformity in the non- of the contracted medial and posterior uterine positioning), although a fam­ weight-bearing position, and supple structures of the foot is necessary. ilial incidence is observed. Metatarsus motion is present at the subtalar and This includes transection of the multi­ adductus can be readily diagnosed in midtarsal joints. This distinguishes a ple joint capsules and ligaments and the early neonatal period, usually simple flatfoot from the more severe lengthening the contracted tendons, without the necessity of radiographs. foot deformities, such as peroneal such as the tendo Achilles.4 Limited Treatment will vary with the spastic flatfoot due to tarsal coalition bony resections can likewise be per­ severity of the adduction deformity. or vertical talus. Radiographic evalua­ formed.5 Tendon transfers to restore Initially, abduction stretching exer­ tion of pes planus was presented muscle balance about the foot are an cises of the forefoot (stretching the earlier. adjunctive form of treatment and forefoot lateral to the midaxis of the One additional word of caution. usually are not done until one is foot) will be sufficient. Occasionally, Infants normally have a plantar fat pad certain that bony deformities will not serial plaster castings to bring the which fills and obliterates the longi­ recur. forefoot out of adduction and into tudinal arch. This fat pad persists until Late treatment, for deformity exist­ greater amounts of abduction are age three, eliminated by the more ing at 12 years of age or more, is necessary, with the casts changed at forceful ambulation established by that age. Thus, it is difficult to distin- directed more at realigning the foot by weekly or biweekly intervals to gain

539 THEJOURNALOF FAMILY PRACTICE, VOL. 3, NO. 5, 1976 Figure 3a. Weight-Bearing AP View of Varus Foot Deformity Note how the TO angle is markedly reduced, that the anterior projection of the midtalar line is well to the lat­ eral side o f the fo o t, and that the forefoot is adducted in relation to Figure 3b. Weight-Bearing Lateral View of Varus Foot Deformity the hindfoot. Note how the lateral TC angle is markedly reduced in degree and that the anterior projection of the midtalar line passes superiorly to the metatarsals. Additionally, the forefoot is inwardly rotated or supinated.

guish the “physiologic” flatfoot from restore and maintain the proper align­ This very severe deformity should a true flatfoot due to a collapse of the ment of the talus and the os calcis so be diagnosed promptly. It requires the longitudinal arch in a youngster under that they may subsequently develop in management of an orthopedic surgeon three years of age. Palpation of the a more normal manner; the usual skilled in the care and treatment of bones of the hindfoot in the weight­ procedure for this is an extra-articular this very rare deformity, for multiple bearing position may distinguish the bone graft at the subtalar joint stabiliz­ staged surgical procedures are neces­ two conditions; a valgus alignment of ing the talus and os calcis in the sary. the heel certainly suggests true flatfoot normal position, a procedure which or pes planovalgus deformity. Infants does not interfere with subsequent Tarsal Coalition with a “physiologic” fat pad suggest­ growth and development of either Varying degrees of union are pres­ ing a pes planus need merely to be bone. ent between two or more tarsal bones observed at yearly intervals. in this congenital abnormality produc­ This condition is readily managed Vertical Talus (Congenital Convex ing a rigid planovalgus foot. Whereas in the office. The less severe forms — Valgus, Congenital " Rocker-bottom" simple flatfoot deformity will appear those in which the hindfoot or heel is Foot) normal in the nonweight-bearing posi­ not in excessive valgus - can be This condition is initially confused tion and will allow motion at the treated with Oxford shoes containing a with flat feet because of the rounded subtalar and midtarsal joints, in tarsal Thomas heel (a heel containing a position of the medial border of the coalition there is no change in appear­ medial heel wedge and a longitudinal foot and the rounded position of the ance from the weight-bearing to the extension of the medial half of the plantar surface of the foot. On closer nonweight-bearing position and there heel), a medial extension of the heel inspection, however, one realizes that is no subtalar or midtarsal joint mo­ counter of the shoe, and a longitudinal the problem is more complex. This is a tion. The exact cause of tarsal coali­ arch support (scaphoid “cookie”). very severe congenital deformity of tion is unknown, but appears to Milder forms respond well to simply the foot in which there is a primary represent a failure of differentiation an arch support in a regular Oxford dislocation of the talonavicular joint, and segmentation of the primary shoe, much less costly for the family. with the navicular articulating with the mesenchyme, with resultant incom­ Remembering that bones develop in dorsal aspect of the talus, locking it in plete bone and joint development. The response to the stress applied to them, a plantarflexed or vertical position. coalition may be completely osseous, the assumption is that by supporting The forefoot is dislocated dorsally in cartilaginous, or fibrous, with involve­ them in the more normal position the relation to the hindfoot. Additionally, ment including any of the bones of the bones of the foot will thus develop the os calcis is markedly plantarflexed. hindfoot in varying degrees and com­ normally. It is doubtful, however, that (Figure 7) Because of the plantar­ binations. the shoes overcome the basic liga­ flexed position of the os calcis and the As occasionally there are no mentous laxity of the foot. talus, with the forefoot dorsiflexed in symptoms, it is only during a careful More severe cases of flat feet, those relation to the two bones of the evaluation of a suspected flatfoot de­ in which the heel is in significant hindfoot, a very distinct “rocker- formity that the true nature of the valgus, may need surgical procedures bottom” deformity of the arch of the deformity is apparent. Usually, how­ at about age five or six in order to foot results. ever, the child will give a history of

540 THE JOURNAL OF FAMILY PRACTICE, VOL. 3, NO. 5, 1976 difficulty of running on rough ground because of the absence of any hind- (oot motion which usually accommo­ dates for the variation in the ground surface. Moreover, there will be a history of frequent “ankle sprains,” which in actual fact are very mild strains of the ankle joints and are the result of the added stress placed on the ankle joint because of the absence of hindfoot motion. Radiographically, an oblique x-ray of the hindfoot in the nonweight-bearing position will usu­ ally demonstrate or suggest the tarsal coalition; laminography is occasionally necessary to delineate the deformity fully.7 Treatment varies with the severity of the symptoms. In the very mild cases no specific treatment will be necessary. Occasionally, where the coalition is rather limited, resection of the fibrous or bony bridge can be accomplished. In a significant number of cases triple arthrodesis of the hind­ foot (fusion of the four bones of the hindfoot) will be required.

Pes Cavus Pes cavus is a fixed equinus (plan- tarflexion) deformity of the forefoot in relation to the hindfoot. If clawing of the toes is associated, the term claw Figure 4. Weight-Bearing AP Projection of a Varus (Left) and of a Normal (Right) Foot This x-ray graphically illustrates the reduced TC angle in the varus foot, with the foot is sometimes used to describe the midtalar axis projecting to the lateral aspect of the foot (or in reality, that the forefoot condition. Cavus deformity is usually a is adducted and supinated in relation to the hindfoot). manifestation of some underlying neuromuscular disease, although some cases of pes cavus are congenital and tion; one should realize that the bones whether the condition is static or whether it is a progressive neuro­ have no detectable neuromuscular of the hindfoot are in proper relation­ deficit. The neuromuscular defect may ship to the tibia and that the forefoot muscular disorder in which further he anywhere from the cerebellum to bones, beginning at the midtarsal joint, muscle weakness and imbalance can be the spinal column, to the anterior horn are markedly plantarflexed in relation expected. The usual complaint of the indivi­ cells or peripheral nerves, or to the to the bones of the hindfoot. dual with congenital or idiopathic muscles. The result is a muscle im­ Once the initial diagnosis is made, balance between the forefoot dorsi- further work-up is vital in order to cavus deformity of the foot is that ol increased pain along the metatarsal flexors and plantarflexors, with the fully delineate the cause of the cavus heads because of the excessive obliq­ latter being relatively stronger than the deformity. If there is any suggestion of uity of the metatarsals, producing the dorsiflexors. Because of the continued a neuromuscular lesion, then the pre­ symptoms of metatarsalgia. I his can imbalance, contractures of the soft cise site of this deficit must be estab­ be treated with a metatarsal or Jones tissue structures, such as the plantar lished by a careful neurologic work-up, which may require diagnostic studies bar, which is applied by an orthopedic fascia of the foot, ultimately develop shoemaker, to relieve the pressure to give a fixed deformity. Clinically, such as electromyography, special x- rays of the spine including myelogra­ from the metatarsal heads. Occasion­ the youngster’s foot presents with a ally arch supports or a metatarsal pad high arch. The additional neuro­ phy, muscle biopsy, and serum en­ zyme studies of muscle function. will likewise provide some symp­ muscular findings will depend on the tomatic relief. particular etiology, with the claw toe Ultimately, an orthopedic surgeon can restore the alignment of the fore­ deformity likewise a result of the Hallux Valgus and Bunion Deformity foot by surgical resection of the con­ muscle imbalance. Again, congenital These terms are commonly used pes cavus does not show a neuro­ tracted structures and by tendon trans­ fers to restore forefoot dorsiflexors, synonymously, although they refer to muscular deficit. different elements of the same syn­ Radiographically, a weight-bearing but the critical issue is to establish the proper diagnosis. Prior to initiating drome - lateral deviation of the great lateral view of the foot will demon­ toe at the metatarsalphalangeal joint strate the exaggerated high arch posi­ orthopedic treatment, one must know

541 THE JOURNAL OF FAMILY PRACTICE, VOL. 3, NO. 5, 1976 Figure 5a. Weight-Bearing AP Projec­ tion of Valgus Foot Deformity Note that the TC angle is markedly increased, that the anterior projec­ tion of the midtalar line extends medial to the forefoot, and that the forefoot is abducted in relation to Figure 5b. Weight-Bearing Lateral Projection of Valgus Foot Deformity the hindfoot. Note that the lateral TC angle is greatly increased and that the anterior projection of the midtalar line extends plantarward to the first metatarsal with these two lines no longer colinear, causing a sag in the longitudinal axis.

and medial prominence of the first ity of the condition and the severity of metatarsal head with its overlying ac­ the symptoms. Initially, just the use of quired bursa. Frequently, particularly adequately wide shoes will suffice, in the pediatric age group, secondary something readily available with the deformities are a progressively increas­ current practical shoe styles. Most ing problem. Frequently the bunion shoe repair shops have a device called a and hallux valgus are secondary or bunion stretcher, with which they can acquired deformities due to a medially literally stretch out the leather over- (toward midline of the body) directed lying the metatarsal head to provide first metatarsal (called metatarsus greater relief from the shoe. primus varus). If there is significant deformity, Examination reveals a widened and particularly if the first metatarsal forefoot with a suggestion that the is in varus, then surgical correction of first metatarsal is more medially di­ this deformity is necessary. Not only rected than normal, unusual promi­ does this eliminate the progressive nence of the medial aspect of the first secondary deformities, thereby reliev­ metatarsal head with or without an ing the symptoms, but the treatment is overlying acquired bursa, and the great directed to the cause of the deformity toe in valgus (directed toward the - the first metatarsal. Here one re­ lateral aspect of the foot). Ultimately stores the normal alignment of the the great toe can be in such increased first metatarsal, as well as eliminating valgus that it is overlapped by the the bunion and realigning the great second toe (which can then develop a toe. hammertoe deformity). The skin over- lying the bursa may be reddened and inflamed depending on the pressure Hammertoe Deformity from the overlying footwear. The sec­ Hammertoe is a deformity charac­ ondary deformities progressively in­ terized by contractures of the crease with time. proximal interphalangeal joint. The Treatment will vary with the sever­ distal interphalangeal joint may be in

542 THE JOURNAL OF FAMILY PRACTICE, VOL. 3, NO. 5, 1976 Figure 7. Weight-Bearing Lateral Projections of Two Examples o f a Vertical Talus Foot Deform ity Note the vertical incline of the talus with the marked increase in the TC angle and complete disruption of the line formed by the midtalar and the first metatarsal axes. The film on the right further shows that the heel, as illustrated by the os calcis, is in marked equinus (plantarflexion).

flexion, neutral, or slight hyperexten­ the extended position. In the adoles­ Closing Comment sion. Ultimately, the metatarsalpha- cent, if the deformity is severe and The deformities described above are langeal joint becomes hyperextended. disabling, surgical correction is indi­ the more common ones seen in the Hammertoe is often bilateral and cated. A very satisfactory method of busy practitioner’s office. The family symmetrical, with the second toe most treatment is resection of and fusion of physician appreciating these condi­ frequently affected and much less fre­ the proximal interphalangeal joint in tions can more effectively initiate their quently the third and fourth toes, The neutral position. prompt and appropriate treatment. deformity is usually congenital, and there is a very high familial incidence. Claw Toes Symptoms are produced at two In contrast to hammertoe defor­ References sites, the PIP joint and the metatarsal mity, clawing of the toes is char­ 1. Ritchie GW, Kevin HA: Major foot acterized by hyperextension of the deformities: Their classification and x-ray heads. Painful callosities develop under analysis. J Can Assoc Radiol 19:155-166, metatarsalphalangeal joint and flexion 1968 the metatarsal heads due to the distor­ 2. Gardner E, Gray DJ, O 'R ahilly R: tion of the toe with its loss of assis­ of both the proximal and distal inter­ The prenatal development of the skeleton phalangeal joints. Additionally, rather and joints of the human foot. J Bone Joint tance in toe push-off to relieve pres­ Surg (Am) 41:847-876, 1959 sure from the metatarsal heads. than being an idiopathic condition, the 3. Wynne-Davies R: Family studies and deformity usually is secondary to pes the cause of congenital clubfoot. J Bone Additionally, a painful corn develops Joint Surg (Brit) 46:445-463, 1964 over the dorsal aspect of the PIP joint cavus or to a neuromuscular deficit. 4. Turco VJ: Surgical correction of the Thus, it is important to distinguish it resistant clubfoot. J Bone Joint Surg (Am) as a result of pressure from overlying 53:477-497, 1971 from hammertoe deformity, for claw­ 5 Evans D: Relapsed clubfoot. J Bone footwear. Joint Surg (Brit) 43:722-733, 1961 Infants and children with hammer­ ing is a much more serious condition. 6. Wynne-Davies R: Talipes equmo- Consequently, a more extensive work­ varus: A review of 84 cases after completion toe can be treated conservatively by of treatment. J Bone Joint Surg (Brit) passive stretching exercises or perhaps up to rule out a neuromuscular dis­ 46:464-476, 1964 order is required. Treatment, natu­ 7. Conway JJ, Cowell HR: Tarsal coali­ with adhesive tape strapping, fastened tion: Clinical significance and roentgeno- to the neighboring two toes, to hold rally, will vary with the particular graphic demonstration. Radiology 92:799 the proximal interphalangeal joint in cause of the clawing. 811, 1969

543 THE JOURNAL OF FAMI LY PRACTICE, VOL. 3, NO. 5, 1976