Foot and Ankle

Club Foot


Approximately 1 per 1000 live births in the USA and 2.5 per 1000 live births in South Australia
Male : Female 2:1
Bilateral in 30 - 50% of cases
10% chance of subsequent child being affected if positive family history
2.3% if no family history



The true aetiology of congenital club foot is unknown- most infants who have clubfoot have no identifiable genetic/ syndromal/ extrinsic cause
  1. Extrinsic causes:
    teratogenic agents eg sodium aminopterin
    Congenital constriction rings

  2. Genetic causes:
    Mendelian inheritance: eg Diastrophic dwarfism- get an autosomal recessive pattern of club foot inheritance. Cytogenetic abnormalities- CTEV can be seen in syndromes involving chromosomal deletion. Multifactorial inheritance- it has been proposed that idiopathic CTEV in otherwise normal infants are the result of a multifactorial system of inheritance. Evidence for this :

incidence in
general pop= ~ 1/1000 live births
1st deg rels= ~ 2%
2nd deg rels= 0.6%
If one monozygotic twin has CTEV- the 2nd twin has a 32% chance of also having CTEV

ref: Cowell and Wein " Genetic aspects of club foot" JBJS 62A: 1381, 1980


Theories of pathogenesis

  1. arrest of foetal development in the fibular stage ( Bohm JBJS 11: 229, 1929)
  2. defective cartilaginous anlage of the talus ( Irani and Sherman JBJS 45A: 45, 1963)
  3. neurogenic factor- histochemical abnormalities have been found in posteromedial and peroneal muscle groups of CTEV pts- thought due to innervation changes in intrauterine life ( Isaacs etal JBJS 59B: 465,1977
    Neurological imbalance deformity
    The incidence of varus and equino-varus deformity in spina bifida is about 35%
  4. retracting fibrosis- increased fibrous tissue in muscles and ligaments
    ( Ippolito and Ponseti: JBJS 62A: 8, 1980)
  5. Myoblasts in medial fascia- found on EM studies-postulated to cause medial contracture (Zimny etal J Paed Orthop 5:577 , 1985)
  6. Anomalous tendon insertions ( Inclan JBJS 40:159, 1958)
    other studies have not supported this - the distorted anatomy can make it appear that tendon insertions are anomalous)



Femur, tibia and fibula-
the entire lower limb can be shorter
fibular shortening most common
all relationships of the talus are abnormal- including:
- anterior extrusion of the body of the talus
- ER of the body in the ankle mortise, quinus
- medial and plantar deviation of the neck of the talus
Os calcis
medial rotation, equinus
medial subluxation
medial subluxation
adducted and supinated, severe cases have cavus also

Atrophy of the leg esp in peroneal group
number of fibres is normal , fibres are smaller in size
Triceps surae, Tib post, FDL,FHL are contracted

Tendon sheaths
frequently thickened, esp about tib post and peronei

Jt capsules
resistant CTEV - contractures of ankle, subtalar, talonavicular, calcaneocuboid jts

Resistant CTEV - contractures of calcaneofibular + talofibular ligs, deltoid lig, long and short plantar ligs, spring lig, bifurcate lig

Contracture of fascial planes and of plantar fascia



Fixed which are either
Flexible correctable
Resistant surgery



A detailed family history of club foot or neuromuscular disorders should be sought and general examination carried out to identify any other abnormalities

If child can stand observe if the foot is plantigrade, if the heel is bearing weight and is it in varus, valgus or neutral
Similar deformities seen with myelomeningocoele and arthrogryposis therefore always examine for these associated conditions

Ankle is in equinus and foot supinated (varus) and adducted (the normal infant foot can usually be dorsiflexed and everted so that the foot touches the anterior tibia) dorsiflexion beyond 90o is not possible

The navicular is displaced medially as is the cuboid and there are contractures in the plantar aponeurosis, abductor hallucis and flexor digitorum brevis cavus deformity of the foot
The calcaneus is not only in a position of equinus but the anterior aspect is rotated medially and the posterior aspect laterally
Even after correction the foot often remains short and the calf thin

AP: taken with the foot in 30 deg plantar flexion with the tube at 30 deg from vertical
Lat: taken with the foot in 30 deg plantar flexion
Measure talo-calcaneal angle in the AP and lateral films
AP line drawn through the centre of the long axis of the talus parallel to the medial border and through the long axis of the calcaneus parallel to the lateral border, usually 25 - 40o , less than 20 deg abnormal

Lateral lines are dawn through the mid point of the head and body of the talus and along the bottom of the calcaneus, usually 35 - 50o club foot range between 35o and minus 10o
These 2 angles are added to give the talocalcaneal index- in a corrected foot more than 40 deg
Flat top talus can be demonstrated radiologically if the talus is sufficiently calcified but care is
required for positioning of the foot

Lateral film with the foot held in maximal dorsi-flexion was the most reliable method of diagnosing an uncorrected club foot as the absence of calcaneal dorsi-flexion is evidence that the calcaneus is still locked in varus angulation under the talus



  1. Correct deformity early
  2. Correct deformity fully
  3. Hold the correction until growth stops

Two categories or varieties identified;

corrects with splintage alone
respond poorly to splintage, relapse quickly and need early operative correction
Associated with thin calf and small high heel

Nonoperative treatment
Counselling and advice to the parents is required, they should be reassured that they are in no way responsible for the deformity and it is most unlikely to be reproduced in subsequent pregnancies
Splintage begins at 2 - 3 days post birth
Order of correction

  1. Forefoot adduction
  2. Forefoot supination
  3. Equinus

attempts to correct equinus first may break the foot producing a rocker bottom foot

Force must never be used
Merely bring the foot around to the best position obtainable and maintain this position by either strapping every few days or casting changed weekly, until either full correction is obtained or correction is halted by some irresistible force
The corrected position is maintained for several months
Surgery should be used as soon as it is obvious that conservative treatment is failing (persisting deformity, rocker bottom deformity or rapid relapse after correction has stopped)
By 6/52 usually apparent that the foot is "Easy" or "Resistant" and this is confirmed on X-Ray due to the orientation of the bones



When to operate?
when a plateau has been reached in nonop treatment
when the child is of sufficient size to enable anatomy to be recognised

theatre- warm, GA, position prn, Tourniquet, good light, magnification
Incision: options include- Cincinnati, Turco, separate 3 incisions- post vertical, med+ lat,
separate 2 incisions- curvilinear med and posterolat
The approach should adequate exposure (Cincinnati= transverse incision that extends from the antero-medial (region of navicular-cuneiform joint) to the antero-lateral (just distal and medial to the sinus tarsi) aspect of the foot and over the back of the ankle at the level of the tibio-talar joint)
Structures to be released or lengthened;
Achilles tendon (ETA)
The tendon sheaths of the muscles crossing the subtalar joint
Posterior ankle capsule and deltoid ligament
Inferior tibio-fibular ligament
The fibulo-calcaneal ligament
Capsules of the talo-navicular and subtalar joints
Division of associated ligaments around the subtalar joint
Plantar fascia and intrinsic muscles
The longitudinal axis of the talus and calcaneum should be separated by about 20o in the lateral projection, and the calcaneal angle should be a right angle to the shaft of the tibia

Treatment by age:
less than 5 years correction can be achieved by soft tissue procedures
more than 5 years requires bony reshaping, eg dorso-lateral wedge excision of the calcaneo cuboid joint (Evans procedure) or osteotomy of the calcaneum to correct varus
more than 10 years lateral wedge tarsectomy or triple if the foot is mature (salvage procedures)

Posterior release:
(Hutchins, Foster, Paterson, Cole JBJS 67B: 791, 1985)
longitudinal incision
Z- lengthened tendo calcaneus
identify NV bundle
tendon sheaths of FHL,FDL,Tib post released - tendons not elongated
ankle jt capsule opened, release of talofibular, calcaneofibular and seep portion of deltoid ligaments ( blunt dissection)
release of distal tib- fib ligs
posterior release of the subtalar jt
with foot held just above neutral , tendo calcaneum repaired + skin closed
POP in corrected position for 4 wks, change to splints until maturity

Postero-medial Release: (Turco)
Make a medial incision 8 - 9cm long from the base of the 1st metatarsal to the tendo calcaneus curving it just inferior to the medial malleolus with out undermining skin. Mobilise and expose the tendons of tibialis posterior, flexor digitorum longus, flexor hallucis longus, the tendo achilles and the posterior neurovascular bundle.

Continuing the incision in the sheaths of FDL and FHL divide the master knot of Henry beneath the navicular. Divide the spring ligament detaching it from the sustentaculum tali and the origin of abductor hallucis. Release the remaining contractures starting posteriorly. Lengthen the tendo achilles (Z plasty) detaching the medial half of the tendon insertion. Retract the neurovascular bundle and FHL anteriorly to expose the posterior aspect of the ankle and subtalar joints then incise the posterior capsule of the ankle joint under direct vision and the posterior talofibular ligament if required at this time. Then divide the subtalar capsule and calcaneofibular ligament.

Retract the neurovascular bundle posteriorly and divide the tibiocalcaneal part of the deltoid ligament. Lengthen tibialis posterior if contracted. Open the talonavicular joint and divide its capsule but avoid damaging the articular surface. Then release the subtalar ligaments and reduce the navicular onto the head of the talus which should properly align the other tarsal bones. Ensure the relationship of the talus to the calcaneus and navicular is correct and stabilise the foot with 'K' wires with the first wire being passed from the dorsum of the foot across the first metatarsal shaft, the medial cuneiform, the navicular and into the talus. A second wire fixes the subtalar joint and this should maintain the foot in the corrected position.

Apply a AK POP which is changed at three weeks and maintained to six weeks. The foot is initially held in slight equinus if there is tension on the skin closure which is corrected at the time of change of POP. Splintage is continued for at least 4 months after surgery and then night splints for several years.

OKU 4:
incision is not of so much issue- they note the Cincinatti gives a good exposure
The approach should be to address the release in quadrants

  1. Plantar: plantar fascia, Abd Hallucis and FDB, long and short plantar ligs
  2. medial: identify med structures, release tendon sheaths
    talonavicular and subtalar release, lengthening tib post ( and also FHL, FDL)
  3. Posterior: ankle and subtalar capsulotomy esp releasing post talofib and the calcaneofibular ligs
  4. Lateral: identify lat structures, release peroneal sheaths
    calcaneocuboid release, completion of talonavicular and subtalar release
    foot is maintained in corrected position by K-wiring the talonavic jt and also the subtalar jt



Infection (rare)
Wound breakdown release skin retractors every 30 mins and the tourniquet before closing the wound and applying a cast
Stiffness / restricted ROM (early stiffness correlates with a poor result)
AVN of the talus: Combined simultaneous medial and lateral release 40% incidence of AVN of the talus
Persistent intoeing is quite common which is not due to tibial intorsion but rather insufficient external rotation correction of the subtalar joint


Overcorrection assoc with:
release of interosseous lig ST jt
excess lat displacement of navicular on talus
overlengthening of tendon units

Residual deformity following initial surgery
must ensure there is not a neurological cause for recurrence eg tethered cord

Residual deformity may be

  1. Dynamic - with residual adductus and supination that are fully correctable passively, treat with SPLATT
  2. Fixed if not too much scarring and less than 5 yo - repeat release
    if more than 5yo will need bony procedure to straighten the lat border of the foot

To correct adductus- options are:

  1. Metatarsal osteotomies- this operation creates a secondary deformity to compensate for a primary deformity in the tarsus rarely indicated
  2. cuboid decancellation
  3. calcaneocuboid fusion (Dillwyn Evans - procedure consisted of a med and post release together with excision and fusion of the calcaneocuboid jt - should be reserved for those over 4 yo)
    These 2 procedures aim to shorten the lat side of the foot
  4. lengthening the medial side of the foot eg talar osteotomy- not widely performed , risk AVN

To correct residual hindfoot deformity-options are

varus heel -
opening medial wedge or closing lateral wedge
lat displacement os calcis osteotomy- preferred
for residual cavus and adductus-
wedge tarsectomy
for failed feet -
triple arthrodesis



Taking all comers ~ 50% of newborn club feet can be corrected by non-operative means (Eilert)
Others report success rates of between 10% (Fixsen) and 35% (Turco)
Most series report 75 - 90% satisfactory results of operative treatment (appearance and function of the foot) and the amount of motion in the joints of the foot and ankle correlate with the degree of patient satisfaction

Adelaide satisfactory results obtained in 81% and the range of ankle movement was a major factor in determining the functional result which was again influenced by the degree of talar dome flattening (suggest the primary bone deformity present at birth dictates the eventual result of treatment) 44% had no dorsi-flexion beyond neutral and 38% needed further surgery of which nearly 2/3 were bony procedures
Recurrence rates of deformity reported at around 25% but range from 10 - 50% (Menelaus reported a 38% recurrence rate)
Best results obtained with children more than 2 years of age and with a foot large enough to perform the surgery without compromise (> 8cm length Simons)
The age at operation id directly related to the result
Less than satisfactory results may be associated with overcorrection which occurs in around 15%
Previous surgery seems to have a deleterious effect on the end result

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Vertical Talus


More than 80% of cases are associated with generalised syndromes and disorders of the CNS
eg spina bifida , arthrogryposis
~ 1/3 may have a +ve family history



Congenital (about 2/3) which are present at birth
Developmental (1/3) which are normal at birth where the deformity develops later secondary to contracture of the tendo-achilles



Fixed dorsal dislocation of the navicular off the talar head
Equinus ankle contracture
abduction contracture of the foot
The heel cord, peroneals, anterior tibial muscles and toe extensors are contracted



plantar aspect of the foot is convex- "rocker- bottom"
heel is in fixed equinus with a tight heel cord and the hindfoot is in valgus
the head of the talus is prominent and palpable medially in the sole
the forefoot is in abduction and dorsiflexion at the midtarsal jt
Natural history: does not respond to manipulation
if uncorrected- develop pain in adolescence or early adulthood



lateral XR in
max plantar flexion- demonstrates the irreducible talonavicular jt
max dorsiflexion- demonstrates the fixed equinus

a line drawn through to the axis of the talus will pass plantar to the metatarsals



Always surgical- closed treatment rarely succeeds- the role of stretching is to prepare the tissues for operation
A single stage operation is recommended:
-ETA and post ankle capsulotomy
- peroneal tendon lengthening and calcaneocuboid capsulotomy
- Tib ant- reroute through the neck of the talus- dynamic restraint to redislocation
- EDL- lengthen
- Talonavicular capsulotomy, reduction- held with K- wire
- reconstruction of the spring lig and plicate Tib post to support talar head

Triple arthrodesis - salvage for symptomatic mature foot


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Metatarsus Adductus

due to intrauterine positioning
less than 10% require operation, 85% resolve spontaneously



Usually correctable by splintage
Children with metatarsus varus requiring cast correction are best treated at the age of 2 - 4 months
in general a passively correctable foot does not require splintage- for more fixed deformity a casting program -serial casts changed 2/wk for ~ 4 wks rapidly corrects deformity
After 6 - 8 months the deformity is so rigid and the child so strong that cast correction is nearly
impossible.The heel must be held in varus with the fulcrum for forefoot correction at the cuboid laterally (a bent long leg cast prevents escape from the cast)

Surgical correction for metatarsus varus is rarely indicated
At 4 years or older surgical options are:

  1. division of the capsules of the tarso-metatarsal joints may enable correction
  2. osteotomy of all five metatarsals- procedure of choice- less stiffness postop
  3. wedge tarsectomy (Evans procedure)

ref: Ponseti and Becker " Congenital metatarsus adductus: the results of treatment"
JBJS 48A:702-711, 1966


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Talipes Calcaneus

Intrauterine positioning
Common 1/ 1000 live births dorsiflexed foot +/- valgus
the deformity is typically flexible and fully correctible
Usually corrects but in some cases requires splintage
If calcaneo valgus has a high association with CDH therefore check the hips
Calcaneovalgus deformity can result from muscle imbalance eg meningomyelocoele with weak or paralysed plantar flexors- this type of deformity will be progressive
Neurologic calcaneus is managed by an AFO until muscle function clear- once this is achieved, may require tendon transfer or bony procedure eg subtalar arthrodesis to stabilise hindfoot


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Intoeing and Outtoeing

Normal development

femoral anteversion decreases from ~ 40o at birth to ~15o at maturity
tibia increases lat rotation from ~ 5o at birth to ~ 15o at maturity


History- age of onset, severity, disability, milestones, family history
  1. hips for dysplasia
  2. rotational profile
    1. ression angle-angular difference bw the axis of the foot and the line of progression.
      Mild = -5 to -10 deg
      Mod = -10 to -15 deg
      Severe = more than -15 deg
    2. rotation - assess with pt prone
    3. Tibial version/torsion- pt prone with knees flexed to 90 deg
      i transmalleolar angle = angle bw line of thigh and normal to line bw malleoli
      ii thigh- foot angle angle bw line of thigh and line along axis of foot
    4. shape of foot



usually not required
Methods include
    plain XR- NB exclude hip dysplasia
  1. Fluorscopy
  2. Biplane radiography
  3. CT = gold standard



orthoses ineffective
NB- benign natural history- observe, most spontaneously resolve
Metatarsus adductus- an intrauterine positional deformity - resolves in 90%
observe, if no improvement® cast correction- long leg cast,change weekly for 4 wks

Tibial torsion
medial torsion will improve with time, lat torsion often worsens
osteotomy if deformitymore than 3 SD from mean ( less than -10 or more than +35 deg)
can osteotomise at any level

Femoral torsion
natural history to resolve - by age 8-9 all remodelling will have occurred and any further correction will be due to conscious modification of posture
osteotomy if deformity more than 3 SD from mean and is a cosmetic or functional problem ( IR 85o, ER less than10o )
can osteotomise at any level- subtrochanteric, shaft, distal
closed method used in adolescent


  1. less than 18 mths metatarsus adductus commonest
  2. ~18 mths up to ~3 yo - tibial torsion commonest
  3. more than3 yo- femoral torsion commonest

Femoral Anteversion
Normal femoral anteversion 40o in the newborn and decreases to 10 - 15o by the age of 8 years and the acetabulum is angled forward 15o.
Does not increase the risk of arthritis of the hip
Spontaneous improvement in the anatomic position can occur until the age of 8 years and improvement in the gait by concious effort until adolesence


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Peroneal Spastic Flat Foot (Tarsal Coalition)

Everted foot associated with peroneal muscle spasm but not produced by muscle imbalance
The syndrome consists of a painful, rigid valgus deformity of both the fore and hind parts of the foot and peroneal muscle spasm but not true spasticity


Often associated with calcaneo-talar or calcaneo-navicular bars (tarsal coalition) with a faulty pattern of movement in the subtalar joint producing pain and muscle spasm
Tarsal coalition in the foetus occurring as a result of failure of differentiation and segmentation of primitive mesenchyme
May also occur in inflammatory conditions such as Reiters disease and other inflammatory arthropathies when there is involvement of the subtalar joint


Usually 12 - 16 years at presentation
Males : Females 2:1
Often bilateral
Calcaneo-navicular and middle facet talo-calcaneal coalitions are the most common


? Fusion of accessory ossicles
? Failure of segmentation
? Autosomal dominant inheritance




Present with pain and gait disturbance usually as coalition ossifies limiting motion (calcaneo-navicular age 8 - 12 and talo-calcaneal age 12 - 16)
Peroneal and extensor tendons can be seen standing out on the lateral foot (not spastic but adaptively shortened)
May be associated with diffuse tenderness around the tarsus
Ankle movement is normal but subtalar movements are restricted or absent

Evidence of a tarsal coalition may be seen on lateral radiographs however oblique views or CT may be required (best seen in 45o oblique radiograph)
Degenerative joint disease may be evident in inflammatory conditions


Conservative initially
In young below skeletal maturity symptomatic treatment, splintage if severe and even BK POP
Calipers may correct deformity or slow progression and are particularly useful in olde patients with deformity due to inflammatory conditions
Operative intervention may take several forms

Young people: excision of the bar in the absence of degenerative changes
In talocalcaneal coalition:
if less than 30% of jt then excise
if greater than 30%, arthrodese

Older people: with degeneration of the talo-navicular and subtalar joints a triple arthrodesis
Calcaneal osteotomy either a medial wedge excision or lateral opening wedge to correct associated valgus heel


Results can be expected to be good or excellent in about 75% of cases and the best results are obtained in patients who had a cartilaginous coalition and who were less than sixteen years old at the time of the operation

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  1. Neuromuscular imbalance due to weak intrinsics
    Conditions associated with cavus or cavo-varus feet:
  2. Central nervous System
    Cerebral palsy
    Friedreich's Ataxia
    Spinal Cord
    Spinal cord tumour
    Spinal dysraphism
    e.g. Tethered cord,Spinal bifida, Diastematomyelia
    Spinal muscular atrophy
    Peripheral Nervous system
    Hereditary peripheral neuropathies eg CMT
    Traumatic peripheral nerve lesions
    Muscle Disease
    Duchenne's muscular dystrophy
  3. post ischaemic (Volkmans contracture)
  4. Common component of residual club feet
  5. Idiopathic


Often complains of fatigue and discomfort in the foot or ankle with the severity of symptoms paralleling the degree and rigidity of the deformity

May be the presenting abnormality representing the early signs of a progressive neurologic degenerative disease

The idiopathic variety usually noticed at about 10 years of age and it is usually bilateral
ankle: usually reduced dorsiflexion
hindfoot: There is inversion of the heel (calcaneo varus) and inversion of the subtalar jt
forefoot: is plantar flexed ( plantaris deformity) with pronation of the forefoot in relation to the hind foot
MTP joints: hyper extended
Inter-phalangeal joints: are flexed

Weight bearing is via a tripod of the heel, the first and fifth metatarsal heads and associated with hind foot varus which becomes fixed, pressure taken over a small area under the metatarsal heads pain and callosities
Callosities also develop over inter phalangeal joints due to pressure from shoe-wear

Coleman's block test establishes whether the hind foot is fixed or flexible and demonstrates the type of surgical correction required (place the foot obliquely on a 1 - 1.5" block so that the first metatarsal hangs free to allow correction of the hind foot during weight bearing- if the hind foot returns to neutral or valgus the deformity is flexible)


Is based on the age of the pt and the flexibility of the deformity
Tendon lengthenings and transfers are used for flexible feet, bony procedures added for fixed deformities

Young children
strengthening exercises and stretching
ensure footwear has enough room for the toes
Flexor to extensor transfers and inter phalangeal joint arthrodesis
- will straighten the toes
if much cavus- Steindlers and short flexor / abductor hallucis release may also be needed to release plantar fascia followed by a BK POP with the foot held in valgus and supination for 6/52 with frequent changes of POP to correct deformity (children aged 4 - 5 years)
Transfer of Tibialis Posterior to the calcaneum may result in correction of calcaneus deformity
if toe deformities become fixed- arthrodese all the PIP jts (so the long flexors no longer bunch the toes up) and the long extensors are reinserted into the MT necks to elevate the forefoot
If hind foot varus is fixed in Coleman's test and the first ray deformity severe calcaneal osteotomy (Dwyer type medial opening wedge or modified Dwyer with a lateral closing wedge osteotomy of the calcaneum) may be indicated (children aged 10 or older)- can be combined with Steindler op
Wedge excision of the tarso-metatarsal joints may be needed for severe deformity in the absence of neurological abnormality- done after maturity
increased arch support and contact area in appropriate fitting shoes best treatment but if severe painful deformities may require operation

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Due to major muscle imbalance, usually weak or absent gastrocs/ soleus eg polio
- usually tib ant, tib post, peronei are preserved
no conservative treatment , progressive


complain of shoe fitting problems, pain over prominences
prominent heel, upward pitch of calcaneus, high arch (= pistol grip deformity)


before 5 years old: no treatment in general as bony deformity usually not present, good muscle testing in this age group difficult, pt not likely to be disabled by the problem

5-12 years basic principles:

  1. stablise ST jt- extra-artic arthrodesis
  2. management of bony deformity of calcaneus and ankle
  3. release of plantar soft tissue contractures with or without calcaneal posterior displacement osteotomy
  4. tendon transfers to improve plantar flexion of os calcis

more than 12 years: these pts have fixed deformity
triple arthrodesis to stabilise and correct hindfoot +/- tendon transfer to improve plantar flexion

Ref: Coleman S.S. "Pes Cavus" Current orthopaedics 6: 81-87, 1992

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