Professional and Research Skills

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Part 1 (Paper 1)

Intra observer reliability of static measures in the normally developing infant foot and in clubfoot

Clubfoot is not an embryonic malformation. A normally developing foot turns into a clubfoot during the second trimester of pregnancy. Clubfoot is rarely detected with ultrasonography before the 16th week of gestation. Therefore, like developmental hip dysplasia and idiopathic scoliosis, clubfoot is a developmental deformation. A 17-week-old male fetus with bilateral clubfoot has more severe on the left. A section in the frontal plane through the malleoli of the right clubfoot the deltoid, tibionavicular ligament, and the tibialis posterior tendon to be very thick and to merge with the short plantar calcaneonavicular ligament. The interosseous talocalcaneal ligament is normal. A photomicrograph of the tibionavicular ligament the collagen fibers to be wavy and densely packed. The cells are very abundant, and many have spherical nuclei (original magnification, x475). (Morcuende 2005, 623)

The shape of the tarsal joints is altered relative to the altered positions of the tarsal bones. The forefoot is in some pronation, causing the plantar arch to be more concave (cavus). Increasing flexion of the metatarsal bones is present in a later medial direction. In the clubfoot, there appears to be excessive pull of the tibialis posterior abetted by the gastrosoleus and the long toe flexors. These muscles are smaller in size and shorter than in the normal foot. In the distal end of the gastrosoleus, there is an increase of connective tissue rich in collagen, which tends to spread into the tendo Achillis and the deep fasciae. In the clubfoot, the ligaments of the posterior and medial aspect of the ankle and tarsal joints are very thick and taut, thereby severely restraining the foot in equinus and the navicular and calcaneus in adduction and inversion. (Dobbs 2004, 22)

The size of the leg muscles correlates inversely with the severity of the deformity. In the most severe clubfoot, the gastrosoleus is seen as a muscle of small size in the upper third of the calf. Excessive collagen synthesis in the ligaments, tendons, and muscles may persist until the child is 3 or 4 years of age and might be a cause of relapses. Under the microscope, the bundles of collagen fibers display a wavy appearance known as crimp. This crimp allows the ligaments to be stretched. Gentle stretching of the ligaments in the infant causes no harm. The crimp reappears a few days later, allowing for further stretching. That is why manual correction of the deformity is feasible.

The clubfoot deformity occurs mostly in the tarsus. The tarsal bones, which are mostly made of cartilage, are in the most extreme positions of flexion, adduction, and inversion at birth. The talus is in severe plantar flexion, its neck is medially and plantarly deflected, and its head is wedge-shaped. The navicular is severely medially displaced, close to the medial malleolus, and articulates with the medial surface of the head of the talus. The calcaneus is adducted and inverted under the ...