Painful Calluses Research Articles

Painful thickened skin on the soles of the feet

A 45-year-old man from Tonga was noted to have thick, scaly skin on both feet. He reported a 20-year history of painful calluses and fissures on the soles, as well as nail thickening and intermittent white patches in the oral cavity. On physical examination, there was thick, yellow-colored hyperkeratotic scale projecting from the plantar aspects of both feet (Fig 1), hypertrophic nail dystrophy, and wedge-shaped subungual hyperkeratosis (Fig 2).

Effectiveness of Three Scalpel Debridement Techniques on Painful Callus in Older People.

Plantar hyperkeratotic lesions are prevalent foot problems in the older population, affecting 30% to 65% of people older than 65 years. Their onset is a common cause of foot pain due to the release of inflammatory mediators. Because of its simplicity, scalpel debridement is the most common treatment. We assessed how the degree of plantar hyperkeratosis debridement affects self-perception of pain in older people. Three hundred older participants (mean ± SD age, 76.3 ± 7.4 years) were randomly allocated to receive full debridement (FD) of plantar hyperkeratoses, partial debridement (PD) of plantar hyperkeratoses, or debridement simulation (control group). Plantar hyperkeratotic pain was measured on a visual analog scale before treatment, just after treatment, 24 hours after treatment, and 7 days after treatment. Both FD and PD of plantar hyperkeratoses of the forefoot generate similar levels of self-perception of pain just after treatment (P = .32), 24 hours after treatment (P = .15), and 7 days after treatment (P = .22). Significant differences were found between the groups treated using a scalpel (FD and PD) and the control group just after treatment (P = .04 for FD; P = .05 for PD), 24 hours after treatment (P = .03 for FD; P = .04 for PD), and 7 days after treatment (P = .04 for FD and PD). The results of this trial suggest that there are no significant differences in pain reduction between PD and FD of forefoot plantar hyperkeratoses in older people.

AOFAS Functional Scoring After Antegrade K Wires Fixation of Multiple Metatarsal Neck Fracture: A Case Report

Introduction & Objectives: Metatarsal Bone fractures contribute 3-7% of all fractures of the body, 35% of all fractures from the foot and also contribute 75 new cases per 10.000 persons per year. Another study evaluated the incidence involvement of multiple metatarsal fractures is higher than isolated metatarsal fractures. Metatarsal bone fractures mostly caused by low energy trauma, and also high energy trauma makes the incidence higher. The previous study said, that 43% of metatarsal fractures are the neck of the second and third metatarsal bones. Intramedullary fixation using Kirschner (K) wires has been chosen as a method of operative treatment for metatarsal bone. There are several outcome evaluation instruments for those who sustained a complex ankle or hindfoot injury. Among them, The American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score is commonly chosen by orthopedics for a quantitative and objective measurement. This study wants to evaluate the results obtained through AOFAS Scoring for fractures of the metatarsal neck, represent the clinical and functional results after K-wire management in surgery.Case Report: A 35-year-old man has admitted to the ER with a chief complain of a painful right hindfoot. Previously, a brick fell upon his hind foot while he was working to repair a wall with nothing to protect his hind foot. In our case, direct trauma due to falling object upon of his dorsal hindfoot caused neck fractures of 2nd - 4thmetatarsal bones, which had confirmed by X-Ray photos. His hind foot had been swelling and his fingers were barely able to do flexion and extension. We waited until the edema regresses for the surgery, in order to reduce the risk of developing compartment syndrome. In our case, we delayed surgery for 2 days. An antegrade K wires fixation is achieved by using antegrade wire insertion at the fracture site followed by retrograde fixation of the proximal fragment with the same wire. We have been following the patient from the beginning until 6 months after the K Wires fixation surgery in an outpatient clinic, and also the patient was kept no-weight-bearing within 2 months.Results & Discussion: In 2 months after the surgery, we did the X-Ray and it showed a callus formation. Then we expelled the K wires. We prospectively evaluated the outcome trough the AOFAS score and the score was 95 in the 6th month of the evaluation. We chose antegrade introduction of the K Wires for the best outcome, prevent a high rate of complications related to this type of treatment, minimize soft tissue insult to avoid the unsatisfactory outcome. When metatarsal bone fracture happened and did more than 10 degrees of angulation, it could make a disturbance of load distribution under metatarsal head that leads to mechanical metatarsalgia. Besides, it can also produce painful calluses and traumatic neuroma formation lead to painful trauma and then disturb a function of the lower limb. The antegrade approach prevents plantar displacement of the distal metatarsal fragment during K-wire insertion continues with an exteriorization by the retrograde manner of the wire in the plantar region. The study said that no complications were identified related to using the type of treatment. Another study said that a patient treated by a percutaneous antegrade surgical approach, had higher AOFAS scores, averaging more than 95 points within the 6th-month postoperative period. Inadequate fracture reduction, failure of fixation and pin-site infection could lower the AOFAS Score.Thus Percutaneous antegrade surgical treatment is an effective treatment for metatarsal fractures, with a lower incidence of complications.Conclusions: A metatarsal bone fracture that not treated properly can lead to changes in gait and foot load distribution, as it would decrease the point of AOFAS Score evaluation. We expect that the AOFAS Ankle-Hindfoot Score could give an objective quantitative scoring for the patients’ foot function, not only after the trauma but also after the surgery. A proper diagnosis and management of this fracture result in a good prognosis and low complication rates, presented by higher AOFAS Score.

Altered keratinocyte differentiation is an early driver of keratin mutation-based palmoplantar keratoderma.

The type I intermediate filament keratin 16 (KRT16 gene; K16 protein) is constitutively expressed in ectoderm-derived appendages and in palmar/plantar epidermis and is robustly induced when the epidermis experiences chemical, mechanical or environmental stress. Missense mutations at the KRT16 locus can cause pachyonychia congenita (PC, OMIM:167200) or focal non-epidermolytic palmoplantar keratoderma (FNEPPK, OMIM:613000), which each entail painful calluses on palmar and plantar skin. Krt16-null mice develop footpad lesions that mimic PC-associated PPK, providing an opportunity to decipher its pathophysiology, and develop therapies. We report on insight gained from a genome-wide analysis of gene expression in PPK-like lesions of Krt16-null mice. Comparison of this data set with publicly available microarray data of PPK lesions from individuals with PC revealed significant synergies in gene expression profiles. Keratin 9 (Krt9/K9), the most robustly expressed gene in differentiating volar keratinocytes, is markedly downregulated in Krt16-null paw skin, well-ahead of lesion onset, and is paralleled by pleiotropic defects in terminal differentiation. Effective prevention of PPK-like lesions in Krt16-null paw skin (via topical delivery of the Nrf2 inducer sulforaphane) involves the stimulation of Krt9 expression. These findings highlight a role for defective terminal differentiation and loss of Krt9/K9 expression as additional drivers of PC-associated PPK and highlight restoration of KRT9 expression as a worthy target for therapy. Further, we report on the novel observation that keratin 16 can localize to the nucleus of epithelial cells, implying a potential nuclear function that may be relevant to PC and FNEPPK.

Long-term outcomes of hallux valgus treated by the suturing of fascial flap of bursa of hallux with the tendon of adductor hallucis

Objective To evaluate the long-term clinical effect of adductor pollicis and pollicis sac fascial flap anastomosis for hallux valgus. Methods Data 12 cases with hallux valgus who who were treated by adductor pollicis and pollicis sac fascial flap anastomosis from April 1993 to November 1996 and were followed up for more than 19 years were retrospectively analyzed. All the patients were female with an average age of 43.6±7.6 years old (range, 24-56 years). HVA, IMA, and tibial sesamoid position (TSP) were measured by foot X-ray and compared between presurgery, 4 years postsurgery and 19 years postsurgery. The American Orthopaedic Foot and Ankle Society (AOFAS), hallux metatarsophalangeal joints, interphalangeal joint function scores were used to evaluatethe foot function. Patient satisfactions were investigated by Glynn's comprehensive clinical evaluation and hallux score. Results Average preoperative HVA was 30.68°±9.71°, and average 1st and 2nd IMA was 12.92°±4.02°. Average HVA 4 years and 19 years post-op were 24.62°±7.61° and 21.47°±6.52°, and average 1st and 2nd IMA were 7.32°±3.21° and 6.15°±2.92°, which were significantly less than those of pre-surgery. Average TSP was 4.46±1.03, average TSP 4 years and 19 years post-op were 2.01±0.75 and 1.79±0.62, which were significantly less than those of pre-surgery. There was no significant difference between 4 years and 19 years post-op. The incidence of plantar anterior callus was 95.2% (20/21); the incidence of pain was 85.7% (18/21), and the number of the corpus callosum was significantly reduced 19 year post-op. Only 1 foot had painful callus under the head of third metatarsal, and the rest of the corpus callosum were painless; the incidence of the corpus callosum was 33.3% (7/21); the incidence of pain of the corpus callosum was 4.7% (1/21); the incidence of pain of the corpus callosum was 4.7%, and patients with long-term improvement of the effect of the corpus callosum was significantly better than preoperative. The results of postoperative follow-up Glynn comprehensive clinical evaluation were 16 excellent feet, 2 good feet, 3 poor feet, and the excellent rate was 88.5% (18/21); the results of Glynn toe evaluation were 18 excellent feet, 3 good feet, and the excellent rate was 100%. Conclusion The adductor pollicis and pollicis sac fascial flap anastomosis in the treatment of hallux valgus can obtain good short-term and long-term clinical efficacy, by which postoperative hallux valgus deformity is excellently corrected, and the rate of patient satisfaction is high. Key words: Foot; Hallux valgus; Follow-up studies

Watch your step: caring for feet

Keeping our toenails neat and our underfoot callouses under control is something we take for granted when we’re relatively young and able bodied. As Age UK’s Foot Care Coordinator for Chorley, West Lancs and Sefton, I work with people who can no longer undertake their own basic foot care independently. If people in this situation cannot readily get someone to help with their feet, for financial reasons or otherwise, serious foot problems can develop. Toenails, for instance, can grow over the toes, piercing the skin and leading to possible infection, mobility problems and falls. The skin in-between toes can also become macerated, providing an ideal environment for fungal infections, which if untreated, can develop into bacterial infection and ulceration. Painful corns and calluses can also cause problems with walking, which can lead to falls, especially if some degree of instability co-exists. Frequently, these serious and often embarrassing foot problems could have been avoided with daily foot care. If only family, friends and carers were given the knowledge and confidence to help with basic foot care, and to recognise when to seek professional help! With this in mind, I developed the concept of Footcareunited: a voluntary initiative to provide free training on basic foot health to family, friends, carers and volunteers involved in care for the elderly. The idea is that Footcareunited will offer basic foot care advice and training to anyone in a caring role, giving them the knowledge and confidence to provide ongoing help to those who need it. This would not only mean that many serious foot problems could be avoided, but would also help to further develop closeness between the care giver and receiver. In 2014 I applied for the Cosyfeet Podiatry Award in the hope that the £1000 prize money could be used to turn the Footcareunited concept into a reality. I’m pleased to say that I was successful! I am now in the planning stages of setting up Footcareunited with Cosyfeet’s help. Now in its tenth year, the Cosyfeet Podiatry Award assists podiatrists and podiatry students to develop their professional knowledge and skills while benefitting others. The award is open to those who are planning voluntary work, a work placement or research, whether in the UK or abroad. As I am currently studying podiatry part-time at Salford University I qualified to enter and am so pleased I did. In a future issue of Nursing and Residential Care I hope to write about how the Footcareunited concept has been turned into a reality, and let you know how you, as a carer, can get involved.

Impact of foot reconstruction surgery on the daily life of patients with cerebrovascular accident sequelae

ObjectiveThe equinovarus deformity of the foot and digital scrolling is very common among people with sequelae from cerebrovascular accidents. The aim of this study was focused on changes produced by surgical correction of the deformity in terms of comfort, balance, independence and ability to move freely within the context of the daily life of the patient. Material and methodsThe data were evaluated using a retrospective survey and a prospective analysis of gait habits using a recording walking device (WalkinSense®) before and after surgery. All the 15 patients enrolled in the study were submitted to similar surgical procedures of lengthening and tendon transfers. ResultsThe use of technical aids to correct the deformity and to aid in walking, as well as painful calluses and difficulties with the shoes and walking on uneven surfaces, decreased significantly. Quantitative analysis of the gait showed that after surgery the patient started to move with smaller steps, although with a higher cadence. Gait analysis also revealed a decrease in the amount of gait segments and speed. Discussion and conclusionsThe results showed a positive development in terms of indicators of comfort, balance, independence and self-image through surgery. However the new way of walking seems to be more tiring for the patients, which could justify a decrease in the number of gait segments and speed.

Scalpel debridement has minimal effects on painful plantar calluses in older people: a randomised trial

Background Plantar calluses are often associated with increased plantar pressure and foot pain, which can have a detrimental impact on the mobility and independence of an older person. Scalpel debridement is a key management strategy for painful calluses; however the effectiveness of this treatment in older people has not been rigorously investigated. The aim of this randomised trial was to evaluate the effectiveness of scalpel debridement in reducing plantar pressure and pain associated with forefoot plantar calluses. Materials and methods Eighty participants aged 65 years and older with painful forefoot plantar calluses were recruited. Participants were randomly allocated to one of two groups: (i) normal scalpel debridement or (ii) sham (control) scalpel debridement. Participants were followed for six weeks. Both participants and assessors were blinded to the intervention. The primary outcomes measured were the difference between groups in pain (100 mm VAS) and barefoot plantar pressure (MatScan ® System).

Impacto de la cirugía reconstructiva del pie en la vida diaria de los pacientes con secuelas de accidentes vasculares cerebrales

ObjectiveThe equinovarus deformity of the foot and digital scrolling is very common among people with sequelae from cerebrovascular accidents. The aim of this study was focused on changes produced by surgical correction of the deformity in terms of comfort, balance, independence and ability to move freely within the context of the daily life of the patient. Material and methodsThe data was evaluated using a retrospective survey and a prospective analysis of gait habits using a recording walking device (WalkinSense®) before and after surgery. All the 15 patients enrolled in the study were submitted to similar surgical procedures of lengthening and tendon transfers. ResultsThe use of technical aids to correct the deformity and to aid in walking, as well as painful calluses and difficulties with the shoes and walking on uneven surfaces, decreased significantly. Quantitative analysis of the gait showed that after surgery the patient started to move with smaller steps, although with a higher cadence. Gait analysis also revealed a decrease in the amount of gait segments and speed. Discussion and conclusionsThe results showed a positive development in terms of indicators of comfort, balance, independence and self-image through surgery. However the new way of walking seems to be more tiring for the patients, which could justify a decrease in the number of gait segments and speed.

Effectiveness of scalpel debridement for painful plantar calluses in older people: a randomised trial

Effectiveness of scalpel debridement for painful plantar calluses in older people: a randomised trial

Distal pedical fibular osteoseptocutaneous flap transfer for the lateral forefoot defect

Objective The anterior-lateral defect of foot that lost one of the three supporting point of foot can lead to collapse of the lateral longitudinal arch, overload of the first metatarsal heads, and painful callus formation. It is meaningful to investigate the effect of reconstructing the lateral forefoot defect with pedical fibular osteoseptocutaneous flap. Methods From March 1989 to June 2008, there were 38 patients with anterior-lateral defect of foot were constructed. The supporting point with the local distal based pedical fibular osteoseptocutaneous flap was constracted. Results All the 38 flaps survived. All 38 patients had been followed up from 6 months to 10 years (mean 23.5 months) postoperatively. The constructed supporting point of the foot was functional. The patients could walk freely with no pain, and was satisfied with the operation. Assessed with the rating system for foot and ankle established by the American Orthopaedic Foot And Anke Society, 8 patients got a score above 85, 23 patients between 75 to 85, 7 patients between 60 to 75. Conclusion It is effective that transferring local distal based pedical fibular osteoseptocutaneous flap to repair the anterior-lateral defect of foot. Key words: Forefoot; Distal pedical fibular osteoseptocutaneous flaps; Transplantation; Microsurgery

Management of the Second and Third Metatarsal in Moderate and Severe Hallux Valgus

Hallux valgus is a common disorder of the forefoot that results from medial deviation of the first metatarsal and lateral deviation and/or rotation of the great. The management of hallux valgus is usually focused on the malalignment of the first ray, however, some patients report that pain at the plantar aspect of second and/or third metatarsal head(s) is more severe than the first metatarsophalangeal joint. In order to alleviate the metatarsalgia, we developed an oblique sliding osteotomy to manage the second metatarsal. This article reports the results of 17 feet that were treated with oblique sliding osteotomy. Average patient age was 55.3 years. The transverse arch of all patients had sagged, and all patients had painful calluses below the lesser metatarsals. Functional outcome was evaluated with the hallux valgus angle, intermetatarsal angle, proximal articular and distal articular set angles, and American Orthopaedic Foot and Ankle Society scoring system. The mean hallux valgus angle was 37.6 degrees preoperatively and 13.2 degrees postoperatively (mean correction, 24.4 degrees) and the mean intermetatarsal angle was 14.6 degrees preoperatively and 6.8 degrees postoperatively (mean correction, 8.8 degrees). American Orthopaedic Foot and Ankle Society scores improved from an average of 58 preoperatively to 87 postoperatively. Based on appearance and function, the outcomes of 16 feet were satisfactory. Pain of the forefoot was ameliorated and Mielke scores of 14 feet were either very good or good (82.3%) and satisfactory for 2 feet. Final follow-up was an average of 16 months and all patients were ambulating normally. We thus conclude that this surgical technique is effective in patients with moderate or severe hallux valgus.

Transfer of the second to the first metatarsal ray in a case of lawn mower injury: A case report

The medial longitudinal arch of the foot plays a major role for a physiologic transfer of the load from the heel to the forefoot during walking and running. Traumatic amputation that involve either the great toe or the whole first metatarsal bone can lead to collapse of the medial longitudinal arch, overload of the metatarsal heads, and painful callus formation. If replant of the amputated part is not possible or has failed, it is advisable to reconstruct the medial longitudinal arch in order to re-establish a functional transfer of the load in the foot. We present a case of a young lady who suffered from traumatic amputation at the distal third of the first metatarsal. Replantation failed due to the severity of the initial injury. Despite a good coverage of the defect with a lateral arm flap, the patient developed a painful plantar callus underneath the amputated stump. The adjacent second metatarsal ray was then raised as a pedicled flap including bone and soft tissues and transferred to the first ray in order to reconstruct a physiologic medial longitudinal arch. The patient had excellent functional results with no recurrence of the callus.

Comparison of Plantar Pressure, Clinical, and Radiographic Changes of the Forefoot after Biplanar Austin Osteotomy and Triplanar Boc Osteotomy in Patients with Mild Hallux Valgus

Boc's modification of the Austin procedure is a triplane distal osteotomy that achieves shortening and plantarflexion of the first metatarsal with a lateral translation of the metatarsal head. The clinical results and influence of the Austin and Boc osteotomies on plantar pressure have been compared retrospectively. The patients were divided into two groups: 30 Austin and 30 Boc osteotomies were performed with a mean followup of 37 (range, 29 to 56) months. Sixty patients with mild hallux valgus deformities and central metatarsalgia, took part in the study. Pressure measurements were performed with a Diagnostic Support system footplate. The average postoperative American Orthopaedic Foot and Ankle Society score of the Austin group was 81.9 and 86.4 for the Boc group. The pressure distributions under the fourth and fifth metatarsal head were comparable in both groups (p>0.05). The Austin group showed decreased load bearing under the hallux and the first metatarsal head (p<0.01), consistent with a persistent overloading of the second and third metatarsal head (p>0.05). The Boc group showed decreased weightbearing under the hallux with better load distribution beneath the second and the third metatarsal head (p<0.05). Correlation of the American Orthopaedic Foot and Ankle Society scores and pressure variables confirmed a significant negative correlation with altered hallux and central metatarsal head loading (p<0.01). The Boc triplane osteotomy seems to restore more physiologic loading of the forefoot in comparison to the Austin procedure, reducing the incidence of painful callus under the second and third metatarsal head.

Surgical Correction of Moderate and Severe Hallux Valgus

The painful bunion deformity is a common and relatively disabling condition that affects individuals of all ages. More than 150 procedures have been described for the treatment of hallux valgus, and the orthopaedic literature has focused predominantly on surgical management of this condition; however, successful treatment is often achieved with use of simple off-the-shelf orthotic devices and appropriate shoe-wear modifications. Given the potential for surgical complications, the substantial recovery period associated with bunion surgery, and patients' occasional dissatisfaction with the results of otherwise technically successful procedures, it is recommended that nonoperative treatment be initiated prior to proceeding with surgery. It is not uncommon for a patient with an asymptomatic bunion to actively seek surgical correction because of cosmetic concerns or because of an inability to wear fashionable shoes comfortably. While pain alone is not the only indication for surgery, it is not recommended that surgery be performed for cosmetic reasons alone. The American Orthopaedic Foot and Ankle Society has issued a position statement reflecting this1. Look for this and other related articles in Instructional Course Lectures , Volume 57, which will be published by the American Academy of Orthopaedic Surgeons in March 2008: • “Total Ankle Arthroplasty,” by James DeOrio, MD, and Mark Easley, MD Pain resulting from hallux valgus deformity is mechanical in nature and can have extrinsic and intrinsic causes. Most commonly, extrinsic pain is related to mechanical irritation of the prominent medial eminence by shoe-wear or is due to impingement of the hallux on the second digit. A painful callus may develop on the medial border of the hallux as a result of pronation of the digit, and pain beneath the second metatarsal head is also common as a result of the transfer of forces as the weight-bearing function of the hallux is compromised by …

Osteochondroma of the Talar Neck

Osteochondroma is the most common benign bone tumor. It rarely affects rearfoot bones, and only a few cases of talar osteochondroma have been reported. We report a case of a solitary osteochondroma of the talus that presented as a painful callus on the anterior portion of the ankle that was refractory to dermatologic treatment.

Lesser toe deformities

Lesser toe deformities often lead to painful calluses and metatarsalgia. Depending on the different underlying etiologies it is mandatory to perform a meticulous clinical assessment including the whole foot and the entire lower limb. Prior to any surgical interventions it is necessary to evaluate the deformity at all three joint levels. The metatarsophalangeal joint acts as a key joint. Any dorsal subluxation or dislocation has to be addressed first. This may include various soft tissue procedures and shortening osteotomies of the metatarsals. After successful realignment contractures of the distal joints have to be corrected. Since function of the lesser toes mainly depends on stability of the distal joints arthrodeses of the proximal and distal interphalangeal joints are superior to any resection arthroplasties.

Functional Hallux Rigidus in the Rheumatoid Foot

Hallux rigidus results from arthritic involvement of the first metatarsophalangeal joint. The authors have observed loss of motion at this joint in patients with rheumatoid arthritis in the absence of hallux valgus or joint destruction. A hyperextension deformity of the interphalangeal joint has also been observed, with a painful callus beneath it. The first metatarsophalangeal joint appears normal on roentgenograms, and passive motion of the joint is normal when it is examined clinically. The loss of first metatarsophalangeal motion is functional, and stems from muscle spasm of the great toe intrinsic muscles in an effort to relieve pressure on the lesser metatarsal heads. The interphalangeal hyperextension may develop secondary to "functional hallux rigidus."

VARUS AND VALGUS FOOT IN CEREBRAL PALSY AND ITS MANAGEMENT

Varus and valgus foot, often associated with equinus, are common problems in cerebral palsy. These deformities can interfere with standing or walking, aggravate shoe wear, and lead to painful calluses on pressure areas of the foot. The deformities are caused by a basic muscle imbalance. If the posterior or anterior tibial muscles are overactive, the foot will swing into varus. If the peroneal muscles predominate, the foot assumes a valgus position. However, the alignment of the hip and knee play an important role in the production of deformity. Correction of the deformity must be preceded by assessment of the deforming forces. In the younger child, simple muscle releases weaken the overpowering muscles and help restore muscle balance. In some instances, muscle transfers, either whole or split, not only alleviate the deforming force but also may provide needed support for the weaker muscles. Once bone deformities are established, they must be corrected either prior to or simultaneously with muscle procedures. The purposes of this article is to outline the evaluation of the deformity and the various soft tissue and bone operations which can be performed to correct them in order to obtain a satisfactory plantigrade foot.

Varus and valgus foot in cerebral palsy and its management.

Varus and valgus foot, often associated with equinus, are common problems in cerebral palsy. These deformities can interfere with standing or walking, aggravate shoe wear, and lead to painful calluses on pressure areas of the foot. The deformities are caused by a basic muscle imbalance. If the posterior or anterior tibial muscles are overactive, the foot will swing into varus. If the peroneal muscles predominate, the foot assumes a valgus position. However, the alignment of the hip and knee play an important role in the production of deformity. Correction of the deformity must be preceded by assessment of the deforming forces. In the younger child, simple muscle releases weaken the overpowering muscles and help restore muscle balance. In some instances, muscle transfers, either whole or split, not only alleviate the deforming force but also may provide needed support for the weaker muscles. Once bone deformities are established, they must be corrected either prior to or simultaneously with muscle procedures. The purposes of this article is to outline the evaluation of the deformity and the various soft tissue and bone operations which can be performed to correct them in order to obtain a satisfactory plantigrade foot.