PERMASALAHAN KAKI PADA ANAK

Growing Pain atau Nyeri kaki pada anak merupakan gejala pada anak tidak umum dibandingkan orang dewasa karena fleksibilitas dan ketahanan dari jaringan. tumbuh ke dalam kuku kaki dapat terjadi dan mungkin akan membutuhkan pengobatan. Non-spesifik sakit tumbuh di kaki adalah keluhan umum dari anak-anak, sering menyebabkan sakit mendalam seperti nyeri kaki di malam hari. Ada beberapa penyebab spesifik dari sakit tumbuh, terutama di bagian tumit, yang disebut penyakit Sever atau apophysitis kalkanealis dan di lutut, di mana disebut nya Osgood-schlatters penyakit. Clubfoot adalah deformitas relatif jarang pada saat lahir yang masih dapat menyebabkan masalah di kemudian hari setelah koreksi. Kaki yang berkeringat deras atau memiliki kaki berbau juga dapat menjadi masalah pada anak yang lebih tua.

Flat foot

Pentingnya alas kaki

In-toe dan out-toe

In-toeing berarti saat berjalan kaki kaki masuk  ke dalam bukan menunjuk lurus ke depan . Masalah yang umum dengan anak-anak dengan in-toeing adalah bahwa mereka dapat perjalanan lebih sering daripada anak lain. Sebagian besar mungkin akan mengatasi kondisi alami. Jika di-toeing tidak persisten atau menyebabkan masalah, sepatu khusus, latihan peregangan atau perawatan lain dapat diperlukan. Sekitar usia 2 tahun kebanyakan anak berjalan dengan kaki mereka menunjuk lurus ke depan atau sedikit ke luar. Orang tua atau anggota keluarga lainnya sering khawatir tentang cara anak berjalan.

Pada usia 2, kebanyakan anak akan berjalan dengan kaki mereka menunjukkan sedikit ke luar. Jika sudut kaki adalah berlebihan ke arah luar, ini disebut out-toeing. Hal ini tidak biasa seperti di-toeing, tetapi dalam banyak kasus, itu juga hanya bagian dari perkembangan normal.

Seringkali hanya diperlukan jaminan jika seorang anak adalah out-toeing atau di-toeing, penanganan yang cepat dan baik akan mencegah kasus tersebut menjadi menetap dan parah. Kadang-kadang di-toeing dan out-toeing tidak menempatkan tekanan yang tidak normal pada struktur dan fungsi kaki, sepatu khusus atau intervensi laitihan kaki  mungkin diperlukan untuk melindungi kaki.

Adductus Metatarsus

Beberapa bayi lahir dengan kaki yang bisa membelokkan ke arah dalam dari tengah kaki ke jari kaki – disebut metatarsus adductus. Ini biasanya membaik dengan sendirinya tanpa pengobatan. Jika anak mencapai sekitar 6 sampai 9 bulan dan kondisi tidak membaik sepatu korektif khusus atau gips sering dianjurkan.

Jalan Jinjit atau Toe walking

Kapan harus Ke Children Foot Clinic Jakarta

• Bila jalan jinjit, duduk leter W
• Bila kaki tidak lurus, bengkok atau berbetuk O atau X
• Bila alas kaki, sandal atau sepat tidak merata ausnya
• Terrdapat kapalan atau kulit yang menghitam dan mengeras atau benjolan pada salah satu kaki yang tidak simetris
• nyeri pada kaki atau kaki ada
• Mudah tersandung dan jatuh terjadi
• Terdapat masalah pada kulit atau kuku

Supported by

CHILDREN FOOT CLINIC (KLINIK KHUSUS GANGGUAN MASALAH KAKI PADA ANAK)

• Children Grow Up Clinic I, JL Taman Bendungan Asahan 5 Bendungan Hilir Jakarta Pusat 10210 Phone : (021) 5703646 – 44466103
• Children Grow Up Clinic II, Menteng Square Jl Matraman 30 Jakarta Pusat 10430 phone : (021) 44466103
• Email : judarwanto@gmail.com narulita_md@yahoo.com

WORKING TOGETHER SUPPORT TO THE HEALTH OF ALL CHILDREN BY CLINICAL, RESEARCH AND EDUCATIONS. Advancing of the future pediatric and future parenting to optimalized physical, mental and social health and well being for fetal, newborn, infant, children, adolescents and young adult

Clinical – Editor in Chief :

Dr WIDODO JUDARWANTO SpA, pediatrician

• email : judarwanto@gmail.com
• curriculum vitae
• For Daily Newsletter join with this Twitter https://twitter.com/WidoJudarwanto

Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. You should not use the information on this web site for diagnosing or treating a medical or health condition. You should carefully read all product packaging. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider

Copyright © 2012, CHILDREN GRoW UP CLINIC Information Education Network. All rights reserved

They are also culturally and genetically normal in certain ethnic groups .

Fig1. Foot with normal arch (left) and a flat foot without an arch (right).

Most children develop an arch in their feet when standing between 4–5 years old .

Normal ——Flat Foot

Flexible Flat Foot Standing—–On Tip Toe

Insoles & Shoe Inserts

Congenital Vertical Talus

Tarsal Coalition

Talo-calceal —Calcaneo-navicular

However, one in five children never develop an arch in standing. Most of these children have low arches because they have loose ligaments. Their arch flattens when they are standing and their feet appear to roll in. However, an arch can be seen when the child stands on tiptoes or their feet are off the ground (Fig. 3).

Fig 3. The foot arch flattens when the child stands (a), but is visible when standing on tiptoes (b) or if the feet are off the ground (c).

Flat feet will not cause long-term problems. Most adults with flexible flatfeet have strong, pain-free feet and are able to do all activities and sports.

Special shoes, shoe inserts (orthotics) or exercises will not make an arch develop in a child with flexible flat feet. Arch supports may create a temporary arch in the foot, but the posture of flat feet returns once the supports are removed. Many children do not feel comfortable with arch supports in their shoes.

• Children who complain about calf muscle pains or any other pains around the foot area, may be developing or have flat feet. Pain or discomfort may also develop in the knee joints.
• A recent randomized controlled trial found no evidence for the treatment of flat feet in children either for expensive prescribed orthoses (shoe inserts) or less expensive over-the-counter orthoses.

Flexible Flat Foot is the more common variety (95%). It is generally observed in the younger child and is frequently associated with generalised joint laxity. This condition is rarely symptomatic or limits the level of activity.

A classical finding in flexible flat foot is that the foot arch develops normally when the child stands on tip toes. whilst standing normally the flat foot deformity recurs.

In vast majority of cases flexible flat foot is an entirely benign condition and requires no treatment. Recent long-term studies have shown that old methods of treatment such as insoles or surgical shoes have no beneficial effect on the ultimate outcome.

Rigid Flat Foot on the other hand this is a sinister finding and often associated with serious conditions such as tarsal coalition or congenital vertical talus.

Unlike flexible flat foot, rigid flat foot is frequently a painful disorder. In this condition when the child stands on tip toes, the medial foot arch does not develop normally. On examination the foot is found to be stiff, lacking normal range of movement in the subtalar joint.

Congenital vertical talus (CVT) is a rare but serious foot deformity. It generally presents at birth and rarely responds to conservative treatment. 50% of cases are associated with underlying neuromuscular conditions or syndromes. Surgical intervention is frequently required as this is a painful condition as an adult. surgical correction is generally carried out at age 1 year.

Tarsal coalition is a relatively common condition (1-2% of population). Most cases are relatively asymptomatic and do not come to the attention of the medical profession.

Tarsal coalition is usually asymptomatic in the younger child and only becomes painful during the adolescent growth spurt. There 2 main varieties of tarsal coalition are: Talo-calcaneal coalition and Calcaneo-navicular coalition. Both varieties present with pain and stiffness in the foot.

Treatment for tarsal coalition is controversial. My preference for early cases is to excise the coalition and insert a fat graft into the gap to stop the coalition from reforming. Other methods of treatment are: short period of casting in a walking plaster or subtalar fusion.

Diagnosis

• A podiatrist, osteopath, physiotherapist or chiropodist can diagnose a flat foot condition during a consultation. An easy and traditional home diagnosis is the “wet footprint” test, performed by wetting the feet in water and then standing on a smooth, level surface such as smooth concrete or thin cardboard or heavy paper. Usually, the more the sole of the foot that makes contact (leaves a footprint), the flatter the foot.
• In more extreme cases, known as a kinked flatfoot, the entire inner edge of the footprint may actually bulge outward, where in a normal to high arch this part of the sole of the foot does not make contact with the ground at all.
• Most flexible flat feet are asymptomatic and do not cause pain. In these cases, there is usually no real cause for concern. Rigid flatfoot, a condition where the sole of the foot is rigidly flat even when a person is not standing, often indicates a significant problem in the bones of the affected feet, and can cause pain in about a quarter of those affected.
• Other flatfoot-related conditions, such as various forms of tarsal coalition (two or more bones in the midfoot or hindfoot abnormally joined) or an accessory navicular (extra bone on the inner side of the foot) should be treated promptly, usually by the very early teen years, before a child’s bone structure firms up permanently as a young adult. Both tarsal coalition and an accessory navicular can be confirmed by x-ray.
• Rheumatoid Arthritis can destroy tendons in the foot (or both feet) which can cause this condition, and untreated can result in deformity and early onset of Osteoarthritis of the joint.
• Such a condition can cause severe pain and considerably reduced ability to walk, even with orthoses. Ankle fusion is usually recommended.

Treatment

• Going barefoot, particularly over terrain such as a beach where muscles are given a good workout, is good for all but the most extremely flatfooted, or those with certain related conditions such as plantar fasciitis.
• One medical study in India with a large sample size of children who had grown up wearing shoes and others going barefoot, found that the longitudinal arches of the barefooters were generally strongest and highest as a group, and that flat feet were less common in children who had grown up wearing sandals or slippers than among those who had worn closed-toe shoes.
• Flat feet can be treated by insoles.Flat feet can also be inherited genetically.
• Treatment of flat feet may also be appropriate if there is associated foot or lower leg pain, or if the condition affects the knees or the lower back. Treatment may include using Orthotics such as an arch support, foot gymnastics or other exercises as recommended by a podiatrist or other physician. In cases of severe flat feet, orthoses should be used through a gradual process to lessen discomfort. Over several weeks, slightly more material is added to the orthosis to raise the arch. These small changes allow the foot structure to adjust gradually, as well as giving the patient time to acclimatise to the sensation of wearing orthoses. Once prescribed, orthoses are generally worn for the rest of the patient’s life. In some cases, surgery can provide lasting relief, and even create an arch where none existed before; it should be considered a last resort, as it is usually very time consuming and costly.
• Studies analyzing the correlation between flat feet and physical injury in soldiers have been inconclusive. A recent study of Royal Australian Air Force recruits that tracked the recruits over the course of their basic training found that neither flat feet or high arched feet had any impact on physical functioning, injury rates or foot health. If anything, there was a tendency for those with flat feet to have fewer injuries.
• But another study of 287 Israel Defense Forces recruits found that those with high arches suffered almost four times as many stress fractures as those with the lowest arches. And a later study of 449 U.S. Navy special warfare trainees found no significant difference in the incidence of stress fractures among sailors and Marines with different arch heights.

Important to consult a paediatric orthopaedic surgeon if the flat feet are:

• stiff
• painful
• causing difficulty with activities (e.g. running, jumping)
• only one side is affected.

REFERENCE

• Rao UB, Joseph B (1992). “The influence of footwear on the prevalence of flat foot. A survey of 2300 children“. J Bone Joint Surg Br 74 (4): 525–7. http://www.jbjs.org.uk/cgi/pmidlookup?view=long&pmid=1624509. quoted in http://www.unshod.org/pfbc/pfmedresearch.htm
• Fallen Arch“. Health A to Z. Aetna InteliHealth(R). 2007-12-18. http://www.intelihealth.com/IH/ihtIH/WS/9339/25652.html. Retrieved 2008-05-27. “Unlike a flexible flatfoot, a rigid flatfoot is often the result of a significant problem affecting the structure or alignment of the bones that make up the foot’s arch.”
• Esterman A, Pilotto L. (July 2005). “Foot shape and its effect on functioning in Royal Australian Air Force recruits. Part 1: Prospective cohort study”. Military Medicine 170 (6): p. 623–8.

Supported by

CHILDREN FOOT CLINIC (KLINIK KHUSUS GANGGUAN MASALAH KAKI PADA ANAK)

• Children Grow Up Clinic I, JL Taman Bendungan Asahan 5 Bendungan Hilir Jakarta Pusat 10210 Phone : (021) 5703646 – 44466103
• Children Grow Up Clinic II, Menteng Square Jl Matraman 30 Jakarta Pusat 10430 phone : (021) 44466103
• Email : judarwanto@gmail.com narulita_md@yahoo.com

WORKING TOGETHER TO STRONGER, SMARTER AND HEALTHIER CHILDREN BY EDUCATION, CLINICAL INTERVENTION, RESEARCH AND NETWORKING INFORMATION. Advancing of the future pediatric and future parenting to optimalized physical, mental and social health and well being for fetal, newborn, infant, children, adolescents and young adult

Clinical – Editor in Chief :

Dr WIDODO JUDARWANTO SpA, pediatrician

• email : judarwanto@gmail.com
• curriculum vitae
• For Daily Newsletter join with this Twitter https://twitter.com/WidoJudarwanto

Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. You should not use the information on this web site for diagnosing or treating a medical or health condition. You should carefully read all product packaging. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider

Copyright © 2012, CHILDREN GRoW UP CLINIC Information Education Network. All rights reserved

Treadmill Training of Infants With Down Syndrome: Evidence-Based Developmental Outcomes
Dale A. Ulrich, Beverly D. Ulrich, Rosa M. Angulo-Kinzler, and Joonkoo Yun
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…that occurs just before the time when infants with DS begin to respond spontaneously…their participation in the study all infants received biweekly pediatric physical…provider and early intervention team (foot orthotics, eyeglasses, ear tubes, surgery…perceived to temporarily delay the onset of walking. Treadmill Intervention Infants in the treadmill intervention group…parents were trained to reposition their children near the front of the belt to maximize…

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Neil Marlow, Enid M. Hennessy, Melanie A. Bracewell, Dieter Wolke, and for the EPICure Study Group
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…of very preterm infants have demonstrated…METHODS. We studied children who were born at…posting coins, heel walking, and 1-leg standing…intervention for disabled infants and their families…preterm and full term children. Eur J Psychol…associated problems in children born at 25 weeks…term in premature infants. Pediatrics. 2005.

RESEARCH FILMS FOR THE STUDY OF CHILD GROWTH AND DEVELOPMENT AND DISEASE PATTERNS IN PRIMITIVE CULTURES
Pediatrics 1966; 37:1 195-234
…mo-torboat. A migration of Tareo people walking along the nutd beach at low tide…Pirimapoen is seen; women car-rying infants and small children carrying loads are seen; men carry…gathering around the mumii pit. Small children carry infants and throw pitpit spears at one…woman removes a thorn from her foot. The latter part of the film shifts…practice traditional wrestling, and children canoe and roll logs in the water…there are long sequences of two infants walking, running, playing, eating, and…

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Earle L. Lipton, Alfred Steinschneider, and Julius B. Richmond
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…s breast.12 Some Iranian infants are rigidly bound with cloth…extremities and carry their infants in a bark container which…to 20% of rural Japanese children are restrained by means of…tightly wrapped from waist to foot. The legs are thus made stiff…the same time as do white children. He reaches for his toes…mouth. Sitting, creeping, and walking follow in the usual sequence. “The social behavior of infants is identi-cal in the two…

Shoes for Children: A Review
Lynn T. Staheli
Pediatrics 1991; 88:2 371-375
…Development of the child’s arch. Foot Ankle. 1989;9:241-245 9. Vanderwilde…Meas-urements on radiographs of the foot in normal infants and children. J Bone Joint Surg. 1988;70A…LT. Evaluation of planovalgus foot deformities with special reference…

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Drowning in Infants, Children, and Adolescents
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Pediatrics 1993; 92:2 292-294
…PEDIATRICS Drowning in Infants, Children, and Adolescents Committee…Prevention: Drowning in infants, children, and adolescents…measures for very young children. The effectiveness…swim-ming instruction for infants and toddlers. The use…

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Pediatrics September 2007; 120:3 538-546; doi:10.1542/peds.2007-0495
…Steinmacher) who was blinded to the infants treatment-group assignment…represents mild abnormality (ie, walking, running, jumping are possible…consists of 18 tasks including walking backward, standing on 1 foot, touching ones nose, jumping…available for this test for children with a mental processing…N. School-age outcomes in children with birth weights under…of very low birth weight infants in the indomethacin intraventricular…

Supported by

CHILDREN FOOT CLINIC  (KLINIK KHUSUS GANGGUAN MASALAH KAKI PADA ANAK)

• Children Grow Up Clinic I, JL Taman Bendungan Asahan 5 Bendungan Hilir Jakarta Pusat 10210 Phone : (021) 5703646 – 44466103
• Children Grow Up Clinic II, Menteng Square Jl Matraman 30 Jakarta Pusat 10430 phone : (021) 44466103
• Email : judarwanto@gmail.com   narulita_md@yahoo.com

WORKING TOGETHER FOR STRONGER, HEALTHIER AND SMARTER CHILDREN BY EDUCATION, CLINICAL INTERVENTION, RESEARCH AND INFORMATINON NETWORKING Advancing of the future pediatric and future parenting to optimalized physical, mental and social health and well being for fetal, newborn, infant, children, adolescents and young adult

Clinical – Editor in Chief :

Dr WIDODO JUDARWANTO SpA, pediatrician

• email : judarwanto@gmail.com
• curriculum vitae
• For Daily Newsletter join with this Twitter https://twitter.com/WidoJudarwanto

Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. You should not use the information on this web site for diagnosing or treating a medical or health condition. You should carefully read all product packaging. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider

Copyright © 2012, CHILDREN GRoW UP CLINIC Information Education Network. All rights reserved

PENILAIAN DAN PEMERIKSAAN

• Gejala klinis dapat ditelusuri melalui riwayat keluarga yang menderita clubfoot atau kelainan neuromuskuler, dan dengan melakukan pemeriksaan secara keseluruhan untuk mengidentifikasi adanya abnormalitas.
• Pemeriksaan dilakukan dengan posisi prone, dengan bagian plantar yang terlihat, dan supine untuk mengevaluasi rotasi internal dan varus.
• Jika anak dapat berdiri , pastikan kaki pada posisi plantigrade, dan ketika tumit sedang menumpu, apakah pada posisi varus, valgus atau netral. Deformitas serupa terlihat pada myelomeningocele and arthrogryposis. Oleh sebab itu agar selalu memeriksa gejala-gejala yang berhubungan dengan kondisi-kondisi tersebut.
• Ankle equinus dan kaki supinasi (varus) dan adduksi (normalnya kaki bayi dapat dorso fleksi dan eversi, sehingga kaki dapat menyentuh bagian anterior dari tibia). Dorso fleksi melebihi 90° tidak memungkinkan.

PEMERIKSAAN RADIOLOGIS

• Tiga komponen utama pada deformitas dapat terlihat pada pemeriksaan radiologi.
• Equinus kaki belakang adalah plantar flexi dari kalkaneus anterior (serupa dengan  kuku kuda) seperti sudut antara axis panjang dari tibia  dan axis panjang dari kalkaneus (sudut tibiocalcaneal) lebih dari 90°
• Pada varus kaki belakang, talus terkesan tidak bergerak terhadap tibia. Pada penampang lateral, sudut antara axis panjang talus dan sudut panjang dari kalkaneus (sudut talocalcaneal) adalah kurang dari 25°, dan kedua tulang mendekati sejajar dibandingkan posisi normal.
• Pada penampang dorso plantar, sudut talocalcaneal adalah kurang dari 15°, dan kedua tulang tampak melampaui normal. Juga axis longitudinal yang melewati talus bagian tengah (midtalar line) melewati bagian lateral ke bagian dasar dari metatarsal pertama, dikarenakan bagian depan kaki terdeviasi kearah medial.
• Pada penampang lateral, tulang metatarsal tampak menyerupai tangga.

DIAGNOSIS

• Bentuk dari kaki sangat khas.
• Kaki bagian depan dan tengah inversi dan adduksi. Ibu jari kaki terlihat relatif memendek.
• Bagian lateral kaki cembung, bagian medial kaki cekung dengan alur atau cekungan pada bagian medial plantar kaki. Kaki bagian belakang equinus. Tumit tertarik dan mengalami inversi, terdapat lipatan kulit transversal yang dalam pada bagian atas belakang sendi pergelangan kaki. Atrofi otot betis, betis terlihat tipis, tumit terlihat kecil dan sulit dipalpasi.
• Pada manipulasi akan terasa kaki kaku, kaki depan tidak dapat diabduksikan dan dieversikan, kaki belakang tidak dapat dieversikan dari posisi varus. Kaki yang kaku ini yang membedakan dengan kaki equinovarus paralisis dan postural atau positional karena posisi intra uterin yang dapat dengan mudah dikembalikan ke posisi normal. Luas gerak sendi pergelangan kaki terbatas. Kaki tidak dapat didorsofleksikan ke posisi netral, bila disorsofleksikan akan menyebabkan terjadinya deformitas rocker-bottom dengan posisi tumit equinus dan dorsofleksi pada sendi tarsometatarsal. Maleolus lateralis akan terlambat pada kalkaneus, pada plantar fleksi dan dorsofleksi pergelangan kaki tidak terjadi pergerakan maleoulus lateralis terlihat tipis dan terdapat penonjolan korpus talus pada bagian bawahnya.
• Tulang kuboid mengalami pergeseran ke medial pada bagian distal anterior tulang kalkaneus. Tulang navicularis mengalami pergeseran medial, plantar dan terlambat pada maleolus medialis, tidak terdapat celah antara maleolus medialis dengan tulang navikularis. Sudut aksis bimaleolar menurun dari normal yaitu 85° menjadi 55° karena adanya perputaran subtalar ke medial.
• Terdapat ketidakseimbangan otot-otot tungkai bawah yaitu otot-otot tibialis anterior dan posterior lebih kuat serta mengalami kontraktur sedangkan otot-otot peroneal lemah dan memanjang. Otot-otot ekstensor jari kaki normal kekuatannya tetapi otot-otot fleksor jari kaki memendek. Otot triceps surae mempunyai kekuatan yang normal.
• Tulang belakang harus diperiksa untuk melihat kemungkinan adanya spina bifida. Sendi lain seperti sendi panggul, lutut, siku dan bahu harus diperiksa untuk melihat adanya subluksasi atau dislokasi. Pmeriksaan penderita harus selengkap mungkin secara sistematis seperti yang dianjurkan oleh R. Siffert yang dia sebut sebagai Orthopaedic checklist untuk menyingkirkan malformasi multiple.

DIAGNOSIS BANDING

• Postural clubfoot- disebabkan oleh posisi fetus dalam uterus. Kaki dapat dikoreksi secara manual oleh pemeriksa. Mempunyai respon yang baik dan cepat terhadap serial casting dan jarang akan kambuh kembali.
• Metatarsus adductus (atau varus)- adalah deformitas pada metatarsal saja. Kaki bagian depan mengarah ke bagian medial dari tubuh. Dapat dikoreksi dengan manipulasi dan mempunyai respon terhadap serial casting.

DAFTAR PUSTAKA

1. Tachdjian Mihran O. Congenital Talipes Equinovarus In: Tachdjian Mihran O [editor]: Clinical Pediatric Orthopaedics The Art of Diagnosis and Principle of Management. Appleton & Lange, 1997; 12-24.
2. Tachdjian Mihran O. Congenital Talipes Equinovarus In: John Anthony Herring [editor]: Pediatric Orthopaedics, From the Texas Scottish Rite Hospital for Children. Saunders elsivier, 2008; 1070-1078.
3. A.Graham. Apley, Louis Solomon. Deformities of the Foot. In: Apley’s System of Orthopaedics and Procedurs,1982; 307-9.

Supported by

CHILDREN FOOT CLINIC (KLINIK KHUSUS GANGGUAN MASALAH KAKI PADA ANAK)

• Children Grow Up Clinic I, JL Taman Bendungan Asahan 5 Bendungan Hilir Jakarta Pusat 10210 Phone : (021) 5703646 – 44466103
• Children Grow Up Clinic II, Menteng Square Jl Matraman 30 Jakarta Pusat 10430 phone : (021) 44466103
• Email : judarwanto@gmail.com narulita_md@yahoo.com

WORKING TOGETHER TO STRONGER, SMARTER AND HELTHIER CHILDREN BY EDUCATION, CLINICAL INTERVENTION AND RESEARCH. Advancing of the future pediatric and future parenting to optimalized physical, mental and social health and well being for fetal, newborn, infant, children, adolescents and young adult

Clinical – Editor in Chief :

Dr WIDODO JUDARWANTO SpA, pediatrician

• email : judarwanto@gmail.com
• curriculum vitae
• For Daily Newsletter join with this Twitter https://twitter.com/WidoJudarwanto

Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. You should not use the information on this web site for diagnosing or treating a medical or health condition. You should carefully read all product packaging. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider

Copyright © 2012, CHILDREN GRoW UP CLINIC Information Education Network. All rights reserved

Pada umumnya bayi menunjukkan kemampuan berjlan saat sekitar ulang tahun pertama, Tetapi sebenarnya kemampuan ini bervariasi antara  rentang usia 9-18 bulan. Jangan khawatir bila bayi Anda mengambil jalan memutar beberapa di sepanjang jalan. Beberapa kelompok anak tidak melalui fase duduk dan  merangkak, tetapi langsung berjalan. Fenomena ini sebenarnya normal. teta[pi keadaan ini sering terjadi pada anak dengan gangguan keseimbangan atau motorik kasar yang ringan. Yang penting pada tahap ini adalah bahwa anak Anda menggunakan lengan dan kaki bersama-sama untuk bergerak.

Seorang bayi membutuhkan sekitar 1.000 jam praktek dari saat mereka berdiri tegak hingga dapat berjalan sendiri. Untuk membantu mempersiapkan berjalan pada anak. Dalam melakukan pembelajaran jalan pada anak sebaiknya orang tua harus bersikap sabar dan telaten. Jangan terlalu menuntut anak harus cepat bisa jalan, karena harus disadari kemampuan berjalan pada anak tidak sama. Orang tua boleh kawatir bila anak hingga usia 18 bulan belum bisa berjalan.

Jika anak Anda melakukan salah satu dari berikut :

• Berguling-guling di lantai
• berjalan  seperti Kepiting
• bergeser  atau merayap
• Panjat tangga dengan tangannya

Lihatlah kemajuan anak Anda dengan cermat. Apakah bulan ini mengalami kemampuan yang lebih baik  dibanding bulan lalu? Apakah dapat mengangkat sedikit lebih dari tubuhnya dari tanah? Jika demikian, Anda punya tidak perlu khawatir. Jika pada akhir tahun pertama, ia tidak melakukan upaya untuk berkeliling entah bagaimana, berbicara dengan dokter Anda.

Persiapan Berjalan Berjalan

• Dari lahir: Persyaratan paling penting untuk berjalan: otot punggung yang kuat, perkembangan  mengangkat bayi kepala mereka sambil berbaring pada perut mereka. Jadi membuat Anda yakin mendapatkan banyak waktu perut saat terjaga. Tempat mainan yang menarik dan benda-benda di luar jangkauan untuk motivasi.
• Setelah dia bisa duduk: Bantuan berlatih keseimbangan dan mobilitas dengan menggelindingkan bola. Atau sering memberi  mainan di depannya dan bergerak dari sisi ke sisi, cara ini mendorong dia untuk bersandar. Ketika dia menerjang maju atau merangkak, dia akan mengembangkan kekuatan yang lebih di leher, punggung, kaki, dan lengan, serta pengendalian lebih pinggulnya – memungkinkan untuk mengangkat tubuhnya ke posisi berdiri yang aman.
• Setelah ia dapat berdiri: Biarkan dia berjalan di depan Anda sambil memegang tangannya  dan  berkala melepaskan satu tangan sehingga ia dapat melakukan belajar jalnnya dengan keseimbangan. Atau berdiri beberapa meter darinya dan akan merasa sangat bahagia ketika dia berdiri sendiri. Kejadian ini harius mendapatkan  dorongan dan pujian.
• Setelah ia dapat  bejalan  Setelah dia telah menguasai berdiri, ia mungkin mulai meninggalkan cetakan tangan ke seluruh rumah saat belajar jalan dengan kaki dan tangan yangbelepotan. Bantu dia dengan furnitur  yang kokoh supaya dia bisa membuat jalan melintasi ruangan. Dia mungkin belum bisa duduk dari posisi berdiri, yang dia ingin lakukan sebelum belajar berjalan sendiri. Bantu meringankan pantatnya ke bawah dengan tangan Anda, kemudian ia akan dapat duduk tanpa menyakiti pantatnya.

Pencegahan Keamanan

• Ketika bayi baru berjalan sangat mungkin mengalami banyak hal  lebih cepat dari yang Anda bayangkan
• Hapus rendah meja dengan sudut tajam yang sulit untuk menutupi cukup baik untuk mencegah cedera. (Lecet di atas atau di alis sangat umum di antara anak-anak belajar berjalan bahwa dalam kamar rumah sakit darurat mereka disebut luka-meja kopi!)
• Singkirkan perabot yang mudah mudah.
• Jauhkan berbagai barang diantaranya  tali, karpet atau barang lain yang membuat anak ;lebih mudah tersandung.
• Perhatikan keamanan tangga dan daerah lantai yang berseiko terjadi kecelakaan saat bayi anda belajar berjalan
• Kunci semua peralatan  rumah tangga yang berpotensi membahayakan.

Apakah saya harus membeli baby walker ?

• Sebaiknya tidak digunakan,  Kanada telah melarang penjualan pejalan kaki, dan American Academy of Pediatrics mendukung larangan serupa di Amerika Serikat. Setiap tahun, ribuan anak-anak berakhir di rumah sakit karena cedera dari menggunakan alat bantu jalan, seperti menjatuhkan menuruni tangga atau mencapai kompor panas.  Bila telah membeli dalam pemakaiannya sebaiknya harus diawasi dengan ketat. Pemakaian baby walker tidak berhubungan dengan kaki bengkok, kaki berbentuk O atau jalan jinjit.
• Kursi elip bukan cara belajar yang baik.Meskipun mereka memegang anak-anak dalam posisi tegak, mereka tidak membantu mereka belajar berjalan lebih cepat. Bahkan, perangkat ini bahkan mungkin menunda berjalan jika mereka digunakan terlalu sering. tubuh seorang anak tidak sejajar dengan benar ketika ia duduk di salah satu dari mereka. bayi Anda jauh lebih baik di lantai atau di sebuah boks.

Sepatu bayi pertama

• Saat  dalam ruangan, sebaiknya biarkan anak Anda berjalan-jalan tanpa alas kaki. Kakinya bisa ambil permukaan licin, seperti lantai kayu dan ubin, lebih baik.
• Bila di luar ruangan sebaiknya memakai  sepasang sepatu.

Tips membeli Sepatu untuk jalan awal pada bayi

• Jangan berbelanja sepatu  di pagi hari, sejak kaki tumbuh sekitar 5 persen pada akhir hari.
• Anak Anda harus berdiri ketika Anda memeriksa cocok. Anda harus dapat menekan lebar penuh dengan ibu jari Anda di antara ujung sepatu dan ujung jari kakinya, dan harus ada cukup ruang di tumit untuk menekan kelingking Anda masuk
• Biarkan berjalan tertatih-tatih ke sekeliling di toko sepatu selama lima menit, kemudian mengambil mereka dan melihat kakinya.
• Perhatikan perkembangan dan pertubuhan kaki setiap  bulan karena akan  berkembang pesat pada tahap ini. Keadaan ini mungkin mengharuskan selalu berganti sepatu  dua sampai tiga bulan.

Supported by

CHILDREN FOOT CLINIC (KLINIK KHUSUS GANGGUAN MASALAH KAKI PADA ANAK)

• Children Grow Up Clinic I, JL Taman Bendungan Asahan 5 Bendungan Hilir Jakarta Pusat 10210 Phone : (021) 5703646 – 44466103
• Children Grow Up Clinic II, Menteng Square Jl Matraman 30 Jakarta Pusat 10430 phone : (021) 44466103
• Email : judarwanto@gmail.com narulita_md@yahoo.com

WORKING TOGETHER TO STRONGER, SMARTER AND HELTHIER CHILDREN BY EDUCATION, CLINICAL INTERVENTION AND RESEARCH. Advancing of the future pediatric and future parenting to optimalized physical, mental and social health and well being for fetal, newborn, infant, children, adolescents and young adult

Clinical – Editor in Chief :

Dr WIDODO JUDARWANTO SpA, pediatrician

• email : judarwanto@gmail.com
• curriculum vitae
• For Daily Newsletter join with this Twitter https://twitter.com/WidoJudarwanto

Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. You should not use the information on this web site for diagnosing or treating a medical or health condition. You should carefully read all product packaging. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider

Copyright © 2012, CHILDREN GRoW UP CLINIC Information Education Network. All rights reserved

Supported by

CHILDREN FOOT CLINIC (KLINIK KHUSUS GANGGUAN MASALAH KAKI PADA ANAK)

• Children Grow Up Clinic I, JL Taman Bendungan Asahan 5 Bendungan Hilir Jakarta Pusat 10210 Phone : (021) 5703646 – 44466103
• Children Grow Up Clinic II, Menteng Square Jl Matraman 30 Jakarta Pusat 10430 phone : (021) 44466103
• Email : judarwanto@gmail.com narulita_md@yahoo.com

WORKING TOGETHER SUPPORT TO THE HEALTH OF ALL CHILDREN BY CLINICAL, RESEARCH AND EDUCATIONS. Advancing of the future pediatric and future parenting to optimalized physical, mental and social health and well being for fetal, newborn, infant, children, adolescents and young adult

Clinical – Editor in Chief :

Dr WIDODO JUDARWANTO SpA, pediatrician

• email : judarwanto@gmail.com
• curriculum vitae
• For Daily Newsletter join with this Twitter https://twitter.com/WidoJudarwanto

Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. You should not use the information on this web site for diagnosing or treating a medical or health condition. You should carefully read all product packaging. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider

Copyright © 2012, CHILDREN GRoW UP CLINIC Information Education Network. All rights reserved

Ankle dan kaki merupakan struktur komplex dan yang paling dinamis pada tubuh manusia. Pergelangan kaki dan kaki bergerak bersama-sama anggota tubuh lainnya selama berdiri dan berjalan. Talus merupakan mekanisme kunci pada puncak kaki, terdiri dari bagian corpus, colum dan caput. Bagian superior dan pinggir corpus berfungsi menyokong dan berartikulasi dengan tibia dan fibula.

Permukaan superior yang cembung dari talus meluncur di bagian bawah tibia selama bergerak. Kedua sisi corpus dan permukaan superior dari talus ditutupi oleh cartilago artikular dan melekat erat diantara maleolus dan disebut ankle mortis. Dalam ankle mortis, talus berfungsi sebagai sendi pegas. Bila dilihat dari atas, ankle mortis berada pada sudut lateral karena maleolus medial berada di anterior maleolus lateral pada bidang transversal. Corpus talus berbentuk baji dengan bagian anterior yang lebih lebar. Saat dorsofleksi, bagian anterior yang lebih lebar akan berada diantara ke dua maleolus dan akan berfungsi membatasi gerakan. Saat plantarfleksi bagian posterior yang lebih sempit akan berada diantara ke dua maleolus dan akan memungkinkan gerakan-gerakan ke arah lateral dari talus dalam ankle mortis.

• Terdapat dua puluh enam tulang utama pada kaki, yaitu tujuh tulang tarsal, lima tulang metatarsal dan empat belas tulang falang.

Secara anatomis, kaki dapat dibagi menjadi tiga bagian fungsional yaitu:

1. Bagian depan kaki, terdiri dari lima tulang metatarsal dan empat belas tulang falang.
2. Bagian tengah kaki, terdiri dari tiga tulang kuneiformis, sebuah tulang kuboid dan tulang navikularis membentuk sebuah deretan.
3. Bagian belakang kaki, terdiri dari, a. tulang talus pada bagian apex kaki yang merupakan bagian dari sendi pergelangan kaki, merupakan kunci mekanis pada bagian apex kaki, mempunyai korpus, kolum dan kaput, berbentuk cembung, pada permukaan superiornya menyerupai pelana kuda, b. tulang kalkaneus merupakan bagian paling belakang dari kaki yang menyentuh permukaan tanah.

Persendian kaki dan Pergelangan kaki

• Sendi pergelangan kaki terdiri dari bagian bawah tulang tibia, tulang fibula dan tulang talus yang berbentuk kubah, sering disebut ankle mortis. Gerakannya berupa plantar fleksi dan dorso fleksi. Sendi pergelangan kaki ini stabil dan terbatas pada semua bidang gerak yang lain.
• Sendi subtalar atau sendi talokalkaneal adalah suatu sendi aksis tunggal yang menghubungkan tulang talus dan tulang kalkaneus. Sendi ini mempunyai aksis sub talar dimana tulang kalkaneus berputar pada tulang talus, mempunyai sudut 45° dari lantai dan 16° medial terhadap garis yang ditarik melalui tulang metatarsal kedua.

Terdapat tiga kombinasi gerakan dapat terjadi disekitar aksis ini, yaitu:

• Disekitar aksis longitudinal berupa inverse yaitu elevasi batas medial kaki dan depresi batas lateral kaki dan gerakan sebaliknya berupa eversi.
• Disekitar aksis vertikal berupa abduksi yaitu rotasi keluar melalui tibia dan adduksi yaitu rotasi ke dalam.
• Disekitar aksis transversa berupa dorso fleksi dan plantar fleksi.

Gerakan utama dari sendi subtalar berupa inversi dan eversi. Bila ketiga gerakan pada sendi subtalar, di sekitar aksis subtalar terjadi bersamaan maka akan menghasilkan gerakan supinasi (adduksi-inversi-plantar fleksi) dan pronasi (adduksi-eversi-dorso fleksi).

Sendi tarsal transversa terdiri dari sendi kalkaneokuboid dan talonavikularis, gerakannya berupa adduksi-inversi dan abduksi-eversi. Sendi tarsal transversa ini disebut juga dengan istilah sendi mid tarsal, surgeon’s tarsal joint atau chopart’s joint merupakan salah satu daerah amputasi pada kaki.

Sendi tarsometatarsal, metatarsofalangeal dan interfalangeal gerakannya berupa fleksi dan ekstensi.

Ligamen Kaki Dan Pergelangan Kaki

• Ligamen dari ankle mortise adalah ligament interoseus beserta membrannya dan ligamen tibiofibular. Ligamen interoseus dan membran melekat pada bagian dalam tibia, berjalan lateral dan ke bawah pada bagian dalam fibula.
• Pada saat dorso fleksi fibula terangkat sedikit ke atas menyebabkan ligamen ini menjadi lebih datar melebarkan ankle mortise, sehingga bagian terluas dari talus dapat melaluinya.
• Pada plantar fleksi akan terjadi sebaliknya. Ligamen interoseus diperkuat oleh ligamen tibiofibular yang berjalan paralel terhadapnya.

Penyangga terkuat dari sendi pergelangan kaki adalah ligamen kolateral pada bagian lateral. Ligamen kolateral ini mempunyai 3 bagian, yaitu :

1. Ligamen talofibular anterior, berasal dari kolum talus dan melekat pada ujung fibula.
2. Ligamen kalkaneofibular, berasal dari kalkaneus melekat pada ujung fibula.
3. Ligamen talofibular posterior, berasal dari korpus talus melekat pada ujung fibula.

Penyangga terkuat bagian medial pergelangan kaki adalah ligamen deltoid yang menghubungkan maleous medialis dengan navikular, sustentakum tali dan bagian posterior talus. Ligamen deltoid mempunyai 4 bagian, yaitu : 1. Tibionavikular, 2. Talotibial anterior, 3. Calcaneotibial, 4. Talotibial posterior.

Ligamen lainnya pada kaki adalah corsal, planter dan interoseus, sesuai dengan tulang yang dihubungkannya. Secara umum ligamen dorsal bersifat tipis, berada pada bagian atas arkus, sedangkan ligamen plantar bersifat tebal berfungsi sebagai ‘tierods’ yang menyangga arkus. Terdapat 2 ligamen plantar yang penting, yaitu:

1. Ligamen plantar kalkaneonavikular, melalui permukaan bawah kalkaneus yang disebut sustentakum tali menuju permukaan bawah navikularis membentuk sling yang menyangga kaput talus. Ligamen ini membatasi gerakan talus ke bawah dan membantu menyangga bagian tertinggi arkus, ligamen ini disebut juga ‘spring ligament’.
2. Ligamen plantar panjang, terletak diantara kalkaneus, kuboid dan bagian lateral tiga tulang metatarsal.

Salah satu ligamen interoseus yang penting adalah ligamen talokalkaneal yang berada sepanjang kanal tarsal dan bagian akhir fibula, ligamen ini membentuk serabut fibrosa yang menghubungkan dua tuberkel dan disebut sebagai ligamentum cervicis.

Otot-Otot Kaki Dan Pergelangan Kaki

• Otot-otot kaki dan pergelangan kaki dapat dibagi menjadi otot intrinsik dimana otot-otot tersebut beroigo dan berinsersi di dalam kaki, dan otot ekstrinsik yang memiliki origo di luar kaki. Pembagian ini seperti pada otot-otot tangan.

Otot-otot ekstrinsik dibagi menjadi :

1. Posterior. Terdiri dari otot triseps surae, disebut triseps surae karena mempunyai tiga kaput, yaitu dua kaput gastrolonemius dan satu kaput soleus. Nama lain otot triseps surae adalah otot gastrosoleus. Otot gastroknemius berasal dari bagian atas lutut, mempunyai dua kaput yang melekat pada setiap kondilus femur. Setengah bagian bawah dari otot gastroknemius menjadi tendon yang tipis disebut tendon Achilles, melekat pada bagian posterior kalkaneus, menyebabkan plantar fleksi pergelangan kaki. Otot triseps surae juga menyebabkan supinasi kaki ketika kaki terfiksasi pada lantai. Otot soleus menyebabkan gerakan plantar fleksi pada saat lutut fleksi. Kelompok otot-otot yang lain pada kaki dan pergelangan kaki melalui bagian belakang maleolus, membantu plantar fleksi kaki. Otot triseps surae sangat berperan mengangkat tumit dari lantai pada saat heel off gait.
2. Lateral. Terdiri dari peroneus longus dan brevis. Peroneus longus letaknya lebih tinggi dan superfisial, berorigo pada fibula dan berinsersi pada basis metatarsal pertama. Peroneus brevis lebih rendah dan dalam, berorigo pada fibula dan berinsersi pada basis metatarsal lima, keduanya berfungsi sebagai otot-otot evertor kaki.
3. Anterior. Terdiri dari tibialis anterior, ekstensor digitorum longus, ekstensor hallucis longus dan peroneus tertius. Ekstensor hallucis longus berasal dari bagian anterior fibula, berinsersi pada bagian anterior distal ibu jari. Fungsinya adalah ekstensi ibu jari dan membantu dorso fleksi. Ekstensor digitorum longus berasal dari bagian lateral tibia dan fibula, berinsersi pada bagian lateral empat jari-jari. Peroneus tertius yang tampaknya berasal dari ekstensor digitorum longus berinsersi pada basis metatarsal lima. Ekstensor digitorum longus dan peroneus tertius berfungsi untuk dorso fleksi dan eversi kaki. Tibialis anterior berasal dari bagian lateral tibia menyilang permukaan dorsal kaki, berinsersi pada bagian metatarsal pertama, berfungsi untuk dorso fleksi dan inversi kaki.
4. Medial. Terdiri dari tibialis posterior, fleksor digitorum kongus dan fleksor hallucis longus. Tibialis posterior berasal dari bagian posterior tibia dan fibula, berinsersi pada tarsal, berfungsi untuk inversi dan plantar fleksi kaki. Fleksor hallucis longus berasal dari bagian posterior tibia dan fibula, berinsersi pada bagian bawah falangs distal jari pertama setelah melalui maleolus medialis. Fleksor digitorum longus berasal dari bagian posterior tibia, melalui bagian belakang maleolus medialis untuk berinsersi pada lateral falangs distal empat jari-jari. Fleksor digitorum longus berfungsi untuk fleksi jari-jari, dalam posisi menggenggam, fleksor hallucis longus berfungsi menekan falangs distal ke lantai.

Secara umum inversi dari kaki terjadi pada sendi subtalar oleh tendon yang menyilang pada permukaan dalam kaki. Eversi juga terjadi pada sendi subtalar oleh tendo-tendo pada bagian lateral kaki. Peronei berfungsi sebagai evertor secara efektif pada posisi kaki plantar fleksi. Baik evertor dan invertor berfungsi sebagai stabilisasi pergelangan kaki pada saat kaki terfiksasi pada lantai. Otot-otot intrinsik kaki tidak dapat diperiksa satu persatu secara klinis. Fungsi utamanya adalah mengisi bagian telapak kaki.

DEFORMITAS

• Istilah spesifik untuk menggambarkan suatu deformitas pada pergelangan kaki dan kaki tergantung dari arah gerakan sendi.
• Deformitas pada sendi kaki dan pergelangan kaki dapat disebabkan karena kontraktur dari kapsul, ligamen dan otot. Posisi kaki netral adalah posisi anatomis (0^°).
• Pada pergelangan kaki dapat terjadi deformitas kalkaneus yaitu dorsofleksi dan ekuinus yaitu plantar fleksi, pada sendi subtalar dapat terjadi deformitas tumit farus yaitu inversi dan tumit valgus yaitu eversi. Pada sendi midtarsal dapat terjadi deformitas adductus yaitu adduksi, abductus yaitu abduksi, cavus yaitu fleksi, rocker bottom yaitu ekstensi dengan tumit dan pergelangan kaki pada posisi ekuinus, supinasi yaitu inversi-adduksi dan pronasi yaitu eversi-adduksi.
• Pada pergerakan ibu jari kaki yang menjadi titik referansi adalah pusat dari kaki, hallux valgus menggaambarkan deviasi ibu jari menuju pusat dari kaki (menjauhi pusat tubuh), sedangkan hallux varus sebaliknya.

Supported by

CHILDREN FOOT CLINIC  (KLINIK KHUSUS GANGGUAN MASALAH KAKI PADA ANAK)

CLINIC FOR CHILDREN  and GROW UP CLINIC Yudhasmara Foundation www.childrenclinic.wordpress.com/ WORKING TOGETHER SUPPORT TO THE HEALTH OF ALL CHILDREN BY CLINICAL, RESEARCH AND EDUCATIONS.  Advancing of the future pediatric and future parenting to optimalized physical, mental and social health and well being for fetal, newborn, infant, children, adolescents and young adult

• Email : judarwanto@gmail.com ,  narulita_md@yahoo.com
• Clinic For Children , JL Taman Bendungan Asahan 5 Bendungan Hilir Jakarta Pusat 10210  Phone : (021) 70081995 – 5703646
• Children Grow Up Clinic, Menteng Square Jl Matraman 30 Jakarta

Clinical -  Editor in Chief :

Dr WIDODO JUDARWANTO, pediatrician

• email : judarwanto@gmail.com
• curriculum vitae
• For Daily Newsletter join with this Twitter https://twitter.com/WidoJudarwanto

Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. You should not use the information on this web site for diagnosing or treating a medical or health condition. You should carefully read all product packaging. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider

Copyright © 2011, Children Foot Clinic  Information Education Network. All rights reserved

Orangtua sebaiknya memperhatikan cara anak berjalan. Jika orangtua melihat cara berjalannya lucu dan tidak seperti balita lainnya, maka tak ada salahnya untuk memeriksakan kondisi tulang kakinya. Cara berjalan anak balita sangat beragam, ada yang berjalan dengan kedua kaki mengangkang, memutar telapak kakinya ke dalam (seperti huruf O), memutar telapak kakinya keluar (seperti huruf X) dan berjalan jinjit.

Sebagian besar cacat kaki pada anak terabaikan kecuali sudah sangat berat sehingga anak mulai mengeluh. Kebanyakan bentuk kaki yang tidak normal pada balita akan kembali lurus dengan sendirinya hingga usia tertentu.

Perkembangan normal untuk telapak kaki dan kaki anak usia di Bawah 5 Tahun

1. Bayi memiliki kaki bengkok sejak lahir hingga anak belajar berjalan.
2. Telapak kaki di putar ke dalam (seperti huruf O) hingga usia 2 tahun, jika tidak ada kelainan maka kaki akan kembali normal.
3. Telapak kaki di putar ke luar (seperti huruf X) mulai usia 3 tahun hingga maksimal anak berusia 7 tahun. Jika tidak ada kelainan, maka anak akan kembali berjalan normal.
4. Anak yang obesitas cenderung memiliki bentuk kaki O, ini dikarenakan kaki harus menopang berat badannya yang berlebih. Kaki anak bisa kembali normal jika anak melakukan diet sejak usia balita.

Jika sampai usia tersebut bayi tidak juga berjalan normal, maka orangtua bisa melakukan pemeriksaan sendiri terlebih dahulu. Caranya dengan menidurkan bayi dan posisi kakinya diluruskan lalu amati apakah kakinya simetris atau tidak, adakah bentuk tulang yang agak bengkok, perhatikan panjang dari kaki anak dan apakah anak suka tersandung jika sedang berlari.

Setelah ditemukan adanya tanda-tanda ketidaknormalan, sebaiknya orangtua membawa anak ke ahli ortopedik agar masih bisa disembuhkan. Dokter biasanya akan mencari tahu terlebih dahulu apa yang menyebabkan kelainan tersebut. Biasanya kelainan bentuk kaki O disebabkan karena bagian bawah kaki yang menekuk ke dalam (internal tibial torsion/ITT) atau karena adanya tulang kaki bagian atas yang menekuk ke dalam. Perawatan yang diberikan adalah berupa terapi. Pada sejumlah perawatan, anak akan diberi penahan agar telapak kaki tidak memutar ke dalam atau luar yang diletakkan pada sepatu khusus.

Selain itu hindari anak tidur dengan posisi meringkuk, jangan biarkan anak duduk dengan posisi kaki ditekuk ke belakang dan ditindih, usahakan anak duduk dengan posisi kaki bersila atau diluruskan ke depan serta biasakan anak duduk dan tidur dalam posisi yang benar untuk mengurangi risiko bentuk kaki yang cacat. Jika kelainan ini bisa diketahui secara dini dan dapat segera ditolong, maka bisa mencegah terjadinya masalah ortopedi lainnya dikemudian hari. Selain itu anak tidak akan menjadi malu karena penampilannya berbeda dari anak-anak lain

Supported by

CHILDREN FOOT CLINIC (KLINIK KHUSUS GANGGUAN MASALAH KAKI PADA ANAK)

• Children Grow Up Clinic I, JL Taman Bendungan Asahan 5 Bendungan Hilir Jakarta Pusat 10210 Phone : (021) 5703646 – 44466103
• Children Grow Up Clinic II, Menteng Square Jl Matraman 30 Jakarta Pusat 10430 phone : (021) 44466103
• Email : judarwanto@gmail.com narulita_md@yahoo.com

WORKING TOGETHER TO STRONGER, SMARTER AND HELTHIER CHILDREN BY EDUCATION, CLINICAL INTERVENTION AND RESEARCH. Advancing of the future pediatric and future parenting to optimalized physical, mental and social health and well being for fetal, newborn, infant, children, adolescents and young adult

Clinical – Editor in Chief :

Dr WIDODO JUDARWANTO SpA, pediatrician

• email : judarwanto@gmail.com
• curriculum vitae
• For Daily Newsletter join with this Twitter https://twitter.com/WidoJudarwanto

Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. You should not use the information on this web site for diagnosing or treating a medical or health condition. You should carefully read all product packaging. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider

Copyright © 2012, CHILDREN GRoW UP CLINIC Information Education Network. All rights reserved

• Untuk melihat kelainan kaki dapat melalui jejak kaki dan foot scan.
• Jejak kaki diperoleh dengan memberikan tinta pada telapak kaki anak, lalu anak diminta berjalan di atas kertas.
• Jejak kaki ini memperlihatkan dengan jelas pola kaki yang sesungguhnya.
• Dari foot scan, didapatkan data tentang panjang kaki, pembebanan kaki saat berdiri, dan sebagainya.
• Dari hasil foot scan ini akan dapat ditentukan sudut yang tepat untuk kaki. Kemudian, kaki akan menjalani serangkaian terapi untuk mengoreksi.
• Selain itu, pasien juga harus memakai sol sepatu khusus yang dibentuk berdasarkan kondisi kakinya. Sol ini diletakkan di dalam sepatu, dan harus dipakai selama delapan jam setiap hari

Supported by

CHILDREN FOOT CLINIC  (KLINIK KHUSUS GANGGUAN MASALAH KAKI PADA ANAK)

CLINIC FOR CHILDREN  and GROW UP CLINIC Yudhasmara Foundation www.childrenclinic.wordpress.com/ WORKING TOGETHER SUPPORT TO THE HEALTH OF ALL CHILDREN BY CLINICAL, RESEARCH AND EDUCATIONS.  Advancing of the future pediatric and future parenting to optimalized physical, mental and social health and well being for fetal, newborn, infant, children, adolescents and young adult

• Email : judarwanto@gmail.com ,  narulita_md@yahoo.com
• Clinic For Children , JL Taman Bendungan Asahan 5 Bendungan Hilir Jakarta Pusat 10210  Phone : (021) 70081995 – 5703646
• Children Grow Up Clinic, Menteng Square Jl Matraman 30 Jakarta

Clinical -  Editor in Chief :

Dr WIDODO JUDARWANTO, pediatrician

• email : judarwanto@gmail.com
• curriculum vitae
• For Daily Newsletter join with this Twitter https://twitter.com/WidoJudarwanto

Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. You should not use the information on this web site for diagnosing or treating a medical or health condition. You should carefully read all product packaging. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider

Copyright © 2011, Children Foot Clinic  Information Education Network. All rights reserved

• Hipermobilitas Sendi adalah terdapat adanya ligamen-ligamen yang mengikat persendian sangat lentur. Akibatnya, sendi-sendi jadi mudah bergerak, tapi kurang memiliki kekuatan. Biasanya baru tampak jelas saat si kecil belajar jalan.
• Dengan pertambahan usia  ligamen akan makin kaku dan kuat, sehingga hipermobilitas pada sendi kakinya akan menghilang
• Terdapat juga hipermobilitas sendi kaki yang menetap, terutama bila hipermobilitasnya memang dari awal agak berat. “Contohnya pada variasi normal bentuk kaki yang disebut flexible flat feet, di mana bagian dalam dari telapak kakinya rata dan menapak seluruhnya.”
• Telapak kaki yang rata ini disebabkan ligamen yang mengikat tulang-tulang di telapak kaki tak cukup kaku dan kuat untuk mempertahankan posisi tulang telapak kaki yang seharusnya agak melengkung ke atas membentuk arkus (berbentuk lengkung). “Sebagai konsekuensinya, biasanya anak yang memiliki telapak kaki rata tak begitu kuat dalam aktivitas yang sifatnya berjalan jauh atau olahraga yang memerlukan kekuatan pada kaki.”
• Akan tetapi, bukan berarti ia akan mengalami keterlambatan dalam perkembangan kemampuannya berjalan, lo. Kalau “kelainan” ini sifatnya ringan dan tak menyebabkan masalah, biasanya tak perlu terapi khusus.
• Dalam keadaan berat dan bila dalam pertambaan usia tidak membaik, perlu dibantu dengan sepatu khusus, yaitu sepatu yang diberikan bantalan di bagian telapak kaki sisi sebelah dalamnya, yang disebut sponge rubber arch support.”
• Dengan ganggan seperti ini, sebaiknya si kecil juga sering diajak berjalan-jalan di atas permukaan yang kasar, seperti pasir di pantai atau karpet yang kasar. Hal ini berguna untuk melatih otot-otot di telapak kakinya agar jadi lebih kuat.
• Hipermobilitas sendi juga bisa terjadi pada sendi lutut. “Hipermobilitas pada sendi lutut menyebabkan bentuk tungkai bawah yang disebut knock knee atau dalam bahasa medis disebut genu valgum, yaitu saat ia berdiri akan tampak kedua lututnya akan bersinggungan di tengah, sehingga bentuk kakinya agak seperti huruf X.” Hal ini dikarenakan kelenturan dari ligamen di sendi lutut sisi sebelah dalam.

• Dengan bentuk tungkai yang seperti ini, anak biasanya akan lebih senang duduk dengan posisi kaki dilipat ke arah samping kiri dan kanan, sedangkan kedua lututnya ke arah depan. Istilahnya, duduk dengan cara television position. Tentu saja, hal ini tak boleh dibiarkan, karena akan menambah parah “kelainan”. Bahkan jika sampai berlanjut, akan terjadi juga putaran ke arah dalam (rotasi internal) pada sumbu tulang panggul dan tulang paha, yang akan berakibat anak berjalan seperti bebek, dengan bokong tampak lebih menonjol ke belakang.
• “Kebiasaan duduk dengan “W” position atau television position ini bisa terjadi pada saat bayi baru belajar duduk. Oleh karenanya, kalau orang tua mendapatkan bayinya hendak duduk dengan posisi ini, harus segera dicegah.” Posisi duduk yang baik adalah posisi bersila, atau istilahnya Buddhist position.
• Untuk keadaan yang berat atau tak membaik walau sudah dibiasakan duduk dengan cara Buddhist position, bisa dilakukan terapi dengan menggunakan sepatu khusus yang sol sisi sebelah dalamnya ditinggikan, disebut inside heel wedge.

Supported by

CHILDREN FOOT CLINIC (KLINIK KHUSUS GANGGUAN MASALAH KAKI PADA ANAK)

• Children Grow Up Clinic I, JL Taman Bendungan Asahan 5 Bendungan Hilir Jakarta Pusat 10210 Phone : (021) 5703646 – 44466103
• Children Grow Up Clinic II, Menteng Square Jl Matraman 30 Jakarta Pusat 10430 phone : (021) 44466103
• Email : judarwanto@gmail.com narulita_md@yahoo.com

WORKING TOGETHER TO STRONGER, SMARTER AND HELTHIER CHILDREN BY EDUCATION, CLINICAL INTERVENTION AND RESEARCH. Advancing of the future pediatric and future parenting to optimalized physical, mental and social health and well being for fetal, newborn, infant, children, adolescents and young adult

Clinical – Editor in Chief :

Dr WIDODO JUDARWANTO SpA, pediatrician

• email : judarwanto@gmail.com
• curriculum vitae
• For Daily Newsletter join with this Twitter https://twitter.com/WidoJudarwanto

Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. You should not use the information on this web site for diagnosing or treating a medical or health condition. You should carefully read all product packaging. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider

Copyright © 2012, CHILDREN GRoW UP CLINIC Information Education Network. All rights reserved

The foot is an anatomical structure found in many vertebrates. It is the terminal portion of a limb which bears weight and allows locomotion. In many animals with feet, the foot is a separate organ at the terminal part of the leg made up of one or more segments or bones, generally including claws or nails.

The foot and ankle contain:

• 26 bones (One-quarter of the bones in the human body are in the feet.);
• 33 joints;
• more than 100 muscles, tendons (fibrous tissues that connect muscles to bones), and ligaments (fibrous tissues that connect bones to other bones); and
• a network of blood vessels, nerves, skin, and soft tissue.

These components work together to provide the body with support, balance, and mobility. A structural flaw or malfunction in any one part can result in the development of problems elsewhere in the body. Abnormalities in other parts of the body can lead to problems in the feet.

Human foot

Anatomy

• The human foot and ankle is a strong and complex mechanical structure containing 26 bones, 33 joints, and more than a hundred muscles, tendons, and ligaments.
• An anthropometric study of 1197 North American adult Caucasian males (men age 35.5 years) found that a mans foot length was 26.3 cm with a standard deviation of 1.2 cm.
• The foot can be subdivided into the hindfoot, the midfoot, and the forefoot:
• The hindfoot is composed of the talus or heel bone and the calcaneus or ankle bone. The two long bones of the lower leg, the tibia and fibula, are connected to the top of the talus to form the ankle. Connected to the talus at the subtalar joint, the calcaneus, the largest bone of the foot, is cushioned inferiorly by a layer of fat.

The five irregular bones of the midfoot  — the cuboid, navicular, and three cuneiform bones — form the arches of the foot which serves as a shock absorber. The midfoot is connected to the hind- and forefoot by muscles and the plantar fascia.

The forefoot is composed of five toes and the corresponding five proximal long bones forming the metatarsus. Similar to the fingers of the hand, the bones of the toes are called phalanges and the big toe has two phalanges while the other four toes have three phalanges. The joints between the phalanges are called interphalangeal and the those between the metatarsus and phalanges metatarsophalangeal (MTP).

Parts of the Foot Structurally, the foot has three main parts: the forefoot, the midfoot, and the hindfoot.

Top View of Foot Bones	Side View of Foot Bones
Click on the images to view a larger version.

The forefoot is composed of the five toes (called phalanges) and their connecting long bones (metatarsals). Each toe (phalanx) is made up of several small bones. The big toe (also known as the hallux) has two phalanx bones—distal and proximal. It has one joint, called the interphalangeal joint. The big toe articulates with the head of the first metatarsal and is called the first metatarsophalangeal joint (MTPJ for short). Underneath the first metatarsal head are two tiny, round bones called sesamoids. The other four toes each have three bones and two joints. The phalanges are connected to the metatarsals by five metatarsal phalangeal joints at the ball of the foot. The forefoot bears half the body’s weight and balances pressure on the ball of the foot.

The midfoot has five irregularly shaped tarsal bones, forms the foot’s arch, and serves as a shock absorber. The bones of the midfoot are connected to the forefoot and the hindfoot by muscles and the plantar fascia (arch ligament).

The hindfoot is composed of three joints and links the midfoot to the ankle (talus). The top of the talus is connected to the two long bones of the lower leg (tibia and fibula), forming a hinge that allows the foot to move up and down. The heel bone (calcaneus) is the largest bone in the foot. It joins the talus to form the subtalar joint. The bottom of the heel bone is cushioned by a layer of fat.

Musles, Tendons, and Ligaments A network of muscles, tendons, and ligaments supports the bones and joints in the foot.

Front View of Foot Muscles	Side View of Foot Muscles	Back View of Foot Muscles
Click on the images to view a larger version.

There are 20 muscles in the foot that give the foot its shape by holding the bones in position and expand and contract to impart movement. The main muscles of the foot are:

• the anterior tibial, which enables the foot to move upward;
• the posterior tibial, which supports the arch;
• the peroneal tibial, which controls movement on the outside of the ankle;
• the extensors, which help the ankle raise the toes to initiate the act of stepping forward; and
• the flexors, which help stabilize the toes against the ground.

Skeleton

A human foot – Enlarge to view legend

• tibia, fibula
• tarsus: talus, calcaneus, cuneiformes, cuboid, and navicular
• metatarsus: first, second, third, fourth, and fifth metatarsal bone
• phalanges

There can be many sesamoid bones near the metatarsophalangeal joints, although they are only regularly present in the distal portion of the first metatarsal bone.

Arches

The human foot has two longitudinal arches and a transverse arch maintained by the interlocking shapes of the foot bones, strong ligaments, and pulling muscles during activity. The slight mobility of these arches when weight is applied to and removed from the foot makes walking and running more economical in terms of energy. As can be examined in a footprint, the medial longitudinal arch curves above the ground. This arch stretches from the heel bone over the “keystone” ankle bone to the three medial metatarsals. In contrast, the lateral longitudinal arch is very low. With the cuboid serving as its keystone, it redistributes part of the weight to the calcaneus and the distal end of the fifth metatarsal. The two longitudinal arches serve as pillars for the transverse arch which run obliquely across the tarsometatarsal joints. Excessive strain on the tendons and ligaments of the feet can result in fallen arches or flat feet.

Muscles

The muscles acting on the foot can be classified into extrinsic muscles, those originating on the anterior or posterior aspect of the lower leg, and intrinsic muscles, originating on the dorsal or plantar aspects of the footExtrinsic

Anterior leg muscles

All muscles originating on the lower leg except the popliteus muscle are attached to the bones of the foot. The tibia and fibula and the interosseous membrane separate these muscles into anterior and posterior groups, in their turn subdivided into subgroups and layers.

Anterior group

Extensor group: tibialis anterior originates on the proximal half of the tibia and the interosseous membrane and is inserted near the tarsometatarsal joint of the first digit. In the non-weight-bearing leg tibialis anterior flexes the foot dorsally and lift its medial edge (supination). In the weight-bearing leg it brings the leg towards the back of the foot, like in rapid walking. Extensor digitorum longus arises on the lateral tibial condyle and along the fibula to be inserted on the second to fifth digits and proximally on the fifth metatarsal. The extensor digitorum longus acts similar to the tibialis anterior except that it also dorsiflexes the digits. Extensor hallucis longus originates medially on the fibula and is inserted on the first digit. As the name implies it dorsiflexes the big toe and also acts on the ankle in the unstressed leg. In the weight-bearing leg it acts similar to the tibialis anterior.

Peroneal group: peroneus longus arises on the proximal aspect of the fibula and peroneus brevis below it on the same bone. Together, their tendons pass behind the lateral malleolus. Distally, peroneus longus crosses the plantar side of the foot to reach its insertion on the first tarsometatarsal joint, while peroneus brevis reaches the proximal part of the fifth metatarsal. These two muscles are the strongest pronators and aid in plantar flexion. Longus also acts like a bowstring that braces the transverse arch of the foot.

Deep and superficial layers of posterior leg muscles

Posterior group

The superficial layer of posterior leg muscles is formed by the triceps surae and the plantaris. The triceps surae consists of the soleus and the two heads of the gastrocnemius. The heads of gastrocnemius arise on the femur, proximal to the condyles, and soleus arises on the proximal dorsal parts of the tibia and fibula. The tendons of these muscles merge to be inserted onto the calcaneus as the Achilles tendon. Plantaris originates on the femur proximal to the lateral head of the gastrocnemius and its long tendon is embedded medially into the Achilles tendon. The triceps surae is the primary plantar flexor and its strength becomes most obvious during ballet dancing. It is fully activated only with the knee extended because the gastrocnemius is shortened during knee flexion. During walking it not only lifts the heel, but also flexes the knee, assisted by the plantaris.

In the deep layer of posterior muscles tibialis posterior arises proximally on the back of the interosseous membrane and adjoining bones and divides into two parts in the sole of the foot to attach to the tarsus. In the non-weight-bearing leg, it produces plantar flexion and supination, and, in the weight-bearing leg, it proximates the heel to the calf. flexor hallucis longus arises on the back of the fibula (i.e. on the lateral side), and its relatively thick muscle belly extends distally down to the flexor retinaculum where it passes over to the medial side to stretch across the sole to the distal phalanx of the first digit. The popliteus is also part of this group, but, with its oblique course across the back of the knee, does not act on the foot.

Intrinsic

• On the back (top) of the foot, the tendons of extensor digitorum brevis and extensor hallucis brevis lie deep to the system of long extrinsic extensor tendons. They both arise on the calcaneus and extend into the dorsal aponeurosis of digits one to four, just beyond the penultimate joints. They act to dorsiflex the digits.

Dorsal and plantar aspects of foot

Similar to the intrinsic muscles of the hand, there are three groups of muscles in the sole of foot, those of the first and last digits, and a central group:

Muscles of the big toe: abductor hallucis stretches medially along the border of the sole, from the calcaneus to the first digit. Below its tendon, the tendons of the long flexors pass through the tarsal canal. It is an abductor and a weak flexor, and also helps maintain the arch of the foot. flexor hallucis brevis arises on the medial cuneiform bone and related ligaments and tendons. An important plantar flexor, it is crucial for ballet dancing. Both these muscles are inserted with two heads proximally and distally to the first metatarsophalangeal joint. Adductor hallucis is part of this group, though it originally formed a separate system (see contrahens.) It has two heads, the oblique head originating obliquely across the central part of the midfoot, and the transverse head originating near the metatarsophalangeal joints of digits five to three. Both heads are inserted into the lateral sesamoid bone of the first digit. Adductor hallucis acts as a tensor of the plantar arches and also adducts the big toe and then might plantar flex the proximal phalanx.

Muscles of the little toe: Stretching laterally from the calcaneus to the proximal phalanx of the fifth digit, abductor digiti minimi form the lateral margin of the foot and is the largest of the muscles of the fifth digit. Arising from the base of the fifth metatarsal, flexor digiti minimi is inserted together with abductor on the first phalanx. Often absent, opponens digiti minimi originates near the cuboid bone and is inserted on the fifth metatarsal bone. These three muscles act to support the arch of the foot and to plantar flex the fifth digit.

Central muscles of foot

Central muscle group: The four lumbricales arise on the medial side of the tendons of flexor digitorum longus and are inserted on the medial margins of the proximal phalanges. Quadratus plantae originates with two slips from the lateral and medial margins of the calcaneus and inserts into the lateral margin of the flexor digitorum tendon. It is also known as flexor accessorius. Flexor digitorum brevis arise inferiorly on the calcaneus and its three tendons are inserted into the middle phalanges of digits two to four (sometimes also the fifth digit). These tendons divide before their insertions and the tendons of flexor digitorum longus pass through these divisions. Flexor digitorum brevis flexes the middle phalanges. It is occasionally absent. Between the toes, the dorsal and plantar interossei stretch from the metatarsals to the proximal phalanges of digits two to five. The plantar interossei adducts and the dorsal interossei abducts these digits and are also plantar flexors at the metatarsophalangeal joints.

Medical aspects

• Due to their position and function, feet are exposed to a variety of potential infections and injuries, including athlete’s foot, bunions, ingrown toenails, Morton’s neuroma, plantar fasciitis, plantar warts and stress fractures. In addition, there are several genetic conditions that can affect the shape and function of the feet, including a club foot or flat feet.
• This leaves humans more vulnerable to medical problems that are caused by poor leg and foot alignments. Also, the wearing of shoes, sneakers and boots can impede proper alignment and movement within the ankle and foot. For example, high heels are known to throw off the natural weight balance (this can also affect the lower back). For the sake of posture, flat soles and heels are advised.

A doctor who specializes in the treatment of the feet practices podiatry and is called a podiatrist. A pedorthist specializes in the use and modification of footwear to treat problems related to the lower limbs.

Smaller muscles enable the toes to lift and curl.

There are elastic tissues (tendons) in the foot that connect the muscles to the bones and joints. The largest and strongest tendon of the foot is the Achilles tendon, which extends from the calf muscle to the heel. Its strength and joint function facilitate running, jumping, walking up stairs, and raising the body onto the toes. Ligaments hold the tendons in place and stabilize the joints. The longest of these, the plantar fascia, forms the arch on the sole of the foot from the heel to the toes. By stretching and contracting, it allows the arch to curve or flatten, providing balance and giving the foot strength to initiate the act of walking. Medial ligaments on the inside and lateral ligaments on outside of the foot provide stability and enable the foot to move up and down. Skin, blood vessels, and nerves give the foot its shape and durability, provide cell regeneration and essential muscular nourishment, and control its varied movements.

In culture

Worldwide, different cultures treat and perceive feet very differently:

• Many societies have “foot taboos”:
  • In countries strongly influenced by Buddhism (e.g., Thailand, Nepal), feet are the least respected parts of the body and strong taboos obtain against touching with feet, pointing with feet, or exposing the sole of the foot toward someone. In Thai custom, feet should not be in a higher position than someone’s head and must never face someone or an image of the Buddha. In Nepal, sleeping on the floor with someone’s feet oriented toward another sleeper is considered entirely unacceptable.
  • Traditional Arab culture also has the same anti-foot bias as in the Nepal or Thailand cultures.
• In traditional China (10th through 20th Centuries), the practice of female foot binding stunted the growth of the feet of young girls, resulting in a very tiny, intensely painful, and aesthetically desirable (though deformed) foot- this was often nicknamed ‘Pink Socking’ as it left the foot bright pink.
• Within several Christian denominations, foot washing is a religious ritual possibly originating in the hospitality customs of the Levant.
• Foot fetishism is a sexual interest and preoccupation with feet and hosiery. Playing footsie is also a term dealing with rubbing each other’s feet, and can have sexual connotations, while a foot job is a sex act involving the feet.

Footwear customs

Customs about footwear while indoors vary significantly from place to place and usually depend on climate, weather, and other factors:

• It is customary to remove one’s footwear when entering a home:
  • in some homes in Europe especially the United Kingdom; as well as countries in the Commonwealth including Canada, New Zealand and Australia. It is generally to keep the carpet clean.
  • in homes in the United States
  • in Korea and Japan the custom is so widespread that floors are often made of materials that are too soft to survive being walked on with shoes.^{[citation needed]}
• In some cultures, bare feet may be considered unsightly or offensive. In Thailand, it is considered extremely offensive to show someone the sole of your foot, although the practice of going barefoot is common, due to various reasons including hot climate and tradition.
• In many religious subgroups of Uzbekistan, touching another’s foot is a sign of affection. However, more conservative families consider this to be an act of promiscuity.
• The feet are one of the most common places to be tickled on the human body. The soles generally tend to be sensitive to tickling.

It is customary that the wearing of toe rings in public be limited to close shoe toes only.

Customary measurement

• One way to measure short distances on the ground is by placing one foot directly in front of the other; this led to the adoption of the foot as a unit of length, even though not all human feet correspond to this measure.
• It is a myth that the Imperial “foot” (304.8 mm) is about the length of the average European male foot. The average today is less than 280 mm and 90% of the population is within 20 mm of that. Although many men today have feet that are 11.5 inches long (size 12-13): most are less than size 11. In the past, the average length would have been even less. The overall length of most shoes however, is above one “foot”. Tradition has it that the Imperial foot was based upon the size of Hercules‘ foot or the size of the king of England’s foot.

Evolutionary variations

• A paw is the soft foot of a mammal, generally a quadruped, that has claws or nails. A hard foot is called a hoof.
• Depending on style of locomotion, animals can be classified as plantigrade (sole-walking), digitigrade (toe-walking), or ungulate (nail-walking).
• The metatarsals are the bones that make up the main part of the foot in humans, and part of the leg in large animals or paw in smaller animals. The number of metatarsals are directly related to the mode of locomotion  — five digits being the most primitivesetup, with many larger animals having their digits reduced to two (elk, cow, sheep) or one (horse).
• The metatarsal bones of feet and paws are tightly grouped compared to, most notably, the human hand where the thumb metacarpal diverges from the rest of the metacarpus.

Supported by

CHILDREN FOOT CLINIC  (KLINIK KHUSUS GANGGUAN MASALAH KAKI PADA ANAK)

CLINIC FOR CHILDREN  and GROW UP CLINIC Yudhasmara Foundation www.childrenclinic.wordpress.com/ WORKING TOGETHER SUPPORT TO THE HEALTH OF ALL CHILDREN BY CLINICAL, RESEARCH AND EDUCATIONS.  Advancing of the future pediatric and future parenting to optimalized physical, mental and social health and well being for fetal, newborn, infant, children, adolescents and young adult

• Email : judarwanto@gmail.com ,  narulita_md@yahoo.com
• Clinic For Children , JL Taman Bendungan Asahan 5 Bendungan Hilir Jakarta Pusat 10210  Phone : (021) 70081995 – 5703646
• Children Grow Up Clinic, Menteng Square Jl Matraman 30 Jakarta

Clinical -  Editor in Chief :

Dr WIDODO JUDARWANTO, pediatrician

• email : judarwanto@gmail.com
• curriculum vitae
• For Daily Newsletter join with this Twitter https://twitter.com/WidoJudarwanto

Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. You should not use the information on this web site for diagnosing or treating a medical or health condition. You should carefully read all product packaging. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider

Copyright © 2011, Children Foot Clinic  Information Education Network. All rights reserved

Aetiology

Most cases of persistent toe-walking are familial or are simply secondary to tight muscles. Toe-walking may indicate a neuromuscular disorder such as cerebral palsy or it could denote developmental dysplasia of the hip or leg length discrepancy (if it involves one foot only).

Supported by

CHILDREN FOOT CLINIC (KLINIK KHUSUS GANGGUAN MASALAH KAKI PADA ANAK)

• Children Grow Up Clinic I, JL Taman Bendungan Asahan 5 Bendungan Hilir Jakarta Pusat 10210 Phone : (021) 5703646 – 44466103
• Children Grow Up Clinic II, Menteng Square Jl Matraman 30 Jakarta Pusat 10430 phone : (021) 44466103
• Email : judarwanto@gmail.com narulita_md@yahoo.com

WORKING TOGETHER TO STRONGER, SMARTER AND HELTHIER CHILDREN BY EDUCATION, CLINICAL INTERVENTION AND RESEARCH. Advancing of the future pediatric and future parenting to optimalized physical, mental and social health and well being for fetal, newborn, infant, children, adolescents and young adult

Clinical – Editor in Chief :

Dr WIDODO JUDARWANTO SpA, pediatrician

• email : judarwanto@gmail.com
• curriculum vitae
• For Daily Newsletter join with this Twitter https://twitter.com/WidoJudarwanto

Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. You should not use the information on this web site for diagnosing or treating a medical or health condition. You should carefully read all product packaging. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider

Copyright © 2012, CHILDREN GRoW UP CLINIC Information Education Network. All rights reserved

Pigeon toe, also called metatarsus varus, metatarsus adductus, in-toe gait, intoeing or false clubfoot, is a condition which causes the toes to point inward when walking. It is most common in infants and children under two years of ageand, when not the result of simple muscle weakness,normally arises from one of three underlying conditions, a twisted shin bone, an excessive anteversion (femoral head is more than 15 degrees from the angle of torsion) resulting in the twisting of the thigh bone when the front part of a person’s foot is turned in. Severe cases are considered a form of clubfoot

Intoe gait (pigeon toed) is a common childhood problem. It is estimated to occur in 10% of children between ages of 2-5 years. In most cases this is an entirely benign condition and is a feature of normal variation of growth pattern.

Lack of any symptoms such as pain, symmetrical deformities, absence of any stiffness in the affected joints and no associated systemic disorders or syndromes indicates a benign condition with excellent long-term outcome.

Most children with this deformity spontaneously stop intoeing before the age of 9 years. No treatment is therefore required in the majority of cases.

There are 3 main causes of intoe gait: • Persistent femoral anteversion • Internal tibial torsion • Forefoot adductus

1. Persistent Femoral Anteversion (PFA). PFA is excessive anterior twist within the upper femur. Normally in adults the upper femur is anteriorly rotated in relation to the lower femur (femoral condyles) by 15°. In young children this angle is about 30°, but this steadily reduces to adult angles by the onset of adolescent growth spurt. On examination of the hips in children with PFA, the most striking feature is excessive range of internal rotation, but limited external rotation. As previously mentioned in most cases this is an entirely benign condition and requires no treatment.
2. Internal Tibial Torsion (ITT). Tibia is normally rotated externally in relation to the femur by 20°. This is best measured by comparing the intermalleolar axis to the intercondylar axis. Another simple way of assessing this relationship is to measure the thigh-foot angle with the child in prone position and knees flexed to 90°. In ITT the tibia is found to be internally by more than 10°-20°. This phenomenon is extremely common at birth and rapidly remodels to normal levels within the first few years of life. However, in a minority of cases ITT may persist until onset of adolescent growth spurt. This condition is unlikely to persist into adult life and rarely creates problems severe enough to require treatment or correction.
3. Forefoot Adductus is another important cause of intoe gait. In this condition the foot has a curved lateral border rather than being straight. The forefoot therefore appears to be turned in. This condition could easily be distinguished from club foot as there are no fixed deformities within the hind foot.

This condition has a tendency for spontaneous correction with age. Long-term prognosis is usually very good and treatment is not required in most cases.

For severe cases, especially when it is unilateral, application of serial corrective casts could be very effective. Surgical correction is rarely needed .

While commonly used as a children’s slang, and not technically, it is simpler and faster to say ‘on tippy toes’ than “on the balls of the feet” (as the latter takes longer, and some are not aware of the meaning). Furthermore, it has use as a verb, “to tip-toe“, which is also simpler than “to walk on the balls of the feet”.

Causes of Intoe Gait

Femoral Anteversion

Internal Tibial Rotation

Thigh Foot Angle

Forefoot Adductus

Kinesiology

To go into tippy toes, the ankle must be flexed to raise the heel off the ground. This requires the engagement of the calf muscle, along with various other muscles in the foot and shin to stabilize the joint. Even with this, this form is often less stable, requiring the engaging of muscles within the torso and a better sense of weight for the person, to stay balanced. There is generally some movement, even subtle, in the ankle, as holding it statically would make balance difficult, so it is the first to give.

Uses

Height

A baby stands on tiptoes to reach a book

Raising up on the toes will increase someone’s height and reach. It is used often to make someone appear taller, whether in an engagement, or when measuring one’s height. It is also used to reach objects that are higher up than one cannot reach when on one’s heels.

Walking only on the balls of the foot greatly reduces the surface area of the foot on the ground, allowing what does touch the ground to be more carefully placed, which is useful for avoiding twigs. The disadvantage is that it will also focus the weight, which leaves greater indentations and exerts more pressure. This will commonly happen in walking, but can be slowly controlled, so it is more a factor for when wearing shoes in the dark (or when one has one’s eyes or attention averted elsewhere), when obstructions cannot be felt with bare feet, or seen.

Moving quickly on tip toes is generally quieter, as the calf muscle can absorb much of the impact. The heel directly striking the ground is quite noisy, and often painful in bare unconditioned feet. Many believe that running heel-toe is quite unnatural and that our build is more accommodating to tip toe running.

Prowling about on tippy-toes is the stereotypical candor of a thief or spy, often accompanied by light tones sounding upon each of his or her steps.

Rotation

When rotating on either one leg or two, the body requires reducing friction. Raising to one leg is often one source of doing this, although since it doubles the weight on the other leg, it is not effective, so is mainly done when the other leg is used to torque to increase a spin, or very quickly so that the mass is more in the air, and has not settled on the other foot.

The main method of decreasing the friction, is decreasing the surface area of the foot. This is done by either going on the heel of the foot, ball of the foot, or sometimes, the toe/toes of the feet (often only possible by very light people, such as Rose in Titanic, or those with ballet shoes for En pointe known as pointe shoes, or ice skates).

The reduction of surface area is not actually what decreases the friction, however. Rather, the weight of the body is centred above the point of contact, so that the centre of gravity occurs on the axis of rotation. This allows a faster spin with far less force placed upon the stabilizers. Bringing in the limbs (much like on a spinning swing) also accelerates this.

With two legs, the centre of gravity would still occur on the axis of rotation, and be centred directly between the two points of contact.

This is utilized in dance (namely ballet, with Relevé, Elevé/rise, and ), martial arts, footbag, and anything else that requires dynamic twists, changes in direction, and spins.

The friction of rotation is still considerable, however, and tends to wear, toughen, and polish the area of the foot being rotated upon. As a comparison, in breakdancing, those who perform headspins often go bald. The foot is more tailored to absorbing and benefitting from such rotations, although perhaps not so much on hard level surfaces, as our natural environment usually is uneven and has some give. This is why it is easier and safer to do by implementing one of two factors:

• Reducing friction by doing it on a polished slippery floor, or ice, or wearing footwear which has less friction or is more able to absorb it, such as a sock, ballet shoe, or skate.
• Increasing give (and possibly friction) but spreading the force to a larger area of the foot by having give, mostly in the surface (such as gym or karate mats).

Rotating on the ball of the foot is normally preferred due to the normal advantage of tippy toe, and the springyness of the body, which is why many martial arts encourage sparring opponents to stay on tip toe the entire match, for better movement as well as rotation. As there are actually two surfaces to the ball of the foot, and toes to grip, it also allows better control.

In theory, however, rotation on the ball of the foot is actually much faster. The main problem being, the danger of either falling backwards, or of not keeping up the pose, falling back on the balls of the foot. Twists done on the heel of the foot are often quick twists, done leaning backwards while bringing the foot upwards in an arc, so that it is more of a controlled fall that the other foot can come out and stabilize.

Walking on Tip Toes on one Side

One of the more common reasons is that one leg is quite short and if the leg is more than about 3 cm short, a child will often compensate by tip toeing so that the leg reaches the ground. A child that is spastic in one leg or one side of the body may tend to tip toe on that side because of the overactive gastrocnemeus (calf muscle). The patient who has a severe achilles tendonitis (pain in the back of the calf muscle) or severs calcaneal apophysitis (heel pain) might tip toe to take some of the tension off of their achilles tendon. A rarer cause of a child tip toeing on one side only could be deep muscular calf hemangioma, this is a vascular neoplasm which causes swelling of the calf muscle.

Walking on Both Tip Toes

The most cause common is idiopathic toe walking (no known cause), also called habitual toe walking. Walking on tiptoes is quite common between 10 and 18 months when children are learning to walk. In some children it simply becomes a habit, when asked to walk normally they put their heel down on the ground before their toes. It’s just that when they’re not concentrating they seem to revert to walking on their toes.

Mild spastic diplegic cerebral palsy is also very common. Then more rarer conditions that can cause children on walking on both tip toes are Charcot-Marie-Tooth peripheral neuropathy or muscular dystrophy, such as Duchene. Then, even some less common things like autism, schizophrenia and finally spinal cord anomalies and juvenile type multiple sclerosis.

Early onset tip toeing is defined as tip toeing that occurs within three months of the the child walking. Far and away the two most common reasons for this are idiopathic toe walking and spastic diplegic cerebral palsy. Cerebral palsy refers to a group of conditions that affect control of movement and posture. Because of damage to one or more parts of the brain that control movement, an affected child cannot move his or her muscles normally. While symptoms range from mild to severe, the condition does not get worse as the child gets older. With treatment, most children can significantly improve their abilities.

Late onset tip-toe gait is defined as tip toeing which begins at least about four months after a patient has had a well-developed normal heel-toe walk. This is virtually always due to some neuromuscular problem which will require an examination by a neurologist.

It is also important to note if their was a family incidence of tip toe walking. One of the most common contributing factors is a tight achilles tendon. Normally, a child should have about 10 degrees of ankle dorsiflexion (the amount your foot can extend towards your body when the foot is not tensed); however, a child can walk with a normal heel-toe gait as long as they can get to this neutral (The sub taler joint in the ankle is neutral when it is neither twisted in nor twisted out.).

Treatment

Most of these conditions are self-correcting during childhood. In the worst cases surgery may be needed. Most of the time this involves lengthening the achilles tendon. Less severe treatment options for pigeon toe include keeping a child from crossing his or her legs, use of corrective shoes and casting of the foot and lower legs, which is normally done before the child reaches 12 months of age or older.

If the pigeon toe is mild and close to the center, treatment may not be necessary. Ballet has been used as a treatment for mild cases. Dance exercises can help to bend the legs outward.

Most children will need to be referred to a physiotherapist, orthopedist and neurologist for treatment.

Idiopathic toe walking may be cured by just observing the condition and hoping that the child might eventually outgrow their tip toe gait. If you want to control an overactive calf muscle then the doctors might try to just hold it still with an ankle-foot orthosis (AFO Brace). If it is being caused by a tight achilles tendon then surgery may be required. The most common procedure is a gastrocnemius recession procedure. An alternative could be casting to correct the achilles tendon.

It can be very difficult to distinguish between idiopathic toe walking and mild spastic diplegic cerebral palsy. It seems simple enough, but it really is not because both conditions are highly associated with premature birth, developmental delay and tight achilles tendons. However a good sign is if the child can walk completely normal when you ask them to, it is more likely that they might have idiopathic toe walking.

For psychiatric toe walking, there is just no literature about how to treat this. There is very little literature about it at all. It’s seen once in a while in schizophrenic children, autistic children or children with learning disorders. There are no relevant treatment option that have been documented for this.

Spastic diplegic cerebral palsy is again almost always early onset tip toeing. The family history is negative and they should have upper motor neuron lesions or dynamic EMG (Electromyography is a test that assesses the health of the muscles and the nerves controlling the muscles) that is abnormal. If their is an over active achilles tendon then you could use bracing. If a patient’s dynamic contracture is so strong that they are fighting the brace, and then the doctors might try casting or Botox (Botox is an experimental treatment) to weaken the muscle and then continue with the brace. If the achilles is physically tight, then a lengthening procedure would be used and perhaps a hamstring lengthening also if the patient is crouching significantly.

Signs of upper motor neuron lesions include weakness, hyperreflexia (Reaction of the autonomic (involuntary) nervous system to over-stimulation), and increased tone. Note that with acute upper motor neuron lesions there is often flaccid paralysis (weakness or loss of muscle tone resulting from injury or disease of the nerves innervating the muscles) with decreased tone and decreased reflexes.

Around the time children start to learn to walk, around 9 to 16 months old, they are often unsteady, have a wide base of support, and they may sometimes prefer to walk on their tiptoes. Studies have shown that toe-walking is considered an acceptable part in normal development. Toe walking is common up to 18 months, but may persist until the child is 2-3 years old. The child usually grows out of toe walking and develops a heel-toe gait pattern at the age of 3.

Persistent toe walking, beyond 3 years of age, may be associated with diagnoses such as cerebral palsy, autism, spina bifida, tethered cord syndrome, muscular dystrophy, sensory integration deficits, or other neuromuscular issues. Other cases of toe walking may have no known etiology, and is diagnosed as Idiopathic Toe Walking. In any of the cases, children may benefit from interventions such as physical therapy, footwear modifications (shoe inserts, heel lifts), ankle foot orthotics (AFO), serial casting. Although it is rare, surgical intervention may be an option to lengthen tight heel cords that may be causing the gait abnormality.

Physical therapy intervention usually involves passive and active range of motion exercises that focus on the ankle stretching (usually tight calf heel cords), strengthening, gait training, balance training, and a home exercise program. In addition, a physical therapist is also involved in suggesting if/when other interventions, such as footwear modifications and orthotics, are appropriate.

Most children will eventually outgrow their tip toe gait but if you have any doubts then you should visit your family doctor as the first point of call.

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CHILDREN FOOT CLINIC (KLINIK KHUSUS GANGGUAN MASALAH KAKI PADA ANAK)

• Children Grow Up Clinic I, JL Taman Bendungan Asahan 5 Bendungan Hilir Jakarta Pusat 10210 Phone : (021) 5703646 – 44466103
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WORKING TOGETHER SUPPORT TO THE HEALTH OF ALL CHILDREN BY CLINICAL, RESEARCH AND EDUCATIONS. Advancing of the future pediatric and future parenting to optimalized physical, mental and social health and well being for fetal, newborn, infant, children, adolescents and young adult

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Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. You should not use the information on this web site for diagnosing or treating a medical or health condition. You should carefully read all product packaging. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider

Copyright © 2012, CHILDREN GRoW UP CLINIC Information Education Network. All rights reserved

Nyeri tumit atau fasciitis plantaris adalah sindroma nyeri tumit berhubungan dengan peradangan atau iritasi pada fascia plantaris. Fascia plantaris adalah bentuk ligament (jaringan yang menghubungakan dua tulang) di bawah kaki yang membentuk lengkungan (arkus). Berorigo pada tulang calcaneous (tulang tumit), dan berinsersio pada caput metatarsale I-V jari kaki dan membentuk lengkungan. Yang paling umum terjadi, cidera overuse yang berkenaan dengan arkus menyebabkan terjadinya peradangan fascia plantaris dengan kerobekan kecil pada daerah yang melekat pada tulang tumit. Cidera overuse dapat disebabkan oleh lamanya posisi berdiri, perubahan pada tingkat aktivitas (misalnya, karena terlalu bersemangat dalam menjalankan program latihan), peningkatan berat badan, lemahnya penyangga pada sepatu, dan cidera kaki. Ketegangan tendon Achilles (jaringan yang menghubungkan otot betis dengan tulang tumit) turut memberikan tekanan pada fascia plantaris dan ini sering dihubungkan dengan nyeri tumit.

Secara khas, gejala-gejala permulaaan munculnya nyeri terjadi pada tumit bagian bawah selama beberapa langkah pertama pada waktu pagi atau setelah duduk pada waktu yang lama. Pada berkembangan gejala selanjutnya, nyeri dapat muncul pada setiap langkah dan terus-menerus. Pada kebanyakan masyarakat, fasciitis plantaris dapat hilang secara spontan atau dengan istirahat. Bagaimanapun, penyembuhannya membutuhkan waktu yang lama. Pada studi penelitian waktu penyembuhan rata-rata sampai 8 bulan.

Terapi nonoperasi

• Program stretching pada fascianya, memakai sepatu penyangga, menghindari untuk bertelanjang kaki. Sering, NSAIDs (seperti aspirin atau ibuprofen) bisa membantu. Menggunakan penyangga arkus over-the-counter atau custom-fitted dapat mengurangi beberapa tekanan pada arkus dan memberikan fascia plantaris dapat sembuh dengan cepat. Pengangkat tumit atau bantalan tumit juga dapat diberikan.
• Pemakaian splint/bandage diwaktu malam atau pembalut fiberglass. Pembalutan dilakukan pada posisi 90 derajat dari tungkai (seperti ketika berdiri), yang mencegahnya dari gerakan plantar fleksi. Terapi ini diaplikasikan ketika anda istirahat atau tidur, dapat memperbaiki gejala pada kebanyakan orang. Bahkan ketika semua terapi nonoperasi telah gagal. Biayanya, pembalutan dilakukan selama tiga minggu. Injeksi steroid ke tumit bisa mengurangi gejala kira-kira sepertiga dari para penderita. Bagaimanapun, terapi ini tidak tepat untuk setiap orang dan tidak boleh secara berulang-ulang. Injeksi yang terus-menerus dapat menyebabkan resiko kelemahan dan rupture pada fascia plantaris.
• Modalitas fisioterapi seperti ultrasound, iontophoresis dan phonophoresis dapat membantu setengah dari penderita yang diterapi. Ultrasound high-impulse teknologi baru menjanjikan kepada penderita yang tidak mendapatkan yang lebih baik dari tipe-tipe terapi nonoperasi yang lain; alat ini akan lebih digunakan untuk masa mendatang.

Terapi operasi

• Jika gejala-gejala anda tidak mengalami perubahan dengan terapi nonoperasi dan terus berlangsung selama enam bulan sampai satu tahun, mungkin membutuhkan operasi.
• Operasi biasanya dilakukan pada pasien rawat jalan. Dokter membuat incise tiga inchi dengan membuka bagian dalam dan tengah pada fascia plantaris dengan dengan tulang tumit. Kemudian, pasien memanjangkan pascia plantarisnya. Dokter bisa juga menghilangkan saraf plantaris dari jaringan yang menekannya jika saraf ini teriritasi.

Terapi pasca operasi

• Setelah operasi, memakai sepatu khusus dan memulai berjalan dengan hati-hati. Setelah enam minggu, biasanya anda dapat memakai sepatu biasa. Maksimal anda mendapatkan kemajuan kira-kira setelah tiga bulan. 75 persen dari penderita secara siknifikan mengalami kemajuan dengan terapi operasi.
• Nyeri tumit membutuhkan waktu untuk penyembuhan, dan anda harus memakai sepatu penyangga, dibarengi dengan latihan khusus, dan menggunakan terapi yang lain. Secara kebetulan, kebanyakan penderita dengan fasciitis plantaris mendapatkan kesembuhan yang komplet tanpa operasi.

Daftar Pustaka

• Gill L, Kiebzak G. Outcome of nonsurgical treatment for plantar fasciitis. Foot Ankle Int. 1996;17(9):527-532. Wolgin M, Cook C, Graham C, Mauldin D. Conservative treatment of plantar heel pain: long-term follow-up. Foot Ankle Int. 1994;15(3):97-102.

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CHILDREN FOOT CLINIC (Klinik Khusus Permasalahan Kaki Pada Anak)

• JL Taman bendungan Asahan 5 Bendungan Hilir Jakarta Pusat 10210  Phone : (021) 70081995 – 5703646
• Menteng Square Jalan Matraman 30 Jakarta Pusat (opening soon)
• email : narulita_md@yahoo.com

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• Picky Eaters Clinic, Klinik Kesulitan makan Pada Anak www.mypickyeaters.wordpress.com/
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Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. You should not use the information on this web site for diagnosing or treating a medical or health condition. You should carefully read all product packaging. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider

Copyright © 2012, Children Foot Clinic   Information Education Network. All rights reserved

• Clubfoot adalah istilah umum yang digunakan untuk menggambarkan deformitas umum dimana kaki berubah dari posisi yang normal.
• Congenital Talipes Equino-varus (CTEV) atau biasa disebut Clubfoot merupakan deformitas yang umum terjadi pada anak-anak,
• Clubfoot  sering disebut juga CTEV (Congeintal Talipes Equino Varus) adalah deformitas yang meliputi fleksi dari pergelangan kaki, inversi dari tungkai, adduksi dari kaki depan, dan rotasi media dari tibia (Priciples of Surgery, Schwartz). Talipes berasal dari kata talus (ankle) dan pes (foot), menunjukkan suatu kelainan pada kaki (foot) yang menyebabkan penderitanya berjalan pada ankle-nya. Sedang Equinovarus berasal dari kata equino (meng.kuda) + varus (bengkok ke arah dalam/medial).
• Sampai saat ini masih banyak  perdebatan dalam etiopatologi CTEV.
• Patogenesisnya bersifat multifaktorial. Banyak teori telah diajukan sebagai penyebab deformitas ini, termasuk faktor genetic, defek sel germinativum primer, anomali vascular, faktor jaringan lunak, faktor intrauterine dan faktor miogenik. Telah diketahui bahwa kebanyakan anak dengan CTEV memiliki atrofi otot betis, yang tidak hilang setelah terapi, karenanya mungkin terdapat hubungan antara patologi otot dan deformitas ini.
• CTEV adalah salah satu anomali ortopedik kongenital yang paling sering terjadi seperti dideskripsikan oleh Hippocrates pada tahun 400 SM, dengan gambaran klinis tumit yang bergeser kebagian dalam dan kebawah, forefoot juga berputar kedalam. Tanpa terapi, pasien dengan clubfoot akan berjalan dengan bagian luar kakinya, yang mungkin menimbulkan nyeri dan atau disabilitas. Meskipun begitu, hal ini masih menjadi tantangan bagi keterampilan para ahli bedah ortopedik anak akibat adanya kecenderungan kelainan ini menjadi relaps, tanpa memperdulikan apakah kelainan tersebut diterapi secara operatif maupun konservatif. Salah satu alasan terjadinya relaps antara lain adalah kegagalan ahli bedah dalam mengenali kelainan patoanatomi yang mendasarinya. clubfoot seringkali secara otomatis diangggap sebagai deformitas equinovarus, namun ternyata terdapat permutasi dan kombinasi lainnya, seperti Calcaneovalgus,, Equinovalgus dan Calcaneovarus yang mungkin saja terjadi.
• CTEV merupakan kelainan kongenital kaki yang paling penting karena mudah mendiagnosisnya tetapi sulit mengkoreksinya secara sempurna, meskipun oleh ortopedis yang berpengalaman. Derajat beratnya deformitas dapat ringan, sedang atau berat, tergantung fleksibilitas atau adanya resistensi terhadap koreksi. CTEV harus dibedakan dengan postural clubfoot atau posisional equinovarus dimana pada CTEV bersifat rigid, menimbulkan deformitas yang menetap bila tidak dikoreksi segera.
• Penatalaksanaan CTEV bertujuan untuk mencegah terjadinya disabilitas sehingga penderita dapat melakukan aktifitas secara normal baik ketika anak-anak maupun setelah tumbuh dewasa. Penatalaksanaan CTEV harus dapat dilakukan sedini mungkin, minimal pada beberapa hari setelah lahir, meliputi koreksi pasif, mempertahankan koreksi untuk jangka panjang dan pengawasan sampai akhir pertumbuhan anak. Pada beberapa kasus diperlukan tindakan pembedahan. Penatalaksanaan rehabilitasi medis pada penderita CTEV sangat penting dalam hal mencegah terjadinya disabilitas secara dini maupun setelah dilakukan tindakan koreksi secara operatif.³
• Beberapa dari deformitas kaki termasuk deformitas ankle disebut dengan talipes yang berasal dari kata talus (yang artinya ankle) dan pes (yang berarti kaki). Deformitas kaki dan ankle dipilah tergantung dari posisi kelainan ankle dan kaki.
• Deformitas talipes diantaranya : – Talipes varus : inversi atau membengkok ke dalam – Talipes valgus : eversi atau membengkok ke luar – Talipes equinus : plantar fleksi dimana jari-jari lebih rendanh daripada tumit – Talipes calcaneus : dorsofleksi dimana jari-jari lebih tinggi daripada tumit
• Club Foot terjadi kelainan berupa : • Fore Foot Adduction (kaki depan mengalami adduksi dan supinasi) • Hind Foot Varus (tumit terinversi) • Equinus ankle (pergelangan kaki dalam keadaan equinus = dalam keadaan plantar fleksi)
• Clubfeet yang terbanyak merupakan kombinasi dari beberapa posisi dan angka kejadian yang paling tinggi adalah tipe talipes equinovarus (TEV) dimana kaki posisinya melengkung kebawah dan kedalam dengan berbagai tingkat keparahan. Unilateral clubfoot lebih umum terjadi dibandingkan tipe bilateral dan dapat terjadi sebagai kelainan yang berhubungan dengan sindroma lain seperti aberasi kromosomal, artrogriposis (imobilitas umum dari persendian), cerebral palsy atau spina bifida.
• Frekuensi clubfoot dari populasi umum adalah 1 : 700 sampai 1 : 1000 kelahiran hidup dimana anak laki-laki dua kali lebih sering daripada perempuan. Insidensinya berkisar dari 0,39 per 1000 populasi Cina sampai 6,8 per 1000 diantara orang.  Clubfoot adalah salah satu cacat lahir yang paling umum. Lebih dari 4.000 bayi (sekitar 1 dari 1.000) lahir dengan Clubfoot di Amerika Serikat setiap tahun (1, 2).  Berdasarkan data, 35% terjadi pada kembar monozigot dan hanya 3% pada kembar dizigot. Ini menunjukkan adanya peranan faktor genetika. Anak laki-laki terkena dua kali lebih sering anak perempuan (1, 2). Cacat kaki ringan bahkan lebih umum daripada Clubfoot.

Penyebab

Penyebab utama CTEV tidak diketahui. Adanya berbagai macam teori penyebab terjadinnya CTEV menggambarkan betapa sulitnya membedakan antara CTEV primer dengan CTEV sekunder karena suatu proses adaptasi.

Beberapa teori mengenai penyebab terjadinya CTEV:

Penyebab pasti Clubfoot masih bel;um diketahui secara pasti. Di masa lalu, dokter mengira bahwa kaki bayi yang bengkok atau sempit karena cara bayi berbaring di dalam rahim ibunya. Hal ini berlaku dari beberapa kelainan kaki yang mengoreksi diri setelah lahir (termasuk calcaneovalgus dan metatarsus ringan adductus).  Para ilmuwan sekarang percaya bahwa faktor genetik dan lingkungan berkontribusi Clubfoot. Faktor lingkungan dapat termasuk infeksi, penggunaan narkoba dan merokok. Satu studi menemukan bahwa wanita dengan riwayat keluarga Clubfoot yang merokok selama kehamilan memiliki risiko 20 kali lipat untuk memiliki bayi yang terkena dampak . Kebanyakan anak dengan Clubfoot tidak memiliki cacat lahir lainnya, meskipun kadang-kadang memang terjadi cacat lainnya. Dalam beberapa kasus, Clubfoot terjadi sebagai bagian dari sindrom yang mencakup sejumlah cacat lahir. Misalnya, anak dengan spina bifida (tulang belakang terbuka) terkadang memiliki bentuk Clubfoot. Hal ini disebabkan oleh saraf tulang belakang rusak yang terjadi pada kaki. Dalam kasus lain, kaki yang normal pada saat lahir dapat menjadi bengkok akibat penyakit otot atau saraf.

Teori Penyebab dan Faktor resiko

• Pada tahun 2008 penerima hadiah March of Dimes  di Washington University School of Medicine di St Louis adalah tim yang mengidentifikasi gen pertama dikaitkan dengan  Clubfoot  pada manusia.  Gen, PITX1, memainkan peran penting dalam pengembangan awal kaki.  Pemahaman yang lebih baik dari faktor genetik yang berkontribusi terhadap kaki pengkor akhirnya dapat menyebabkan cara-cara baru untuk mencegah dan mengobati gangguan tersebut.  Peneliti juga sedang mempelajari bagaimana otot bayi yang belum lahir, tulang dan saraf tumbuh, dan faktor genetik dan lingkungan yang mempengaruhi mereka, karena wawasan tentang penyebab dan pencegahan cacat lahir kaki pengkor dan lainnya.
• Teori kromosomal, antara lain defek dari sel germinativum yang tidak dibuahi dan muncul sebelum fertilisasi.
• Teori embrionik, antara lain defek primer yang terjadi pada sel germinativum yang dibuahi (dikutip dari Irani dan Sherman) yang mengimplikasikan defek terjadi antara masa konsepsi dan minggu ke-12 kehamilan.
• Teori otogenik, yaitu teori perkembangan yang terhambat, antara lain hambatan temporer dari perkembangan yang terjadi pada atau sekitar minggu ke-7 sampai ke-8 gestasi. Pada masa ini terjadi suatu deformitas clubfoot yang jelas, namun bila hambatan ini terjadi setelah minggu ke-9, terjadilah deformitas clubfoot yang ringan hingga sedang. Teori hambatan perkembangan ini dihubungkan dengan perubahan pada faktor genetic yang dikenal sebagai “Cronon”. “Cronon” ini memandu waktu yang tepat dari modifikasi progresif setiap struktur tubuh semasa perkembangannya. Karenanya, clubfoot terjadi karena elemen disruptif (lokal maupun umum) yang menyebabkan perubahan faktor genetic (cronon).
• Teori fetus, yakni blok mekanik pada perkembangan akibat intrauterine crowding.
• Teori neurogenik, yakni defek primer pada jaringan neurogenik.
• Teori amiogenik, bahwa defek primer terjadi di otot.

Manifestasi klinis

• Gejala klinis dapat ditelusuri melalui riwayat keluarga yang menderita clubfoot atau kelainan neuromuskuler, dan dengan melakukan pemeriksaan secara keseluruhan untuk mengidentifikasi adanya abnormalitas.
• Pemeriksaan dilakukan dengan posisi prone, dengan bagian plantar yang terlihat, dan supine untuk mengevaluasi rotasi internal dan varus. Jika anak dapat berdiri , pastikan kaki pada posisi plantigrade, dan ketika tumit sedang menumpu, apakah pada posisi varus, valgus atau netral.
• Deformitas serupa terlihat pada myelomeningocele and arthrogryposis. Oleh sebab itu agar selalu memeriksa gejala-gejala yang berhubungan dengan kondisi-kondisi tersebut. Ankle equinus dan kaki supinasi (varus) dan adduksi (normalnya kaki bayi dapat dorso fleksi dan eversi, sehingga kaki dapat menyentuh bagian anterior dari tibia). Dorso fleksi melebihi 90° tidak memungkinkan.

Diagnosis

Clubfoot dan beberapa cacat kaki yang lain secara umum dapat diakui selama pemeriksaan baru lahir.  Cacat ini biasanya dapat didiagnosis dengan pemeriksaan fisik saja, meskipun kadang-kadang penyedia bisa merekomendasikan tes tambahan, seperti sinar-X.  Clubfoot kadang didiagnosis sebelum kelahiran, selama USG.  Meskipun gangguan tersebut tidak dapat diobati sebelum kelahiran, orang tua memiliki kesempatan untuk menemukan seorang ahli bedah ortopedi dan belajar tentang pilihan pengobatan.

• Kelainan ini mudah didiagnosis, dan biasanya terlihat nyata pada waktu lahir (early diagnosis after birth). Pada bayi yang normal dengan equinovarus postural, kaki dapat mengalami dorsifleksi dan eversi hingga jari-jari kaki menyentuh bagian depan tibia. “Passive manipulation dorsiflexion → Toe touching tibia → normal”.
• Bentuk dari kaki sangat khas. Kaki bagian depan dan tengah inversi dan adduksi. Ibu jari kaki terlihat relatif memendek. Bagian lateral kaki cembung, bagian medial kaki cekung dengan alur atau cekungan pada bagian medial plantar kaki. Kaki bagian belakang equinus. Tumit tertarik dan mengalami inversi, terdapat lipatan kulit transversal yang dalam pada bagian atas belakang sendi pergelangan kaki. Atrofi otot betis, betis terlihat tipis, tumit terlihat kecil dan sulit dipalpasi. Pada manipulasi akan terasa kaki kaku, kaki depan tidak dapat diabduksikan dan dieversikan, kaki belakang tidak dapat dieversikan dari posisi varus. Kaki yang kaku ini yang membedakan dengan kaki equinovarus paralisis dan postural atau positional karena posisi intra uterin yang dapat dengan mudah dikembalikan ke posisi normal. Luas gerak sendi pergelangan kaki terbatas. Kaki tidak dapat didorsofleksikan ke posisi netral, bila disorsofleksikan akan menyebabkan terjadinya deformitas rocker-bottom dengan posisi tumit equinus dan dorsofleksi pada sendi tarsometatarsal. Maleolus lateralis akan terlambat pada kalkaneus, pada plantar fleksi dan dorsofleksi pergelangan kaki tidak terjadi pergerakan maleoulus lateralis terlihat tipis dan terdapat penonjolan korpus talus pada bagian bawahnya. Tulang kuboid mengalami pergeseran ke medial pada bagian distal anterior tulang kalkaneus. Tulang navicularis mengalami pergeseran medial, plantar dan terlambat pada maleolus medialis, tidak terdapat celah antara maleolus medialis dengan tulang navikularis. Sudut aksis bimaleolar menurun dari normal yaitu 85° menjadi 55° karena adanya perputaran subtalar ke medial.
• Terdapat ketidakseimbangan otot-otot tungkai bawah yaitu otot-otot tibialis anterior dan posterior lebih kuat serta mengalami kontraktur sedangkan otot-otot peroneal lemah dan memanjang. Otot-otot ekstensor jari kaki normal kekuatannya tetapi otot-otot fleksor jari kaki memendek. Otot triceps surae mempunyai kekuatan yang normal.
• Tulang belakang harus diperiksa untuk melihat kemungkinan adanya spina bifida. Sendi lain seperti sendi panggul, lutut, siku dan bahu harus diperiksa untuk melihat adanya subluksasi atau dislokasi. Pmeriksaan penderita harus selengkap mungkin secara sistematis seperti yang dianjurkan oleh R. Siffert yang dia sebut sebagai Orthopaedic checklist untuk menyingkirkan malformasi multiple.

DIAGNOSIS BANDING

1. Postural clubfoot- disebabkan oleh posisi fetus dalam uterus. Kaki dapat dikoreksi secara manual oleh pemeriksa. Mempunyai respon yang baik dan cepat terhadap serial casting dan jarang akan kambuh kembali
2. Metatarsus adductus (atau varus)- adalah deformitas pada metatarsal saja. Kaki bagian depan mengarah ke bagian medial dari tubuh. Dapat dikoreksi dengan manipulasi dan mempunyai respon terhadap serial casting.

Prognosis

Asalkan terapi dimulai sejak lahir, deformitas sebagian besar dapat diperbaiki; walupun demikian, keadaan ini sering tidak sembuh sempurna dan sering kambuh, terutama pada bayi dengan kelumpuhan otot yang nyata atau disertai penyakit neuromuskuler. Beberapa kasus menunjukkan respon yang positif terhadap penanganan, sedangkan beberapa kasus lain menunjukkan respon yang lama atau tidak berespon samasekali terhadap treatmen. Orangtua harus diberikan informasi bahwa hasil dari treatmen tidak selalu dapat diprediksi dan tergantung pada tingkat keparahan dari deformitas, umur anak saat intervensi, perkembangan tulang, otot dan syaraf. Fungsi kaki jangka panjang setelah terapi secara umum baik tetapi hasil study menunjukkan bahwa koreksi saat dewasa akan menunjukkan kaki yang 10% lebih kecil dari biasanya

Penanganan

Sekitar 90-95% kasus club foot bisa di-treatment dengan tindakan non-operatif atau pendekatan non-bedah. Kebanyakan melibatkan beberapa bentuk manipulasi, gips, merekam dan belat. Pendekatan ini telah banyak mengurangi kebutuhan untuk perbaikan pembedahan besar, yang sering dikaitkan dengan komplikasi jangka panjang, seperti kaki dan pergelangan kaki sakit dan kekakuan. Seorang bayi dengan Clubfoot harus ditangani oleh ahli bedah ortopedi yang berpengalaman dalam berurusan dengan Clubfoot dan dapat membahas berbagai pilihan pengobatan dengan orang tua.

Penanganan yang dapat dilakukan pada club foot tersebut dapat berupa :

Non-Operative :

• Pertumbuhan yang cepat selama periode infant memungkinkan untuk penanganan remodelling. Penanganan dimulai saat kelainan didapatkan dan terdiri dari tiga tahapan yaitu : koreksi dari deformitas, mempertahankan koreksi sampai keseimbangan otot normal tercapai, observasi dan follow up untuk mencegah kembalinya deformitas.
• Pendekatan yang paling umum untuk mengobati Clubfoot menggunakan manipulasi dan casting, yang biasanya memperbaiki kaki pengkor dalam 2 sampai 3 bulan .  Idealnya, pengobatan harus dimulai dalam beberapa minggu pertama kehidupan.  Pada usia ini, ligamen dan tendon di kaki sangat fleksibel dan merespon dengan baik terhadap pengobatan. Studi menunjukkan bahwa pendekatan ini juga bisa sukses dalam mengobati anak yang lebih dari 1 tahun dengan kaki pengkor dikoreksi. Koreksi dari CTEV adalah dengan manipulasi dan aplikasi dari serial “cast” yang dimulai dari sejak lahir dan dilanjutkan sampai tujuan koreksi tercapai. Koreksi ini ditunjang juga dengan latihan stretching dari struktur sisi medial kaki dan latihan kontraksi dari struktur yang lemah pada sisi lateral.
• Manipulasi dan pemakaian “cast” ini diulangi secara teratur (dari beberapa hari sampai 1-2 bulan dengan interval 1-2 bulan) untuk mengakomodir pertumbuhan yang cepat pada periode ini.
• Jika manipulasi ini tidak efektif, dilakukan koreksi bedah untuk memperbaiki struktur yang berlebihan, memperpanjang atau transplant tendon. Kemudian ektremitas tersebut akan di “cast” sampai tujuan koreksi tercapai. Serial Plastering (manipulasi pemasangan gibs serial yang diganti tiap minggu, selama 6-12 minggu). Setelah itu dialakukan koreksi dengan menggunakan sepatu khusus, sampai anak berumur 16 tahun.
• Perawatan pada anak dengan koreksi non bedah sama dengan perawatan pada anak dengan anak dengan penggunaan “cast”. Anak memerlukan waktu yang lama pada koreksi ini, sehingga perawatan harus meliputi tujuan jangka panjang dan tujuan jangka pendek. Observasi kulit dan sirkulasi merupakan bagian penting pada pemakaian cast. Orangtua juga harus mendapatkan informasi yang cukup tentang diagnosis, penanganan yang lama dan pentingnya penggantian “cast” secara teratur untuk menunjang penyembuhan.
• Perawatan “cast” (termasuk observasi terhadap komplikasi), dan menganjurkan orangtua untuk memfasilitasi tumbuh kembang normal pada anak walaupun ada batasan karena deformitas atau therapi yang lama.
• Perawatan “cast” meliputi : – Biarkan cast terbuka sampai kering – Posisi ektremitas yang dibalut pada posisi elevasi dengan diganjal bantal pada hari pertama atau sesuai  intruksi – Observasi ekteremitas untuk melihat adanya bengkak, perubahan warna kulit dan laporkan bila ada perubahan yang abnormal – Cek pergerakan dan sensasi pada ektremitas secara teratur, observasi adanya rasa nyeri – Batasi aktivitas berat pada hari-hari pertama tetapi anjurkan untuk melatih otot-otot secara ringan, gerakkan sendi diatas dan dibawah cast secara teratur. – Istirahat yang lebih banyak pada hari-hari pertama untuk mencegah trauma – Jangan biarkan anak memasukkan sesuatu ke dalam cast, jauhkan benda-benda kecil yang bisa dimasukkan ke dalam cast oleh anak – Rasa gatal dapat dukurangi dengan ice pack, amati integritas kulit pada tepi cast dan kolaborasikan bila gatal-gatal semakin berat – Cast sebaiknya dijauhkan dari dengan air

CAST PADA CTEV (POSENTI TRETMENT)

Traditional manipulation and casting methods fail, as they do not allow the free rotation of the calcaneum and the talus

Ilizarov distraction for arthrogrypotic clubfoot.

Operatif

• Indikasi dilakukan operasi adalah sebagai berikut : • Jika terapi dengan gibs gagal • Pada kasus Rigid club foot pada umur 3-9 bulan
• Operasi dilakaukan dengan melepasakan karingan lunak yang mengalami kontraktur maupun dengan osteotomy. Osteotomy biasanya dilakukan pada kasus club foot yang neglected/ tidak ditangani dengan tepat.
• Kasus yang resisten paling baik dioperasi pada umur 8 minggu, tindakan ini dimulai dengan pemanjangan tendo Achiles ; kalau masih ada equinus, dilakuakan posterior release dengan memisahkan seluruh lebar kapsul pergelangan kaki posterior, dan kalau perlu, kapsul talokalkaneus. Varus kemudian diperbaiki dengan melakukan release talonavikularis medial dan pemanjangan tendon tibialis posterior.(Ini Menurut BuKu Appley).
• Pada umur > 5 tahun dilakukan bone procedure osteotomy. Diatas umur 10 tahun atau kalau tulang kaki sudah mature, dilakukan tindakan artrodesis triple yang terdiri atas reseksi dan koreksi letak pada tiga persendian, yaitu : art. talokalkaneus, art. talonavikularis, dan art. kalkaneokuboid.

Komplikasi

1. Komplikasi dapat terjadi dari terapi konservatif maupun operatif. Pada terapi konservatif mungkin dapat terjadi maslah pada kulit, dekubitus oleh karena gips, dan koreksi yang tidak lengkap. Beberapa komplikasi mungkin didapat selama dan setelah operasi. Masalah luka dapat terjadi setelah operasi dan dikarenakan tekanan dari cast. Ketika kaki telah terkoreksi, koreksi dari deformitas dapat menarik kulit menjadi kencang, sehinggga aliran darah menjadi terganggu. Ini membuat bagian kecil dari kulit menjadi mati. Normalnya dapat sembuh dengan berjalannya waktu, dan jarang memerlukan cangkok kulit.
2. Infeksi dapat terjadi pada beberapa tindakan operasi. Infeksi dapat terjadi setelah operasi kaki clubfoot. Ini mungkin membutuhkan pembedahan tambahan untuk mengurangi infeksi dan antibiotik untuk mengobati infeksi.
3. Kaki bayi sangat kecil, strukturnya sangat sulit dilihat. Pembuluh darah dan saraf mungkin saja rusak akibat operasi. Sebagian besar kaki bayi terbentuk oleh tulang rawan. Material ini dapat rusak dan mengakibatkan deformitas dari kaki. Deformitas ini biasanya terkoreksi sendir dengan bertambahnya usia

Clubfoot atau secara luas dikenal sebagai sinonim untuk talipes equinovarus, merupakan deformitas kongenital yang bahkan sebelum jaman hippocrates sudah menarik perhatian dunia medis. Banyak keadaan bisa menyebabkan deformitas clubfoot dengan perubahan struktur serupa abnormalitas ini terbentuk selama masa pertumbuhan capat tulang. Pada saat bayi dilahirkan, deformitas kaki kongenital bisa tampak mirip satu dengan lainnya, apapun etiologinya. Kesalahpahaman menyangkut etiologi, patologi dan efikasi penatalaksanaan telah mengisi berbagai literatur karena kegagalan dalam membedakan bentuk idiopatik dari deformitas yang didapat atau sekunder.

Apapun masalahnya, yang terpenting adalah pengenalan dini penyebab deformitas, sehingga rangkaian penatalaksanaan dapat segera direncanakan dan keluarga penderita memperoleh informasi yang akurat, prognosis yang realistik dan menghindari komplikasi iatrogenik akibat kekeliruan dalam program penatalaksanaan clubfoot. Keluarga penderita harus diberikan edukasi yang sejelas-jelasnya, terutama mengenai kemungkinan terjadinya kekambuhan dan kelainan ini tidak dapat terkoreksi sempurna atau normal, adanya gejala sisa.

Posteromedial release for clubfoot.

Never forcibly evert or pronate the foot during clubfoot casting (A), Spontaneous correction of the hind foot varus by abducting the forefoot and allowing the calcaneum to freely rotate under the talus (B)

Komplikasi dari manipulasi dan terapi :  Rockerbottom foot.

Pencegahan

Tidak ada cara untuk mencegah Clubfoot  saat ini.  Namun, wanita hamil tidak boleh merokok, terutama jika mereka memiliki riwayat keluarga Clubfoot. Merokok juga meningkatkan risiko memiliki bayi dengan berat lahir rendah atau prematur, serta komplikasi kehamilan lainnya. Konseling genetik dapat membantu orang tua memahami kemungkinan memiliki anak dengan kaki pengkor. Umumnya, jika seorang anak memiliki Clubfoot terisolasi (tidak ada cacat lahir lainnya sekarang), risiko kekambuhan pada kehamilan lain adalah rendah (sekitar 5 persen), tetapi secara substansial lebih besar daripada risiko pada populasi umum

End Point :

• Banyak keadaan bisa menyebabkan deformitas clubfoot dengan perubahan struktur serupa abnormalitas ini terbentuk selama masa pertumbuhan capat tulang. Pada saat bayi dilahirkan, deformitas kaki kongenital bisa tampak mirip satu dengan lainnya, apapun etiologinya.
• Kesalahpahaman menyangkut etiologi, patologi dan efikasi penatalaksanaan karena kegagalan dalam membedakan bentuk idiopatik dari deformitas yang didapat atau sekunder.
• Paling utama adalah pengenalan dini penyebab deformitas, sehingga rangkaian penatalaksanaan dapat segera direncanakan dan keluarga penderita memperoleh informasi yang akurat, prognosis yang realistik dan menghindari komplikasi iatrogenik akibat kekeliruan dalam program penatalaksanaan clubfoot.
• Keluarga penderita harus diberikan edukasi yang sejelas-jelasnya, terutama mengenai kemungkinan terjadinya kekambuhan dan kelainan ini tidak dapat terkoreksi sempurna atau normal, adanya gejala sisa.

Reference :

• Ponseti IV. Clubfoot management. J Pediatr Orthop. Nov-Dec 2000;20(6):699-700.
• Cooper DM, Dietz FR. Treatment of idiopathic clubfoot. A thirty-year follow-up note. J Bone Joint Surg Am. Oct 1995;77(10):1477-89.
• Bor N, Herzenberg JE, Frick SL. Ponseti management of clubfoot in older infants. Clin Orthop Relat Res. Mar 2006;444:224-8.
• Noonan KJ, Richards BS. Nonsurgical management of idiopathic clubfoot. J Am Acad Orthop Surg. Nov-Dec 2003;11(6):392-402.
• Docker CE, Lewthwaite S, Kiely NT. Ponseti treatment in the management of clubfoot deformity – a continuing role for paediatric orthopaedic services in secondary care centres. Ann R Coll Surg Engl. Jul 2007;89(5):510-2.
• Ippolito E, Ponseti IV. Congenital club foot in the human fetus. A histological study. J Bone Joint Surg Am. Jan 1980;62(1):8-22.
• Scher DM. The Ponseti method for treatment of congenital club foot. Curr Opin Pediatr. Feb 2006;18(1):22-5.
• American Academy of Orthopaedic Surgeons. (2007). Children’s clubfoot: Treatment with casting or operation? Retrieved May 19, 2009 from: orthoinfo.aaos.org.
• Dobbs, M.B., & Gurnett, C.A. (2009). Update on clubfoot: Etiology and treatment. Clinical Orthopaedics and Related Research, 467(5), 1146-1153.
• Duke University Department of Orthopaedics. (2009). Calcaneovalgus foot. Retrieved May 19, 2009 from: wheelessonline.com/ortho/calcaneovalgus_foot.
• American Academy of Orthopaedic Surgeons. (2009). Intoeing. Retrieved May 19, 2009 from: orthoinfo.aaos.org..
• Richards, B.S., Faulks, S., Rathjen, K.E., Karol, L.A., Johnston, C.E., et al. (2008). A comparison of two nonoperative methods of idiopathic clubfoot correction: The Ponseti method and the French functional (physiotherapy) method. The Journal of Bone and Joint Surgery (11), 2313-2321.
• Honein, M.A., Paulozzi, L.J. & Moore, C.A. (2000). Family history, maternal smoking and clubfoot: An indication of a gene-environment interaction. American Journal of Epidemiology, 152(7), 658-665.
• Gurnett, C.A., Alaee, F., Kruse, L.M., Desruisseau, D.M., Hecht, J.T., et al. (2008). Asymmetric lower-limb malformations in individuals with homeobox PITX1 mutation. American Journal of Human Genetics, 83, 616-622.
• Freedman JA, Watts H, Otsuka NY. The Ilizarov method for the treatment of resistant clubfoot: is it an effective solution?. J Pediatr Orthop. Jul-Aug 2006;26(4):432-7.
• Ponseti IV. Relapsing clubfoot: causes, prevention, and treatment. Iowa Orthop J. 2002;22:55-6.
• Tachdjian Mihran O. Congenital Talipes Equinovarus In: John Anthony Herring [editor]: Pediatric Orthopaedics, From the Texas Scottish Rite Hospital for Children. Saunders elsivier, 2008; 1070-1078.
• Reyes Tyrone M, Luna-Reyes Ofelia B. The Ankle and the Foot. In: Kinesiology. Manila, Philipines: UST Printing Office, 1978;152-166.
• Graham. Apley, Louis Solomon. Deformities of the Foot. In: Apley’s System of Orthopaedics and Procedurs,1982; 307-9.
• David H. Sutherland. Congenital Clubfoot. In: Gait Disorders in Chilhood and Adolescence. William and Wilkins, 1984, 81
• Http://www.emedicine/spesialities/radiology/pediatrics. Author: Ellen M Chung.
• Http://www.ijoonline.com, Indian Journal of Orthopaedics, November 2008

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Three studiesof military recruits have shown no evidence of later increased injury, or foot problems, due to flat feet, in a population of people who reach military service age without prior foot problems. However, these studies cannot be used to judge possible future damage from this condition when diagnosed at younger ages. They also cannot be applied to persons whose flat feet are associated with foot symptoms, or certain symptoms in other parts of the body (such as the leg or back) possibly referable to the foot.

Kulowski first described tenosynovitis of the posterior tibial tendon in 1936.Key described surgical findings of partial posterior tibial tendon rupture in 1953.In 1974, Goldner et al described the surgical treatment of 9 patients with posterior tibial tendon dysfunction.In the early 1980s, Jahss, Mann, and Johnson recognized posterior tibial tendon dysfunction as a common cause of acquired adult flatfoot.

The appearance of flat feet is normal and common in infants, partly due to “baby fat” which masks the developing arch and partly because the arch has not yet fully developed. The human arch develops in infancy and early childhood as part of normal muscle, tendon, ligament and bone growth. Training of the feet, especially by foot gymnastics and going barefoot on varying terrain, can facilitate the formation of arches during childhood, with a developed arch occurring for most by the age of four to six years. Flat arches in children usually become proper arches and high arches while the child progresses through adolescence and into adulthood. A survey of 297 school children at Allahabad, Uttar Pradesh, India revealed that 40.32% of children under 5, 22.15% of children between 5 and 10, and, 15.48% of children older than 10 suffered bilateral flat foot.^[1]

Because young children are unlikely to suspect or identify flat feet on their own, it is a good idea for parents or other adult caregivers to check on this themselves. Besides visual inspection, parents should notice whether a child begins to walk oddly or clumsily, for example on the outer edges of the feet, or to limp, during long walks, and to ask the child whether he or she feels foot pain or fatigue during such walks. Children who complain about calf muscle pains or any other pains around the foot area, may be developing or have flat feet. Pain or discomfort may also develop in the knee joints. A recent randomized controlled trial found no evidence for the efficacy of treatment of flat feet in children either for expensive prescribed orthoses (shoe inserts) or less expensive over-the-counter orthoses

Adult flatfoot refers to a deformity that develops after skeletal maturity is reached. Adult flatfoot should be differentiated from constitutional flatfoot, which is a common congenital nonpathologic foot morphology.

Etiology

There are numerous causes of acquired adult flatfoot, including fracture or dislocation, tendon laceration, tarsal coalition, arthritis, neuroarthropathy, neurologic weakness, and iatrogenic causes. The most common cause of acquired adult flatfoot is posterior tibial tendon dysfunction. This article focuses primarily on the diagnosis and treatment of this condition.

The etiology of posterior tibial tendon dysfunction is varied; it is attributed to degenerative, inflammatory, and traumatic causes. In 1 study, 60% of patients were obese or had diabetes mellitus, hypertension, previous surgery or trauma to the medial foot, or treatment with steroids. Myerson has described 2 subsets of patients with posterior tibial tendon dysfunction.One patient group was younger with associated enthesopathies at multiple sites, a higher incidence of HLA-B27 positivity, and a significant family history for inflammatory disease and psoriasis, thus suggesting a seronegative spondyloarthropathy. The other patient group was older and had isolated dysfunction, suggesting a purely mechanical degenerative cause.

Arthropathies can result in posterior tibial tendon dysfunction as well. In 1 study, 11% of 99 rheumatoid patients were found to have posterior tibial tendon pathology.A zone of tendon hypovascularity exists 1-1.5 cm distal to the medial malleolus, continuing 14 mm distally. Poor blood supply in this area of the tendon, where it takes a sharply curving course around the medial malleolus, could result in tendon degeneration and may explain a mechanical cause for tendon rupture.

A study by Dyal et al compared weightbearing radiographs of symptomatic feet with posterior tibial tendon dysfunction to those of the contralateral asymptomatic feet.Interestingly, there was strong correlation between the measurements of both feet, leading the authors to suggest that a predisposing constitutional flatfoot may be a possible etiologic factor in the development of dysfunction. The authors cautioned against using radiographic measurements alone for diagnosis.

 Pathophysiology

Research has shown that tendon specimens from people who suffer from adult acquired flat feet show evidence of increased activity of proteolytic enzymes. These enzymes can break down the constituents of the involved tendons and cause the foot arch to fall. It is possible that in future these enzymes will become targets for new drug therapies

The medial longitudinal arch has both passive and active support. The 3 most important static contributors to arch stability, in order of importance, are the plantar fascia, the long and short plantar ligaments, and the spring ligament (calcaneonavicular ligament). The spring ligament forms a sling for the talar head, which prevents medial and plantar migration of the talar head and provides static arch support. The major dynamic stabilizer for the arch is the posterior tibial tendon.

Contraction of the posterior tibial tendon causes inversion of the midfoot and elevation of the medial longitudinal arch through its broad insertion on the navicular, cuneiforms, medial 3 metatarsal bases, and cuboid.

The posterior tibial tendon also indirectly affects hindfoot inversion due to its course running behind the medial malleolus and its close association with the deep deltoid and spring ligaments. With hindfoot inversion, the axes of the talonavicular and calcaneocuboid joints diverge, and the transverse tarsal joint (Chopart joint) becomes locked, which transforms the foot into a rigid lever.

Loss of posterior tibial function due to stretching or rupture of the tendon removes the primary inverter of the foot and leaves the primary and secondary everters of the foot, the peroneus brevis and longus, relatively unopposed. Therefore, posterior tibial dysfunction leads to flattening of the medial longitudinal arch, forefoot abduction, and hindfoot valgus. During the late stance phase of gait, the patient loses push-off strength due to inability to invert the hindfoot and achieve forefoot rigidity. With loss of the posterior tibial tendon function, the powerful gastrocsoleus complex acts at the talonavicular joint instead of at the level of the metatarsal heads.

The talar head is then pushed downward and medially, stretching the calcaneonavicular (spring) ligament. Continued weight bearing on the medial side of the heel eventually leads to deltoid ligament insufficiency and valgus instability of the ankle. Three-dimensional CT analysis of patients with acquired flatfoot has documented subluxation of the subtalar joint with less contact between all 3 facets of the calcaneus and talus compared to controls.

Studies analyzing the correlation between flat feet and physical injury in soldiers have been inconclusive, but none suggest that flat feet are an impediment, at least in soldiers who reached the age of military recruitment without prior foot problems. Instead, in this population, there is a suggestion of more injury in high arched feet. A 2005 study of Royal Australian Air Force recruits that tracked the recruits over the course of their basic training found that neither flat feet nor high arched feet had any impact on physical functioning, injury rates or foot health. If anything, there was a tendency for those with flat feet to have fewer injuries. Another study of 287 Israel Defense Forces recruits found that those with high arches suffered almost four times as many stress fractures as those with the lowest arches. A later study of 449 U.S. Navy special warfare trainees found no significant difference in the incidence of stress fractures among sailors and Marines with different arch heights

Presentation

The patient with posterior tibial tendon dysfunction initially complains of pain and swelling in the medial ankle and midfoot during weight bearing. Over time, the patient may notice loss of the arch and the tendency to walk on the inner border of the foot. Loss of push-off strength during gait occurs, and the patient may develop a limp. As the patient’s heel displaces into valgus and the forefoot abducts, pressure between the calcaneus and fibula may develop, causing painful impingement between the lateral ankle and calcaneus. Abnormal wear of the medial heel and inner border of shoe wear may also be noted.

The patient is first examined while standing, allowing comparison of the symptomatic to the asymptomatic foot. Arch height is assessed and compared with the asymptomatic foot. In later stages of posterior tibial tendon dysfunction, the arch is lowered and the forefoot abducted. Viewing the patient’s foot from behind allows the examiner to evaluate forefoot abduction and heel valgus. The toes visible lateral to the heel are counted. The finding of 1 or 2 toes visible lateral to the heel is normal. In cases of significant forefoot abduction, 3 or more toes are visible. This too-many-toes sign is a test to confirm forefoot abduction

The angle that the heel forms with the longitudinal axis of the lower leg also should be measured. This posterior tibiocalcaneal angle is increased in cases of significant heel valgus. The patient should then be asked to stand on 1 foot and rise up on the toes. The patient usually needs to hold on to the examining table or wall for balance during this maneuver. Normally, the heel inverts as the posterior tibial muscle contracts and as the gastrocsoleus fires. In cases of posterior tibial tendon dysfunction, the heel does not invert, and the patient finds this single-limb heel rise maneuver painful, difficult, or impossible.

The patient then is examined seated on the examining table, and the course of the posterior tibial tendon is palpated for tenderness. Swelling along the posterior tibial tendon heath may be noted, and fluid may be palpated within the sheath. Posterior tibial strength is tested by holding the forefoot in a position of plantar flexion and eversion and asking the patient to invert the foot. During this maneuver, the posterior tibial tendon should be palpated to assess its continuity. The sinus tarsi and distal fibular area also should be palpated for tenderness because in later stages of posterior tibial tendon dysfunction, these areas of impingement may also be painful. The knee is extended, the foot is held in a subtalar neutral position, and passive ankle dorsiflexion is measured.

Usually, 10-20° of dorsiflexion is possible, but in cases of long-standing pes planus, dorsiflexion past neutral is often limited because of the development of a plantar flexion contracture. During the final stages of posterior tibial tendon dysfunction, the subtalar joint may be fixed in eversion, and inversion to neutral may be impossible. Finally, forefoot flexibility is assessed by pronating and supinating the forefoot while holding the heel in neutral position. Although the subtalar joint may be flexible, the transverse tarsal joint may have become fixed in varus, preventing plantigrade positioning of the forefoot . This finding has important implications for surgical treatment.

Indications for treatment of posterior tibial tendon dysfunction are disabling pain, deformity, shoe wear problems, and difficulty with ambulation. A painless deformity that can be accommodated by normal footwear and allows for normal gait does not require treatment.

Contraindications to surgical treatment are active or chronic infection, open ulceration, and severe peripheral vascular disease. A relative contraindication to surgical treatment is peripheral neuropathy with loss of protective sensation.

Medical Therapy and Treatment

Going barefoot, particularly over terrain such as a beach where muscles are given a good workout, is good for all but the most extremely flatfooted, or those with certain related conditions such as plantar fasciitis. One medical study in India with a large sample size of children who had grown up wearing shoes and others going barefoot, found that the longitudinal arches of the barefooters were generally strongest and highest as a group, and that flat feet were less common in children who had grown up wearing sandals or slippers than among those who had worn closed-toe shoes

Medical or nonoperative therapy for posterior tibial tendon dysfunction involves rest, immobilization, nonsteroidal anti-inflammatory medication, physical therapy, orthotics, and bracing.This treatment is especially attractive for patients who are elderly, who place low demands on the tendon, and who may have underlying medical problems that preclude operative intervention.

During stage 1 posterior tibial tendon dysfunction, pain, rather than deformity, predominates. Cast immobilization is indicated for acute tenosynovitis of the posterior tibial tendon or for patients whose main presenting feature is chronic pain along the tendon sheath. A well-molded short leg walking cast or removable cast boot should be used for 6-8 weeks.

Weight bearing is permitted if the patient is able to ambulate without pain. If improvement is noted, the patient then may be placed in custom full-length semirigid orthotics. The patient may then be referred to physical therapy for stretching of the Achilles tendon and strengthening of the posterior tibial tendon. Steroid injection into the posterior tibial tendon sheath is not recommended due to the possibility of causing a tendon rupture.

In stage 2 dysfunction, a painful flexible deformity develops, and more control of hindfoot motion is required. In these cases, a rigid University of California at Berkley (UCBL) orthosis or short articulated ankle-foot orthosis (AFO) is indicated.

Once a rigid flatfoot deformity develops, as in stage 3 or 4, bracing is extended above the ankle with a molded AFO, double upright brace, or patellar-tendon-bearing brace. The goals of this treatment are to accommodate the deformity, prevent or slow further collapse, and improve walking ability by transferring load to the proximal leg away from the collapsed medial midfoot and heel.

Nonoperative therapy for posterior tibial tendon dysfunction has been shown to yield 67% good-to-excellent results in 49 patients with stage 2 and 3 deformities.A rigid UCBL orthosis with a medial forefoot post was used in nonobese patients with flexible heel deformities correctible to neutral and less than 10° of forefoot varus. A molded ankle foot orthosis was used in obese patients with fixed deformity and forefoot varus greater than 10°. Average length of orthotic use was 15 months. Four patients ultimately elected to have surgery. The authors concluded that orthotic management is successful in older low-demand patients and that surgical treatment can be reserved for those patients who fail nonoperative treatment.

The following is a summary of conservative treatments for acquired flatfoot:

• Stage 1 – NSAIDs and short-leg walking cast or walker boot for 6-8 weeks; full-length semirigid custom molded orthosis, physical therapy
• Stage 2 – UCBL orthosis or short articulated ankle orthosis
• Stage 3 – Molded AFO, double-upright brace, or patellar tendon–bearing brace
• Stage 4 – Molded AFO, double-upright brace, or patellar tendon–bearing brace

Most flexible flat feet are asymptomatic, and do not cause pain. In these cases, there is usually no cause for concern, and the condition may be considered a normal human variant. Flat feet were formerly a physical-health reason for service-rejection in many militaries. However, three military studies on asymptomatic adults (see section below), suggest that persons with asymptomatic flat feet are at least as tolerant of foot stress as the population with various grades of arch. Asymptomatic flat feet are no longer a service disqualification in the U.S. military.

Rigid flatfoot, a condition where the sole of the foot is rigidly flat even when a person is not standing, often indicates a significant problem in the bones of the affected feet, and can cause pain in about a quarter of those affected.^[7][8] Other flatfoot-related conditions, such as various forms of tarsal coalition (two or more bones in the midfoot or hindfoot abnormally joined) or an accessory navicular (extra bone on the inner side of the foot) should be treated promptly, usually by the very early teen years, before a child’s bone structure firms up permanently as a young adult. Both tarsal coalition and an accessory navicular can be confirmed by x-ray. Rheumatoid Arthritis can destroy tendons in the foot (or both feet) which can cause this condition, and untreated can result in deformity and early onset of Osteoarthritis of the joint.^{[citation needed]} Such a condition can cause severe pain and considerably reduced ability to walk, even with orthoses. Ankle fusion is usually recommended.^{[citation needed]}

Treatment of flat feet may also be appropriate if there is associated foot or lower leg pain, or if the condition affects the knees or the lower back. Treatment may include using Orthoses such as an arch support, foot gymnastics or other exercises as recommended by a podiatrist/orthotist or physical therapist. In cases of severe flat feet, orthoses should be used through a gradual process to lessen discomfort. Over several weeks, slightly more material is added to the orthosis to raise the arch. These small changes allow the foot structure to adjust gradually, as well as giving the patient time to acclimatise to the sensation of wearing orthoses. Once prescribed, orthoses are generally worn for the rest of the patient’s life. In some cases, surgery can provide lasting relief, and even create an arch where none existed before; it should be considered a last resort, as it is usually very time consuming and costly

Surgical Therapy

Surgical treatment of stage 1 dysfunction

If initial conservative therapy of posterior tibial tendon insufficiency fails, surgical treatment is considered. Operative treatment of stage 1 disease involves release of the tendon sheath, tenosynovectomy, debridement of the tendon with excision of flap tears, and repair of longitudinal tears. A short-leg walking cast is worn for 3 weeks postoperatively. Teasdall and Johnson reported complete relief of pain in 74% of 14 patients undergoing this treatment regimen for stage 1 disease.Surgical debridement of tenosynovitis in early stages is believed to possibly prevent progression of disease to later stages of dysfunction.

Surgical treatment of stage 2 dysfunction

Treatment of the flexible deformity of stage 2 posterior tibial tendon dysfunction is controversial. Direct repair of the torn tendon, tendon transfer or tenodesis by using the flexor digitorum longus (FDL) or flexor hallucis longus (FHL), spring ligament repair, medial displacement calcaneal osteotomy, lateral column lengthening, and limited arthrodeses of the hindfoot or midfoot have all been reported to yield satisfactory outcomes. Achilles tendon lengthening is recommended if ankle dorsiflexion is limited to 10° or less. The difficulty in obtaining an excellent surgical result is evidenced by the multitude of surgical procedures proposed for stage 2 dysfunction.

Direct repair

The torn tendon may be directly repaired by suturing the ends of an acute rupture. If the tendon is avulsed distally, it can be repaired to the navicular, or the portion of the tendon that is attenuated can be excised and the proximal and distal tendon stumps repaired end to end.

Proximal Z-lengthening of the posterior tibial tendon may be needed to achieve direct repair. The distal half of the anterior tibial tendon can be detached proximally and left attached to its insertion into the base of the first metatarsal and used to reinforce the directly repaired tendon.

Tendon transfer with FDL or FHL

The posterior tibial tendon often has an irreparable gap or is attenuated and scarred to the tendon sheath. The posterior tibial muscle may function poorly, even if the tendon can be directly repaired. This has led several authors to recommend tendon transfer to substitute for the dysfunctional or irreparable posterior tibial tendon. Jahss reported side-to-side tenodesis of the proximal and distal stumps of the posterior tibial tendon to the intact FDL tendon in 5 patients, reporting short-term satisfactory results, although all patients had residual heel valgus.

Transfer of the FDL tendon to the distal stump of the posterior tibial tendon or directly into the navicular tuberosity through a vertically oriented tunnel has been advocated by several authors with good short-term subjective results. The procedure uniformly failed to correct the flatfoot deformity but functioned well in relieving pain and improving inversion strength.

Some authors have emphasized the importance of spring ligament (calcaneonavicular ligament) repair or reconstruction in conjunction with FDL transfer. A retrospective study of spring ligament repair/reconstruction and FDL transfer demonstrated excellent functional results in 14 of 18 patients, although arch correction on radiographs was inconsistent.

Goldner et al reported using the FHL for transfer into the distal stump of the posterior tibial tendon in 2 patients, 1 had a previous laceration of the tendon and the other had a chronic tear.The younger patient had a full and complete recovery, and the outcome in the other patient was not reported.

Calcaneal osteotomy

Follow-up examination of patients who have undergone FDL tenodesis or transfer alone has not shown consistent correction of deformity. Because of a concern of deteriorating clinical results over time with soft-tissue procedures alone, some surgeons added bony procedures to the soft-tissue reconstruction. They theorized that the restoration of arch height and heel position might produce more durable and improved clinical results. The ideal bony procedure to treat acquired pes planovalgus corrects the foot deformity, decreases strain on the spring and deltoid ligaments, and protects the soft-tissue reconstruction.

Gleich first described a medial and inferior displacement osteotomy of the posterior third of the calcaneus in 1893.Koutsogiannis first described the medial displacement calcaneal osteotomy as a treatment of valgus hindfoot deformity.The addition of a medial displacement osteotomy through the posterior portion of the calcaneus moves the valgus heel under the weightbearing axis of the leg. The osteotomy also decreases the heel valgus producing deforming force of the Achilles tendon by shifting the Achilles insertion medially. In vitro studies have shown that a 1-cm medializing osteotomy of the calcaneal tuberosity decreases strain on the spring ligament and deltoid ligament. A 1-cm translational calcaneal osteotomy actually moves the center of pressure in the ankle joint 1.58 mm medially.

A retrospective study of 32 patients undergoing FDL transfer and calcaneal osteotomy with an average of 20 months follow-up showed 94% pain relief, improved function, and significant improvement in radiographic arch measurements. Sammarco and Hockenbury reported satisfactory results in 19 patients undergoing FHL transfer and medial displacement calcaneal osteotomy.Despite the fact that the FHL is stronger than the FDL, postoperative radiographs did not show significant arch correction, indicating that a medial soft-tissue procedure in conjunction with calcaneal osteotomy may not result in arch correction.

Lateral column lengthening

The Evans anterior calcaneal lengthening osteotomy lengthens the lateral column of the foot by inserting a 10- to 15-mm bone graft 10-15 mm proximal to the calcaneocuboid joint. This lateral column-lengthening procedure radiographically improves forefoot abduction and hindfoot valgus and restores the medial longitudinal arch. Cadaveric studies show that lateral column lengthening protects the calcaneonavicular (spring) ligament form overload during weight bearing. A retrospective study of 19 patients undergoing Evans calcaneal osteotomy in conjunction with posterior tibial tendon repair or shortening and deltoid ligament repair or reconstruction reported 6 excellent, 11 good, and 2 fair results. Significant radiographic arch correction was noted at 23-month follow-up.

A cadaver study of Evans calcaneal lateral column lengthening in normal feet showed elevated calcaneocuboid joint pressures following the procedure, raising questions about potential long-term degenerative arthritis of the calcaneocuboid joint following the procedure. This concern has led to the recommendation of lengthening the lateral column through distraction arthrodesis of the calcaneocuboid joint. However, results of another cadaver study failed to confirm elevation of calcaneocuboid joint pressure following calcaneal Evans osteotomy in preexisting flatfeet and, in some cases, actually showed lowering of calcaneocuboid pressure after lateral column lengthening.

A retrospective study of 41 feet undergoing lateral column lengthening through distraction arthrodesis of the calcaneocuboid joint in conjunction with FDL transfer and selective medial midfoot arthrodesis found satisfactory outcomes in 85% of cases and a uniform radiographic correction of flatfoot, but a calcaneocuboid nonunion rate of 20% was found. Note that this series included several patients who also had fusions of the naviculocuneiform or first metatarsocuneiform joints and that distraction arthrodesis of the calcaneocuboid joint was not the only bony procedure performed.

Thomas et al reported on 25 patients who underwent FDL transfer to the navicular and lateral column lengthening using 2 different methods.Postoperative American Orthopedic Foot and Ankle Society (AOFAS) scores were 87.9 for the osteotomy group and 80.9 for the calcaneocuboid distraction arthrodesis group, but the difference was not statistically significant. Significant improvement in radiographic parameters was seen in both groups. Complication rates were high in both groups, with an especially high rate of nonunion and delayed union in the calcaneocuboid distraction group.

A combination of FDL transfer to medial cuneiform, medial displacement calcaneal osteotomy, and Evans lateral column lengthening has produced good short-term results in a retrospective study of 17 patients with stage 2 posterior tibial tendon dysfunction. Significant improvement in the AOFAS hindfoot score was seen, and radiographs showed significant improvement in arch measurements at 17.5-month follow-up.

Fusion

The difficulty with achieving consistent lasting correction of the flatfoot deformity with soft-tissue procedures alone or in conjunction with osteotomies has led some surgeons to recommend fusion as a treatment of stage 2 deformity. Some surgeons feel that soft-tissue procedures are less successful in patients who are obese and that obesity is an indication for joint fusion.

Kitaoka et al compared subtalar arthrodesis versus FDL transfer in an in vitro study of flatfooted specimens and found a more consistent correction of deformity following subtalar arthrodesis.A retrospective study of 21 feet treated with subtalar arthrodesis for posterior tibial tendon dysfunction yielded good-to-excellent results in 16 of 21 feet and significant correction of flatfoot deformity based on radiographic measurements. Stephens et al emphasize the need for reducing the subtalar joint prior to fusion and for differentiating a subtalar repositional arthrodesis from a subtalar fusion in situ.

Another in vitro study compared subtalar fusion alone, calcaneocuboid fusion alone, talonavicular fusion alone, double (talonavicular and calcaneocuboid) arthrodesis, and triple arthrodesis in their abilities to correct an experimentally corrected flatfoot deformity. The study found that talonavicular or double arthrodesis resulted in better correction of flatfoot deformity than did subtalar fusion alone. A retrospective study of 29 patients with posterior tibial tendon dysfunction treated with isolated talonavicular fusion found good-to-excellent results in 86% of patients at an average follow-up of 26 months.

Combination treatments

Johnson et al used subtalar fusion, FDL transfer, and spring ligament repair in 17 feet with stage 2 dysfunction.²⁶ At an average follow-up of 27 months, they reported excellent radiographic correction of pes planus deformity and improvement in AOFAS hindfoot score.

Chi et al reported on 65 feet that underwent FDL transfer with lateral column lengthening and/or medial column fusion.²⁷ Lateral column fusion was performed for calcaneovalgus deformity with a flat calcaneal pitch angle. If the naviculocuneiform or first metatarsocuneiform joint showed sag on lateral radiographs, they also were fused. At 1- to 4-year follow-up, 88% of the feet that underwent lateral column lengthening, 80% of the feet that had medial column stabilization, and 88% that had medial and lateral procedures had decreased pain or were pain-free. Significant radiographic correction of the pes planus deformity was seen in all groups. The authors concluded that fusion of these unessential joints effectively corrected deformity and relieved pain.

Surgical treatment of stage 3 dysfunction

Surgical treatment of stage 3 posterior tibial tendon dysfunction requires realignment and arthrodesis of rigidly malaligned joints. The principle of fusing the fewest number of joints possible should be followed. Over time, the subtalar joint becomes fixed in valgus, and a subtalar arthrodesis is indicated to realign the hindfoot. If the forefoot is fixed in varus at the transverse tarsal (Chopart) joint or degenerative changes are present in the talonavicular and calcaneocuboid joints, fusion of these joints should be added. Stage 3 posterior tibial tendon dysfunction with fixed forefoot varus is treated with triple arthrodesis.

Surgical treatment of stage 4 dysfunction

The valgus ankle in stage 4 dysfunction develops because of deltoid ligament instability. The deltoid ligament is difficult to reconstruct with a tendon transfer. Arthritic valgus ankle deformities secondary to deltoid ligament insufficiency have not been treated successfully with a total ankle arthroplasty because of the inability to achieve ligamentous balance. Treatment of a fixed subtalar deformity and degenerative ankle valgus requires tibiotalocalcaneal fusion. If fixed forefoot varus is also present, pantalar fusion may be necessary to realign the foot adequately. Either tibiotalocalcaneal or pantalar fusion results in a stiff foot, which results in an altered gait. Shoe modifications and bracing are often required after surgery.

The following is a summary of surgical treatments for acquired flatfoot:

• Stage 1 – Tenosynovectomy, tendon debridement, and tendon repair of partial tears
• Stage 2 (add Achilles tendon lengthening or gastrocnemius recession in cases of equinus contracture)
  • PTT repair
  • FDL or FHL transfer alone
  • FDL or FHL transfer and calcaneal osteotomy
  • FDL transfer and lateral column lengthening
  • FDL transfer, lateral column lengthening, and medial column fusion
  • FDL transfer, lateral column lengthening, and calcaneal osteotomy
  • Subtalar fusion
  • Talonavicular fusion
• Stage 3
  • Subtalar fusion
  • Triple arthrodesis
• Stage 4
  • Tibiotalocalcaneal fusion
  • Pantalar fusion

Preoperative Details

The stage of the disease, the overall medical condition of the patient, and the patient’s expectations determine the recommended treatment. If the patient has low physical demands or has serious underlying medical problems, he or she should be treated nonoperatively. Patients should be advised about the prolonged length of recovery following surgical reconstruction of the foot. Generally, 6 weeks of no weight bearing is required for soft-tissue procedures and osteotomies, and up to 3 months of no weight bearing is required for fusions. Swelling of the foot should be expected for 4-10 months after surgery. Finally, although high rates of good-to-excellent results  are reported for most surgical procedures, many patients continue to have some foot discomfort with prolonged standing or walking.

Intraoperative Details

FHL transfer

An 8-cm incision is made along the course of the posterior tibial tendon from a point just proximal and posterior to the medial malleolus to the navicular tuberosity. The posterior tibial tendon sheath is opened and a tenosynovectomy is performed. Partial tears of the tendon are repaired with 2-0 nonabsorbable Dacron sutures. If the tendon is attenuated and irreparable, it is excised, leaving a 1-cm stump attached to the navicular tuberosity. If the spring ligament is torn or attenuated, it is repaired and imbricated with 2-0 nonabsorbable sutures. The FDL tendon is identified in its sheath just deep to the posterior tibial tendon sheath. The FHL tendon is identified deep to the sustentaculum tali. The FHL tendon is sutured to the FDL tendon distally with 2-0 nonabsorbable sutures and then divided proximal to the anastomosis

A suture anchor is placed in the navicular tuberosity, and the transferred FHL tendon is sutured to the navicular and to the distal stump of the posterior tibial tendon with number 2 nonabsorbable suturesTension on the FHL tendon is adjusted with the foot in inversion and plantarflexion. The tendon sheath, subcutaneous tissue, and skin are closed in layers. Percutaneous triple-cut Achilles tendon-lengthening or gastrocnemius recession is performed if the foot cannot be easily dorsiflexed past neutral.

After surgery, the foot is placed in a posterior splint in a position of equinus and inversion. A short-leg non–weightbearing cast is applied 3 days after surgery to maintain the position of equinus and inversion, and is worn for 4 weeks. The foot then is placed in a short-leg walking cast in a neutral position, which is worn for an additional 2 weeks. A Cam walker boot is worn beginning 6 weeks postoperatively and is removed for range of motion and strengthening exercise. Immobilization is discontinued 10 weeks postoperatively.

FDL tendon transfer

A similar approach is used for the FDL tendon transfer. In this case, the distal FDL is sutured into the FHL, and the FDL is released just proximal to the suture to give adequate length to the tendon. A vertical hole then is drilled into the navicular bone. The surgeon should be careful to leave an adequate bridge of bone in place medially. The plantar hole is rounded smooth proximally to take any sharp edge away that may damage the tendon. With the aid of a suture passer, the FDL tendon is routed from plantar to dorsal and sutured to itself (if enough tendon length is available) and to the surrounding tissue. The foot is held in an inverted position during this maneuver to place appropriate tension on the FDL tendon. Closure and postoperative care are similar to those for FHL transfer.

Calcaneal osteotomy

Calcaneal osteotomy is used in conjunction with FDL or FHL transfer. The calcaneal osteotomy is performed prior to the tendon transfer. A 5-cm oblique incision is made along the lateral heel from posterosuperior to anteroinferior. The incision is made posterior to the peroneal tendon sheath and sural nerve . Sharp dissection is used to proceed directly down to bone. Skin flaps are kept thick. The lateral wall of the calcaneus is exposed subperiosteally using a Key elevator. Small Hohmann retractors are placed over the superior aspect of the calcaneus anterior to the Achilles tendon and at the plantar aspect of the calcaneus anterior to the plantar fascial attachment.

A straight, wide power osteotome (Micro-Aire, Inc) or sagittal saw is used to make a cut across the calcaneus in line with the incision at a 45° angle to the plantar surface of the foot and perpendicular to the surface of the calcaneus. C-arm fluoroscopy is used to document proper osteotomy position prior to making the bone cut. The medial aspect of the heel is palpated to gauge the depth of the osteotomy and to avoid overpenetration of the osteotome, which could cause injury to the tibial nerve and vessels. The depth of the osteotome cut also can be judged with a freer elevator during completion of the cut. After completion of the osteotomy, the medial soft tissues are spread by inserting a large Key elevator into the osteotomy site and levering the calcaneal tuberosity downward. A laminar spreader also can be placed into the osteotomy site and used to spread the medial soft tissues

The tuberosity should be easily translated medially 1 cm if the medial soft tissues are adequately mobilized. It is important to ensure that the plantar surface of the osteotomy has been adequately mobilized. Otherwise, the posterior calcaneal fragment rotates internally rather than slide medially. The calcaneal tuberosity then is translated 1 cm medially, while avoiding superior translation of the fragment. A surgical assistant then holds the osteotomy in a corrected position while it is fixated with 2 4.0-mm diameter partially threaded cancellous screws placed perpendicular to the osteotomy cut.Typically, no washers are used.

Avoid placement of the screws into the subtalar joint and keep the screw heads off of the weightbearing surface of the heel. Screws are placed in a parallel fashion. Because the tuberosity has been shifted medially, the screws should be aimed slightly laterally in order to hit the main calcaneal body or the screw(s) may miss the anterior calcaneus. Screw position is documented with intraoperative fluoroscopy .

The wound is closed in layers. Postoperative care is the same as for FDL transfer, except weight bearing is not allowed until radiographs indicate that the osteotomy has healed, usually 6-8 weeks postoperatively.

Lateral column lengthening by distraction arthrodesis of the calcaneocuboid joint

Lateral column lengthening by distraction arthrodesis of the calcaneocuboid joint is also performed in conjunction with FDL or FHL transfer. A 5-cm dorsolateral incision is made over the calcaneocuboid joint. The sural nerve and peroneal tendons are retracted plantarly. The joint is exposed, and the articular cartilage is removed with osteotomes and curettes. The joint then is distracted using a smooth laminar spreader. An alternative technique is to use a small joint external fixator (EBI) to distract the lateral column, placing pins in the cuboid and calcaneus. Correction of the medial longitudinal arch and correction of heel valgus to neutral or slight valgus serve as the endpoint for distraction. The forefoot also should be rotated into neutral position prior to graft insertion.

A trapezoidal tricortical iliac crest graft then is fashioned to fit the distracted joint. The bone graft should be wider both dorsally and laterally, and tapering towards the plantar and medial aspects, respectively. A graft width of 8-12 mm usually suffices A cervical plate placed laterally with 2 screws in the calcaneus and 2 screws in the cuboid is used for fixation. The remainder of the calcaneocuboid joint is filled with cancellous graft. The postoperative course is the same as for the calcaneal osteotomy, except weight bearing is delayed until fusion is confirmed radiographically.

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CHILDREN FOOT CLINIC (Klinik Khusus Permasalahan Kaki Pada Anak)

• JL Taman bendungan Asahan 5 Bendungan Hilir Jakarta Pusat 10210  Phone : (021) 70081995 – 5703646
• Menteng Square Jalan Matraman 30 Jakarta Pusat (opening soon)
• email : narulita_md@yahoo.com

Other Clinic :

• Picky Eaters Clinic, Klinik Kesulitan makan Pada Anak www.mypickyeaters.wordpress.com/
• Children Foot Clinic http://footclinic.wordpress.com/
• Children Rehabilitation Clinic http://rehabilitationclinic.wordpress.com/

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