2 P H Y S I O T H E R A P Y M A R C H , 1975 CONGENITAL TALIPES EQUINO-VARUS by J o a n E. C resw ell, S e n io r O rth o p a e d ic P h y s io th e ra p is t, T h e A d e la id e C h ild r e n ’s H o s p ita l, A d e la id e , S o u th A u s tra lia . C o n g e n i t a l tal ip es e q n i n o - v a r u s (Fig . I) o r c l u b fo o t, is o n e o f th e c o n d i t i o n s de s c ri b e d by H i p p o c r a t e s , w h o t a u g h t th a t t h e c o n d i t i o n w as r e m e d i a b l e a n d s h o u l d be t r ea t ed ea rl y, with r e p e a t e d m a n i p u l a t i o n s , a n d the a p p l i c a t i o n o f a b a n d a g e to h o l d th e foo t s u b s e q u e n t l y . O v e r the y ea r s m a n y di fferen t f o r m s o f t r e a t m e n t f o r thi s c o n d i t i o n h av e been d e s c ri b e d , e a c h w r i t er c l a i m i n g at least p ar t i al success. I n v a ri a b l y , h ow ev er , t h e re sults h a v e been d i s a p p o i n t i n g , with r el ap se s o c c u r r i n g t o v a r y i n g d egr ees . T h a t t h e p r o b l e m is still far f r o m sol ve d is e v i d e n t in t he gr eat v a r i a t i o n s in t r e a t m e n t seen a n d d es c ri b e d t h r o u g h o u t th e w o r l d t o da y. H is to ric a l In tro d u c tio n In 1839 W . J. Little de s c ri b e d suc ces s in t r e a t i n g r ela ps ed club -fe et with t e n o t o m i e s a n d ca r e f u l sp li nt in g, his o w n c l u b - f o o t h a v i n g been c o r r e c t e d in thi s m a n n e r . W. A d a m s in 1866, c l a i m e d " c o m p l e t e a n d p e r m a n e n t c u r e ” with a r t h r o d e s i s o f all the m a j o r j o i n t s in the fo ot . F o l l o w i n g this, m a n y di ffe re nt o p e r a t i o n s we re de vi se d, s o m e on soft tissues a n d o t h e r s on b o n e s ; m a n y were very m u t i l a t i n g , a n d they of te n r esu lt ed in re lap ses a n d stiff, rigid, p ain fu l feet. T h e n c a m e th e s w in g f r o m su r g e r y to co n s e r v a ti v e t r e a t ­ m e n t . with m a n y wr it ers a d v o c a t i n g fo rcible m a n i p u l a t i o n s u n d e r an a e s t h e si a . J. H. Ki te, w ri t in g in th e ea r l y 1930's, d es cr ib ed his t r e a t m e n t o f c l u b - fo o t by a series o f fixed p laste rs. T h e se were d o n e w i t h o u t g ene ra l a n a e s t h e s i a , o r a n y fo rcible m a n i p u l a t i o n s , as he m a i n t a i n e d th a t w h e n force w as used f ib ro u s o r b o n y a n k y l o s is a l m o s t a l w a y s a p p e a r e d in th e j o i n t s o f th e foot. In c o n t r a s t to Kite, D e n i s B r o w n e in I937 w r o t e th a t "full c o r r e c t i o n m us t be o b t a i n e d at the first m a n i p u l a t i o n " . He m a i n t a i n e d th a t thi s p r i m a r y vi ol ent m a n i p u l a t i o n h a d a t ot al l y di ffe re nt effect f r o m g r a d u a l m a n i p u l a t i o n , w h e n the foo t ga ve at the j u n c t i o n o f th e t a r s u s a n d t h e m e t a t a r s u s a n d th e h i n d f o o t w as left u naf fe cte d. T o him , full c o r r e c t i o n o c c u r r e d o nl y w h e n the d o r s a l s u r f a c c o f th e fifth t o e to u c h e d t he l ate ra l sid e o f th e leg in th e e x t r e m e c a l c a n e o v a l g u s p o si t i o n . A l t h o u g h he h ad his follo win g, De ni s Br o w n e received m u c h cr iticism o f his t h e o r i e s o n th e e t i o l o g y a n d t r e a t m e n t o f club- fee t. N ev er t h el es s, m a n y o f t h e spl in ts he d ev i s ed a r e widely u se d t o d a y , bu t of te n with m o d i f i c a ­ tions. K i t e 's m e t h o d s a r e lar gely fol low ed by m a n y pe o p l e t o d a y ; but re ce n tl y su r g er y ha s been a d v o c a t e d a g a i n , in less d r a s t i c w ay s t h a n pr ev io u sl y , a n d o f t e n c o m b i n e d with p la s te r co r r e c t io n . P r o c e d u r e s pr ac ti se d in re cen t yea rs i n c lu de : (1) E l o n g a t i o n o f th e T e n d o Achil les a n d p o s t e r i o r c a p - s u l o t o m y o f the a n k l e jo i n t . (2) T r a n s p l a n t a t i o n o f tibialis a n t e r i o r t o the m i d d l e o r l ate ra l b o r d e r o f t h e foot. (3) T r a n s p l a n t a t i o n o f tibialis p o s t e r i o r to t he d o r s u m of th e foot. (4) D. E v a n s , w ri t in g in 19 6 1, d e s c ri b e d his success wit h a p r o c e d u r e i nv ol vi ng soft tissue re lease on th e med ial b o r d e r o f th e fo o t , re-s ectio n o f th e c a l c a n e o - c u b o i d j o i n t , a n d l e n g t h e n i n g o f th e T e n d o Achilles a n d the t ibial is p o s t e r i o r t e n d o n . H e m a i n t a i n e d t h a t the es se n ti al d e f o r m i t y in a c l u b - f o o t w as t h e m ed i al d i s l o c a ­ tion o f t h e n a v i c u l a r o n the h e a d o f th e tal us, a n d t h a t th e o t h e r e l e m e n t s o f the d e f o r m i t y we re s e c o n d a r y a n d a d a p t i v e . ( 5) F. C. D w y e r ( I9 63 ) believed t h a t a sm all in v er t ed heel p r e v e n t e d c o m p l e t e c o r r e c t i o n o f a c l u b - f o o t , a n d p r o m o t e d re lapse. In his p r o c e d u r e , he le n g t h e n e d the T e n d o Achilles, o s t e o t o m i z e d t he c a l c a n e u m , and p lac ed a w ed ge o f b on e in its m ed ia l side to co r re c t the var us. F u r t h e r , he c l a i m e d th a t th e f o re f o o t ad du cti on g r a d u a l l y s t r a i g h t e n e d o u t o n c e t h e heel h a d been f:|||v co r re ct ed . Fig. 1 : U n tre a te d c o n g e n ita l ta lip e s e q u in o -v a ru s. E tio lo g y M a n y t h e o r i e s for t h e c a u s e o f c o n g e n i t a l tal ip es eq u i n o - v a r u s h av e been a d v a n c e d , but m os t h av e been largely c o n j e c t u r e w i t h o u t a n a t o m i c a l s u p p o r t , a n d t h e eti o l o g y is still un ce r t ai n . De ni s B r o w n e (1934 a n d 1937) pu t f o r w a r d th e hy p o th es is t h a t tali pes w as o n e o f a series o f d e f o r m i t i e s c a u s e d by m e c h a n i c a l p r e ss u re in ut er o. He m a i n t a i n e d t h a t : (1) wh en C o n g e n i t a l T a l ip e s E q u i n o - v a r u s w as unila ter al, it was ne ve r severe. (2) w h e n it was bil ate ra l it w as ne ve r ex ac t l y e q u a l , as the foot o n t he o u t e r side w as al w ay s wo rse , a n d (3) t h er e w as ne ve r a severe d e f o r m i t y on o n e sid e and.,') mild o n e o n the o t h e r . »M f: V a r i o u s p e o pl e h av e d o n e di ss ect io ns, but they m o si. y give l o a g d e s c r i p t i o n s o f b o n e a n d j o i n t c h a n g e s , a n d very little a t t e n t i o n t o the muscles. H o w e v e r , A. M. Wiley (1959) r e p o r t e d p o s t - m o r t e m d iss ect io ns o f six s pe ci m en s, in wh ich he f o u n d th a t the m us c le bellies o f the g a s t r o c n e m i u s - s o l e u s mu sc les were s h o r t e n e d a n d n a r r o w e d , a n d the t e n d o n s w ere l o n g er th an n o r m a l , t he to tal lengt h o f th e ca l f m u sc le s bein g s h o r t e r t h a n n o r m a l . All the o t h e r mu sc les w er e a p p r o x i m a t e l y n o r m a l in leng th . His to lo gi ca l e x a m i n a t i o n s h o w e d no de finite o r in v ar i ab l e a b n o r m a l i t y . N o c o n s t a n t inse rti ona l a b n o r m a l i t i e s we re f o u n d . It was i nt er es ti n g to n o t e t h a t by l e n g t h e n i n g th e T e n d o Achilles, he eas ily o b t a i n e d passive c o r re c t io n in t w o ca se s; a n d , a f t e r c o r r e c t i o n , the b o n e s of th e foo t lay in co r re c t a n a t o m i c a l a l i g n m e n t . W y n n e - D a v i e s , in 1965, p r o v i d e d e v i d en ce t h a t t h er e is of ten a ge n et ic f a c t o r in vol ved . T h i s a p p e a r s t o be s u b ­ s t a n t i a t e d w h e n the d e f o r m i t y o c c u r s in se veral g e n e r a t i o n s of a fam ily , o r in several sib li ngs in a family. F u r t h e r m o r e , Rits ila (1965) p r o d u c e d e q u i n o - v a r u s d e f o rm i t i e s in e x p e r i m e n t a l w or k wi th o v e r 40 0 r ab bi ts , s u p p o r t i n g the view t h a t soft tissue a b n o r m a l i t i e s m a v be a basic f a c t o r in th e etio lo gy . R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) iy]AART 1975 F I S I O T E R A P I E 3 c U n ical F e a tu re s „enital tal ipes e q u i n o - v a r u s is th e c o m m o n e s t o f all genital foo t d ef o rm i t i e s . It m a y be e i t h e r un il at er al or l a t e r a l . I' affects b o t h m al es a n d fe males, in th e r a t i o of nor ox im ate ly 2 to I. 3 The d e fo rm ity o f a c lu b - fo o t is c la s s ic a lly ta u g h t as in s is tin g o f three m a in c o m p o n e n ts : Adduction o f th e fo re f o o t . ' V aru s, o r in v e rs io n , o f the heel. n i E q u in u s . o r p l a n t a r fle-;ion, o f t h e a n k l e j o i n t . H e n c e the n a m e tal ip es e q u i n o - v a r u s . K ite (1 939) e la b o ra te d f u r th e r on these d e fo rm itie s : n ) T h e c a lc a n e u m is ro ta te d in w a rd s u n d e r the talus, g iv in g v a ru s o f th e heel a n d th e e n tire fo o t. n ) T h e e q u in u s d e fo r m it y can be d iv id e d in to tw o p a rts : (a) fo r e fo o t e q u in u s , w here the re is p la n ta r fle x io n ot the fo r e fo o t in re la tio n to the h in d fo o t. (b ) a n k le e q u in u s , w here the re is p la n ta r fle x io n at the a n k le jo in t . As the d e fo rm itie s are fix e d a n d are n o t c o rre c ta b le assively. the c h ild w ith an u n tre a te d o r p a r tia lly c o rre c te d ^ b - f o o t w a lk s on his toes w ith his heel up o f f the g ro u n d , J fd the heel an d fo o t are in v e rte d . D u rin a tre a tm e n t, each o f the three c o m p o n e n ts o f the d e fo rm ity m ust be c o m p le te ly c o rre c te d , an d in the o rd e r m entioned. A ss o c ia te d A b n o rm a litie s A ssociated w ith the a c tu a l fo o l d e fo rm itie s are o th e r a b n o rm a litie s , p ro b a b ly in m ost s tru c tu re s b e lo w the knee. Th ey in c lu d e : (1) T ig h t c a lf muscles. (2) W a s t e d c a l f muscles. (3) W e a k pe rone i. (4) ‘ Tibia! i n t o r s i o n " . (5) T ib ia l s h o r t e n i n g . R adiological F e a tu re s An a n t e r o - p o s t e r i o r X - r a y o f a n u n c o r r e c t e d o r rela pse d club- foot s h o w s t he tar sal b o n es a r e s m a ll e r a n d o f a different s h a p e f r o m n o r m a l . T h e n a v i c u l a r b o n e ar t i c u l a t e s with t h e m ed ia l sid e o f t he h e a d o f th e tal us, i nst ea d of lying d ir ect ly in f ro nt o f it. T h e a n t e r i o r e n d o f th e c a l c a n e u m is u n d e r th e h ea d o f t h e ta lu s i n st e a d o f lying lateral to it. T h e lat eral X - r a y sh o w s th e ta lu s is in e q u i n u s , a n d ofte n the s u p e r i o r a r t i c u l a r su r f ac e is fl att e ne d, i nst ea d o f being ro u n de d. Kit e m a i n t a i n e d t h a t : (1) W h e n f or ef oo t a d d u c t i o n is c o r r e c t e d th e n a v i c u l a r is f di re ct ly in f r o n t o f th e he ad o f th e talus, a n d th e m id li n e ’ o f th e t a l u s p o i n t s t o w a r d s t h e first m e t a t a r s a l space. (2) W h e n in ver sio n is c o r r e c t e d th e c a l c a n e u m is rolled ou t f ro m u n d e r t he talus so th at th ei r a n t e r i o r e n d s ar e s e p a r a t e d , a n d t h e m id l i n e o f t h e c a l c a n e u m p o in ts t o w a r d s th e f o u r t h a n d fifth toes. P rin c ip les o f T re a tm e n t As t h e eti o l o g y o f this c o n d i t i o n is so u n c e r t a i n , pre sen t t r e a t m e n t is a i m e d at c o r r e c t io n o f the d e f o r m i t y itself. T h er e a r e g r ea t differ enc es in the initial sev erity o f it, a n d in the r e sp o n s e o f th e i n d iv id ua l foo t to t r e a t m e n t . T h e r e is also a wi de v a r i a t i o n in t he m e t h o d s o f t r e a t m e n t used. Re sul ts v ar y g re at ly f r o m place t o place t h r o u g h o u t the w or ld , eve n with si m i l a r m e t h o d s o f t r e a t m e n t , o n e perso n a c c e p ti n g as g o o d w h a t a n o t h e r a c c e p ts as fair. Mo s t pe o pl e a gr ee t h a t t he initial c o r r e c t io n o f a cl u b - fo o t is the easiest to o b t a i n ; a n d a f t e r re lapse, full c o r r e c t io n is often no t o b t a i n a b l e . T h e best f oo t is t h a t w hi ch is t r e a t e d by f r e q u e n t g en tl e m a n i p u l a t i o n s i m m e d i a t e l y a f t e r birth — it h as been said t h at , in a b re ech b ir th , o n e s h o u l d s t a rt m a n i p u l a t i n g the feet as t h e y a p p e a r ! C o r r e c t i o n is held by e i t h e r ad h es iv e s t r a p p i n g , a light met al splin t c o m b i n e d wi th ad h e s i v e s t r a p p i n g , o r pl as te r o f par is as ei t h e r a r e m o v a b l e sp li n t or a fixed pl aster. A f t e r sufficient c o r r e c t i o n has been o b t a i n e d , s o m e k i n d o f r e m o v a b l e splin t is used l o r a v a r y i n g length o f time. De ni s B r o w n e d e s c ri b e d in detail his m e t h o d o f s t r a p p i n g a b a b y 's feet o n t o his sel f-d esi gne d h o b b l e spl in t. By p la ci n g ad h e s i v e felt u n d e r t he o u t e r side o f t h e feet, a n d by us i n g t he leg-piece as a lever, he c o n t r o l l e d b o th t h e v a r u s a n d e q u i n u s . H e th en c o n n e c t e d th e t w o feet by a b a r so t h a t t h e y were r o t a t e d o u t w a r d s , as he m a i n t a i n e d t h a t c o r r e c t io n o f tibial i n t o rs i o n w as a n i m p o r t a n t a n d o f t e n neglected f ac t o r, a n d th a t t h e n o r m a l f oo t po i n t e d 20 o u t w a r d s f r o m th e sa g itt al pl an e o f th e b od y. W h e n t h e b a b y w a s f o u r to five m o n t h s old, th e h o b b l e splin t w as re pl ac ed by night b o o t s, a g a i n j o i n e d by a b ar at t h e b o t t o m , a n d t h es e were w o r n at n ig h t fo r at least five year s. T h e ch i l d ’s m o t h e r was a ls o s h o w n h o w t o s t r e t c h t h e f o ot t h r e e times daily. Kit e r e c o m m e n d e d c o r r e c t i o n by serial fixed p laste rs, c h a n g e d we ekl y un t i l the b a b y was t h r e e m o n t h s ol d, a n d th en w ed g ed pl aste rs. As m e n t i o n e d ear li er, he m a i n t a i n e d f o re f o o t a d d u c t i o n m u st be c o m p l e t e l y c o r r e c t e d first. U n d e r - c o r r e c t i o n re su lt ed in weight fa lling o b l i q u e l y o n the late ral sid e o f t he n a v i c u l a r , p u s h i n g t h e f o r e f o o t back i n t o a d d u c t i o n , relap se t h u s o c c u r r i n g wit h we ig ht bear in g. S ec o n d l y , inv er sio n m u st be c o r r e c t e d . A f t e r this, d or si- flexion c o u l d be ea si ly o b t a i n e d . If t h e i n ve r si on w as no t fully c o r r e c t e d , (he foo t b e c a m e r o c k e r - b o t t o m w h e n dor sif lex ed, b r e a k i n g at th e m i d -t ar s al j o i n t . A f t e r full c o r r e c t io n was o b t a i n e d . K it e held th e feet in fixed plas ter s f o r a p p r o x i m a t e l y n in e weeks. R e si st a n t a n d r el ap se d club- fee t a r e seen all t o o o f t e n , a n d m a n y articles h a v e been wr it ten in recent y ea r s a b o u t th em . It is g en er al ly a g r e e d t h a t m a x i m u m c o r r e c t i o n s h o u l d be o b t a i n e d by co n s e r v a ti v e m ea ns , usu a lly by m o d i f i c a ti o n s o f K i t e 's m e t h o d wi th fixed plasters, fol low ed by o p e r a t i v e p r o c e d u r e s . T h e r e is very little m e n l i o n o f a n y a f t e r - c a r e o r r et en ti ve sp l i n t i n g t h o u g h , a n d o n e w o n d e r s h o w a d e q u a t e l y thes e a r e used. Aim s o f T r e a t m e n t (1) T o o b t a i n full c o r r e c t i o n o f t he d e f o r m i t y , so t h a t t h e foo t is g o o d b o t h s t r u c t u r a l l y a n d f u nc ti on al ly . (2) T o m a i n t a i n this c o r r e c t i o n indefinitely. T h e d e f o r m i t y o f a c l u b - f o o t is g e n er al ly c o n s i d e r e d tully c o r r e c t e d w h e n t h e foo t c a n be pas sively b r o u g h t i n t o th e n o r m a l c a l c a n e o - v a l g u s p o s it io n f o r t h a t age. In th e n e w ­ b o r n , thi s is su ch t h a t t h e c e n t r e o f th e d o r s u m o f th e f oo t a l m o s t t o u c h e s t he a n t e r o l a t e r a l a s p e c t o f th e leg, a n d it g r a d u a l l y de cr ea s es with age. Fig. 2 : C o rre c tio n is held by a long leg p a d d ed fixed p la s te r, w ith th e k n e e flexed to 90 d eg rees. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 4 P H Y S I O T H E R A P Y M ARCH, 1975 T h r o u g h o u t g r o w t h , t he c l u b - f o o t will t e n d t o relap se i n t o its o ri g in a l p o si t i o n . T h is m u st be p r e v e n t e d by c o n ­ t i n u o u s a f t e r- c a r e , in t he f o r m o f r e g u l a r m a n u a l s t r e t c h i n g , exer cises a n d nig ht s p l i n t a g e used ind efin itely, p e r h a p s until th e ag e o f I 3 - I 4 y ea r s w h e n t h e f oo t is fully g r o w n . F ig . 3 : F e e t s tra p p e d o n to a D e n is B row ne h o b b le sp lin t. M e th o d s o f T re a tm e n t O u r p r es en t m e t h o d s o f t r e a t m e n t at the A d e l a i d e C h i l d r e n ’s H o s p it a l, w h e r e we see s o m e 30 new club- feet e a c h y ea r , h a v e ev o l v e d o v e r th e last 17 y ear s. I shall a t t e m p t to d e s c ri b e t h e m here. (1) T r e a t m e n t is c o m m e n c e d on t h e d a y o f bir th if possible. (2) T h e f oo t is m a n i p u l a t e d ver y gen tl y i n t o the c o r r e c t e d po si ti on . T h e c o r r e c t i o n is t h e n held by: (a) a long -le g p a d d e d fixed p la s te r ( Fi g . 2) or (b) a D e n i s B r o w n e h o b b l e sp li n t a n d n o n - el as t i c one inch w i d e a d h e s i v e s t r a p p i n g (Fig . 3) o r (c) s o m e t i m e s ad h e s i v e s t r a p p i n g a l o n e , wit h n o force u se d t o o b t a i n m o r e c o r r e c t io n . ( F o r c e f u l m a n i p u l a ­ t i o n p r o d u c e s a sw oll en f o o t , d a m a g e s t he b o n e s a n d j o i n t s , a n d re sul ts in a very stiff foot). (3) G e n t l e m a n i p u l a t i o n a n d s p l i n t i n g ar e r e p e a t e d in 2 o r 3 d a y s at first, a n d thi s is g r a d u a l l y le n g t h e n e d ou t to wee kl y a n d t h e n f o r t n i g h t l y in te rv al s in a p p r o x i m a t e l y 2-3 wee ks . As s o o n as t h e f o ot c o r r e c t s to th e ne u t r a l p o s i t i o n , t h e D e n i s B r o w n e sp li nt is used, a n d is re­ a p p l i e d ev er y t w o w e e k s until th e b a b e is a p p r o x i m a t e l y 3 m o n t h s o f age. M e th o d o f S tra p p in g w ith th e D en is B row ne S p lin t A st r ip o f a d h e s i v e felt j u s t o v e r o n e inch wi de is pl aced d o w n t h e lat er al side o f t h e low er leg, a n d c o n t i n u e s u n d e r th e heel t o th e m id li ne. O n e o r m o r e sm a ll pieces o f ad h e s i v e felt a r e a ls o p l a c e d on t h e later al h a l f o f th e sole, a n d o ft en a piece is p la ce d o ve r t h e m e d i a l b o r d e r o f th e f o re f o o t . T h e foo t is held firmly o n t o t h e f o o t p ie c e o f t h e splint, wi th the side pi e ce free, a n d ad h e s i v e s t r a p p i n g is a p p l i e d — first the f o re f o o t is fixed t o th e s pl in t, a n d th en th e heel is fixed t o the p o s t e r o - l a t e r a l c o r n e r o f t h e fo ot pi e ce . N e x t , the side pi e ce is b r o u g h t g en t l y ag a i n s t t h e leg, a n d is s t r a p p e d i n t o po si t i o n . T h e g a p s a r e filled in wit h ad h e s i v e t a p e , so th a t t h e leg is f i rm l y a t t a c h e d t o the sp li n t a n d c a n n o t be k i cke d lo ose by th e ba b y . C a r e m u s t be t a k e n no t t o a p p l y th e s t r a p p i n g t o o t i g h t l y — it is no t pu ll ed a r o u n d t h e leg, bu t is j u s t p la ce d on t h e skin . T h e c r o s s - b a r is th en a d d e d , so th a t t h e legs a r e in s o m e e x t e r n a l r o t a t i o n . If th e c o n d i t i o n is un i l a t e r a l , t h e n o r m a l f o ot is s t r a p p e d to t he sp l i n t in t he n e u t r a l p o si t i o n , a s th e affe cte d leg c a n n o t be k ep t in e x t e r n a l r o t a t i o n unl ess th e c r o s s - b a r is a t t a c h e d to t h e n o r m a l leg. (4) If th e f oo t s h o w s full o r ver y g o o d c o r r e c t i o n a n d is of a v e r a g e size at 3 m o n t h s , this c o r r e c t i o n is m a i n t a i n e d ( n o t g a i n e d ) by a r e m o v a b l e b e l o w - k n e e pl as te r back sp li nt m a d e in t h e p o s it io n o f m a x i m u m do rsi fi exi on (Fig . 4). A l t e r n a t i v e s to thi s a n d us ed o c c a s i o n a l l y ar e a D e n i s B r o w n e nig ht b o o t , a n d a n a b o v e - k n e e pl as ter b a c k s p l i n t wit h th e k n e e flexed t o 90 . T h e sp li nt is w o r n all n ig h t a n d fo r m o st o f t h e d a y at first, but is re m o v e d for p e r i o d s o f a p p r o x i m a t e l y h a l f a n h o u r tw o o r t h r ee t im es e a c h d a y for mo b il isi n g. G r a d u a l l y this free ti m e is in cr ea se d , so t h a t by th e t im e th e b a b e is s t a n d i n g , he is u si n g th e sp li nt o n ly at ni ght a n d for d a y t i m e sleeps. At thi s st a g e the m o t h e r is t a u g h t by th e p h y s i o t h e r a p i s t t o s t r e t c h a n d ex er cis e th e foot, th r ee t im es d ail y at first, a n d late r o nl y o n c e o r twice daily, to he lp m a i n t a i n th e co r r e c t io n . T h e s t r e t c h e s a n d exercises us ed a r e : (a) pas siv e dor sif iex io n o f t h e a n k l e , wit h p r e ss u re up in t he m id -s ol e r egi on , a n d p u ll in g th e heel d o w n , for five m i n u t e s (Fig. 5). (b) pas sive a b d u c t i o n o f t h e f o re f o o t , w i t h o u t fo rc in g th e heel i n t o excessive valgu s, for t h r ee m i n u t e s (Fig. 6). (c) pas siv e p l a n t a r flexion a n d do rsi fi exi on o f the a n k l e j o i n t — to in cr ea se m o b i l i ty o f th e a n k l e j o i n t , es pec ial ly in to p l a n t a r flexion. (d) the m o t h e r e n c o u r a g e s activ e do rsi fi exi on a ? ' ' ev er sio n o f th e foo t to s t r e n g t h e n t h e pe ro ne i. O t h e r acti ve exer cises a r e a ls o used at t h e d i sc re t i on o f the p h y s i o t h e r a p i s t , t o i nc re ase th e s t r e n g t h a n d m o b i l i ty o f the f o ot a n d leg. T h e s e c h i l d r e n usu a lly r e q u i r e n o special f o o t w e a r o r ir ons w h e n they s t a r t w al k i n g , w h ic h is at the n o r m a l age. H o w ­ ever, I prefe r t h e m in little b o o t s at first, as th ey he lp t o kee p t h e feet p l a n t a r -g r a d e . (5) A t a n y t im e a f t e r t h r ee m o n t h s o f age , if th e f oo t is r esi st ant t o c o r r e c t i o n a n d is b e c o m i n g b o a t e d o n th e m ed i al o r p l a n t a r as p ec ts , o r s h o w s a pe rsi st ent high heel with a d e e p tr a n sv e r se cr eas e a b o v e it, su r g e r y is p e r f o r m e d . As o u r e x p e r i e n c e h a s in cr ea se d, it has b e c o m e po ss ib le t o re co g ni se th es e r esi st ant feet at an e ar ly age, of te n at 10 - 12 weeks , a n d n o w a d a y s m o r e t h a n 8 0 % o f o u r club- fee t u n d e r g o thi s su rg er y . T h e T e n d o Achil les is l e n g t h e n e d in a Z - f a s h i o n a n d a p o s t e r i o r c a p s u l o t o m y o f th e a n k l e j o i n t is d o n e , t o a l l o w t h e heel t o c o m e d o w n i n t o th e n o r m a l p o s i t i o n . S o m e o f o u r s u r g e o n s h a v e al s o d o n e i n t r a m u s c u l a r le n g t h e n i n g s of tibialis p o s t e r i o r a n d t h e l o ng flexors o f th e t o es at t h e s a m e t i m e — bu t I h a v e no t o b s e r v e d a n y a d v a n t a g e l at er fr o m these. T h e T e n d o A ch il les is s u t u r e d so t h a t it is j u s t tight F ig. 4 : B e lo w -k n ee p la s te r b a c k splint. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) M AART 1975 F I S I O T E R A P I E 5 5 : P a ssiv e stre tc h in g o f th e a n k le jo in t in to d o rsifiex io n . with th e f o ot at 90 d or sif iex io n a n d t h e kn ee ex te n d e d . P o st -o pe ra ti ve ly , t he leg is held in a long-leg p a d d e d fixed pl aster f o r 4-6 wee ks , wi th th e a n k l e in m a x i m u m d o r s i ­ fiexion, a n d t h e kn ee flexed t o 90 t o t a k e t he st r a i n off th e su tu re d T e n d o Achilles. If unsufficient d o rs if ie xi on is o b t a i n e d , the p la s te r is c h a n g e d u n d e r g en er al an a e s t h e s i a at t w o wee ks , w h e n this is signif ica nt ly im p ro v e d . A ft er this, the f oo t r e q u i re s th e s a m e t r e a t m e n t as the u n o p e r a t e d fo ot , wit h o n e e x c e p t i o n , t he pl as te r splin t is only m a d e at a right a n g l e o f d o rs if ie x io n . T h i s is t o c o u n t e r ­ act t he t e n d e n c y f o r th e foo t t o b e c o m e fixed in t he c a l c a n e u s p osi ti on , w h e n th e ch i l d will w al k w it h little o r n o ca lf ac t i o n , a n d of te n w i t h flexed knees. I f it o cc u r s, it is f u r t h e r i m p ro v e d by st r e t c h i n g the f oo t i n t o p l a n t a r flexion also. it is o u r o b s e r v a t i o n t h a t , fo l lo w in g ea r l y e l o n g a t i o n o f the T e n d o Ac hilles, a f t e r- c a r e o f th e f oo t is n o t i c e a b l y easier, as it st r e t c h e s m u c h m o r e easily, s ta ys m o r e re ad il y in the pl aster sp l i n t , a n d s h o w s less t e n d e n c y o v e r th e y e a r s to relapse. H o w e v e r , t he o p e r a t i o n is n o t a c u r e in itself, but merely p ar t o f the m a n a g e m e n t o f the c o n d i t i o n , a n d we must m a k e this very cl ea r t o th e p a r e n t s . W e h a v e seen s o m e bad re lap ses w h e r e the a f te r - c a r e h a s n o t been c o n t i n u e d , the s a m e as wit h u n o p e r a t e d feet. (6) As m e n t i o n e d ear li er, m u c h stres s is p la ce d o n the a f t e r c a r e o f the c o r r e c t e d fo ot . N i g h t sp li nt s, st r et ch i n g , a n d exercises a r e c o n t i n u e d in definitely at th e d isc re ti on o f t h e d o c t o r , as m o st cl ub -fe et, even w h e n fully c o r r e c t e d , r ela ps e t o s o m e e x t e n t d u r i n g g r o w t h . T h e ch il d c o n t i n u e s t o h a v e r e g u l a r s u p e r v i s i o n by the p h y s i o t h e r a p i s t, w h o c h e c k s th e st r e t c h e s d o n e by the p a r e n t s a n d t he exercises d o n e at h o m e , a n d th e nig ht spl in t, w hi ch n ee ds r e n e w i n g at f r e q u e n t in te rv al s as t he ch il d g ro ws . I f t he f oo t is h o l d i n g its c o r r e c t io n a n d t he p a r e n t s a r e c o - o p e r a t iv e , th e c h il d is seen o nl y at int er val s o f 3-4 m o n t h s. (7) "T i b ia I i n t o r s i o n ' ' , w hi ch is n e a r l y a l w a y s p r es en t a n d rec ur s d u r i n g g r o w t h , ca u s e s th e ch il d t o w al k wi th his feet p o i n t i n g s o m e w h a t m e d i a l l y (i.e. he in toes). It is c o r r e c t e d at in t er v al s d u r i n g g r o w t h by a d d i n g a n a d j u s t a b l e e x t e r n a l r o t a t i o n b a r b etw een t h e nig ht spl ints, so th a t t he ch il d sleeps wit h t h e feet a n d legs ex t er n al l y r o t a t e d . If he h a s a u n i la te r al c l u b - f o o t , a n o r d i n a r y l e a t h e r b o o t is w o r n o n t he g o o d fo o t , a n d the e x te r na l r o t a t i o n b a r is a t t a c h e d t o this. (8) R e la p s i n g feet, a n d th o se c o m m e n c i n g t r e a t m e n t w h e n several m o n t h s o ld , a r e first st r e t c h e d in s e ri al - w ed ge d lo ng fixed pl as te rs a n d / o r s h o r t fixed w a l k i n g plas ter s f o r 6-8 weeks. W e d o n o t c o n t i n u e w i t h fixed plas ter s f o r lo n g er t h a n this, as th e feet ca n b e c o m e very stiff. C o r r e c t i o n is very o f t e n i n c o m p l e t e , a n d s u r g e r y is t h e n c o n s i d e r e d n ec es sa ry — f r e q u e n tl y a n e l o n g a t i o n o f the T e n d o Achil les a n d a p o s t e r i o r c a p s u l o t o m y o f the a n k l e ar e d o n e , a n d t he se i m p r o v e t h i n g s im m en se l y . O n c e sufficient c o r r e c t i o n h a s been o b t a i n e d , a f t e r- c a r e is c o n t i n u e d as de s c ri b e d prev io usl y. (9) I n c o m p l e t e l y — c o r r e c t e d a n d b a d l y - r e l a p s i n g feet, m a n y o f w hi ch h av e n o t received a d e q u a t e a f t e r- c a r e in t he h o m e , c a n be i m p r o v e d t h r o u g h o u t g r o w t h by v a r i o u s s ur gi ca l p r o c e d u r e s . T h o s e used m ost f r e q u e n t l y a r e : (a) r e p e a t E . T . A . a n d p o s t e r i o r a n k l e c a p s u l o t o m y . (b) t r a n s p l a n t a t i o n o f tibialis a n t e r i o r t o t he m i d d l e o f th e d o r s u m o f t h e foot. (c) t r a n s p l a n t a t i o n o f tibialis p o s t e r i o r t o t h e d o r s u m o f t h e foot. ( C o m p l i c a t i o n — it ac ts as a ten od es is , a n d limits p l a n t a r flexion o f th e an kl e) . W i t h b o t h o f thes e t e n d o n t r a n s p l a n t s , it is es sen ti al t o s tr et ch t h e f o o t p r e -o p e ra t i v e l y in fixed p la s te r. (d) o s t e o t o m i e s o f all m e t a t a r s a l s — t o c o r r e c t f o r e f o o t a d d u c t i o n . (e) o s t e o t o m y o f os cal cis — t o c o r r e c t i n ve r si o n o f the heel. T h i s c a n be d o n e by t w o m e t h o d s : (i) i n s e rt i o n o f a w ed g e o f b o n e on th e m ed i al side, as d e s c r i b e d by D y w e r ( C o m p l i c a t i o n — o f t e n leave s a n ugl y scar). (ii) L a t e r a l d i s p l a c e m e n t o f di sta l f r a g m e n t o f os calcis ( D i s a d v a n t a g e — m a k e s t h e heel sm all er ). (f) r o t a t i o n o s t e o t o m y o f th e tibia — t o c o r r e c t per sis ten t ti bial i n t o r s i o n . F o l l o w i n g th es e p r o c e d u r e s , a f t e r- c a r e is still n e c e s­ sa ry unt il g r o w t h o f th e foo t h a s cea se d. (10) Def initive s u r g e r y a t t he e n d o f g r o w t h is o c c a s i o n a l l y n ec es sa ry f o r c o n t i n u a l l y - r e l a p s i n g feet. T h e s e a r e essent ial ly b o n y p r o c e d u r e s , w h e n a w ed g e t a r s e c t o m y o r a trip le a r t h r o d e s i s a r e p e r f o r m e d . ( C o n t i n u e d o n p a g e 7) F ig. 6 : P a ssiv e s tr e tc h in g o f th e fo re fo o t in to ab d u c tio n R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 6 P H Y S I O T H E R A P Y M ARCH, 197i TH E p r e s e n t s - M i n i d y n e m k III T R A N S IS T O R IS E D F A R A D IC UNIT R e p re se n tin g another a d va n ce in the evolu tio n of the M in id yn e, the M ark 111 ve rsio n in co rp o ra te s printed c ir c u its w h ic h red u ce the s iz e but a ls o e nhance the reliab ility; c o n tin u in g featu res are wide range of surge speed control with output sufficient for all forms of faradic techniques audible as well as visual indication of surge speed enabling the operator to anticipate a muscle reaction without having to watch the control panel fitted with Ever Ready PP9 batteries which will give up to six months' use without replacement and are obtainable worldwide W E IG H T red u ced to: 4 lb s. (1 ,8 k g ) S I Z E redu ced to 8 " x 5 i " x 2 } " (2 0 cm x 13,5 cm x 6 c m ). PRICE: R112.50 co m p lete w ith a c c e s s o r ie s . MEDICAL DISTRIBUTORS eptD M s t bd p k ‘CAPE YO R K ’ | 252 JEPPE ST. | JO HANNESBURG | D e W aal H ouse, 172 V ic to ria Road | W oodstock, C.P. PLEASE ADDRESS ALL CORRESPONDENCE TO P.O . BOX I R IG ASSEBLIEF ALLE KORRESPONDENSIE A A N POSBUS [ JOHANNESBURG TEL. A D D . 'D IS M E D ' PHONE | FO ON 23-8106 TELEX: 43-7129 S .A . R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) M AART 1975 F I S I O T E R A P I E Non - A rticular Rheum atism By W. A. M cD O N A L D SC O T T M .B ., Ch.B.(Aberd), M .R .C .P.(Lond.) W h e n S h a k e s p e a r e in M id s u m m e r N i g h t ’s D r e a m s a i d : “ T h e n o r th - e a s t w in d — A w a k ’d th e sle e p ie r h e u m e , a n d so by c h a n c e D i d g ra c e o u r h o llo w p a r tin g w ith a t e a r e ” , he w a s sa y in g a s m u c h a s w a s k n o w n a b o u t r h e u m a tis m th ree h u n d r e d a n d fifty y e a rs a g o . W e c a n a d d little m o r e to d a y in sp ite o f m a s siv e a d v a n c e s in th e w h o le field o f m e d ic in e , a l t h o u g h in th e “ c l i m a t r o n ” o f th e U n iv e r s ity o f P e n n s y lv a n ia , “ w e a th e r ” c a n b e a r r a n g e d by a d ju s tm e n ts o f t e m p e r a tu r e , h u m id ity , a i r e le c tric ity a n d b a ro m e tric p r e s s u re : in th is w a y p a tie n ts w ith r h e u m a tic d ise ase u n d e r d o u b le - b lin d c o n d itio n s w e re f o u n d t o h a v e v s e n i n g o f th e ir s y m p to m s w ith “ a c h a n g e in t h e w e a th e r L /11”" N o n - a r t ic u la r r h e u m a tis m c o v e r s a w id e r a n g e o f a c h e s a n d p a in s fe lt in t h e s o ft tis s u e s b u t n o t a s s o c ia te d w ith a r th ritis . T h e m u sc le s a n d f ib ro u s s tr u c tu r e s o f th e b o d y C ongenital Talipes (continued from page 5) Conclusion C o n g e n ita l ta lip e s e q u i n o - v a r u s is a s e rio u s f o o t d e ­ d e fo rm ity , a n d r e q u ire s p r o lo n g e d a n d s t r e n u o u s tr e a tm e n t. It is o f te n v ery d iffic u lt to c o r re c t a d e q u a te ly , a n d m a y s h o w a v ic io u s te n d e n c y to r e la p se t h r o u g h o u t g ro w th . H o w e v e r, w ith e a r ly g e n tle m a n ip u la tio n a n d c o n tin u o u s sp lin tin g , s o f t tis s u e re le a se a s y o u n g a s th r e e m o n th s o f ag e , a n d c o n s t a n t a f te r- c a r e u n til g r o w th h a s c e a s e d , a s a tis f a c to ry b u t n e v e r n o r m a l f o o t c a n b e o b t a i n e d . REFERENCES B row ne, D e n is : T a lip e s e q u in o - v a r u s . L a n c e t I I , 9 6 9 , 1934. B ro w n e, D e n is : M o d e r n M e th o d s o f T r e a t m e n t o f th e C lu b f o o t. B r itis h M e d ic a l J o u r n a l , 2, 570, 1937. B row ne, D e n i s : S p lin tin g f o r C o n tr o lle d M o v e m e n t. R e ­ p rin te d f r o m C lin ic a l O r th o p a e d ic s , N o . 8 , 1956. D w y er, F . C . : T r e a t m e n t o f R e la p s e d C lu b F o o t b y th e In se rtio n o f a w e d g e in to th e C a lc a n e u m . J o u r n a l o f B o n e # J o i n t S u rg e ry , 45B , 67, 1963. ( n n s , D . : R e la p s e d C lu b F o o t . J o u r n a l o f B o n e & J o i n t iu T g e ry , 43B , 722, 1961. F rip p , A . T . : P ro b le m o f R e la p s e d C lu b F o o t . J o u r n a l o f Bone & J o i n t S u rg e ry , 4 3B , 626, 1961. K ite, J . H . : T r e a tm e n t o f C o n g e n ita l C lu b F e e t. J o u r n a l o f A m e ric a n M e d ic a l A s s o c ia tio n , 99 -2 , 1156, 1932. K ite, J . H . : P rin c ip le s I n v o lv e d in th e T r e a t m e n t o f C o n ­ ge n ita l C lu b f o o t. J o u r n a l o f B o n e & J o i n t S u rg e ry , 21, 595, 1939. K ite, J. H . : T r e a t m e n t o f C o n g e n ita l C lu b fe e t. O f fp r in t fro m A m e ric a n A c a d e m y o f O r th o p a e d ic S u rg e o n s . I n s tr u c tio n a l C o u rse L e c tu re s , V o l. V 1948. K u h lm a n n , R . F ., & B ell, J. F . : C lin ic a l E v a lu a tio n o f O p e ra tiv e P ro c e d u re s f o r C o n g e n ita l T a lip e s E q u in o - v a r u s . J o u r n a l o f B o n e & J o i n t S u rg e ry , 3 9 A , 265, 1957. S inger, M .: T ib ia lis p o s te r io r tr a n s f e r in C o n g e n ita l C lu b F o o t. J o u r n a l o f B o n e & J o i n t S u rg e ry , 4 3B , 717, 1961. S in g er, M ., & F r i p p , A . T . : T ib ia lis a n t e r i o r tr a n s f e r in C o n g e n ita l C lu b f o o t. J o u r n a l o f B o n e & J o i n t S u rg e ry , 40B , 252, 1958. S o u th w o o d , R . T . : S o u th A u s tr a lia n C lin ic s, N o . 4 V o l. 5, 1971. W iley, A . M .: A n A n a to m ic a l & E x p e rim e n ta l S tu d y o f M u scle G r o w th . J o u r n a l o f B o n e & J o i n t S u rg e ry , 4 1 B, 821, 1959. m a y b e a ffe c te d b y p o s tu r a l s tr a in , b y ex c e s siv e u se , b y p s y c h o lo g ic a l o r c lim a tic stre s s a n d b y p h y sic a l in ju ry . T h is le a d s t o p a in , te n d e r n e s s a n d stiffn e ss w ith a s s o c ia te d m u sc le s p a s m in m a n y . T h e p re c ise p a th o lo g y o f th e s e c o n d itio n s re m a in s o b s c u re . F ib ro s itis o r m u s c u la r r h e u m a tis m is p r o b a b ly th e c o m m o n e s t o f a ll f o rm s . I t is c a lle d p sy c h o g e n ic r h e u m a tis m in A m e r ic a , su g g e stin g t h a t p sy c h o lo g ic a l stre ss is a lw a y s a c a u s e , w h ic h is d iffic u lt t o p ro v e . I f w e c o n s id e r r h e u m a tis m a s a n e x p r e s s io n o f th e r e s u lt o f stre s s o n a p a r t i c u l a r te m ­ p e r a m e n t — th e “ r h e u m a tic y ” ty p e — th o s e w h o s e m u s c u lo ­ sk e le ta l sy s te m re p re s e n ts a t a r g e t o r g a n in t h a t in d iv id u a l — th e n th e r e m u s t b e a p s y c h o lo g ic a l c o m p o n e n t, a t le a st. I n su c h a p e rs o n th e r e is o f te n a h is t o r y fro m c h ild h o o d , s ta r tin g w ith “ g ro w in g p a i n s ” a n d c o n tin u in g th r o u g h a d o le s c e n c e a n d a d u lt life w ith e p is o d e s o f r h e u m a tic n a tu r e . T h e d ia g n o s in g o f n o n - a r t i c u l a r r h e u m a tis m m u s t b e te m p e r e d w ith c a u tio n , b u t in th e f a c e o f o b v io u s g o o d g e n e ra l h e a lth , a n o r m a l b l o o d s e d im e n ta tio n r a te , a n o r m a l o r ra is e d s e ru m u r ic a c id a n d n e g a tiv e L a te x s c re e n in g te st f o r r h e u m a to id a r t h r i t i s , it is re a s o n a b le t o m a k e it. A lth o u g h th e r e a r e se v e ra l r e a s o n a b ly c le a r - c u t sy n d r o m e s , so f t- tis s u e r h e u m a tis m is m o r e e a sily re v ie w e d r e g io n by re g io n . NECK T h e d iffu s e a c h in g p a in o f r h e u m a tis m is d iffic u lt to lo c a lis e a n d th is h a s b e e n c h e c k e d e x p e r im e n ta lly w ith h y p e r to n ic sa lin e . E a c h s p in a l se g m e n t h a s a c h a r a c te r is tic r e fe rra l a r e a . A n i n je c tio n in to th e n e c k a t C 2 w ill p r o d u c e a c h in g in th e b a c k o f th e n e c k a n d h e a d r a d i a t i n g o fte n t o t h e f o re h e a d . A t C 4, p a in is fe lt in th e s id e o f t h e n e c k . A t C 5, p a in is fe lt in th e s id e o f t h e n e c k a n d t h e p o in t o f th e s h o u ld e r. A t C„, p a in te n d s t o s p r e a d d o w n t h e o u te r sid e o f t h e a r m . A t C , a n d T j , p a in s p r e a d s d o w n t h e in n e r sid e o f t h e a r m . I n a ll th e s e a r e a s , t h e s k in a n d su p e rfic ia l m u sc le s a r e t e n d e r t o to u c h a n d s p o ts n o r m a lly s e n s itiv e t o p re s s u re b e c o m e e s p e c ia lly so . T h is is t h e c o m m o n p ic tu r e o f f ib ro s itis o f n e c k a n d s h o u ld e rs — th e w o r d t h a t in c o r re c tly s u g g e sts a n in fla m ­ m a to r y s ta te . T h e “ n o d u le s ” a r e m u s c le b u n d le s w h ic h c a n b e fe lt, a n d t h e i r d is p e rs a l su g g e sts th e r e lie f o f s p a s m o f th e s e b u n d le s . LOW BACK P A IN (Lumbago, Sciatica, “ Slipped D isc ” ) A c u te e p is o d e s a g a i n s t a b a c k g r o u n d o f a “ b a d b a c k ” a r e p e r h a p s t h e c o m m o n e s t o f a ll th e p r o b le m s o f n o n - a r t i c u l a r r h e u m a tis m . A l th o u g h th e g r e a t m a jo r ity a r e f o r p r a c tic a l p u r p o s e s m u s c u lo -s k e le ta l th e p o s s ib ility o f u n d e r ­ ly in g p a th o lo g y m u s t b e re m e m b e re d . P h y sic a l, l a b o r a t o r y a n d ra d io lo g ic a l in v e s tig a tio n s s h o u ld b e k e p t t o a m in im u m a n d re s p o n s e to th e r a p y u s e d a s c o n f irm a tio n o f d ia g n o s is . I t is r a r e t o fin d t h e a b s e n c e o f p sy c h o lo g ic a l f a c to rs , th e m o s t i m p o r t a n t b e in g a lo ss o f c o n fid e n c e in th e b a c k w h ic h h e lp s t o p e r p e tu a te s y m p to m s . A m y th o lo g y h a s g r o w n u p a b o u t th e “ s lip p e d d is c ” a n d t h e in e v ita b ility o f t r o u b le if th e r e is ra d io lo g ic a l e v id e n c e o f d e g e n e r a te d isc s. I t se e m s t h a t t h e r e d u c tio n in size o f t h e s h o c k a b s o r b e r b e tw e e n tw o v e r te b ra l b o d ie s is c o n s id e re d c ritic a l in th e p r o d u c t i o n o f p a in a n d y e t th e m o s t m o d e r n tr e a t m e n t o f d isc o ly sis p r o ­ d u c e s c h e m ic a l d e s tr u c tio n o f t h e d is c w ith re lie f o f p a in . U n le s s th e r e is m e c h a n ic a l p r e s s u re o n n e r v e r o o ts o r s p in a l c o r d b y d is p la c e m e n t o f t h e d isc , t h e r e d u c tio n o f siz e is u n im p o r ta n t. T r e a t m e n t o f t h e p a t i e n t a s a p e r s o n a lity c o m b in e d w ith t r e a t m e n t o f trig g e r p o in ts in t h e b a c k w ill o fte n p r o d u c e re g re ssio n o f s y m p to m s a n d g r a d u a l r e h a b ilita tio n . I n g e n e r a l, t h e s u p p o r t o f a c o r s e t o r sim ila r a p p lia n c e w ith o u t p o sitiv e f o r m s o f th e r a p y c a n b e in e ffe c tu a l a n d e x tre m e ly u n c o m f o r ta b le in a h o t c lim a te . U PPER LIM B T h e p a in f u l s h o u ld e r, a c o m m o n f e a tu r e o f r h e u m a to id a r t h r i t i s , is e v e n m o r e c o m m o n a s a n e x p re s s io n o f n o n - R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )