shoe congenital clubfoot

OCTOBER 2004 • PODIATRY MANAGEMENTwww.podiatrym.com 125

functioning foot possible. The ini-tial treatment for this conditionusually involves either serial immo-bilization casting, surgery, or both.All too often, though, after the ini-tial dramatic correction is obtained,the follow-up care is not carried for

a long enough period of time andmuch of the deformity recurs. Thisis usually due to a combination ofthe patient’s parents becoming laxon returning for the extended peri-od of post correction visits after the

Continued on page 126

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Continuing

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The early recognition andtreatment of congenital tal-ipes equinovarus, or clubfoot

deformity, is acknowledged asbeing necessary to obtain the best

By Mark A. Caselli, DPM

The Role of Shoe Therapy in the

Management of Pediatric Congenital

Clubfoot

Proper footgear helps maintain the correctionachieved by surgery or serial casting.

Goals and Objectives

After reading this article thepodiatric physician shouldbe able to:

1) Recognize a talipesequinovarus (clubfoot) de-formity in an infant

2) Understand the meth-ods of treatment used inthe initial correction of aclubfoot deformity

3) Prescribe maintenanceshoe therapy for an infantwith a recently correctedclubfoot

4) Address the complica-tions associated with postcorrection clubfoot shoetherapy

5) Utilize shoegear in atreatment plan for the postcorrection residual foot and gait problems found in clubfoot

The Role of Shoe Therapy in the

Management of Pediatric Congenital

Clubfoot

Proper footgear helps maintain the correctionachieved by surgery or serial casting.

Shoes&

Podiatry

Shoes&

Podiatry

126 www.podiatrym.comPODIATRY MANAGEMENT • OCTOBER 2004

Clubfoot...

foot looks “good” and thedoctor’s reluctance to strongly

encourage these visits. It is well-recognized that rigorous post-oper-ative physical therapy is of equalimportance to good surgical tech-nique in the outcome of joint re-construction procedures. This anal-ogy can be used in the correction oftalipes equinovarus; that is, rigor-

ous shoe follow-up therapy is oftenof equal importance to the initialcorrection for long-lasting results.

Talipes EquinovarusTalipes equinovarus, or club-

foot, is one of the most commoncongenital deformities of the foot.First described by Hippocrates, ithas been known since ancienttimes. The incidence of talipesequinovarus varies with race and

sex. In whites,the birth fre-quency is 1.2per 1000, witha male-to-fe-male ratio of

2:1. The incidence in Asians hasbeen reported as low as 0.57 per1000, whereas in full-bloodedHawaiians, it is 6.81 per 1000. In-volvement is bilateral in about 50%of the cases. In unilateral cases, theright side is affected slightly morefrequently than the left .5

The deformity resembles theembryonic foot position at the7th—9th weeks of development.The clinical picture of talipesequinovarus is characteristic. Thefoot points plantarward with thesmall heel drawn up and rolled inunder the talus in an inverted posi-tion (fig.1). There are deep creasesat the posterior aspect of the ankle

joint. Themidfoot andforefoot areadducted, in-verted, andhave an equi-nus pitch (fig.2).1 Internaltibial torsionis a commona s s o c i a t e dfinding.

The etiol-ogy of talipesequinovarusremains con-t r o v e r s i a lwith the po-tential causesincluding 1)Abnormalitiesof develop-ment and in-sertion ofmuscles, ten-dons, and lig-aments; 2)Bony abnor-malities; 3)N e u r o g e n i cproblems; 4)Intrinsic talard e f o r m i t ywith headand neck me-dially deviat-ed; 5) Degen-eration ofmuscle andnerve tissue;6) Arrestede m b r y o n i cdevelopment;

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Figure 4: Lateral radiograph of clubfoot with diminished lat-eral talocalcaneal angle

Figure 2: The adducted, inverted, and equinus deformity ofclubfoot

Figure 3: A-P radiograph of clubfootwith decreased talocalcaneal angle

Figure 1: Talipes equinovarus foot deformity demonstratinga small, inverted heel

Figure 5: Ankle creasing associated withclubfoot

Continued onpage 127


ing clinical signs to be found on ex-amination of a corrected clubfoot isthe creasing that is left, just plantarand medial to the talonaviculararea and lateral to the externalmalleolus (fig. 5). In cases in whicha clinician is called upon to exam-ine a foot that may have been aclubfoot at birth, this constant clin-ical sign invariably reinforces theopinion that the child once didhave a true clubfoot. It is also use-ful in differentiating a correctedclubfoot from a residual metatarsus

and 7) Abnormal uterine pressure[B]. Congenital talipes equinovarusmay be categorized into idiopathicclubfoot, which is an isolated defor-mity, and extrinsic teratogenicclubfoot, which usually occurs as aresult of outside influences such asmyelomeningocele, intraspinal tu-mors, diastematomyelia, po-liomyelitis, distal type progressivemuscular dystrophy, cerebral palsy,and Guillain-Barre syndrome.5

Radiographs providea useful baseline not onlyfor assessment of the de-formity in clubfoot butalso for monitoringprogress of treatment andfor determining recur-rence following treat-ment. In the AP view, theintersection of the longaxes of the talus and cal-caneus forms the talocal-caneal angle (normalrange 20-40 degrees),which will be less than20 degrees in clubfoot(fig. 3). Similar linesdrawn through the longaxes of the talus and cal-caneus on the lateralview form the lateraltalocalcaneal angle (nor-mal range 35-50 de-grees). The equinus de-formity of the clubfootreduces this angle to -10to 35 degrees4 (fig. 4). Onboth the AP and lateralviews, the lines bisectingthe talus and calcaneusbecome more parallelwith the increasingseverity of the deformity.

If talipes equinovarusremains untreated, thedeformity will progres-sively increase and thecontractures will becomemore rigid. The child willbear weight on the later-al border of the foot andon the fibular malleolus.Ambulation will becomedifficult and the gait willbe awkward. Painful cal-losities and bursae oftendevelop over the lateralside of the foot.

One of the outstand-

Clubfoot... adductus or rigid pescavus.

Initial TreatmentTreatment for talipes equino-

varus should begin as soon afterbirth as possible. Manipulation—at-tempting to remold the foot into amore normal shape—should be at-tempted early and be combinedwith other treatments. One shouldput traction on the forefoot whenremolding position in order tobring the displaced navicular

around the talar head,thereby preventing animpingement of the nav-icular on the talus. Plas-ter of Paris above kneecasts should be appliedfrom toes to groin. Thesecasts are changed fromtwice weekly in the new-born to semiweekly inolder infants.

Throughout treat-ment, the practitionershould be wary of creat-ing a rocker-bottom footwhich can result fromforced dorsiflexion of theforefoot against a plantar-flexed hindfoot. To avoidthis complication, the de-formity should be cor-rected from distal toproximal, the correctingsequence being a) the ad-ducted forefoot; b) the in-verted rearfoot; and final-ly c) the equinus. Correc-tion should be confirmedby x-ray. The x-rayshould demonstrate thatthe long axis of the talusis in line with the firstmetatarsal. Surgical treat-ment is necessary whenconservative measures areinadequate and after aproper trial period of 3-6months of conservativeserial casting.

Shoe TherapyOnce full correction

of the foot has been ac-complished, the next stepin the logical sequence ofmanagement is the main-tenance of the correctionachieved. If no method of


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Figure 7: Open toe straight last shoes

Figure 8: Open toe abducted last shoes

Figure 6: Denis Browne shoe-splint combination

Browne splint (Fig. 6). Maintenanceof correction is accomplished bytwo mechanical factors: one is theexternal rotation of the shoes onthe bar (usually 30-45 degrees exter-nal), and the other is the forceplaced on the foot by the shoes. The

two commonly used shoesare the open toe straightlast shoe (Fig. 7) and theopen toe abducted lastshoe such as the MarkelTarso-Pronator (Fig. 8).

The straight last shoeis divided equally betweenright and left halves, withthe functional axis downthe center. This high shoeis open at its distal endwith a large tongue that isattached to one side sothat the upper part of theshoe can be opened to theside and the foot easilyplaced into the shoe. Theshoe is also laced from themost proximal to distalend of the upper to allowfor a snug fit. The opentoe abducted last shoe hasa C-shaped last abductedboth in the forefoot andthe rearfoot. The rest ofthe shoe is constructed ina similar manner as theopen toe straight last shoe.

The function of theseshoes can further be en-hanced with the additionof felt padding placed inthe shoes. Padding can bedone with layers of 1/8-inch adhesive felt. Theshoe is padded from the

distal end of the shoe along the firstray, ending at the first metatarsalbase, at the cuboid area of the footto act as counter pressure, andwhen used in the treatment ofmetatarsus adductus, a varus heelpad can be added to maintain neu-tral heel position (fig. 9). Padding isalso added as necessary to increasecorrective pressure. Spot padding isadded at any point where promi-nences must have increasedpadding. This is particularly true ofthe first metatarsophalangeal joint.This method of treatment gives theclinician immediate visible controlover the correction as it proceeds.6

The parent is advised to main-tain the shoe-splint in place 21-22hours a day, permitting the child 2-3 hours daily of freedom from thisapparatus as well as relieving areasthat might be subjected to exces-sive pressure, thus reducing the in-cidence of pressure sores on thefoot. This discipline should be con-tinued until the child is ready for

walking, at whichstage the splint isworn only at nightand an out-flareforefoot last shoeis worn during theday. This is a highshoe with a closedtoe-box; only thefront of the shoe isabducted. The rearpart of the shoeenclosing the rear-foot and midtarsalarea remains in afunctionally neu-tral attitude (fig10). This type ofContinued on page 129


Clubfoot...

maintenance of correction isapplied, the deformity will recur.

Correction is maintained by substi-tuting the cast for corrective shoesplaced on a splint such as a Denis

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Figure 11: Circular nut on Denis Browne splintshould be tightened sufficiently enough to pre-vent removal by young patient

Figure 10: Out-flare forefoot last shoe

Figure 9: Felt padding is added to an open toestraight last shoe to improve the corrective func-tion of the shoe

Figure 12: Residual forefoot adductus of incom-pletely corrected clubfoot

In a primary well-corrected clubfoot,

correction can bemaintained in most

instances by the wearing of the

shoe-splint 21 to 22hours a day until

the child starts walking.


In some instances, the parentmay call attention to the fact thatthe foot will not remain in the shoeor that a blister forms on the child’sheel from use of the shoe-splintcombination. There are two mainreasons for these occurrences. Oneis that the shoe is too small or toolarge. The other is that there re-mains an element of persistentfixed equinus position. The formeris easily corrected by an accuratefitting of shoe size for the individu-al foot. The latter indicates that ad-equate correction of the equinusdeformity has not been obtainedand further treatment of this ele-ment of deformity must be under-taken before resorting to the use ofthe shoe-splint.

Fixed equinus deformity andthe shoe-splint are in-compatible. Unless thechild’s heel engagesthe inside bottom partof the heel of the shoe,the child can thrustwith his forefoot inflexion and work hisfoot out of the shoe. Itis inappropriate to per-sist in forcing such afoot to remain in the

shoe is designed to prevent therearfoot from pronating excessivelywhile the forefoot is being abduct-ed. Frequently, a foot orthosis isused to establish good rearfoot andlong arch position in this shoe.

Clubfoot... shoe by a strap over thetarsus or tight lacing of theshoe. Success in keeping sucha foot in a shoe will only resultin producing a rocker bottom de-formity of the foot. This is not onlyundesirable but also productive ofan additional deformity which, initself, will require special correctivemeasures to overcome.3

If the failure of the foot to stayin the shoe is due to a fixed equi-nus position of the foot, the defor-mity should be corrected by furtheruse of corrective casts or by surgicalmeans and then progression to theshoe-splint maintenance of the cor-rection. With the equinus positioneliminated, there will be no diffi-culty in keeping the foot in theshoe provided the fit is proper.

The tendency for some childrento remove the shoe from the barcan be overcome by setting the cir-cular or wing nut with a wrench orpliers so that the child cannot un-screw it manually (Fig. 11). Forthose children who untie the shoelaces and remove the shoes, thereare obtainable barrel-shaped con-tainers which screw together in twohalves over the bow knot so thechild has no access to the knot.

In a primary well-cor-rected clubfoot, correctioncan be maintained in mostinstances by the wearing ofthe shoe-splint 21 to 22hours a day until the childstarts walking. Then thesplint is applied at nightand the out-flare forefootlast shoe is worn through-out the day. The childshould be seen every one totwo months until one yearof age, then every two tothree months thereafteruntil age five years. Thenight splint and tarso-pronator shoe combinationshould be worn as long aspossible at night, thoughusually is discontinued by18 to 24 months of agewhen the child rejects thisform of treatment.

At this time, the correc-tive shoe can be used alonewithout the splint. This isusually well tolerated.When the child outgrows


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Figure 15: Neoprene outer sole wedge placed on ath-letic shoegear helps reduce tripping and falling fromin-toe gait

Figure 13: Athletic shoe with forefootrocker sole

Figure 16: Cable twisters can beused to reduce in-toe gait

Figure 14: A 4-ply leather laminate orthosis withdeep heel cup and high medial and lateral flanges insupportive shoegear used for reduced subtalar jointmotion

ferences are found but are less pro-nounced. Studies have shown thatthe average limb length discrepan-cy in a unilateral clubfoot is 0.5inch and 0.3 inch in a bilateralcase. This difference should be ad-dressed to prevent undesirablebiomechanical compensations inother segments of the skeletal struc-ture. An internal lift placed in theshoe can be used to equalize up to1/4 to 3/8 inch difference depend-ing on the available depth of theshoe.

Above this, the sole of the shoecan be split and the necessary liftadded. The average foot length dif-fered 1.6 inches in the unilateralclubfoot and 0.4 in bilateral situa-tions.2 There are many ways of han-dling this problem, including pre-scribing mismatched sized shoes,using high top shoes/boots of thesame size which prevent the shortfoot from sliding forward in theshoe, or using a foot orthosis totake up space within the shoe whileholding the foot in proper align-ment. If the difference is small, noaccommodation might be neededand only periodic evaluation offoot size is indicated.

Ankle dorsiflexion is generallyfound to be reduced after clubfootcorrection. This can be addressedby adding a heel lift in the shoeand/or using shoegear with a fore-foot rocker sole configuration.There are many athletic shoes onthe market that fill this need (Fig.13). A supportive athletic shoe witha well-molded foot orthotic can beused in the management of a pa-tient with reduced subtalar jointrange of motion (Fig. 14).

Forefoot adduction is the mostcommon residual problem in club-foot correction.2 A patient with thiscondition usually presents with thecomplaint of pain, irritation, hyper-keratosis, and/or bursitis at the sty-loid process at the base of the fifthmetatarsal. A leather foot orthosiswith a deep heel cup and a paddedlateral flange extending just proxi-mal to the styloid process placed ina deep shoe can reduce many ofthese symptoms.

In-toe, attributed to internal tib-ial torsion, is a frequently seen con-dition associated with clubfoot.2

The most common presenting com-plaint is tripping and falling, espe-


Clubfoot...

the largest size open toe shoe(usually by age three years), a

closed toe out-flare forefoot lastshoe, with the end of the toe boxcut out for comfort, can be used forseveral years more during thenight. This type of shoe is availablein larger sizes. Corrective shoe ther-apy, both day and night, is recom-mended until the child is at leastfive years of age.

Discontinuance of maintenanceof correction has consistently showna recurrence of the deformity, espe-cially the forefoot adductus compo-nent.2 (Fig 12). This is why a five-year period of treatment has beenchosen to avoid recurrence and toassure maintenance of correction. Itcannot be overemphasized that thechief cause of persistent or recurrentdeformity in the clubfoot is failureto achieve an initial full correctionas well as failure to maintain correc-tion after the initial full correctionhas been procured by premature in-terruption or discontinuance oftreatment in the child, two, three, orfour years of age.

Even if the foot is completelycorrected, and the correction ap-pears well maintained, the childshould be reexamined at least everysix months until the foot has at-tained its full growth. Even in feetwhich have been corrected easilyand rapidly, this deformity is notori-ous for its recurrence if maintenancetreatment is discontinued too soon.

Other Shoegear ConsiderationsEven when an appropriate treat-

ment regimen is followed for thecorrection of a talipes equinovarusfoot deformity, there often remaina number of foot and gait problemsthat should be recognized and ad-dressed with proper footgear pre-scriptions and/or modifications.These conditions include 1) limb-length; 2) foot-length; 3) limitedankle joint dorsiflexion; 4) reducedsubtalar joint range of motion; 5)Forefoot adduction; and 6) in-toegait.

Differences in the clubfoot sideare consistently found. Both limblength and foot length are reducedin the unilateral clubfoot as com-pared with the normal side. Evenwhen the clubfoot is bilateral, dif-

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Dr. Caselli is StaffPodiatrist at theVA Hudson Val-ley Health CareSystem and isAdjunct Profes-sor at NYCPM.He is a Fellow ofthe AmericanCollege of SportsMedicine.

cially when running. A commonprescription for this problem is anout-flare last shoe with a 1/8 to3/16 inch outer sole wedge. Al-though this combination may behelpful in maintaining the forefootadduction correction component ofthe clubfoot, it appears to have lit-tle value in reducing the trippingand falling, and indeed can exacer-bate this problem.

A shoe modification that ap-pears to help in this situation inyoung children is one in which a1/8 to 1/4 inch neoprene outer solewedge is placed on a flexible sneak-er (Fig. 15). Another device, cabletwisters, although appearing slight-ly cumbersome, can be effective incertain difficult situations (Fig. 16).These braces can also be used inconjunction with corrective ortho-pedic shoes. Most often, a thoroughevaluation of the post-correctionclubfoot will indicate the use ofone or more of these shoegear ap-plications. ■

References1 Caselli M A, Sobel E, McHale KA:

Pedal manifestations of musculoskeletaldisease. Clin Podiatr Med Surg 15:481-497.

2 Cohen-Sobel E, Caselli M, GiorginiR, Giorgini T, Stummer S: Long termfollow-up of clubfoot surgery: analysisof 44 patients. J. Foot Ankle Surg 32:411-423.

3 Gaston SR, Goldner JL: The club-foot. In Giannestras NJ (ed). Foot Disor-ders, Medical and Surgical Management.2nd edition. Philadelphia: Lea &Febiger: 1973, p.237-301.

4 Rendall G, Stuart PR, Hughes SPF:Orthopedics. InThompson P (ed). Intro-duction to Podopediatrics. London: W.B. Saunders Company Ltd: 1993, p. 201-230.

5 Tachdjian MO: Pediatric Orthope-dics. Philadelphia: W. B. Saunders Com-pany: 1990, p.2405-3012.

6 Tax HR: Podopediatrics. Baltimore:Williams & Wilkins: 1985. p. 276-279.


6) The most common site forpainful callosities in an untreatedclubfoot is:

A) medial ankleB) distal halluxC) posterior heelD) fifth metatarsal base

7) At what age is it best to begin treatment of a congenitalclubfoot?

A) BirthB) One monthC) Six monthsD) One year

8) Plaster casts applied on a two week old infant for thecorrection of clubfoot are usually changed:

A) every dayB) once or twice a weekC) every two to three weeksD) every four to six weeks

9) In order to prevent creating a rocker bottom foot when casting a clubfoot, the correctingsequence should be:

A) equinus, inversion,adductionB) adduction, equinus,inversionC) adduction, inversion,equinusD) abduction, eversion,equinus

10) Surgical treatment isnecessary when conservativemeasures are inadequate after atrial period of:

A) 1-2 monthsB) 3-6 monthsC) 8-10 monthsD) 1-2 years

1) The incidence of congenitaltalipes equinovarus is usuallyreported as 1 per 1000 livebirths, though the frequencyvaries dramatically with race. Inwhich one of the followingethnic groups is there anexceptionally high incidence?

A) CaucasiansB) HawaiiansC) AsiansD) Native Americans

2) Which of the following footpositions best describes that ofan infant with a talipesequinovarus foot deformity?

A) plantar flexion-abductionB) dorsiflection-abductionC) plantar flexion-adductionD) dorsiflexion-adduction

3) Which one of the following isnot considered a potential causeof a talipes equinovarusdeformity at birth?

A) Down syndromeB) Talar deformityC) Neurogenic problemsD) Arrested embryonicdevelopment

4) A talocalcaneal angle on anAP radiograph consistant withtalipes equinovarus would be:

A) 15 degreesB) 30 degreesC) 45 degreesD) 60 degrees

5) The lines bisecting the talusand calcaneus become ______with the increasing severity ofthe clubfoot deformity.

A) more obliqueB) more parallelC) longerD) shorter

11) When a Denis Browne splintis used in the maintenance ofclubfoot correction, it should beset at what angle?

A) 10 degrees internalB) 30 degrees internalC) 10 degrees externalD) 30 degrees external

12) Which one of the followingshoes is not used in conjunctionwith a Denis Browne splint in themanagement of clubfoot?

A) Open toe straight lastB) Open toe abducted lastC) Tarso-pronatorD) Tarso-supinator

13) The function of an open toeabducted last shoe can beenhanced by:

A) Adding felt paddingB) Using a smaller shoeC) Reversing the shoesD) Stretching the shoe

14) To best maintain the initialcorrection obtained fromclubfoot casting or surgery, theshoe-splint combination shouldbe worn _____ hours daily.

A) 24B) 21-22C) 18-20D) 12

15) The main causes for difficultyin maintaining the foot in theshoe-splint combination or theformation of blisters include allof the following except:

A) shoe too smallB) shoe too largeC) fixed equinus deformityD) residual adductusdeformity

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E X A M I N A T I O N

See answer sheet on page 133.


132 PODIATRY MANAGEMENT • OCTOBER 2004

16) The type of shoe commonly used tomaintain forefoot adductus correction in theambulating child is the:

A) Out-flare forefoot last shoeB) Rocker-sole shoeC) Orthopedic oxford with outer wedgeD) Adducted-last shoe

17) Residual forefoot adductus, commonly seenin the previously treated clubfoot, is commonlydue to:

A) The child walking too earlyB) The wrong type of corrective shoes usedC) Improperly setting the Denis Brown splintD) Early discontinuance of maintenance of correction

18) Studies have shown that the averagedifference in foot length in a patient having aunilateral clubfoot is:

A) 0.4 inchB) 1.1 inchesC) 1.6 inchesD) 2.6 inches

19) A shoe that appears to reduce the tripping and falling resulting from in-toe gait is the:

A) Rigid oxford with inner sole wedgeB) Flexible sneaker with outer sole wedgeC) Rocker-sole shoeD) Padded abducted-last shoe

20) Which one of the following statements bestdescribes the use of corrective shoegear inmaintaining correction in clubfoot?

A) Corrective shoes should be used to oneyear of ageB) Corrective shoes should be used untiltotal correction is obtainedC) Corrective shoes are only necessary wheninadequate surgery is performedD) Corrective shoes should be used in someform until at least five years of age

E X A M I N A T I O N

(cont’d)

See answer sheet on page 133.

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fax 24 hours a day to 1-631-563-1907. Your CPME certificate willbe dated and mailed within 48 hours. This service is available for$2.50 per exam if you are currently enrolled in the annual 10-examCPME program (and this exam falls within your enrollment period),and can be charged to your Visa, MasterCard, or American Express.

If you are not enrolled in the annual 10-exam CPME pro-gram, the fee is $20 per exam.

Phone-In GradingYou may also complete your exam by using the toll-free ser-

vice. Call 1-800-232-4422 from 10 a.m. to 5 p.m. EST, Mondaythrough Friday. Your CPME certificate will be dated the same dayyou call and mailed within 48 hours. There is a $2.50 charge forthis service if you are currently enrolled in the annual 10-examCPME program (and this exam falls within your enrollment peri-od), and this fee can be charged to your Visa, Mastercard, Ameri-can Express, or Discover. If you are not currently enrolled, the feeis $20 per exam. When you call, please have ready:

1. Program number (Month and Year)2. The answers to the test3. Your social security number4. Credit card information

In the event you require additional CPME information,please contact PMS, Inc., at 1-631-563-1604.

Enrollment/Testing Informationand Answer Sheet

✄


LESSON EVALUATION

Please indicate the date you completed this exam

_____________________________

How much time did it take you to complete the lesson?

______ hours ______minutes

How well did this lesson achieve its educational objectives?

_______Very well _________Well

________Somewhat __________Not at all

What overall grade would you assign this lesson?

A B C D

Degree____________________________

Additional comments and suggestions for future exams:

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

EXAM #9/04Pediatric Congenital Clubfoot

(Caselli)

1. A B C D

2. A B C D

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D

12. A B C D

13. A B C D

14. A B C D

15. A B C D

16. A B C D

17. A B C D

18. A B C D

19. A B C D

20. A B C D

Circle:

E N R O L L M E N T F O R M & A N S W E R S H E E T (cont’d)Con

tinuin

g

Medica

l Edu

catio

n

shoe congenital clubfoot

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