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 Table of Contents  
ORIGINAL ARTICLES
Year : 2021  |  Volume : 36  |  Issue : 3  |  Page : 51-56

Clinical presentation of congenital talipes equinovarus via detailed case scenarios


1 Department of Paediatric Orthopaedics, King George’s Medical University, Lucknow, Uttar Pradesh, India
2 Department of Paediatrics, King George’s Medical University, Lucknow, Uttar Pradesh, India
3 Department of Biochemistry, King George’s Medical University, Lucknow, Uttar Pradesh, India
4 Department of Orthopaedic Surgery, King George’s Medical University, Lucknow, Uttar Pradesh, India

Date of Submission26-Nov-2021
Date of Acceptance29-Nov-2021
Date of Web Publication22-Dec-2021

Correspondence Address:
Ajai Singh
Department of Paediatric Orthopaedics, King George’s Medical University, Shah Mina Rd, Chowk, Lucknow 226003, Uttar Pradesh.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jbjd.jbjd_20_21

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  Abstract 

Background: Clubfoot is a developmental deformity stirring at ankle, sub-taloid, and metatarsal joints. This deformity includes three elements: the foot inversion; forefoot-adduction relative to the hindfoot; and equinus position. The need for this case study was to understand the effectiveness of various treatment/management programs. Methodology: The study was performed for relating the severity of congenital talipes equinovarus (CTEV) with the need of Achilles tendon tenotomy (ATT) in the management along with demographic parameters. Overall, 95 patients of both sexes having 159 clubfeet were included. Clinicodemographic data were recorded, and the severity of CTEV was analyzed (Pirani scoring). Patients only presented at the tertiary hospital King George’s Medical University (KGMU), Lucknow for the first time, were included in the study, were provided with the facilities including casting, taping, and in extreme scenarios were projected for surgical interventions. Cases who had already registered under the Rastriya Bal Swastha Karyakram (RBSK) program were projected to the non-government organization “CURE” within the O.P.D. of the Paediatric Orthopaedics Department, KGMU, Lucknow. Via “CURE” the treatment facilities offered to the cases were completely free. Result: The mean age of the included cases was 102.44 days. Out of the 95 included cases with 159 clubfeet, 67.37% were males, and 32.63% were females. The mean of the presenting Pirani score was 3.17, the mean of the pre-ATT Pirani score was 2.72, and the mean of the Pirani score at the completion of management was 0.043. From these 159 clubfeet, 73 feet were subjected to ATT, and the remaining 86 feet were managed via casts only. The mean duration of correction was 6.1 weeks, and the mean of the required number of casts was 4.68. The total relapse observed was 32.70%. These were further managed by re-casting 44.23% and re-ATT, along with re-casting 55.77%. We found that out of 95 cases, 70.53% were rural rest, and 29.47% were urban. Similarly, 64.21% were literate, and 35.79% were illiterate [Table 1] and [Table 2].{Table 1} {Table 2} Special Case Scenarios: The present clinical article is a type of an observational-descriptive case series, with the focus on two different but similar anomaly-based cases. The first case is based on the simple idiopathic CTEV; however, the second one represents the case of complex clubfoot, that s, the patient is suffering from the clubfoot along with other deformities as a secondary anomaly. Conclusion: Clubfoot is a genetic deformity targeting the lower limb, with an effectively high rate of incidence in live births.

Keywords: Antenatal care, clubfoot, congenital, dietary, idiopathic, RBSK


How to cite this article:
Pandey V, Singh A, Gond AK, Raikwar A, Siddiqui S, Ali S. Clinical presentation of congenital talipes equinovarus via detailed case scenarios. J Bone Joint Dis 2021;36:51-6

How to cite this URL:
Pandey V, Singh A, Gond AK, Raikwar A, Siddiqui S, Ali S. Clinical presentation of congenital talipes equinovarus via detailed case scenarios. J Bone Joint Dis [serial online] 2021 [cited 2022 May 25];36:51-6. Available from: http://www.jbjd.in/text.asp?2021/36/3/51/333205




  Introduction Top


Hippocrates mentioned clubfoot, popularized as talipes equinovarus (CTEV), in the medicinal texts about 300 Before Christ (BC). In around half of the cases, the involvement is bilateral. However, in unilateral cases, the right foot is significantly more affected than the left foot.[1],[2] During the second trimester of pregnancy, a healthy developing foot may become a clubfoot. The etiology of the disease has been investigated, but it remains a mystery. Several systems such as neurological, bony, muscular, connective tissue, and vascular systems are all involved, but the only conclusive evidence indicated that the minor cases are directly connected to intrauterine posturing of the fetus. Genetic contributions have also been found for the congenital CTEV etiology.[2]

Clubfoot is not a congenital defect. According to Hippocrates’ theory, the foot became equinovarus due to the compression of the uterus. Parker and Browne, on the other hand, suspected that oligohydramnios hampered the fetus’ movement. Clubfoot may be caused by a halt in the intrauterine fetal development that is caused by a nutritional deficiency, certain obstetric disorders, or teratogenic agents in the atmosphere. Exposure to cigarette smoke, as well as a family history of smoking, has been linked to the development of clubfeet, especially in the antenatal era.

The diagnosis of clubfoot is typically made immediately after birth, based on a visual observation and examination of the foot. Males are around twice as likely as females to develop idiopathic clubfoot. Clubfoot is an easily recognizable deformity. The talipes-equinus, midfoot-cavus, forefoot-adduction, and hindfoot-varus are the four elements. The idiopathic clubfoot is actually a cosmetic as well as a functional deformity on the medial side, along with the ligaments, hypoplasia of skin, tendons, bones, and neurovascular bundle. Also, the affected foot is smaller than the average healthy foot.

Management of clubfoot should be started just the after birth and should be nonsurgical. The Ponseti process is based on the casting, then serial manipulations, and then afterward if required surgery. Management is given right away after the baby is born. On a weekly basis, the ligaments and tendons of the foot are stretched and manipulated, accompanied by the application of a soft fiber glass cast that aids in the restoration of the ligament to its natural position. Surgical correction is typically postponed until the infant is between the ages of six and nine months. Surgery is used to correct the clubbed foot and align it in its actual position. A case of clubfoot is addressed, as well as how to avoid and treat it.[3],[4] Clubfoot is a developmental deformity that affects the heel, subtaloid, and metatarsal joints.[5] The incidence rate of this deformity is 1–2 /1000 live births; in the United States, it is about 2.29/1000 live births; and among orientals, it is 0.57 in thousands.[6]

Various theories have been postulated in order to describe and elaborate the causes of CTEV. Mechanical factors in the uterus proposed by Hippocrates say that the foot must be held in the situation of equino varus by external uterine compression. However, Parker believed that there was a diminishing in the amniotic fluid, which prevents fetal movement and condenses the fetus susceptible to external pressure. Also, a study wherein the researcher had dissected the foot of the children in order to check for the bone deviation in terms of CTEV revealed that the talus neck was always shorter with anterior rotation medially and plantarly.[7] It can be labeled as “syndromic” if it happens in association with structures of genetic syndrome and is termed “idiopathic” if it occurs in isolation. Various treatment methods have been advised corrections and bandages, and immobilization with straps/casts underprops modern nonoperative treatments.

This study represents a case series with case reports of two patients with primary and secondary congenital talipes equinus varus, respectively. The main purpose of this case report study is to advise and motivate pregnant women to have routine antenatal tests, eat a balanced diet during pregnancy, and avoid congenital deformities in their children.


  Materials and Methods Top


Study area

The present case-control clinical study [Table 1] was performed at the Department of Paediatric Orthopedics, Orthopedic Surgery, and Department of Paediatrics in the tertiary care medical and teaching center. A total of 104 patients was enrolled according to the criterion for inclusion/exclusion. However, a total of 95 (91.34%) cases with 159 feet were further included and analyzed, as we have lost 09 (8.66%) patients in the casting follow-up management because of certain reasons such as plaster complications, relocation of patients, and the parents’ transportation costs.

Ethical approval

The present study was permitted via the institutional ethical committee with the registered reference number 96th ECM II A / P37, and the consent was taken from each patient’s guardian.

Data collection and study protocol

The common demographical data were recorded in all cases, including family’s smoking history, educational status, and the status of the case’s parents. The Ponseti method was used for the management of the cases in the study, which further includes the ATT, casting and bracing, etc. Alongside this, the counseling of the case’s parents was also performed around the present situation, management procedure, and, most importantly, the entire duration of the Ponseti method.

Severity evaluation

Pirani scoring system is used for grading the severity of the deformity and for quoting its functional outcomes. It scores six health signs: According to that, 03 is for mid-foot, and 03 is for hind-foot; three signs of the midfoot score and hind-foot score rate the sum of deformity from 0 to 3. Pirani score 0 is for ideal foot; a score of 03 is for slightly anomalous foot; and a score of 06 is for the highly severe anomalous foot [Table 1].


  Special Case Scenario Top


Case evaluation of typical CTEV

A two-month-old male baby was diagnosed with bilateral clubfoot while presenting the first time for the checkup at the tertiary medical hospital, KGMU, Lucknow. Then after the diagnosis of clubfoot the child was registered under the RBSK.

The child was born with clubfoot, according to the parents’ medical records. A comprehensive history of the mother’s antenatal checkup, socioeconomic status, food consumption, and supplementary iron-calcium history of medical disease was taken and reported properly. Also, in terms of family history, the active smoking history of the father and other relatives was observed along with the remarkable genetic transfer of clubfoot within the family tree. The baby’s general and physical examinations were conducted in various positions to ascertain the degree of various CTEV anomalies. Also, the Pirani scoring was recorded by the guide, co-guide, and the primary investigator (student) herself. Also, different positions were evaluated via standup like, whether the foot is not plant-grade? whether the heel is not bearing weight? and whether the foot is varus or valgus?

Then after the complete examination and evaluation, the diagnosis was made as idiopathic clubfoot, and the patient was enrolled in the Department of Paediatric Orthopaedics, of the tertiary medical hospital and teaching center, that is, KGMU, Lucknow. The ligaments and tendons of the foot were overextended and corrected on a weekly basis, accompanied by the application of a soft fiber glass-cast in order to support the ligament’s returning to the actual anatomical location. This was done so that the child could bear his weight on his own and on the heels [Figure 1]A and B.
Figure 1: (A and B) Image of the 2-month-old male child before and after the treatment of CTEV, respectively

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Case evaluation of complex talipes equinovarus

A 13-month-old child was delivered in the Department of Gynecology, of the tertiary hospital and teaching center, KGMU Lucknow, with a full-term normal delivery. She cried immediately after birth and was hospitalized at the age of nine months at the Department of Paediatrics of the same tertiary hospital, KGMU Lucknow due to an increase in her WBC counts; various investigations were performed. These investigations later brought about the conclusion that she was suffering from cerebral palsy.

It was discovered that she completed all the gross motor skills a bit late, that is between 7 and 11 months. Later, the relatives observed that she had difficulties in performing activities that children of her age group could easily perform and one of them involved difficulty in standing and walking. Hence, the child was presented at the same pediatric department from where she was suspected with some bony deformity therefore referred to the Department of Paediatric Orthopaedics of the same tertiary hospital, KGMU Lucknow. Where she was evaluated and the diagnosis was formed that, the child had CTEV. On examination, the child tended to plantarflex her ankle bilaterally. When made to stand with support, she curled her toes which was an indicator of weakness of intrinsic muscles of the foot. She bore more weight on the medial aspect of the foot. Also, it was found that, in standing, her right pelvis fell down. This was due to her keeping her left knee slightly plantarflexed and her right knee hyperextended.

Foot deformity index was taken, where the height and the congruence of the medial arch was observed to be flattened and was making direct contact with the ground. Inversion/Eversion of calcaneum was taken, where it was observed that the foot was everted and valgus of more than 5º was seen. Arch index was taken to keep a check on the development of the arches, where the right foot value was 10.2 mm and 10.9 mm, which indicated bilateral flat foot with the left foot more affected than the right. Gait was observed, where she was walking with the help of the walker. It was found that she bore more weight on the right lower limb, leading to hyperextension of the knee in the stance phase. When she stepped forward with her left foot, there was no heel impact, and she immediately went into flat foot with medial weight bearing and toe curling. On passive movement, ATT was bilaterally found to be tight [Figure 2]A–C.
Figure 2: Image of the 13-month-old female child in different potions while evaluation of CTEV: (A) Pesplanus, (B) Calcaneum inversion with medial weight bearing, and showing CTEV; and (C) left knee flexion. CTEV: Congenital Talipes Equino Varus (clubfoot)

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  Means and Modes of Managements Top


Physiotherapy management, parental education, rhythmic and repeated gentle manipulation along with bracing, ATT and stretching, consistent taping and casting, and strengthening the intrinsic muscles of the foot are a few of the popular modes of management that are discussed in detail later.

Physiotherapy management

The goal of physiotherapy rehabilitation consists of short-duration and long-duration targets. The aim of short-duration targets was to correct the malformation at ankles and restore them to a planti-grade role. However, the aim of long-duration targets was to keep the functionally corrected ankle as it is and follow up on it; hence, the patient will walk on its own or with the assistance of an assistive device. If possible, further follow-up is needed to avoid relapse.

Parent education

The parents were assured and reassured with the cooperation, compliance, and consistency of the treatment. They were made to recognize the condition and the correction should be gradual and follow-up should be maintained so as to get the best possible result.

Rhythmic and repeated gentle manipulation

Before commencing the procedure, the lower limb being treated was flexed to 900 at the knee joint, so as to avoid the damage to the lowest ending of the fibular-tibial epiphyses, and knee joint. Assuming the right foot was being treated, so, here, the right knee was flexed to 900. After that, soft tissues of the right foot were extended passively, and the forefoot curled away from the ipsilateral heel, a process known as forefoot abduction. The foot was then rotated in such a way that the sole faced outward, in an effort to fix the inverted foot. Finally, for the correction of the foot equinus, the right hand cupped the heel from the front of the foot and applied pressure upward, causing the forefoot to rise. The entire procedure resulted in dorsiflexion of the ankle. The entire process was repeated four times, with each manipulation lasting 2 min. The same procedure was repeated for the bilateral foot.

Rigid taping

The use of tape will support the foot arches. The procedure includes: An anchor was placed at the ball of the foot. Another anchor strip was connected across the top of the foot from the bottom. These anchors were used to attach the arch tape; then a strip of tape was placed from the ball of the big toe around the heel and was attached to the back at the mid-point of the anchor strip. This was repeated two to three times; then, a strip of tape was connected from the ball of the little toe around the heel and was attached to the back of the anchor strip. This procedure was again repeated two to three times; later, closing strips were applied. This was done by overlapping strips across the bottom of the foot. It began at the ball and was continued up till the middle of the foot. Lastly, finishing strips were then applied on the side of the foot. It started from the top of the anchor strips and was wrapped around the heel to finish on the top of the other side of the foot.

Strengthening intrinsic muscles of the foot

For strengthening purpose, the child was made to stand in a sand box with support for a period of 10 min. Also, spike ball exercise was prescribed. Here, the child was made to stand with support and the spike ball was placed below the foot region. The child was made to apply pressure on the spike ball and roll it forward and backward with the assistance of a therapist. The exercise was performed for 15–20 repetitions per session.


  Discussion Top


Clubfoot is often related with other birth defects, but it is typically an idiopathic finding. Its etiology has been the subject of several hypotheses. One is that clubfoot is caused by any halt in the growth of the foot during fetal life.[8],[9] The “arrest of development” hypothesis was endorsed by Ignacio V. Ponseti. This theory describes how teratogenic agents can damage a fetus’ environment and growth, as seen by the effects of rubella and thalidomide. Many writers agree that different environmental factors cause clubfoot and temporary growth arrest.[10] Palmer supported the multifactorial arrangement of legacy, that is possible with intrauterine factors having some effect.[11] Wynne Davis backed up the polygenic hypothesis by demonstrating a rapid decline in clubfoot incidence rate within first-degree to third-degree relatives. Insley reported the association of clubfoot with a deficiency of a part of the long arm of chromosome eighteen. About 2.9% of siblings in the first-degree relatives had this deformity as compared to 1–2/1000 in general population that is, 25 times more chances in siblings of an affected child.[12],[13],[14] A total of nine environmental factors have been implicated for triggering the intrauterine fetal-developmental anomalies, including: hydroamnios/oligohydramnios, infectious disease during pregnancy, maternal nutritional defects, vitamin deficiency, toxic agents such as azaserine, and maternal metabolic disorders.[1] Vitamin B12 is necessary for proper nervous system function. Women who have low levels of vitamin B12 are not only developing health issues, but they are also increasing the risk of their children being born with a severe birth defect.” To minimize the risk of deficiency for vitamin B12 and birth defects, women of childbearing age, women in the initial phase of pregnancy, and women who are planning to become pregnant soon should consume a healthy diet that includes foods high in vitamin B12 or take supplements.[13] This could result in a nutritional deficiency as well as poor health. This is why children are born with a clubfoot. Insley et al.[14] demonstrated in their study that, an exposure to smoking along with a positive family history is a prominent risk factors for clubfoot, especially in the antenatal age. The nonsurgical management with Ponseti method of clubfoot is highly appreciated and accepted for better correction, ranging from as low as 50% to as high as 90%.[14]

The choice of treatment for treating foot deformities has recently swung toward nonsurgical management,[15],[16] probably as the surgical management is highly unpredictable and the condition may relapse.[17] Various conservative techniques such as Kite method,[18] French method, and Ponseti technique[19] have been shown to various degrees of improvement. This case report showed how physiotherapy treatment management can be a boon and can add on, improving a patient’s condition. Treatment in the case report involves stretching, manipulation, strapping/casting, taping technique, and strengthening the intrinsic muscles of the foot.

Though there is no generally accepted protocol for assessing the outcome of CTEV,[20] the basic aim is to restore the normal functioning and make patients who are functionally able to use the lower extremity, especially the foot. Beginning physiotherapy at an early stage is vital, as there is a massive potential for renovation of soft tissues via various techniques. Manipulation and bracing technique applies a continuous force, which causes the joint capsules and ligament to gradually relax. This will retain their position within the brace, which is the key to manual correction. Also, the brace can be removed at any time in case of discomfort, which will also help in making the skin care technique more convenient.[21] The small intrinsic muscles of the foot, the interossei and lumbricals, help in stabilizing the toes during movement. Weakness of these muscles often leads to conditions such as plantar fascitis, ankle sprain, and flat foot. Ball exercises help in improving the strength of these muscles; they also lengthen the tightened ligaments. The taping technique provides support to the arch. It also improves the strength in combination to provide stability during exercise training. The length of muscle fibers is affected by nonelastic tapes, and muscle-length stress causes overlapping changes in the arch of the foot. As a result, the crosslinking of actin and myosin filaments increases.[22],[23]


  Conclusion Top


The recent necessity of the management of the clubfeet is to have a plantigrade, supple-foot in less time, and the management technique of Ponseti is ideally suited to accomplish those goals. The Ponseti approach is considered the gold standard for the treatment of club feet; however, even in the best possible situation, recurrences are also known to occur. The remanagement should, therefore, be carried out very carefully on repetitive castings via repetitive ATT. Via the Pirani scoring system, the seriousness of the clubfeet can be reported and rated, that is completely reproducible, and not showing any difference between observers. Even the subparameter of the scoring system aids in the ongoing management developments in decision making. The Pirani scoring scheme also allows us to document the success of treatment and assessment. Further, stringent policies of Ponseti technique usually includes the casting and bracing. However, in certain situations it also includes ATT.

Ethical policy and institutional review board statement

Institutional ethical clearance was taken (Protocol number 1702/Ethics/19: ECR/262/ Inst/UP/2013/RR-16. Dated: 05/11/19; Ref. Code: 96th ECM II A/P37).

Financial support and sponsorship

This study was supported by the Prime Minister Doctoral Research Fellowship (SERB/PM Fellow/CII-FICCI/Meeting/2019).

Conflicts of interest

Nil.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.



 
  References Top

1.
Wynne-Davis R. Family studies and the causes of congenital clubfoot: Talipes Equinovarus, Talipes calcaneal valgus, and metatarsus varus. J Bone Joint Surg Br 1964;46:445-63.  Back to cited text no. 1
    
2.
Cummings RJ, Lovell WW. Current concepts review: Operative treatment of congenital idiopathic clubfoot. J Bone Joint Surg 1988;76A:1108-112.  Back to cited text no. 2
    
3.
Ponseti IV, Smoley EN. Congenital club foot: The results of treatment. J Bone Joint Surg1963;45:261-344.  Back to cited text no. 3
    
4.
Brockman E. Relapsed clubfoot by Dilwyn Evan’s. J Bone Joint Surg 1963;143:538-42.  Back to cited text no. 4
    
5.
Ezeukwu AO, Maduagwu SM. Physiotherapy management of an infant with bilateral congenital Talipes Equino Varus. Afr Health Sci 2011;11:444-8.  Back to cited text no. 5
    
6.
DePuy J, Drennan JC. Correction of idiopathic: A comparison of result of early versus delayed posteromedial release. J Pediatr Orthop 1989;9:44-8.  Back to cited text no. 6
    
7.
Turco VG, Spinella AJ. Current management of clubfoot in Institutional course lecture of the American Academy of Orthopedic Surgeons. Vol. 31. St. Louis, MO: CV Mosby; 1982. p. 218-34.  Back to cited text no. 7
    
8.
Bohm M. Pathological anatomy of clubfoot. J Bone Joint Surg 1963;45:45-52.  Back to cited text no. 8
    
9.
Grant AD, Atar AD, Lehman WB. The Ilizarov technique in correction of complex foot deformities. Clin Orthop Relat Res 1992;280:94-103.  Back to cited text no. 9
    
10.
Ippolito E, Ponseti IV. Congenital club foot in the human fetus. A histological study. J Bone Joint Surg Am 1980;62:8-22.  Back to cited text no. 10
    
11.
Palmer RM. The genetics of talipes equinovarus. J Bone Joint Surg Am 1964;46:542-56.  Back to cited text no. 11
    
12.
Wynne-Davies R. Family studies and aetiology of clubfoot. J Med Genet 1965;2:227-32.  Back to cited text no. 12
    
13.
Jenjifer W. Birth Defects Linked to Low Vitamin B12. Web Med cancer newsletter, 2018. Available from:https://www.webmd.com/baby/news/20090302/birth-defects-linked-to-low-vitamin-b12#1.[Last accessed on 6 Dec 2021].  Back to cited text no. 13
    
14.
Insley J. Syndrome associated with a deficiency of part of the long arm of chromosome no. 18. Arch Dis Child 1967;42:140-6.  Back to cited text no. 14
    
15.
Benjamin DR, Joshua H, David PR. Congenital idiopathic talipes equinovarus. Paediatr Rev 2004;26:124-30.  Back to cited text no. 15
    
16.
Siapkara A, Duncan R. Congenital talipes equinovarus: A review of current management. J Bone Joint Surg 2007;89B:995999.  Back to cited text no. 16
    
17.
Andrei GZ, Vermesan S. Considerations in treating congenital clubfoot in children: A two year retrospective study. Revistade Ortopedie si traumatologic- Asoris 2009;3:19-23.  Back to cited text no. 17
    
18.
Kite JH. Non-operative treatment of congenital clubfoot. Clin Orthop 1972;84:29-38.  Back to cited text no. 18
    
19.
Charles EJD, Simon L, Nigel TK. Ponseti treatment in the management of club foot deformity a continuing role for paediatric orthopaedic services in secondary care centres. Ann R Coll Surg Engl 2001;89:510-12.  Back to cited text no. 19
    
20.
Herman Z. Barriers Experienced by Parents/Caregivers of Children with Clubfoot Deformity Attending Specific Clinics in Uganda. Unpublished MSc Dissertation, Uganda: University of Western Cape; 2006.  Back to cited text no. 20
    
21.
Yuxi S, Guoxi N. Manipulation and brace fixing for the treatment of congenital clubfoot in newborns and infants. Su and Nan BMC Musculoskeletal Disorders 2014;15:363.  Back to cited text no. 21
    
22.
Lee S-M, Lee D-Y, Hong J-H, Yu J-H, Kim J-S. The effect of elastic and non-elastic tape on flat foot. Indian J Sci Technol 2015;26:12-8.  Back to cited text no. 22
    
23.
Neumann DA. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. Vol. 12. St Louis, MO: Mosby & Elsevier; 2010. p. 45-7.  Back to cited text no. 23
    


    Figures

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    Tables

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