lleolus is
obscured by the approximation of the navicular, and the lateral
malleolus is unduly prominent.

In extreme cases, the supinated foot forms an acute angle with the
leg, and there is frequently a deep transverse depression across the
sole, the result of contraction of the plantar fascia--a feature which
is distinctive of the congenital form of club-foot.

_In children who have walked_, the deformity becomes aggravated. The
dorsum of the foot is markedly uneven, partly because of the
prominence of the individual tarsal bones, and especially of the head
of the talus and greater process of the calcaneus, and partly because
of a depression over the neck of the talus. Instead of resting on its
lateral border, the foot may finally rest on the dorsum, the sole
looking upwards and backwards. While the skin over the heel remains
comparatively thin and delicate, that covering the lateral border and
dorsum of the foot becomes the seat of callosities, beneath which
adventitious bursae are formed. These bursae are liable to become
inflamed, and are then a source of great suffering, and if they
suppurate may cause persistent sinuses. The muscles of the leg and
foot, although not paralysed, undergo atrophy from disuse. In walking,
the patient lifts one foot over the other in an ungainly and laborious
manner, without any spring, as if walking on stilts.

_In adults_, these features are further aggravated, and there are
permanent changes in the bones (Fig. 144).

[Illustration: FIG. 144.--Congenital Talipes Equino-varus in a man aet.
24; seen from behind.]

_Treatment._--This should be commenced as soon as the viability of the
infant is beyond question, as the younger the patient the more easily
and completely is the deformity rectified. Manipulations to correct
the deformity should be carried out twice or thrice daily, and the
limbs are also massaged and douched. At the end of two or three
months, assistance may be derived from the use of a simple lateral
poroplastic or aluminium splint with a foot-piece, or more simply by a
strip of rubber plaster. The foot is held in the over-corrected
attitude and the plaster is applied so as to maintain this attitude.
If this regime is systematically persevered with from within a few
days after birth, by the time the child begins to walk the sole can be
brought into contact with the ground, and the weight of the body will
aid in correcting the deformity. If the equinus element resist