ankylose the ankle and mid-tarsal joints. It may be
necessary to divide in several places the plantar fascia and other
structures that have undergone secondary shortening.

As using the limb hastens the restoration of function, the child
should be got on to his feet as soon as possible.

The spastic form of talipes equino-varus is comparatively rare. The
plantar flexors and invertors distort the foot into the equino-varus
attitude. The heel is drawn up, the anterior part of the foot is
adducted and inverted at the mid-tarsal joint. The muscles are tense
and rigid, and the reflexes exaggerated. The condition is frequently
bilateral, and is often associated with other deformities of the lower
limb and with a characteristic spastic gait. Considerable improvement
may be brought about by lengthening the tendons of the shortened
muscles. In severe cases it may be necessary to resect a portion of
the tarsus.

The occurrence of #varus without equinus# is so exceptional as not to
call for separate description.

#Pes Equinus.#--This deformity, in which the foot is in the position
of plantar-flexion with the heel drawn up and the toes pointed, is
nearly always acquired as a result either of poliomyelitis or of
spastic paralysis. In typical cases the patient walks on the balls of
the toes (Fig. 145). It is seldom met with as a congenital condition.
Occasionally it is due to nerve lesions such as peripheral neuritis,
or to injuries and diseases in the region of the ankle, when the foot
has been allowed to remain for long periods in the attitude of
plantar-flexion. In a limited number of cases the equinus attitude is
assumed to compensate for shortening of the limb.

[Illustration: FIG. 145.--Bilateral Pes Equinus in a boy aet. 7, the
result of Spastic Paralysis.]

In _poliomyelitis_ the deformity is most often unilateral (Fig. 146),
while in _spastic paralysis_ it is frequently bilateral (Fig. 145),
and is usually accompanied by excessive arching of the foot--pes
cavus--as a result of plantar-flexion at the mid-tarsal joint, and
hyper-extension of the first phalanges and plantar-flexion of the
second and third phalanges of the toes--"clawing of the toes."

[Illustration: FIG. 146.--Extreme form of Pes Equinus in a girl aet. 8,
the result of Anterior Poliomyelitis.]

_Clinical Features._--In the mildest cases the patient is able to
bring the foot to a right angle. In average cases the heel is raised
off the ground, and the