Timely diagnosis feet are the key to preventing many unwanted deviations of the musculoskeletal system.
Computer plantography
Computer plantography – modern method, intended for research functional state foot, as a screening method, for quantitative and qualitative assessment of the condition of its arch.
This method allows you to determine the presence and degree of flat feet, assess the condition of the arches of the feet, while taking an imprint from the plantar part of the foot - a plantogram.
Currently, when assessing flatfoot, more and more demands are made on objectivity, not only in establishing the fact of flatfoot, but also in quantitatively assessing the prognosis of effectiveness. possible options its correction.
Examination of the foot using a hardware and software system is aimed at increasing the diagnostic accuracy of the examination. This is achieved by taking foot prints on a specially reinforced flatbed scanner. They are processed using special program, which allows you to automate the examination process, resulting in increased objectivity and uniformity of diagnostic characteristics. The program issues a conclusion for each foot and selects an individual treatment method (physical therapy, massage, physical therapy). The anatomical and functional data of the foot obtained using this method make it possible to select orthopedic insoles for each patient and select the necessary method of rehabilitation and treatment.
The original computer plantography program allows you to calculate: integral (total length, width, height, contact surface area and foot instep angle) data, as well as data separately characterizing the forefoot, middle and rear sections of the foot.
Using computer plantography, individual values of the somatotype and indicators of the morphofunctional state of the foot are determined, which allows you to select and prescribe individual program treatment of foot pathology.
Computer diagnostics with direct scanning allows you to obtain high-quality prints (without size distortion). The program analyzes and calculates parameters, indices and angles that help determine various disorders, the presence and type of flatfoot. The obtained data can be used for manufacturing orthopedic shoes and insoles.
Computer plantography has important during correction different types flat feet. Regular conduct of this study allows us to evaluate the effectiveness of methods for correcting this pathology.
The following indications for plantography are distinguished:
- primary diagnosis of flat feet;
- determination of the type and degree of flat feet;
- control of treatment of flat feet;
- diagnosis of hallux valgus and other types of foot deformities.
- There are no contraindications to this research method.
Procedure for conducting the study
Today, classical plantography is used much less frequently, although the old proven method is still used. Modern clinics provide procedures using a computer and scanner.
- Before starting the examination, it is important to write down basic information about the patient in the procedural card or enter into the computer database: passport data, weight and height.
- Subject bare feet gets on the scanner. The picture is taken with the patient in an upright (anatomical) position to ensure uniform distribution body weight on legs. If necessary, carry out additional examination and repeat the scan in a sitting position (to obtain images in other planes).
- The computer program processes the received information with full analysis each foot.
- The orthopedic doctor issues a conclusion with recommendations for eliminating foot changes.
It is probably difficult to associate migraines, pain in the spine, joints, swelling and varicose veins with flat feet. But, often, the cause of these ailments is precisely this - flat feet - our “invisible enemy”.
The human foot is a unique structure. It acts as a spring, shock absorber and softens the impact of each step, protecting the spine and joints from overload. Imagine riding in the back seat of a hard-driving car. Do you remember the feeling? Any road will seem like an endless staircase - bam-bam-bam. The same thing happens to your body when the arches of your feet do not work: the impact of each step is taken by the knees, hip joints and spine, receiving microcracks, which over time will form into chondrosis of varying severity.
Flat feet is a disease, a deformity in which the arches of the feet droop and the shock-absorbing function of the arches decreases.
At first nothing hurts. And then, arthrosis appears, curvature of the spine... and like a snowball, they accumulate chronic diseases... And the reason for everything is “banal” flat feet.
This is why it is very important to diagnose flat feet as early as possible. IN childhood, foot deformation can still be treated, but after 7 years, this is impossible and all that remains is to maintain the arches physiologically correct position using orthopedic insoles.
If you have following symptoms, then 100% - you have flat feet:
- varicose veins in the form spider veins and mesh
- swelling of the legs in the ankle area
- fast fatiguability when walking or standing still
- calluses and corns
- foot deformity
- heel spur
- painful, protruding bunions on the big toes
- severe burning, pain in the front of the foot
- leg pain
- back and neck pain
- rachiocampsis
- leg joint diseases
- pinched intervertebral discs
- headache
Almost 80% of people are at risk:
- pregnant women
- athletes
- all professions related to sitting (office specialties)
- all professions associated with walking or standing for long periods of time (salespeople, hairdressers, etc.)
- people with a hereditary predisposition
- overweight people
- patients with diabetes mellitus
Correct orthopedic insoles significantly reduce pain in the legs and spine and, in general, have a positive effect on general state body.
To choose orthopedic insoles that are right for you, you need to undergo a foot diagnosis.
Until recently, all diagnosis of foot pathology was based only on X-ray data. This is a rather labor-intensive method that required the doctor to have certain skills and desire to measure the position of the bones using a ruler. Naturally, in conditions of incredible queues and eternal rush, many patients were given the very common diagnosis of “flat feet” during a routine medical examination, sometimes without sufficient grounds or, on the contrary, only in an advanced stage. For a competent diagnosis of flat feet, for unclear reasons, medical workers are rarely resorted to, only if the patient has to surgical treatment or registration medical documents(for example, disability groups, etc.). Now, at last, a computer study has appeared that allows one to accurately diagnose deviations in the position of the feet in a matter of minutes.
Computer diagnostic process
Indications for computer diagnostics of feet
* High risk detection of flat feet (unfavorable heredity, physical overload, injury, pregnancy, heavy lifting, age, incorrectly selected shoes (high thin heels, narrow toes), endocrine pathology (diabetes, obesity).
* Professional overload of the spine and feet (during sports, dancing, excess body weight).
* Diseases of the spine and joints (osteoarthrosis, arthritis, scoliosis, osteochondrosis, osteoporosis).
* To detect scoliosis, kyphosis, different lengths of legs or feet.
* Preventive examination of children to identify minimal pathology.
*To evaluate results manual therapy and rehabilitation measures (massage, physiotherapy).
* Long-term monitoring of the condition of the musculoskeletal system. A repeat examination (usually after 1 year or earlier) allows you to assess the dynamics of the condition of the spine, pelvis and feet.
* For the purpose of manufacturing individual orthopedic insoles, optimal correction of foot pathology and further assessment compensatory possibilities body.
In our center you can undergo examination using the Plantovisor complex
The complex is intended for screening visual and full-scale computer analysis of the condition and biomechanics of the musculoskeletal system, diagnosis and monitoring of orthopedic diseases and deformities in children and adults (primarily the spine and feet), as well as for the selection and manufacture of insoles (orthreses).
Examination with a plant imager is absolutely harmless, since X-rays are not used.
The procedure for computer analysis of the condition of the feet itself is short and very informative; in just 5-10 minutes you will know everything about your feet and receive recommendations on how to keep your feet healthy, because the health of the entire musculoskeletal system depends on them!
How is diagnosis performed?
Computer diagnostics of the feet is based on the use of digital photometry. The patient stands on a special plate that provides recording of the plantar surface of the foot and projection of a system of points from the plantar surface of the foot onto the computer in the patient’s position while sitting, standing, or while supporting both or one lower limb. Thus, the proposed method makes it possible to study the shock-absorbing function of the foot. Using a mirror plantovisiograph and cameras, the condition of the feet is analyzed using 26 parameters, and then special computer programs conduct a full-scale graphical and mathematical analysis. It allows you to evaluate not only the feet, but also posture, identify differences in leg length, deformations and displacements of the pelvic bones (for example, an oblique or twisted pelvis), and body proportions.
Computer diagnostics of feet allows you to obtain a three-dimensional photo matrix. It allows you to assess the condition of the arches of the feet, identify overload zones, and determine the type and degree of flat feet. Insoles made using plantoscopy are always unique. They “strictly” correct all defects of your foot. Computer diagnostics allows you to accurately “fit” the purchased shoes to your needs. individual characteristics legs
Grifka test
Evaluates the degree of inversion of the foot (flat feet).
Methodology. After passive dorsiflexion of the toes, the doctor presses with his fingers from the plantar side on the heads of the patient's metatarsal bones, causing compression in the metatarsophalangeal joints.
Grade. This test corresponds to the loads that occur during walking in the metatarsophalangeal joints and causes pain in the affected toe. In bunion feet this is often painful, whereas plantar compression alone does not cause pain.
Strunsky test
Provocative test to evaluate metatarsalgia.
Methodology. The patient is positioned on the table so that his feet hang over the edge of the table. Having tightly squeezed the first toes of the patient’s feet with the first and second fingers of his hands, and also grasping the remaining toes of the patient’s feet, the doctor performs maximum plantar flexion in the metatarsophalangeal joints.
Grade. With available chronic pathology metatarsophalangeal joint with metatarsalgia, this test significantly increases symptoms as a result of increased pressure on the metatarsophalangeal joints. Subsequent palpation of the metatarsophalangeal joints can identify the affected joint.
Finger displacement test
Used to assess instability of the metatarsophalangeal joints.
Methodology. Fixing the middle part of the forefoot with one hand, the doctor covers distal section proximal phalanx with the other hand and shifts it alternately posteriorly and in the plantar direction relative to the head of the metatarsal bone.
Grade. Painful sensations when moving in the metatarsophalangeal joint, accompanied by symptoms of instability, confirm increasing deformation of the finger, leading to a functional claw-shaped deformity of the finger during walking with a load. Progression of this instability leads to a permanent claw deformity of the toe, in which the metatarsophalangeal joint is fixed in a dorsiflexed position.
If there is a dislocation in the metatarsophalangeal joint, then it is impossible to eliminate it in this test. The result is metatarsalgia with the development of plantar calluses.
Mulder click test
Used to diagnose interdigital neuroma (Morton's neuroma).
Methodology. The doctor grasps the patient's forefoot with his fingers in a "claw" manner and squeezes it. This causes the metatarsal heads to move closer to each other.
Grade. In the presence of an interdigital neuroma, pain and sometimes paresthesia occurs, radiating to adjacent fingers. Occasionally, a small fibroid-like hard mass may be palpated between the toes and may become dislodged, sometimes with an audible click as the forefoot is compressed. Morton's neuroma is shaped like a fusiform bulb and develops in the plantar nerve. Painful interdigital neuromas usually develop in the second or third interdigital space; Neuromas in the first or fourth spaces are rare.
Gaenslen maneuver
Allows you to evaluate pain in the forefoot.
Methodology. The doctor fixes the heads of the patient's metatarsal bones in one plane, holding them between the fingers of the hand on the plantar side and the first finger of this hand, located on the back of the foot. With the other hand, folded in a “claw” shape, the doctor grasps the patient’s toes, applying medial and lateral compression to the forefoot from the metatarsal heads of the first and fifth toes.
Grade. This "claw" compression of the forefoot causes pain between the metatarsal heads, often with sharp, episodic pain radiating to nearby toes in the presence of Morton's neuroma (painful interdigital neuroma). It also often causes pain when there is significant hallux valgus when there is irritation of the joint capsule.
Metatarsal Tapping Test
Provocative test to determine metatarsalgia
Methodology. The patient lies on his back with his feet hanging over the edge of the table. The physician slightly hyperextends the patient's toes with one hand and taps the metatarsal heads or metatarsophalangeal joints with a hammer with the other hand.
Grade. In patients with metatarsalgia due to chronic irritation of the metatarsophalangeal joints, effleurage causes an increase in metatarsalgia symptoms. Pain during tapping, which appears between the heads of the metatarsal bones (primarily the third and fourth, with acute pain, radiating to adjacent fingers), characteristic of Morton's neuroma (see Mulder click test)
Achilles tendon
Thompson compression test (Achilles tendon compression test)
Methodology. The patient lies on his stomach. His feet hang over the edge of the table. The doctor grasps the muscles of the upper third of the affected leg with one hand and squeezes them tightly.
Grade. Normally, compression of the calf muscles causes rapid passive plantar flexion of the foot. The absence of this plantar flexion indicates an Achilles tendon rupture. In patients with partial rupture Achilles tendon this test is not always conclusive and depends on the severity of the rupture. Patients with a torn Achilles tendon cannot stand on their toes, especially on the injured limb, and the Achilles reflex will be absent.
Note. This test can also be performed with the patient lying prone with the leg flexed to 90° at the knee. In this position, the doctor covers the muscles of the upper third of the leg with both hands and squeezes it tightly. Loss of plantar flexion is a symptom of an Achilles tendon rupture (Simmond test).
Hoffa's sign
Allows you to diagnose old rupture of the Achilles tendon.
Methodology. The patient lies on his stomach with his feet hanging over the edge of the table. The therapist passively performs dorsiflexion (dorsiflexion) of both feet.
Grade. In the presence of old breakup Achilles tendon tension decreases, and the affected foot can achieve greater dorsiflexion compared to the healthy one. The patient is then asked to stand on his toes, alternately on each leg. On the limb where there is a rupture of the Achilles tendon, the patient will not be able to stand up as suggested.
Achilles tendon tapping test
Allows you to diagnose Achilles tendon rupture.
Methodology. The patient lies on his stomach with his legs bent to 90° at the knee joints. The doctor taps the Achilles tendon in its distal third with a neurological hammer.
Grade. Increased pain and decreased plantar flexion (Achilles reflex) are symptoms of an Achilles tendon rupture. In the absence of the Achilles reflex, a differential diagnosis with neurological changes must be made.
Foot elasticity test
Evaluates the rigidity or elasticity of persistent flatfoot deformity (clubfoot).
Methodology. Planovalgus deformity (clubfoot) is characterized by an increase in the valgus position of the heel and flattening of the medial longitudinal arch (flatfoot or flat foot - pes planus). The feet are examined from the side and behind in patients standing normal position and then on your fingertips.
Grade. In the presence of a rigid planovalgus deformity, the valgus position of the heel and flattening of the medial longitudinal axis persist when the patient stands on his fingertips. With elastic planovalgus deformity, standing on the toes leads to varus of the heel, thereby compensating for the valgus deformity, and the medial longitudinal arch reappears.
Forefoot adduction test
Used for assessment and differential diagnosis rigidity and elasticity of foot adduction.
Methodology. The child lies on his back. The physician grasps the foot of the affected limb with one hand and tries to eliminate adduction of the foot by pressing on the medial edge of the forefoot with the first finger of the other hand.
Grade. If this manipulation easily eliminates foot adduction, then the deformity can correct itself spontaneously. A deformity that cannot be corrected is rigid.
Congenital deformity that can be corrected manually requires careful timely treatment using corrective plaster casts.
Ankle joint
Lateral and medial ankle stability test
Allows assessment of damage to the lateral ligaments of the ankle joint.
Methodology. The patient lies on his back. The doctor fixes with one hand lower limb behind the ankles. With the other hand, he grasps the lateral part of the midfoot and performs supination, trying to widen the joint space of the ankle joint on the lateral side. To evaluate the medial ligaments, the physician grasps the medial side of the midfoot and pronates, attempting to widen the medial joint space.
Grade. Injury to one of these ligaments results in instability and increased opening of the medial or lateral joint space. Increased supination may result from injury to the anterior talofibular and calcaneofibular ligaments. Increased pronation can occur when the deltoid ligament is damaged. Supination rotational injury is the most common mechanism of ankle injury and almost invariably involves the anterior talofibular ligament. Children usually have a greater range of motion in ankle joint, and this should not be misdiagnosed as ligament damage.
Comparison of both feet during examination is mandatory. Stress radiographs are necessary to document ligamentous injury, especially in the ankle.
Drawer test
Used to assess ankle stability.
Methodology. The patient lies on his back. The doctor fixes the patient's lower leg with one hand from behind and covers the midfoot with the other hand. The doctor moves the foot posteriorly at the ankle joint, against the force of the hand fixing the lower leg. In the second stage, the doctor covers the lower leg from the front and the heel from the back. Then the foot moves forward against the force of the hand fixing the lower leg.
Grade. A comparative examination of both limbs is performed. A rupture of the lateral collateral ligament of the ankle results in increased mobility of the foot at the ankle joint; rupture of the anterior ligaments leads to an increase in anterior mobility, and rupture of the posterior ligaments leads to posterior displacement.
Heel compression test
Indicates the presence of a stress fracture of the calcaneus.
Methodology. The physician performs symmetrical compression of the patient's heel between the thenars of his palms.
Grade. When a stress fracture is present, the patient experiences intense pain in the heel. Stress fractures mainly occur in patients with severe osteoporosis. Patients with such fractures develop a certain gait due to pain, often walking without putting any weight on the heel at all. The heel area itself may be swollen and painful on palpation. Heel compression rarely causes significant pain in patients with other conditions, such as subcalcaneal bursitis.
Tinel symptom
Methodology. The patient lies on his stomach, the leg is bent to 90° in knee joint. The doctor performs percussion with a neurological hammer behind the inner malleolus in the projection of the tibial nerve.
Grade. Pain and discomfort in the plantar part of the foot confirms tarsal tunnel syndrome. This disease is a chronic neuropathy located behind the medial malleolus under the retinaculum of the flexor tendons. The nerve can be palpated behind the medial malleolus and palpation usually causes pain. The progression of neuropathy leads to sensory disturbances in the zone of innervation of the plantar nerve and atrophy of the plantar muscles.
Cuff symptom
Indicates the presence of tarsal tunnel syndrome.
Methodology. The patient lies on his back. A measuring device cuff is placed above the ankles blood pressure, in which a pressure is created above the patient's systolic pressure.
Grade. Pain and discomfort in the plantar region of the foot that occurs after a minute of compression with a cuff indicates the presence of neuropathy of the tibial nerve in the area of the medial malleolus.
- Survey- questioning, examination, palpation.
- Survey- radiography and fluorometry.
- Survey- plantography.
- Clinical picture - assessment of deformation.
Examination - questioning, examination, palpation
Static deformities of the forefoot are a complex, multicomponent pathology, and therefore the decision on the choice of method surgical intervention should be based on a comprehensive and maximally complete study of each specific situation. First of all, the patient’s medical history and main complaints are ascertained. The places of greatest pain in the area of the first and other metatarsophalangeal joints, as well as the conditions for the occurrence and duration of pain are determined. It is important to try to find out whether the cause of suffering is wearing certain shoes, the structural features or condition of the foot, or high physical activity. An important factor in assessing the complexity of the upcoming treatment is the patient’s age, because You need to count on a long-term favorable functional and cosmetic result of the intervention. In addition, the state of the vasculature, musculoskeletal system, skin and neurological status of the limb must be taken into account.
The main task of the preoperative examination is to choose the optimal method surgical intervention in each specific case. Often the main complaints are related to the presence of advanced longitudinal flatfoot (severity, It's a dull pain, especially at the end of the day, in the area of the dorsum of the foot, in the projection of the talus and navicular bones, heaviness in the lower third of the leg), which makes it necessary to differentiate problems depending on the type of flatfoot.
During visual inspection, the following is determined: localization of deformation, degree of deformation, presence or absence skin changes, the presence of other types of static pathology of the foot.
Depending on the results of the examination, a palpation examination of the foot is performed, which determines: the degree of elasticity of the foot, areas of greatest pain, range of motion in the joints concerned, the presence of contractures, subluxations and dislocations in the metatarsophalangeal and interphalangeal joints, hypermobility of the medial metatarsocuneiform joint.
The elasticity of the foot is determined by squeezing the foot from the sides at the level of the heads of the metatarsal bones as follows:
Type A
Easy, without resistance, bringing the heads together to form a transverse arch.
Type B
Type IN
Some rigidity of the foot, which does not allow the heads to be significantly brought together; the arch is formed slightly
Groups of complaints with pathology of the first ray of the foot:
- Associated with displacement of the head of the first metatarsal bone, which causes discomfort in wearing shoes, pain, often recurrent bursitis of the base of the first toe;
- Associated with displacement of the first toe (Hallux valgus) - its deviation outward, rotation, displacement under or onto the second toe, which causes pain when wearing shoes, often when walking, and is also a serious cosmetic defect;
- Associated with deformation of the very first finger (Hallux valgus interphalangeus) – outward deviation nail phalanx, which is more of a cosmetic defect;
- Associated with displacement of the sesamoid bones, which is accompanied by pain when walking under the head of the first metatarsal bone;
- Associated with the phenomena of arthrosis of the first metatarsophalangeal joint, which is accompanied by pain when moving in this joint, restriction of movements;
- Associated with increased mobility or arthrosis of the medial metatarsocuneiform joint, which is accompanied by pain that appears when walking and standing.
The examination of the foot itself begins with palpation of tissue in the area of the first metatarsophalangeal joint in order to determine areas of greatest pain and localization of exostoses. If pain occurs with maximum movements in the metatarsophalangeal joint, it can be assumed that there is damage to the synovium or articular cartilage.
A standard assessment of the condition of the foot of a patient with hallux valgus to determine the tactics of surgical intervention consists of assessing the following parameters:
Parameters for assessing the condition of the foot:
- Type of foot elasticity;
- The presence or absence of exostosis on the inner surface of the head of the first metatarsal bone;
- The presence or absence of an inflamed mucous bursa;
- The degree of displacement of the first finger laterally, the position of the second finger in relation to the first;
- The degree of valgus rotation of the first finger. Determining the presence or absence of crepitus, effusion, and pain during movements in the joint.
Presence of movement restrictions. When the first toe is in a normal position, pain appears in the medial part of the head of the first metatarsal bone, or movement is severely limited. Assessment of movements in the metatarsocuneiform joint. Assessment of ligamentous instability. The normal range of motion at the first metatarsophalangeal joint is 65˚ dorsiflexion to 15˚ plantar flexion. Any decrease in the range of motion in the joint (hallux limitus or hallux rigidus) indicates the presence of arthrosis or arthritic changes. Significant, especially arthritic changes in the articular ends of bones make almost all types of reconstructive interventions ineffective. The study of the range of motion in the remaining metatarsophalangeal joints is of less practical importance; it is more important to assess the presence of zones of hyperkeratosis on both the plantar and dorsal surfaces of the foot. Calluses (“corns”) on the sole indicate drooping of the heads of the corresponding metatarsal bones, their presence on back side fingers accompanies fixed deformities of the fingers. The presence of signs of metatarsalgia should be taken into account when choosing the type of intervention, since a number of techniques can be corrected this pathology by simply changing the standard operation protocol.
Examination - radiography and fluorometry
A standard x-ray examination of the foot allows one to determine all the parameters necessary to select the type and extent of surgical intervention. Dorsoplantar and lateral projections under load show an objective functional picture of the deformation and make it possible to make the necessary measurements. The axial view of the forefoot is rarely used; it records the degree of displacement of the sesamoid bones, their degenerative changes, as well as rotation of the first metatarsal. An oblique medial projection at an angle of 45˚ allows one to visualize exostoses of the head of the first metatarsal bone, destruction of the articular ends of the bones, as well as the lack of parallelism between the first and second metatarsal bones. In practical terms, the most relevant is the dorsoplantar projection. The attention of orthopedic surgeons should be focused on the basic radiological parameters that must be taken into account when reading standard radiographs of the foot, since ignoring a number of them leads to fatal errors in foot surgeries.
It is recommended to perform the dorsoplantar projection under load, since the difference in measurements can reach 20%. In addition, with a focal length of 1 meter, the X-ray tube beam should be directed with an inclination of 15-20˚, which allows for the most accurate measurement absolute dimensions and distances when planning the operation, as well as visualize the shape of the articular ends of the bones and the direction of the joint spaces.
Survey - plantography
Plantography is one of the simplest and most informative methods for studying the foot based on the imprint of the sole. A foot print allows not only to determine the presence of flat feet, but also to determine the distribution of loads on individual bones. In subjects who are overweight or have a pronounced fat pad in the anterior part of the sole, plantograms do not reflect the true distribution of loads and are not very informative.
Plantography technique: on the left and in the center - a method of obtaining an imprint, on the right - foot prints on paper
Various authors have proposed many methods for obtaining the necessary prints, many of them have proven the effectiveness of the method in studying the results of treatment of injuries and diseases of the feet. IN last years The method was developed after a camera (photoplantography) and a computer (computer photoplantography and podometry) began to be used in conjunction with a plantograph.
Plantography and podometry, characterizing not the degree of development of the bony arch of the foot, but the entire set of tissue relief in this area in the horizontal plane, are not methods that allow making a choice of the method of surgical intervention. The purpose of using these techniques is to be able to objectify the results surgical treatment and draw a conclusion about the future use of orthotic devices. Once the surgeon has determined and assessed the radiographic and clinical parameters described above, it becomes possible to objectively select the appropriate type of surgical intervention.
Clinical picture – assessment of deformity
To date, many have been proposed and used various classifications degrees of valgus deviation of the first finger, however, in our opinion, most of them are overloaded with parameters and cannot be used in practice. In order to simplify the application as much as possible, we have developed a simple and practical classification, according to which three degrees of deformation of the first ray are distinguished.
The use of the estimated parameters makes it possible to determine the volume of surgical intervention; the decision on additional interventions or correction of basic ones is made by the surgeon. At any stage of the process, the operation should include measures aimed at restoring the capsular-ligamentous balance (CLB) in the MCP joint (medial exostosectomy, lateral release, medial capsulorrhaphy).
