Topic Overview

What is clubfoot?

Clubfoot (also called talipes
equinovarus) is a general term used to describe a range of unusual positions of
the foot. Each of the following characteristics may be present, and each may
vary from mild to severe:

  • The foot (especially the heel) is usually
    smaller than normal.
  • The foot may point downward.
  • The
    front of the foot may be rotated toward the other foot.
  • The foot
    may turn in, and in extreme cases, the bottom of the foot can point up.

Most types of clubfoot are present at birth (congenital
clubfoot). Clubfoot can happen in one foot or in both feet. In
almost half of affected infants, both feet are involved.

Although
clubfoot is painless in a baby, treatment should begin immediately. Clubfoot
can cause significant problems as the child grows. But with early treatment
most children born with clubfoot are able to lead a normal life.

What causes clubfoot?

In some cases,
clubfoot is just the result of the position of the baby while it is developing
in the mother’s
womb (postural clubfoot).

But more often
clubfoot is caused by a combination of
genetic and environmental factors that is not well
understood. If someone in your family has
clubfoot, then it is more likely to occur in your infant. If your family has
one child with clubfoot, the chances of a second infant having the condition
increase.

Clubfoot present at birth can point to further health
problems because clubfoot can be linked with other conditions such as
spina bifida. For this reason, as soon as clubfoot is
noticed, it’s important that the infant be screened for other health
conditions. Clubfoot can also be the result of problems that affect the nerve,
muscle, and bone systems, such as stroke or brain injury.

What are the symptoms of clubfoot?

Clubfoot is
painless in a baby, but it can eventually cause discomfort and become a
noticeable disability. Left untreated, clubfoot does not straighten itself out.
The foot will remain twisted out of shape, and the affected leg may be shorter
and smaller than the other. These symptoms become more obvious and more of a
problem as the child grows. There are also problems with fitting shoes and
participating in normal play. Treatment that begins shortly after birth can
help overcome these problems.

How is clubfoot diagnosed?

Ultrasound done while a
baby is in the womb can sometimes detect clubfoot. It
is more common for your doctor to diagnose the condition after the infant is
born, though, based on the appearance and mobility of the feet and legs. In
some cases, especially if the clubfoot is due just to the position of the
growing baby (postural clubfoot), the foot is flexible and can be moved into a
normal or nearly normal position after the baby is born. In other cases, the
foot is more rigid or stiff, and the muscles at the back of the calf are very
tight.

X-rays may not be helpful to confirm
the diagnosis. Some of the baby’s foot and ankle bones are not fully ossified
(filled in with bony material) and do not show well on X-ray.

How is clubfoot treated?

When treatment
for clubfoot starts soon after birth, the foot grows to be stable
and positioned to bear weight for standing and moving comfortably.

Nonsurgical treatments such as casting or splinting are usually tried
first. The foot (or feet) is moved (manipulated) into the most normal position
possible and held (immobilized) in that position until the next treatment. In
Canada and the United States this is usually done with a cast, but in some
countries strapping with adhesive tape or splinting is more common. This
manipulation and immobilization procedure is repeated every 1 to 2 weeks for 2
to 4 months, moving the foot a little closer toward a normal position each
time. Some children have enough improvement that the only further treatment is
to keep the foot in the corrected position by splinting it as it grows.

The two common methods of manipulation and casting are the “traditional”
and the Ponseti (Iowa) methods. In traditional treatment, one position of the
foot at a time is treated with manipulation and casting. Usually, the inward
direction of the front of the foot is corrected first. If the foot is not
responsive, major surgery is performed to further straighten the foot.

In the Ponseti method, two problems with foot position (the front part of
the foot being turned in and up) are corrected at the same time. Toward the end
of the series of castings, if the whole foot is pointing down, children treated
with this method still need a minor surgery to lengthen the tight
Achilles tendon. This is usually an outpatient
procedure
. The Ponseti method works well if it is started right away and if the
doctor’s instructions for bracing are followed after casting is finished. It
helps at least 90 out of 100 children who have clubfoot.footnote 1

If a few months of progressive manipulation and
immobilization don’t move the foot into a more normal position, your child’s
doctor may suggest surgery. The most common surgical procedures are to lengthen
or release the tight soft-tissue structures, including
ligaments and
tendons such as the heel cord (Achilles tendon), and
to reposition the bones of the ankle as needed. Small wires are often used to
hold the bones in place and then are removed after 4 to 6 weeks. Splinting or
casting is usually used after surgery to keep the foot in the correct position
during healing.

After either nonsurgical or surgical treatment,
your child usually wears splints for a period of time to keep the clubfoot from
starting to form again. Your child should also have regular check-ups until he
or she stops growing. If your child had surgery, he or she may also need
physical therapy.

A mild recurrence of
clubfoot is common, even after successful treatment. Also, the affected foot
will continue to be somewhat smaller (often 1½ shoe sizes or less) and stiffer
than the unaffected foot, and the calf of the leg will be smaller. But after
treatment most children are able to wear shoes comfortably and to walk, run,
and play. If your child is not walking by the time he or she is 18 months old,
you may need to see a specialist to make sure that your child doesn’t have
another health problem.

References

Citations

  1. Staheli LT (2006). Foot. In Practice of Pediatric Orthopedics, 2nd ed., pp.105-142. Philadelphia: Lippincott Williams and Wilkins.

Other Works Consulted

  • American Academy of Orthopaedic Surgeons and American Academy of Pediatrics (2010). Clubfoot. In JF Sarwark, ed., Essentials of Musculoskeletal Care, 4th ed., pp. 1025-1028. Rosemont, IL: American Academy of Orthopaedic Surgeons.
  • Bridgens J, Kiely N (2010). Current management of clubfoot (congenital talipes equinovarus). BMJ, 340(6): 355.
  • Gray K, et al. (2012). Interventions for congenital talipes equinovarus (clubfoot). Cochrane Database of Systematic Reviews (4).
  • Hosalkar HA, et al. (2011). Talipes equinovarus (clubfoot). In RM Kliegman et al., eds., Nelson Textbook of Pediatrics, 19th ed., pp. 2336-2337. Philadelphia: Saunders Elsevier.
  • Johnston CE (2011). Disorders of the foot. In CD Rudolph et al., eds., Rudolph’s Pediatrics, 22nd ed., pp. 845-850. New York: McGraw-Hill.
  • Kasser JR (2006). The foot. In RT Morrissy, SL Weinstein, eds., Lovell and Winter’s Pediatric Orthopaedics, 6th ed., vol. 2, pp. 1257-1328. Philadelphia: Lippincott Williams and Wilkins.
  • Rab GT, et al. (2014). Pediatric orthopedic surgery. In HB Skinner, PJ McMahon, eds., Current Diagnosis and Treatment in Orthopedics, 5th ed., pp. 517-567. New York: McGraw-Hill.

Credits

ByHealthwise Staff
Primary Medical Reviewer John Pope, MD – Pediatrics
Adam Husney, MD – Family Medicine

Current as ofMay 4, 2017