Clubfoot

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.