Many times, a healthcare professional diagnoses clubfoot soon after birth just from looking at the shape and position of the newborn's foot. Sometimes X-rays are taken to fully understand how severe the clubfoot is. But usually X-rays are not needed.
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Often clubfoot can be seen before birth during a routine ultrasound exam in week 20 of pregnancy. While the condition can't be treated before birth, knowing about the condition may give you time to learn more about clubfoot. You'll have time to talk with health experts, such as a pediatric orthopedic surgeon, to plan treatment. If needed, a medical genetics counselor can talk with you about genetic test results and your risk of having a baby with clubfoot in future pregnancies.
Because a newborn's bones, joints and tendons are very flexible, treatment for clubfoot usually begins in the first week or two after birth. The goals of treatment are to move the child's foot into a corrected position with the bottom of the foot facing the ground. Treatment with casting allows for the best movement of the foot and best long-term results. Treatment is most effective if done in the first few months of age.
Treatment options include:
Casting is the main treatment for clubfoot. The healthcare professional typically:
After the shape of your baby's foot is improved, the foot needs to stay in position. To help your child keep the foot in position:
For this method to be successful, the braces need to be worn exactly as instructed so that the foot doesn't go back to its original turned position. When the Ponseti casting approach doesn't work, the main reason is because the braces aren't worn as instructed. If your child can't wear the braces or outgrows the braces, talk with your healthcare professional right away.
Even with treatment, clubfoot may not be totally correctable. For some children, the foot may begin to turn in again. If this happens before age 2, it can require more casting to return the foot to the correct position. But most of the time, babies who are treated early grow up to wear regular shoes without braces, participate in sports, and lead full, active lives.
The French method was developed in France and is most often used only in France. It is a type of stretching treatment that is best for mild clubfoot. The foot is stretched into position, then taped and splinted every day. The method involves frequent physical therapy appointments and daily treatments done by parents until the child is 2 to 3 years old. A minor procedure to lengthen the heel tendon, called the Achilles tendon, is usually needed.
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If a baby's clubfoot doesn't improve with the casting method or if a child doesn't have complete correction later in life, surgery may be needed. Even with a successful result in infancy, surgery is sometimes needed around 3 to 5 years of age if the child's foot is still turning in. During surgery, an orthopedic surgeon repositions tendons to help keep the foot in a better position. This surgery is called a tibialis anterior tendon transfer and has very good results.
Rarely for severe clubfoot or for clubfoot that is part of a syndrome or other underlying medical conditions, more extensive surgery may be needed in infancy. This surgery is called a posterior release or posteromedial release. This surgery loosens the ligaments in the back and side of the ankle and can result in larger correction of the foot. Even though the foot is in a better position, the foot can become stiff and pain in the foot is more likely later in life.
After surgery, the child is in a cast for up to two months. Then the child wears a brace for several years or so to keep clubfoot from coming back.
If your baby is born with clubfoot, the condition will likely be diagnosed during pregnancy or soon after birth. Your baby's healthcare professional will likely refer you to a specialist in bone and muscle conditions in children called a pediatric orthopedic surgeon.
If you have time before meeting with your child's healthcare professional, make a list of questions to ask. These may include:
Feel free to ask other questions during your appointment.
Also tell your healthcare professional if you:
Being ready for your appointment can give you time to talk about what's most important to you.
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View Related VideosThe etiology of idiopathic clubfoot is not well understood, but thought to be multifactorial. Higher concordance of clubfeet in monozygotic twins than dizygotic twins, parent to child transmission as high as 20% in some families, the Carter effect, and effect of ethnicity on prevalence all suggest a genetic etiology.Idiopathic clubfoot is one the most common congenital deformities of the lower extremity. Its incidence is reported to be 1-2 cases per live births. The incidence is higher in Polynesians and lower in Chinese.The major deformities of clubfeet include cavus, forefoot adductus, hindfoot varus and equinus. These deformities are the results of intraosseous (abnormal bone morphology) and interosseous (abnormal relationship of bones to each other) abnormalities. Intraosseous deformity is most pronounced in the talus with a short talar neck and medial and plantar deviation of the talar head. Interosseous deformity is seen as medial displacement of navicular and cuboid on the talar head and calcaneus, respectively.Clubfoot diagnosis can be made prenatally via ultrasound as early as the second trimester, although studies show a false positive rate between 0-29 percent. Diagnosis is usually evident at birth with the heel in equinus and foot inverted on the tibia. In examination of clubfeet, neurological status of the feet should be carefully assessed. This can typically be done by plantar stimulation of the feet. Lack of dorsiflexion of the toes and resting position in plantar flexion, i.e. &#;The Drop Toe Sign,&#; has been reported and potentially indicates a neurological etiology of the clubfoot deformity.The degree of initial deformity is usually reported using the Pirani or Dimeglio classification. Both classifications have shown very good interobserver reliability after an initial learning curve (Flynn et al, ). Pirani classification assesses the severity by using a 6-point scoring system and 6 different physical exam findings. 3 points assess the midfoot deformity and 3 points assess the hindfoot deformity. Dimeglio classification uses a 20-point scoring system by assessing the residual deformity after applying gentle corrective maneuver. The severity of the deformity is then graded I-IV based on this scoring (Dimeglio et al,).Radiographs typically show a decrease in the talocalcaneal angle in both the AP and lateral views and ankle equinus in the lateral view. If the diagnosis is clearly an isolated clubfoot, radiographs at the time of diagnosis are not commonly used. As treatment progresses, radiographs may be used to assess the relationship of the calcaneus and talus.Treatment of isolated clubfeet has significantly changed in the past two decades in North America with most treated successfully with serial Ponseti casting in addition to an Achilles tenotomy. Complete surgical release is reserved for those clubfeet that either cannot be corrected by non-operative means or rapidly recur.The Ponseti method is based on gradual correction of the deformity with serial weekly long leg casting. The deformities are corrected in order of the CAVE (Cavus, Adductus, Varus, and Equinus) pneumonic. Cavus is corrected first by elevating the first metatarsal and supinating the forefoot resulting in correction of the adductus deformity. Sequential casts then allow correction of the forefoot and calcaneus around the fixed talus. This is done by upward pressure on the first metatarsal (to prevent forefoot pronation) and downward pressure on talar head. Equinus is the last deformity to be corrected. Equinus is the hardest deformity to correct with casting and is treated with percutaneous Achilles tenotomy in most cases. After full correction of the deformity, patient is placed in foot abduction orthosis with external rotation full time for 3 months followed by part time wear for 2-4 years.The success of serial casting and tenotomy is reported to be approximately 95% for isolated clubfeet. The recurrence rate of the deformity is reported between 37-47% after initial correction (Richards et al, ). Discontinuation of brace wear is shown to strongly correlate with recurrence (Dobbs et al, ), and usually happens before the age of four years. Tibialis anterior tendon transfer (TATT) to the lateral aspect of the foot is shown to prevent recurrence in patients who present with &#;dynamic supination,&#; which indicates forefoot supination with ankle dorsiflexion in swing phase and weight bearing on the lateral side of the foot.Cooper et al published their thirty year follow up of forty-five patients with seventy-one congenital clubfeet treated by Ponseti casting. Thirty-five (78 %) of forty-five patients treated by Ponseti casting reported excellent or good outcome (Cooper et al, ).This method involves daily manipulation of the newborn&#;s feet by a skilled physical therapist, followed by temporary immobilization with elastic or non-elastic adhesive taping. Richards et al. reported that this method was successful in 50.7% of the cases with mean follow up of 20 months (Richards, ). Rampal et al. reported average fourteen year follow up of 187 feet treated by this method. 85 of 187 feet (45.5%) required comprehensive soft tissue release to correct the remaining deformity. They reported very good or good results in 183 of 187 (98%) treated clubfeet and in eighty-one (95%) of eight-five operated feet (Rampal, ).Soft tissue release had been the main treatment for isolated clubfeet before the rise in popularity of the current non-operative methods in the last two decades. The procedure usually involves circumferential release of the subtalar joint and posterior capsule of the ankle joint with lengthening of the Achilles, flexor tendons, and posterior tibialis.Dobbs et al. studied the long-term outcome (average thirty-one years) of forty-five patients treated with soft tissue release. (Dobbs, ) Only twelve (26%) of forty-five patients reported good and excellent results with remaining thirty-three patients (73%) reporting fair/poor results.Isolated clubfoot is a common anomaly that involves all the tissues below the knee. The initial treatment should be non-operative. Good to excellent long term outcomes can be expected with this treatment despite a slight amount of residual deformity. The feet treated with comprehensive surgical release may have good short term outcomes during but result in painful, stiff feet in adulthood.Pooya Hosseinzadeh MD
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