Club Foot

(Congenital Talipes Equinovarus, CTEV)

In this condition factsheet:

• The Facts
• Causes
• Symptoms and Complications
• Making the Diagnosis
• Treatment and Prevention

The Facts

Congenital talipes equinovarus, commonly known as clubfoot, is a foot deformity in which the foot is twisted inward with the toes pointing down. It affects approximately 1 in every 1,000 newborns worldwide each year. It is more common in males. Clubfoot may affect one or both feet. In 60% to 70% of affected children, it involves both feet.

This condition sometimes runs in families. If one child in the family has club foot, the likelihood of another child having this condition increases to 10%.

Causes

There is an increased risk in families with a history of clubfeet, but the exact cause of clubfoot is not known. An abnormality of the tendons and ligaments in the foot causes an abnormal structure and position of the foot. In some children, bones may also be abnormal in terms of shape, size, or position. There may be a link to maternal smoking during pregnancy.

If the foot is abnormally positioned in the uterus during pregnancy, it may not grow into a normal shape, but this is not usually considered a "true" club foot.

Club foot may, in rare instances, be associated with spinal deformities such as spina bifida or other neuromuscular diseases; however, in these cases, the foot is usually more deformed.

Symptoms and Complications

Club foot is easy to recognize.The key identifying features are:

• tightening of the Achilles tendon (heel cord)
• inward turning of the front of the foot
• downward-pointing toes
• resting of the foot on its outer border
• abnormal shape of the foot
• rigidity and other changes in the movements of the foot

In some children, the foot may have a higher-than-normal arch. The foot and calf on the affected side are smaller than normal.

It is important to remember that although it is a painless condition at birth, club foot can worsen with time. If left untreated, the child may begin walking on the outer surface of the foot and the toes. This abnormal walking pattern causes hardening of the skin and development of corns and ulcers over the outer border of the foot. Wearing shoes is difficult, and over time it may become a crippling and unsightly condition.

Making the Diagnosis

Club foot is diagnosed at birth and may be diagnosed earlier, during pregnancy, or through ultrasound.

Although club foot may be diagnosed on the basis of physical examination alone, your doctor may also order X-rays of the foot in order to assess the position of the bones and to determine if there are any abnormalities in the bone. A complete physical examination is performed to rule out other spinal and muscular diseases.

Treatment and Prevention

The goal of treatment is to make a club foot functional, painless, and stable, especially for walking. A pediatric orthopedic surgeon experienced in this condition will normally be the best person to treat it. The earlier the treatment starts, the better the results.

Non-surgical treatment includes manipulating the foot into a corrected position and then holding it in position with a cast. This is usually done shortly after birth. The cast is applied from the toes to up to the groin and is changed every week until the deformity is adequately improved. Frequently, release of the Achilles tendon is needed to completely correct the deformity. Your doctor will make regular assessments of this treatment. In most cases, it is apparent within 6 to 8 weeks whether the treatment is successful. An X-ray can also confirm this.

This treatment, if done by a trained doctor, is successful in about 90% of children with club foot. Special footwear or braces may be required to ensure that the muscles do not pull the foot back into the clubbed position. These may be used until the child is 2 or 3 years old.

Surgery may be performed to correct the abnormal tendons, ligaments, and joints. This may also include moving tendons into better positions for the best function. Fortunately, surgery to correct the club foot (excluding the simple release of the Achilles tendon) is quite rare today. The surgery requires a hospital stay of 2 to 3 days. After surgery, a cast is applied to maintain the foot in the corrected position for 10 to 12 weeks. After the cast, a splint is used throughout the day. Once the child starts walking, the use of splint is gradually reduced.

There is no clear consensus regarding when to operate and which surgery to perform. Most orthopedic surgeons prefer to operate when the child is 6 months old, though some prefer to wait until 9 months of age.

If there are persistent bone abnormalities, surgery may be required when the child is older, such as osteotomy (cutting the bone) or arthrodesis (fusing and stabilizing the bones). Not all children require more than one operation.

Physiotherapy is occasionally an important part of the treatment. It may begin once the child is 3 months old. The therapist manipulates the affected foot and may also tape it. This may be successful in milder cases. Parents can learn these techniques and continue the treatment at home.

Most children do well with treatment when it is started early. If treatment is delayed, non-surgical treatment may be less successful, but it is usually performed. Modern techniques of casting have high success rates even in older children. Some degree of deformity could persist. The foot and the calf on the affected side often remain smaller than normal.

Since the exact cause of club foot is not understood, there is no specific prevention. However, regular monitoring is recommended until the person reaches adulthood. Approximately 20% of affected children experience a recurrence of the club foot, usually in the first 2 to 3 years of life. The recurrence is often more difficult to correct. Your doctor may also advise using corrective shoes and splints until the child matures. But when treatment is started early, most children are able to enjoy full and active lives.

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