Clubfoot & Other Deformities

Clubfoot & Other DeformitiesClubfoot is a word used to describe a foot abnormality present at birth. The defect can be mild or severe and it can involve one foot or both. The medical term for clubfoot is talipes equinovarus. There also are a number of other milder foot deformities that may appear similar.

How common is clubfoot?
Clubfoot is one of the most common birth defects. More than 4,000 babies (about 1 to 2 in 1,000) are born with clubfoot in the United States each year. Boys are affected twice as often as girls. Mild foot deformities are even more common than clubfoot.

How does clubfoot affect a child?
An affected foot points downward and twists inward. If both feet are “clubbed,” the soles of the feet may face each other. The foot bones, ankle joints, and muscles and ligaments of the foot may be abnormal.
Clubfoot is not painful, and it doesn’t bother the baby until he or she begins to stand and walk. Untreated, the ankle remains twisted, and the foot can’t move up and down as it normally would. If both feet are affected (as is true in about 50 percent of cases), the child walks on the sides or even on the top part of the feet instead of the soles. The part walked on may become infected and develop a large, hard callus. Painful arthritic changes also develop.
If only one foot is affected, that foot and calf are smaller than those on the other side.

What are some other common foot defects?
Calcaneovalgus and metatarsus adductus are common, mild, foot abnormalities.
In calcaneovalgus, the foot bends sharply at the ankle so that the foot points upward and outward. In many cases, the top of the foot can touch the shinbone. Calcaneovalgus usually goes away without treatment, and there are no lasting effects.

In metatarsus adductus, the front part of the foot turns inward. This condition causes the child to walk with a toe-in gait. Most affected children require no treatment, as the condition often resolves itself. However, more severe cases are treated to help the foot work better and to prevent later problems in fitting shoes.

How is clubfoot diagnosed?
Clubfoot and certain other foot defects generally can be recognized during the newborn examination. These defects usually can be diagnosed with a physical examination alone, though occasionally the doctor may recommend additional tests such as x-rays.
Clubfoot sometimes is diagnosed before birth, during an ultrasound examination. Though the disorder cannot be treated before birth, parents have a chance to locate a good orthopedic surgeon and learn about treatment options.

How are clubfoot and other foot defects treated?
There are a number of treatments for clubfoot. Most involve some form of manipulation, casts and sometimes surgery. A baby with clubfoot should be treated by an orthopedic surgeon who is experienced in dealing with clubfoot, and who can discuss the various treatment options with parents.
The most common approach for treating clubfoot in the United States is the Ponseti method. This method usually corrects clubfeet in 6-8 weeks using manipulation and casting. Fewer than 5 percent of babies with very severe clubfoot require major surgery, compared with more than 50 percent using other casting methods. When necessary, surgery usually is performed between 6 and 12 months of age.
Treatment with the Ponseti method should begin in the first week or two of life. At this age, the ligaments and tendons in the foot are very flexible and respond well to treatment. Studies suggest that this approach is also highly successful in treating children up to age 2. The doctor gently manipulates the baby’s foot and then puts on a plaster cast to hold the foot in the corrected position. The cast extends from the upper thigh down to the toes. Every 5-7 days, the doctor takes off the cast, manipulates the foot and puts on a new cast. Each manipulation and casting brings the foot closer to normal. Between five and seven casts are usually needed to correct the clubfoot. 

Before the final cast, the doctor often cuts the Achilles tendon (which connects the heel bone and calf muscle). This tendon usually is tight and limits foot movement in babies with clubfoot. The procedure is usually done in the doctor’s office with local anesthesia. The baby wears the final cast for 3 weeks while the tendon heals and grows to a normal length.

After the last cast is removed, the baby must wear a brace for 23 hours a day for 2-3 months, then at night for 2-4 years. The brace uses open-toed, high-top shoes attached to a metal bar. It is crucial that parents follow the doctor’s instructions about using the brace. Clubfoot often recurs when the baby does not wear the brace as recommended.

With early expert treatment, most children with even severe clubfoot can grow up to wear regular shoes, take part in sports and lead full, active lives. However, the affected foot is generally 1 to 1½ shoe sizes smaller than the unaffected one, and the calf appears slightly thinner. The differences are minimal and have no impact on function.

Babies with calcaneovalgus generally do not need treatment. The condition usually resolves in the first few months of life. In some cases, the doctor may teach parents gentle stretching exercises to hasten improvement.
Most cases of metatarsus adductus also resolve without treatment by age 1. However, when the foot stays firmly in the abnormal position (i.e., the doctor has trouble moving the foot into normal position), treatment is recommended. The doctor most likely recommends special shoes or manipulation and casting, usually between 6 and 9 months of age.

What causes clubfoot and other foot defects?
The exact causes of clubfoot are not known. In the past, doctors thought that the baby’s feet were twisted or cramped because of the way the baby lay in its mother’s womb. This is true of some foot abnormalities that correct themselves after birth (including calcaneovalgus and mild metatarsus adductus).
Scientists now believe that both genetic and environmental factors contribute to clubfoot. Environmental factors may include infection, drugs, cigarette smoking or other exposures in the uterine or outside environment. One study found that women with a family history of clubfoot who smoked cigarettes during pregnancy had a 20-fold increased risk of having an affected baby. Clubfoot appears to develop by the second trimester of pregnancy.

Although most children with clubfoot have no other birth defects, occasionally other defects do occur. In a minority of cases, clubfoot occurs as part of a syndrome which includes a number of birth defects. Children with spina bifida (open spine) sometimes have a form of clubfoot. This is caused by damaged spinal nerves that affect the legs. In other cases, feet that are normal at birth may become twisted as a result of muscle or nerve diseases. 

Can clubfoot be prevented?
There is no way to prevent clubfoot at this time. However, women should refrain from smoking, which may reduce their risk of having an affected baby, especially if they have a family history of clubfoot. (Smoking also increases the risk of having a low-birthweight or premature baby, as well as other pregnancy complications.)
Genetic counseling can help parents understand the odds with each pregnancy for having a child with clubfoot. Generally, if a child has an isolated clubfoot (no other birth defects present), the recurrence risk in another pregnancy is low (about 5 percent).