What is clubfoot?

How is it treated --and why?

 

Clubfoot, also known as congenital talipes equinovarus, is a developmental deformity where a child is born with one or both feet in excessive plantar flexion (equinus), inversion (varus), and an exaggerated arch (cavus). Taken together, these deformities cause the foot to resemble a club, hence the name.

 
Figure 1: Bilateral clubfoot in a newborn with characteristic equinus and varus deformities. (Courtesy of Steve Richards MD, Texas Scottish Rite Hospital)

 

Clubfoot is often idiopathic and seen as an isolated birth defect, but it can also be caused by an underlying congenital disorder in approximately 20% of cases.

 

Clubfoot must be treated because without treatment the foot will not strike the ground normally. Although clubfoot is not intrinsically painful, once a child starts walking, an uncorrected clubfoot can be very painful and normal gait is difficult, if not impossible.

 

The main deformity in clubfoot is excessive plantarflexion resulting in a medial deviation of the forefoot and an inward facing sole. In fact, the name talipes equinovarus is from the latin talus (meaning ankle) plus pes (meaning foot) and equino (of or resembling a horse) plus varus (turned inward).

 

In a club foot, the anatomic abnormality centers on the talus; however, excess plantar flexion at the ankle has deforming effects on interrelated structures, including the talo-calcaneo-navicular joints, medial foot soft tissue, gastrocsoleus, and Achilles tendon. Because of these deformities, the forefoot cannot properly strike the ground, causing patients to walk on their ankles or the outer edges of their feet. To preserve mobility, early intervention is key to correcting the deformity.

 

Treatment for Clubfoot

Ideal treatment for clubfoot should begin as early as possible. The first line of treatment is known as the Ponseti Method, a treatment plan developed by Dr. Ignacio Ponseti that utilizes serial casting to manipulate the foot back to a normal position.

 

Figure 2: Clubfoot Cast (Courtesy of Steve Richards MD, Texas Scottish Rite Hospital)

 

Treatment for clubfoot should begin within the first week of life.

 

The casts, or straps, should be changed weekly until full correction is achieved.

 

When applying casts, it is important to never use excessive force, as otherwise there is an excessive risk of bone damage. The foot should be gently brought to the best possible position and then placed in a strap or cast.

 

If started in infancy, serial casting may be complete within two months. This should correct all of the deformity but the plantar flexion. Correction of the plantar flexion deformity requires “heel cord lengthening.” This is done by cutting the Achilles tendon (Achilles tenotomy). Often, this can be done percutaneously with a needle.

 

Tenotomy is necessary because the fibers of the Achilles tendon, unlike those in the ligaments of the foot, is non-stretchable. After the tenotomy, the foot is placed in a final cast in maximal dorsiflexion. It is also important to note that the Achilles tendon regrows after tenotomy and long-term weakness of the gastrocnemius or soleus muscles is not seen.

 

In >95% of cases, a combination of Ponseti casting, bracing, and tenotomy is successful. Patients who achieve successful treatment continue to wear foot abduction braces at night for approximately 5 years to maintain their correction.

 
Figure 3: Abduction Bracing (Courtesy of Steve Richards MD, Texas Scottish Rite Hospital)

 

In some cases, clubfoot cannot be treated with bracing and requires more substantial surgical intervention. This is often when the deformity is diagnosed outside of infancy, highlighting the importance of early diagnosis and treatment. In cases where surgery is required there are higher rates of long-term pain, stiffness, continued deformity, and muscle weakness.

 

In sum, clubfoot is a developmental deformity defined by excessive plantar flexion and resulting in a medial deviation of the forefoot and inward facing sole. When treatment is started early, ideally in the first weeks of life, the Ponseti method of serial casting, combined with percutaneous achilles tenotomy, is >95% successful in correcting the deformity.