Clubfoot

Clubfoot describes a condition present at birth in which a baby's foot is pointed in and down. The tissues connecting the muscles to the bone are called tendons. In clubfoot, the tendons are shorter than usual, pulling the foot out of position.

Also called congenital talipes equinovarus (TAL-ih-peez e-kwie-no-VAY-rus), clubfoot is a common foot condition. It can occur in up to 1 in 1,000 babies. Most newborns with clubfoot do not have other medical conditions.

Clubfoot can be mild to severe. About half of children with clubfoot have it in both feet. If a child has clubfoot that is not treated, the child may walk on the side or top of the foot. This can cause a limp, skin sores or calluses, and problems wearing shoes.

Clubfoot will not get better without treatment. But it can be successfully treated using a specific casting technique. Usually, babies also need a minor procedure to lengthen the heel tendon. Treatment results are best with casting that begins within several weeks after birth.

If your child has clubfoot, here's what it might look like:

• The top of the foot is usually pointed in and down. This raises the arch and turns the heel inward.
• The foot may be turned so severely that it looks like it is upside down.
• The foot or big toe may be slightly shorter than the other foot.
• The calf muscles in the leg with clubfoot are usually smaller.

At birth, clubfoot doesn't cause any discomfort or pain.

When to see a doctor

Your healthcare professional is likely to notice clubfoot during an exam soon after your child is born. You may be referred to a doctor who specializes in bone and muscle conditions in children called a pediatric orthopedic surgeon.

The cause of clubfoot is not known, but it may be due to genetics and environmental factors.

Boys are about twice as likely as girls to have clubfoot.

Risk factors include:

• Family history. If a child has a parent, brother or sister with clubfoot, that child is more likely to have it too.
• Part of other conditions. Sometimes clubfoot may happen with other skeletal conditions that are present at birth. One example is spina bifida, a condition that happens when the spine and spinal cord don't develop or close properly before birth. Certain conditions related to changes in chromosomes also may raise the risk of clubfoot.
• Environment. Smoking during pregnancy can raise the baby's risk of clubfoot.
• Not enough amniotic fluid during pregnancy. Amniotic fluid is the liquid that surrounds the baby in the womb. Not having enough amniotic fluid may raise the risk of clubfoot.

Clubfoot usually doesn't cause any problems until a child starts to stand and walk. Treatment can bring the foot into the proper position and help a child walk well. But a child may still have some problems with:

• Movement. The foot may be a little stiff and not bend easily.
• Leg length. The leg with clubfoot may be slightly shorter, but this usually doesn't stop a child from learning to walk.
• Shoe size. The foot may be up to 1 1/2 shoe sizes smaller than the other foot.
• Calf size. The muscles of the calf on the side with clubfoot may always be smaller than those on the other side.
• Foot shape. It's common for the foot to have a bean shape and a small inward point, even after treatment.

If clubfoot is not treated, more-serious problems can happen. These can include:

• Problems walking. When clubfoot is not treated, children with the condition can walk but may put their weight on the side of the foot or the top of the foot. This can cause sores or calluses, problems finding shoes, and a limp.
• Problems with late treatment. Delayed treatment of clubfoot can result in needing more casts and even surgery to correct the foot. Results are better with early treatment before the bones of the foot become misshapen from the poor foot position.
• Arthritis. There may be swelling and tenderness in one or more joints.
• Poor self-image. The unusual look of the foot may make body image a concern during the teen years.

Because healthcare professionals don't know what causes clubfoot, there's no sure way to prevent it. But if you're pregnant, you can do things to have a healthy pregnancy and lower your baby's risk of problems that affect the baby's development:

• Don't smoke or spend time in places with secondhand smoke.
• Don't drink alcohol.
• Don't use legal or illegal drugs that may be sold on the streets or take medicines that aren't approved by your healthcare professional.

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.

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:

• Stretching and casting, called the Ponseti method.
• Stretching, splinting and taping, called the French method.
• Surgery.

Casting: Ponseti method

Casting is the main treatment for clubfoot. The healthcare professional typically:

• Moves your baby's foot into an improved position and then places it in a cast to hold it there.
• Repositions and recasts your baby's foot once a week for several months.
• Performs a minor procedure to lengthen the heel tendon, called the Achilles tendon, toward the end of this process.

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:

• Put your child in special shoes and braces.
• Make sure your child wears the shoes and braces as long as needed. This is usually all day and all night for 3 to 6 months, and then at night and during naps until your child is 3 to 4 years of age.

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.

Stretching, splinting and taping: French method

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.

Surgery

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:

• Do you commonly treat newborns with clubfoot?
• Should my child be referred to a specialist?
• What types of treatment are available?
• Will my child need surgery?
• What kind of follow-up care will my child need?
• Should I get a second opinion before beginning my child's treatment? Will my insurance cover it?
• After treatment, will my child be able to walk well?
• Do you have any information that can help me learn more? What websites do you suggest?

Feel free to ask other questions during your appointment.

Also tell your healthcare professional if you:

• Have family members, including extended family, who have clubfoot.
• Had any problems during your pregnancy.

Being ready for your appointment can give you time to talk about what's most important to you.