Clubfoot refers to a condition in which a newborn’s foot or feet appear to be rotated internally at the ankle.

The foot points down and inwards, and the soles of the feet face each other.

It is known as talipes equinovarus (TEV) or congenital talipes equinovarus (CTEV). In 50 percent of cases, both feet are affected.

According to the National Institutes of Health (NIH), just over 1 in every 1,000 infants are born with clubfoot.

Symptoms


Clubfoot is a congenital physical deformity.
Image credit: OpenStax College, April 2013

In clubfoot, the tendons on the inside of the leg are shortened, the bones have an unusual shape, and the Achilles tendon is tightened.

If left untreated, the person may appear to walk on their ankles or the sides of their feet.

In an infant born with clubfoot:

  • the top of the foot twists downwards and inwards
  • the arch is more pronounced and the heel turns inward
  • in severe cases, the foot may look as if it is upside-down
  • the calf muscles tend to be underdeveloped
  • if only one foot is affected, it is usually slightly shorter than the other, especially at the heel

A person with a clubfoot does not usually feel discomfort or pain when walking.

A health care professional normally notices a clubfoot when a baby is born. Sometimes it can be detected before birth.

Most children will have only a clubfoot and no other condition, but sometimes clubfoot occurs with other problems, such as spina bifida.

Risk factors for clubfoot

Risk factors for clubfoot include the following:

  • Gender: Males are twice as likely as females to be born with clubfoot.
  • Genetics: If a parent who was born with clubfoot, their children have a higher chance of having a child with the same condition. The risk is higher if both parents have the condition.

Researchers at Washington University School of Medicine in the United States traced the condition to a mutation in a gene critical for early development of lower limbs called PITX1.

Causes

Clubfoot is mainly idiopathic, which means that the cause is unknown. Genetic factors are believed to play a major role, and some specific gene changes have been associated with it, but this is not yet well understood. It appears to be passed down through families.

It is not caused by the fetus’ position in the uterus.

Sometimes it may be linked to skeletal abnormalities, such as spina bifida cystica, or a developmental hip condition known as hip dysplasia, or developmental dysplasia of the hip (DHH).

It may be due to a disruption in a neuromuscular pathway, possibly in the brain, the spinal cord, a nerve, or a muscle.

Environmental factors may play a role. Research has found a link between the incidence of clubfoot and maternal age, as well as whether the mother smokes cigarettes, and if she has diabetes.

A link has also been noted between a higher chance of clubfoot and early amniocentesis, before 13 weeks of gestation during pregnancy.

Diagnosis

The condition is immediately visible at birth.

It can also be detected before birth by ultrasound, especially if both feet are affected. If it is detected before birth, no treatment is possible until after the baby is born.

Whether the condition is detected during pregnancy or after birth, doctors will recommend more tests to check for other health problems, such as spina bifida and muscular dystrophy.

X-rays may help to observe the deformity in more detail.

Treatment

A clubfoot will not improve without treatment. Leaving the foot untreated increases the risk of complications later in life.

Treatment occurs during the weeks after birth. The aim is to render the feet functional feet and free of pain.

The Ponseti method

The primary way of treatment is the Ponseti method, in which a specialist manipulates the baby’s foot with their hands. The aim is to correct the bend in the foot. Then a plaster cast is applied from the toes to the thigh, to hold the foot in position.

There is normally one session a week. The manipulation and casting are done very gently, and the patient should experience no pain.

At each session, the plaster cast is changed, and each time the foot is corrected a little more. The whole process may be done 4 to 10 times, using 4 to 10 new casts.


A cast must be worn following manipulation to help reshape the foot.

Minor surgery may follow the Ponseti method treatment, if necessary, to release the Achilles tendon.

After the foot is corrected, the patient needs to wear special boots attached to a brace to hold the foot, or feet, in the best position. This is to prevent relapse.

For 2 to 3 months, the boots are worn 23 hours a day. After this, they are only worn at night and during daytime naps, until the age of around 4 years.

For the Ponseti method to be effective, it has to be done very early on, and parents have to make sure the boots are worn according to instructions.

If instructions are not followed strictly, the foot may return to its original position, and treatment has to start again.

While the infant is wearing a cast, parents should monitor for changes in skin color or temperature, as this could mean that the cast is too tight.

The French method

The French functional method consists of daily stretching, exercise, massage, and immobilization of the foot with nonelastic tape. The aim is to move the foot slowly to the correct position.

For the first 3 months, these therapy sessions are performed primarily by a physical therapist. Most of the improvement occurs at this time.

Parents receive training during this time, so that they can perform some of the treatments at home.

The taping and splinting continue until the child is 2 years old. This method is currently not available in many parts of the U.S.

If clubfoot is the only problem that the infant has, treatment is usually completely successful.

Even when the problem cannot be fully corrected, the appearance and function of the foot will improve significantly.

Surgery

Surgery may be used if other methods do not work, but this is normally on a case-by-case basis.

Surgery aims to adjust the tendons, ligaments, and joints in the foot and ankle, for example, by releasing the Achilles tendon or by moving the tendon that goes from the front of the ankle to the inside of the foot.

More invasive surgery releases soft tissue structures in the foot. The surgeon then stabilizes the foot using pins and a cast.

Surgery may lead to overcorrection, stiffness, and pain. It has also been associated with arthritis later in life.

Complications

A well-treated clubfoot should not leave a child at a disadvantage. They will be able to run and play like other children.

Left untreated, however, complications can occur.

There will usually be no pain or discomfort until the child comes to stand and walk. It will be hard to walk on the soles of the feet.


Clubfoot can cause long-term mobility issues.

Instead, the child will have to use instead the balls of the feet, the outside of the feet, and in very severe cases the top of the feet.

There is a long-term risk of eventually developing arthritis.

The inability to walk properly can make it difficult for a person with clubfoot to participate fully in some activities. The unusual appearance of the foot may also cause self-image problems.

Even with treatment, the foot will be between one and one-and-a-half times smaller than the other foot, and slightly less mobile. The calf of the leg will also be smaller.

Famous people born with a clubfoot

Some famous people who were born with a clubfoot include:

  • Claudius, the Roman emperor
  • Dudley Moore, the English actor
  • Damon Wayans, the American actor and comedian
  • Troy Aikman, the American football player, TV presenter
  • Steven Gerard, the English soccer player
  • Kristi Yamaguchi, winner of 1992 Olympic gold medal for figure skating

A person with a clubfoot or two clubfeet may face some limitations in mobility. As a result, the Social Security Administration (SSA) consider some cases as a reason for Social Security Disability (SSD), but this depends on severity.

Parents of children with a clubfoot may feel anxious, but with proper treatment the individual should, in time, be able to use their foot without major difficulty.

Source: Clubfoot: Causes and treatments