Clubfoot

Clubfoot, or congenital talipes equinovarus (CTEV), is a birth defect where a baby’s foot or feet are twisted out of their normal position. This condition is visible at birth and affects about 1 to 2 infants per 1,000 worldwide. Clubfoot can occur in one foot or both, causing the foot to turn inward and downward. Without treatment, the affected foot can interfere with a child’s ability to walk properly, resulting in lifelong disability.

Fortunately, with early diagnosis and appropriate care, clubfoot is highly treatable, and most children grow up with little to no disability. Over the years, treatment options have improved, particularly the Ponseti method — a non-surgical approach involving gentle manipulation and casting that corrects the foot position in most cases.

This article provides a comprehensive overview of clubfoot, detailing its causes, symptoms, prevalence, treatment options, and how to manage life with the condition.

Clubfoot is a complex deformity involving bones, muscles, tendons, and blood vessels in the foot and ankle. The main characteristics include:

• Equinus: The foot points downward.
• Varus: The heel turns inward.
• Adductus: The front part of the foot turns inward.
• Cavus: The arch of the foot is abnormally high.

The combination results in a foot that looks twisted or “club-shaped.” This deformity causes the affected foot to be smaller and shorter, with tight tendons and muscles limiting movement. Clubfoot is present at birth and is usually diagnosed through a physical exam shortly after delivery or prenatally via ultrasound.

If untreated, the foot remains deformed, making walking painful and difficult. Over time, the child may walk on the sides or tops of their feet, leading to skin sores, arthritis, and disability.

Clubfoot is one of the most common congenital musculoskeletal anomalies globally. The condition affects roughly 1 to 2 infants per 1,000 live births. The prevalence varies slightly depending on ethnicity and region but remains significant across populations.

Worldwide

• Approximately 100,000 children are born with clubfoot annually worldwide.
• Male infants are affected twice as often as females.
• About 50% of cases affect both feet (bilateral clubfoot).

In India

India, with its large birth rate, accounts for a substantial proportion of clubfoot cases. Estimates suggest that 20,000 to 25,000 babies are born with clubfoot each year. Unfortunately, many children, especially in rural or underserved areas, do not receive timely diagnosis or treatment, leading to avoidable disability.

Increasing awareness, screening, and the availability of affordable treatments like the Ponseti method have begun to improve outcomes for Indian children with clubfoot.

Understanding the type of clubfoot is crucial to determine the best treatment approach. There are three main types:

1. Idiopathic Clubfoot

This is the most common form, accounting for about 80% of cases. It occurs in otherwise healthy infants and has no known underlying cause. The foot is rigidly fixed in its abnormal position. It can affect one or both feet.

2. Non-Idiopathic (Syndromic) Clubfoot

This form is associated with other medical conditions such as:

• Neuromuscular disorders (e.g., cerebral palsy, spina bifida).
• Genetic syndromes (e.g., arthrogryposis).
• This type tends to be more severe and resistant to treatment.

3. Positional Clubfoot

Positional clubfoot results from restricted movement in the womb, often due to limited amniotic fluid or fetal positioning. Unlike idiopathic clubfoot, the foot is flexible and can be corrected without surgery or casting, often improving spontaneously.

The exact cause of clubfoot remains unknown but is believed to be due to a combination of genetic and environmental factors:

Genetic Factors

• Family history significantly increases risk. Studies suggest multiple genes influence limb development and muscle formation.
• Certain ethnic groups may have slightly higher predisposition.

Environmental Factors

• Maternal smoking and exposure to toxins during pregnancy.
• Reduced amniotic fluid (oligohydramnios), which limits fetal movement.
• Infections or illnesses during pregnancy.
• Maternal nutritional deficiencies.

Neuromuscular and Structural Factors

• Abnormal nerve supply or muscle function during fetal development.
• Abnormal positioning of the baby in the womb.

While these factors contribute, clubfoot is likely multifactorial with no single cause.

The symptoms of clubfoot are typically obvious at birth and include:

• One or both feet turned inward and downward.
• Smaller affected foot and calf muscles.
• Limited ability to move the foot upward or sideways.
• The sole of the foot may face inward or upward.
• The Achilles tendon is shorter and tighter than normal.
• Walking difficulties if untreated, including walking on the sides or tops of feet.

In some cases, the affected leg may be shorter or thinner than the other.

At Birth

Clubfoot is usually diagnosed by a paediatrician or orthopaedic specialist through a physical examination. The doctor will observe:

• Position and rigidity of the foot.
• Size and development of the foot and calf muscles.
• Range of motion of the foot and ankle.

Prenatal Diagnosis

Ultrasound can detect clubfoot as early as 18-20 weeks of gestation. Prenatal diagnosis allows parents and doctors to prepare for treatment immediately after birth.

Imaging

X-rays may be taken to assess bone structure before treatment, especially if surgery is considered.

Timely treatment is essential to prevent disability and restore normal foot function.

1. Ponseti Method

The Ponseti method is the preferred treatment worldwide due to its high success rate and minimal invasiveness:

• Manipulation and Casting: The foot is gently manipulated and placed in a cast, which is changed weekly over 4 to 8 weeks to gradually correct the deformity.
• Achilles Tenotomy: A minor procedure to release the tight Achilles tendon, allowing the foot to be placed in a normal position.
• Bracing: After correction, the child wears a foot abduction brace (boots connected by a bar) to maintain the position and prevent recurrence. This is usually worn full-time for 3 months and then during naps and night for several years.

The Ponseti method corrects clubfoot in over 90% of cases.

2. French Functional Method

This method involves daily physiotherapy with stretching, mobilisation, and taping to correct the foot’s position. It requires a trained physiotherapist and consistent parental involvement.

3. Surgical Intervention

Surgery is considered when non-surgical methods fail or in severe cases, usually involving:

• Lengthening tendons.
• Releasing tight ligaments.
• Realigning bones.

While surgery can improve foot position, it carries risks and may lead to stiffness or arthritis.

4. Orthotics and Physical Therapy

After correction, orthotic devices, physical therapy, and regular follow-ups ensure continued mobility and function. Some of the medications such as Zerodol-SP also helps in Clubfoot.

Though conventional treatments are the mainstay, some alternative therapies may provide supportive benefits:

• Physiotherapy: Strengthens muscles and improves joint flexibility.
• Hydrotherapy: Water exercises reduce weight-bearing stress and improve motion.
• Massage: Can help improve circulation and muscle tone.
• Acupuncture: Some parents explore this, but evidence is limited.

Always consult your healthcare provider before using alternative therapies.

• Family history of clubfoot increases risk.
• Male infants are twice as likely to be affected.
• Firstborn children have a higher incidence.
• Oligohydramnios during pregnancy.
• Maternal smoking or substance use.
• Other congenital conditions or neuromuscular disorders.
   

Without proper treatment, clubfoot can lead to:

• Permanent disability and difficulty walking.
• Pain due to abnormal pressure on foot structures.
• Skin infections and ulcers from abnormal foot contact.
• Arthritis in the foot and ankle.
• Psychological impacts from mobility issues.
• Early treatment drastically reduces these risks.

• Adhere strictly to treatment plans, including brace-wearing.
• Encourage your child to participate in regular physiotherapy exercises.
• Ensure your child maintains a healthy weight.
• Provide emotional support and understanding.
• Educate teachers and caregivers about the condition.
• Seek support groups for parents and children living with clubfoot.
   

• “Clubfoot is caused by the mother’s actions.” False. It’s a developmental condition, not a result of maternal fault.
• “Surgery is always necessary.” False. Most cases are corrected with non-surgical methods like the Ponseti technique.
• “Children with clubfoot cannot walk normally.” False. With treatment, children can lead normal, active
   

• If clubfoot is noticed at birth, consult a paediatrician or orthopaedic specialist immediately.
• If your child has walking difficulties, uneven gait, or foot deformities.
• If braces cause skin irritation or pain.
• For any signs of pain, swelling, or infection.

Early intervention is key.

• What type of clubfoot does my child have?
• What treatment options are best suited for my child?
• How long will the treatment last?
• Are there any side effects or risks of the treatment?
• How can I care for my child during casting or bracing?
• What are the chances of recurrence?
• Will my child need surgery?
• How often should we have follow-up visits?

• Provide emotional support and encouragement.
• Help with treatment routines, such as assisting with braces.
• Educate yourself and others to reduce stigma.
• Celebrate progress and milestones.
• Encourage social interaction and physical activity within comfort.
   

Clubfoot is a common yet treatable congenital condition that can affect a child’s mobility and quality of life if left untreated. Early diagnosis, preferably at birth or even prenatally, followed by appropriate treatment—mainly the Ponseti method—can correct the deformity in most cases. Awareness of the condition, adherence to treatment, and ongoing support are vital to ensure children with clubfoot grow into healthy, active adults. If you suspect your child has clubfoot, seek medical advice immediately to begin early intervention.