Clubfoot

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Clubfoot (talipes equinovarus) is a term used to describe a range of unusual positions of the foot. Each of the following characteristics may be present, or some (or all) of them may be present in some combination, and each may vary from mild to severe:

• The foot (especially the heel) is smaller than normal
• The foot may point downward
• The front of the foot may be rotated toward the other foot
• The foot may turn in, and in extreme cases, the bottom of the foot can point up

Most types of clubfoot are present at birth (congenital clubfoot). Clubfoot can happen in one foot or both feet. In almost half of affected infants, both feet are involved.

Although clubfoot is painless for a baby, treatment should begin immediately. Clubfoot can cause significant challenges as your child grows. With early treatment, most children born with clubfoot are able to lead a normal life.

In some cases, clubfoot is the result of the position of the baby while developing in the mother’s womb (postural clubfoot).

Most often, clubfoot is caused by a combination of genetic and environmental factors that is not well understood. If someone in your family has clubfoot, it is more likely to occur in your baby. If your family has one child with clubfoot, the chances of a second child having the condition increases.

Clubfoot present at birth may be linked with other conditions such as spina bifida. For this reason, as soon as you or your child’s physician notices clubfoot, it is important for your child to be screened for other health conditions. Clubfoot can also be the result of problems that affect the nerve, muscle and bone systems, such as stroke or brain injury.

Clubfoot is painless for a baby, but it can eventually cause discomfort and become a noticeable disability. Left untreated, clubfoot does not straighten itself out. The foot will remain twisted out of shape, and the affected leg may be shorter and smaller than the other.

These symptoms become more obvious and problematic as a child grows. Fitting shoes and participating in typical activities and play can also pose challenges. Treatment that begins shortly after birth can address these issues.

An ultrasound done while a baby is in the womb can sometimes detect clubfoot. However, it is more common for your doctor to diagnose the condition after the infant is born, based on the appearance and mobility of your baby’s feet and legs.

In some cases, especially if clubfoot is due to the position of the growing baby while in utero (postural clubfoot), the foot can be moved into the proper position after the baby is born. In other cases, the foot is more rigid or stiff, and the muscles at the back of the calf are very tight.

X-rays may be used to confirm the diagnosis in older infants since a newborn’s foot and ankle bones are not fully ossified (filled in with bone) and may not show up clearly on an X-ray.

When treatment for clubfoot starts soon after birth, the foot grows to be stable and positioned to bear weight for standing and moving comfortably.

Nonsurgical treatments such as casting or splinting are usually tried first. The foot is moved (manipulated) into the most optimal position possible and held (immobilized) in that position until the next treatment. In Canada and the United States, this is usually done with a cast, but in other countries, strapping with adhesive tape or splinting is more common. This manipulation and immobilization procedure is repeated every one to two weeks for two to four months, moving the foot a little closer toward the proper position each time. Some children have enough improvement that the only further treatment needed is keeping the foot in the corrected position by splinting it as it grows.

The two common methods of manipulation and casting are the traditional and Ponseti (Iowa) methods. In traditional treatment, one position of the foot at a time is treated with manipulation and casting. Usually, the inward direction of the front of the foot is corrected first. If the foot is not responsive, major surgery is performed to position the foot properly.

In the Ponseti method, two issues with foot position (the front part of the foot being turned in and up) are addressed at the same time. Toward the end of the series of castings, if the whole foot is pointing down, children treated with this method still need minor surgery to lengthen the tight Achilles tendon. This is usually an outpatient procedure. The Ponseti method works well if it is started right away and if the doctor’s instructions for bracing are followed after casting is finished. It effectively addresses the condition in 90 percent of children who have clubfoot.

If a few months of progressive manipulation and immobilization do not move the foot into the proper position, your child’s doctor may suggest surgery. The most common surgical procedures are to lengthen or release the tight soft-tissue structures, including ligaments and tendons such as the heel cord (Achilles tendon), and reposition the bones of the ankle as needed. Small wires are often used to hold the bones in place and then removed after four to six weeks. Splinting or casting is usually used after surgery to keep the foot in the proper position during healing.

After either nonsurgical or surgical treatment, your child usually wears splints for a period of time to keep the clubfoot from forming again. Your child should also have regular checkups until they stop growing. If your child had surgery, they may need physical therapy.

A mild recurrence of clubfoot is common, even after successful treatment. The affected foot will also continue to be somewhat smaller (as much as 1.5 shoe sizes) and stiffer than the unaffected foot, and the calf of the affected leg will be smaller. But after treatment, most children can wear shoes comfortably and walk, run and play. If your child is not walking by 18 months, you may need to see a specialist to make sure your child does not have another health condition.