Clubfoot

What Is Clubfoot?

Clubfoot, also known as talipes equinovarus, is a congenital (present at birth) foot disorder in which the foot is curved toward the middle of the body, and the toes point downward. With clubfoot, the muscles of the foot are out of balance. The muscles pulling the foot inward and down are pulling too strongly and this puts the foot in an unusual position. The muscles in the calf and the foot size are smaller than a typical lower leg and foot. Despite its appearance and name, the affected foot and leg contain all the same bones, muscles, tendons and anatomic parts as the unaffected limb — but they may seem misshapen until corrected.

Clubfoot is a highly treatable condition. It occurs in approximately one in every 1,000 live births and occurs in males twice as often as females. One in every two cases affects both feet. Children who undergo corrective treatment for clubfoot generally have excellent outcomes and lead healthy, active lives. Several famous athletes have had clubfeet. But successful treatment requires effort by patients and families.  

What Causes Clubfoot?

We don’t know exactly what causes clubfoot, but it appears to be due to atypical muscles on the inside of the foot and lower leg which pull the foot in too tightly during fetal development.

Clubfoot has a tendency to run in families. About one out of every four children born with clubfoot has a family history. There is nothing that parents can do to prevent clubfoot, so there is no reason to feel guilty if you have a child with this disorder.

How Is Clubfoot Diagnosed?

Clubfoot can often be diagnosed by ultrasound (sonogram) examination before birth. 

Approximately 10% of all clubfeet can be diagnosed by 13 weeks’ gestation, and about 80% can be diagnosed by 24 weeks’ gestation. However, diagnosis based on ultrasound alone produces a 20% false positive rate. This is because the normally shaped foot sometimes turns inwards momentarily as the baby wiggles his toes and feet, and if an ultrasound picture is made at that instant, the foot can have an atypical appearance.  

How Is Clubfoot Treated?

After a fetus is diagnosed with clubfoot, parents have the opportunity to meet with our team of specialists to learn about what to expect when their baby is born. The condition is correctable after birth and no intervention is done before delivery. If they wish, parents can meet with an orthopaedic specialist before their baby is born to discuss how the stretching and casting are done. Parents are asked to bring their infants for evaluation in the first few weeks after birth.

Our Division of Orthopaedics and Orthotics and Prosthetics Department at Lurie Children’s follows the Ponseti Method​, the most recognized approach to treating clubfoot worldwide. The method includes the following three phases:

Casting

The baby’s affected foot and leg will be placed into a plaster cast from the top of the leg to the toes, with the toes left open. Each week, for about five or six weeks, the cast will be removed, we’ll gently stretch your baby’s foot closer to a normal position, then put on a new cast to hold the stretch in place. 

Since most infants do not move around very much in the first weeks of life, they do not have too much difficulty or discomfort in the casting phase. Casting is usually started in the first six weeks of life; however, treatment can be successful even if it is started later. On average, infants with clubfoot require five or six casts, although this can vary.

Achilles Tendon Release

The majority of children with clubfoot require this brief outpatient procedure (also called an Achilles tenotomy) after five to seven weeks of casting. With one stroke, the orthopedic surgeon makes a small incision in the Achilles tendon, located at the back of your baby’s heel. When the tendon releases, it lengthens and allows the foot to move more easily up and down at the ankle. Sutures or stitches are not usually needed.

A new cast is then placed on the foot and lower leg immediately following the procedure. Worn for two or three weeks, this cast holds the new position of the foot and aids healing. Most babies feel no pain or a little pain, which tends to go away very quickly on its own or with a little bit of acetaminophen.

Bracing

In this phase, the feet are braced and our orthotic team collaborates with the physician to ensure there is a smooth transition from casting to bracing. There are several varieties of braces which consist of two shoes connected by a bar. Both of the child’s feet are braced, even if the clubfoot is only on one side.

Young infants wear the brace full time (except while bathing) for about three to four months. After that, they gradually switch to wearing it 12 to 14 hours (at night and during naps) until they are 4 or 5 years old.

Your child may require some time to adjust to the brace, but it is very important to keep a consistent schedule and encourage a positive attitude with bracing. Your orthotist and doctor can provide tips or make necessary adjustments to braces as needed. Throughout this phase, your child will return to clinic regularly — every three months until they are walking well, and then for return visits every six months until the age of 5. After age 5 or 6, the frequency of visits decreases.

Using a bar-and-shoe brace is the most important way to prevent clubfoot from coming back. Research has shown that the recurrence rate decreases dramatically when children consistently wear their brace as prescribed.

What Are the Long-Term Outcomes for Clubfoot?

Clubfoot is highly correctable with the Ponseti Method, especially when braces are used properly and for the prescribed amount of time.

We stress the importance of using the brace as prescribed since clubfoot recurrence can be more difficult to treat in older children. As children get older, they are more likely to be upset by the casting procedure and more likely to be bothered by the casts. Also, the feet get less flexible with age and getting good correction can be more challenging.

About a quarter of children with clubfoot will have some type of recurrence.  Often, these recurrences are mild and respond well to repeat casting. Some children will need a second tenotomy to lengthen the Achilles tendon. A small number of children will need surgery to move one of the tendons in the foot to help balance the muscles.

Treatment of clubfoot is generally very successful. Children’s feet will have a normal appearance and function, and they will be able to participate in sports and other physical activities with few, if any, limitations. If an individual has clubfoot on one side only, the calf muscles and foot on that side will always be a little smaller as compared to the opposite side. Significant differences in leg length are not common with clubfoot.

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