What is Clubfoot?
Clubfoot is a term used to describe a deformity in which the foot is noticeably rotated inward and downward. Congenital refers to the deformity’s presence at the time of birth. There is sometimes a genetic factor in congenital clubfeet, as the deformity is occasionally seen in other family members. True congenital clubfeet must be differentiated from less severe deformities including curved feet (metatarsus adductus) and positional clubfeet, both of which are caused by crowding of the growing feet in the uterus.

What Causes Clubfeet?
Even though clubfeet have been seen since ancient times, the cause remains unknown. Multiple different theories have been proposed, but there is no clear answer. It does appear that the deformity is present early in embryonic life. Therefore, the cause seems unrelated to the “crowding” of the limb seen late in fetal life. This tight packing of the foot in the uterus leads to so-called “positional” deformities of the foot. Positional deformities may resemble clubfeet, but are much more flexible and may not require treatment.

In most children, clubfeet are not associated with other birth defects.

How Is the Diagnosis Made?
The diagnosis of clubfoot is made by physical examination. While milder positional deformities may resemble clubfeet, they are much less stiff and correct easily with gentle pressure.
Congenital clubfeet are stiff, and have 3 components:
1. Curvature of the foot
2. Twisting of the foot and ankle, such that the sole of the foot turns inward, toward the other leg
3. Contracture of the ankle into “tip-toe” position. This is initially less obvious than the first two, but becomes more evident with correction of the curvature of the front portion of the foot.

X-ray and other imaging studies are usually not helpful in newborns, as most of the bony structures will not contain enough calcium to be visible until they are more mature.

What Happens to Children with Clubfeet?
Left untreated, children grow up to walk on the outside border or top of their foot. Shoe wear is difficult in untreated feet, and increasing deformity and pain is expected.

What Treatments are Available?
All treatments for clubfeet depend on stretching the tight, contracted tendons and ligaments in order to move the bones into a more normal position. Casting, bracing, or taping is used to hold the correction obtained.
If satisfactory foot position cannot be obtained with stretching and splinting, then surgery is needed to loosen the tight structures and to move the bones into a more normal position.

Traditional Treatment:
Stretching and casting is begun as soon as possible after birth. A below-knee cast is applied after stretching. The casts are changed on a weekly basis, attempting to progressively stretch out and correct the deformity. Weekly casting continues for about six weeks. If adequate correction is obtained, further casting or bracing may be used to maintain the correction. If surgery is needed, a complete release of the contracted ligaments, lengthening of shortened tendons and placement of the bones in their proper positions is performed at 3 to 9 months of age. Therefore, this treatment should be completed before the child is of walking age.

At least ten percent of children will require further surgical treatment, later in childhood.
This was the treatment most commonly used in the United States in the 1990s.

Iowa (Ponseti) Treatment:
Casting proceeds on a weekly basis as in the more standard treatment described above. In Dr. Ponseti’s treatment, above-knee casts are used. Minimal surgery to lengthen the contracted Achilles tendon is usually performed at about six weeks of age, followed by several more weeks of casting. The child wears a Denis-Browne brace full-time for three months. Nighttime brace wear continues after that for two to four years.

Ponseti reports that approximately one-fourth of children will require a surgical transfer of a tendon after walking age for residual deformity.

Physical Therapy Treatment:
This treatment depends on daily stretching of the foot by a specially trained physical therapist. Splinting or bracing is used between sessions to maintain correction. This method is used extensively in France, but is not well known in the United States. To our knowledge, the only physical therapists in the Chicago area with experience in this treatment are at the DuPage Easter Seal Center in Villa Park and Naperville.

US experience with the technique reports a decreased incidence of surgery and less involved surgery in children treated by experienced physical therapists.

Care of an Infant in a Clubfoot Cast
Toes are often slightly purple for about fifteen minutes after application of a clubfoot cast. This is more noticeable with the first casting and resolves quickly. Take note of where the edge of the cast is relative to the toes. If the toes seem to be progressively disappearing up into the cast, it may be that the cast is slipping off. The cast should be removed early, as the fit is no longer proper and cast sores may result.

Cast Removal:
Casts should be removed at home to allow for bathing. Fiberglass (Softcast®) casts are removed by unwrapping the cast material.

Plaster casts are removed by soaking the limb in a baby tub of warm water containing 2 cups of vinegar. Baby magic soap can be used rather than vinegar. Once the cast is thoroughly soaked, the plaster is kneaded gently to break up the plaster bond. The cast can then be unraveled.

After cast removal, the baby’s skin may be sensitive. Bathe gently. You do not have to remove all adhesive or callous, as it will just be covered up with the next casting.

Bibliography

Bensahel H, et al.: Results of Physical Therapy for Idiopathic Clubfoot: A Long-Term Follow-Up Study. Journal of Pediatric Orthopaedics 1990; 10: 189-192.
Ponseti IV: Treatment of Congenital Clubfoot. Journal of Bone & Joint Surgery 1992; 74-A: 448-454.
Carroll NC: Congenital Clubfoot: Pathoanatomy And Treatment; Instructional Course Lectures 36, American Academy of Orthopaedic Surgeons, 1987.

Matthew J. Bueche, MD