Clubfoot

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An adult hand gently supports a baby’s feet.

Clubfoot is a range of congenital foot deformities affecting one or both feet in which the foot is twisted out of shape or position. Usually recognized at birth or by prenatal ultrasound, there are varying degrees of severity and may include a number of abnormalities to the foot and calf.

A clubfoot has a high arch (cavus), the toes point inward (metatarsus adductus), the back of the foot turns inward (hindfoot varus), and the Achilles tendon is tight. If there is a clubfoot only on one side, then the foot and calf will be smaller on the affected side.

There is also a subcategory for an atypical complex clubfoot. Some characteristics seen with this diagnosis include:

A short first toe that flexes slightly upward
A shorter, more swollen (edematous) foot
Casts that fall off shortly after placement.

What Causes Clubfoot?

The cause of clubfoot is unknown. There is evidence that it has a genetic component, but no single gene has been identified as the cause. Rather, it is thought to be multifactorial, meaning that multiple genes and non-genetic factors are involved.

Who Is Affected by Clubfoot?

Clubfoot is more common in boys than in girls. If you gave birth to a child with clubfoot, there is a 4 percent risk that you will have another child born with this condition. Nearly 40 percent of children with clubfoot have the abnormality in both feet. If a parent has clubfoot, there is a 3-4 percent risk that they will give birth to a child with clubfoot. If both parents have clubfoot, the risk increases to 15 percent.

How Is Clubfoot Diagnosed?

Our doctors do a physical exam soon after birth. However, because prenatal ultrasound has become more advanced, diagnosis is occasionally made before birth. We often do prenatal consults with parents to go over a treatment plan so they know what to expect after the birth. Diagnostic tests other than an X-ray are rare.

A patient diagnosed with clubfoot will have a hip ultrasound done after they are 2 weeks old to evaluate the hips for dysplasia. Clubfoot and hip dysplasia are often associated.

What Is the Treatment for Clubfoot?

Casting

Treatment begins within 5-8 weeks of casting. Casts are changed weekly. The first 1-2 casts correct the high arch. After the high arch and crease in the middle of the foot are corrected, the rest of the casts work on the hindfoot varus and the forefoot adductus. We use long plaster leg casts that extend from the foot to the thigh. Parents remove the casts at home the morning of the appointment so they can bathe the child. We can also remove the cast in the office with a cast saw.

Clubfoot Cast Care

Weekly serial casting is the initial treatment. A long leg cast is applied at each visit after a brief period of stretching for a total of approximately 5-8 weeks. Typically, the cast is removed in the office. You may bring a washcloth and soap if you wish to wash your child's legs prior to the next cast.

Things to Check During Casting Treatment

All the toes should be warm, pink, and able to move easily.
If the foot/feet are pulled back into the cast to the point that they are difficult to see, the cast must be removed.
You may call the office for an urgent appointment or remove the cast yourself. (See instructions below regarding soaking off the cast.)If the cast cracks or becomes soft, call the doctor.
Inspect the skin at the top and bottom of the cast for any signs of redness or irritation. Tell the doctor if the skin is irritated.

Please call us if you have any questions or concerns.

Home Cast Removal

Soak the cast(s) with a solution of warm water (2/3) and vinegar (1/3).
Take a hand towel, soak it in the solution, and wrap it around the cast.
Place a plastic bag around the cast for about an hour or until the cast becomes softer.
Cut the cast off with small wire-cutting scissors that are not sharp at the end.
You'll often need two people to do this.

The process takes about 1 hour

Achilles Tenotomy

The last part of the initial treatment is to fix the tight Achilles tendon. Ninety-five percent of children with clubfoot need an Achilles tenotomy or cutting of the Achilles tendon. This procedure can be done in the operating room under general anesthesia or in the office with local anesthesia. After the Achilles tenotomy, the child is placed back in a cast for three weeks to allow the cut tendon to heal.

Boots-and-Bar Brace

After three weeks, children are placed in a boots-and-bar brace. The bar holds the feet out and up, so the boots must be worn full-time with the bar in place for four months. The brace can be removed for bathing, stretching, and physical therapy. A follow-up is required after one month of wearing this brace and again three months later. At the three-month mark, most children will start wearing this brace only at night and for naps, and continue this way until ages 4-5.

Boots-and-Bar

Wearing the Boots and Bar is a critical part of the Ponseti treatment. They maintain the correction achieved with casting and the tenotomy (if performed). It is dependent entirely on the parents’ compliance. Taking the boots and bars off for only a few hours or overnight can result in a relapse and may lead to the need for recasting. Parents can find this stage of treatment challenging, but persistence will result in the best possible outcome. We are always available to discuss strategies to help you and your child.

Tips and Tricks:

Seamless cotton socks are the preferred choice.
Make sure you are not using double-layered socks; this can cause friction and redness on the front of the ankle.
The socks should cover the entire area that the boot touches.
Pull the sock a little at the toe if there is a seam or if it seems snug against the toes to prevent rubbing.
When the orthotist fits the boots, they will mark the straps so you know how tight they need to be in the first few days as the child gets used to them.
The leather straps will stretch over time, and as the foot grows, you may need to change which hole you use.
Use the holes at the back of the boot to check that the heel is flat.
Start with the middle strap to keep the heel flat, then strap the top and bottom.
Make sure you understand how to adjust the boots yourself so you don’t get stuck in the event of a problem.
Make it part of the child’s daily routine and make sure they understand it is non-negotiable.
If sore or red patches appear, you can use 2nd-skin bandages and contact the office to discuss other options.
Do not use lotion on any areas of redness as that can make the situation worse by enabling more motion and friction.

Treatment for Recurrences

Sometimes clubfoot recurs after initial treatment and requires additional casting or surgical intervention, such as a tibialis anterior tendon transfer, a hindfoot release, and/or a repeat Achilles tenotomy.

We customize treatment to the child's age and severity of the recurrence. We usually recommend a period of weekly casting to either correct the recurrence or put the foot in a better position, thereby decreasing the amount of surgery needed.

Most children born with clubfoot will be walking at the appropriate age and have normal use of their feet and ankles by school age. They are expected to live healthy, normal lives.

Orthopedics

Foot