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Clubfoot (Pediatric)

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What is clubfoot?

Clubfoot is a congenital deformity recognized at birth or by prenatal ultrasound. It can affect one or both feet. There are a number of abnormalities to the foot and calf with varying degrees of severity. 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 are a short first toe that flexes slightly upward, a shorter and more edematous foot, and casts that continue to fall off shortly after they are placed.

What causes clubfoot?

The cause of clubfoot is unknown. There is evidence that it is related to a genetic component but there hasn’t been one gene identified as being the cause. Rather it is thought to be multifactorial which means that a number of different genes and non-genetic factors are involved.

Who is affected by clubfoot?

Clubfoot is more common in boys than girls. If you gave birth to a child with clubfoot, there is a 4 percent risk 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 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 on a weekly basis. 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 go from the foot up to the thigh. Parents remove the casts at home the morning of the appointment so they can bathe the child. We also can remove the cast in the office with a cast saw.

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 heel.

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. Children can come out of this brace for bathing, stretching, and physical therapy. 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 years old.

Treatment for Recurrences

Sometimes clubfoot recurs after initial treatment and needs additional casting or surgical intervention such as a tibialis anterior tendon transfer, a hindfoot release, and/or a repeat of the 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 to decrease 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.