Club foot

Medical quality assurance by Dr. Albrecht Nonnenmacher, MD at July 29, 2016
StartDiseasesClub foot

Club foot also called congenital talipes equinovarus (CTEV) is a common congenital disorder in which an infant's foot is turned sideways. Despite its sometimes disturbing appearance, the condition is not painful to the infant but does require treatment and will not resolve on its own. If left untreated, the child may experience permanent deformity and the inability to walk normally.

Contents

Definition & Facts

According to the American Academy of Orthopedic Surgeons (AAOS) about one in 1,000 infants are born with the condition, making it one of the more common birth defects. The condition results from a shortness and tightness of the tendons that connect the foot to the leg muscles.

Statistics show that males are twice as likely to be affected by the condition as females and it's likely to be the only problem present in an otherwise healthy infant. In rare cases, the condition may be associated with neuromuscular disease and other health conditions. When this is the case, treatment becomes more difficult and prognosis may not be as good.

Symptoms & Complaints

The appearance of club foot is fairly obvious upon physical inspection. The front of the foot tends to turn upwards, while the toes point down. In severe cases the foot may be so twisted that it appears to be upside-down. The foot may have a higher-than-normal arch.

Supply of blood flow to the area may also be compromised. The leg and foot affected are usually slightly shorter than usual and the calf muscle (triceps surae muscle) tends to be underdeveloped. In about 50 percent of cases only one foot is impacted, and in the other half, both feet are compromised.

If left untreated, the child may begin walking on the outside of the foot, causing painful corns and calluses and ulcers. It may become difficult to wear shoes and children may start to see other physical problems which are likely to worsen over time.

Causes

There is no medical consensus regarding the cause of club foot, but it is generally agreed that a combination of genetic factors and environmental factors may impact its likelihood. It is thought that maternal smoking during pregnancy may be a factor, and other possible causes include genetic predisposition, viral infection, or lack of sufficient amniotic fluid (a condition called oligohydramnios).

Contrary to popular belief, doctors have determined that the condition is not caused by the fetus' position in the uterus. In rare cases, club foot may be connected to spinal deformities or neuromuscular diseases.

For parents who have a child with club foot, the chance of future children being born with the defect is approximately 3% and for people who have had club foot themselves, there is a 20-30% chance of producing a child with the same condition.

Diagnosis & Tests

Prenatal diagnosis is possible with an ultrasound. About 10% of cases can be diagnosed by the time the fetus has reached 13 weeks, 80% of cases by 24 weeks, and the likelihood of rendering an accurate diagnosis continues to increase until birth. It should be noted that when using ultrasound images there is about a 20% false-positive diagnosis rate and in all cases the severity of the condition won't be known until after birth.

The defect is usually obvious at birth, but physicians may recommend X-rays and CT scans to determine the extent of the deformity and to confirm whether there are other issues impacting the area. A full physical examination should also be performed in order to rule out any other serious medical conditions such as spinal disease or disease of the muscles.

Treatment is not possible until after birth, but knowing that the condition exists ahead of time provides parents with the opportunity to logistically, emotionally, and financially prepare.

Treatment & Therapy

When club foot presents itself as an isolated medical condition, most patients who receive the proper treatment are able to fully recover and live normal, active lives. It is recommended that treatment begins as early as possible after birth since the flexibility of a newborn's joints and tendons make the treatment more effective. Many parents will choose to take a few days to bond with their infant prior to beginning treatment. Results will not be negatively impacted as long as treatment is started within the first few weeks of life.

Non-surgical treatment is always the first course of action regardless of the severity of the deformity. Surgery can cause scarring and stiffness in the foot which can actually worsen the condition. Gentle stretching and casting, also known as the Ponseti method, is the most widely used treatment in North America. With this technique the foot is gently moved into the correct position and held in place with a cast that stretches from the toes to the thighs. Weekly adjustments are needed until the foot begins to take the correct shape, typically within six to eight weeks.

For most infants, the next step is a small surgical procedure to release tension on the Achilles tendon that runs along the heel. The procedure involves a tiny incision and does not require stitches. A new cast will then be placed on the leg for an additional three weeks in order to protect the tendon while it heals. After removal of the final cast, the deformity is likely to be fully corrected.

The patient will be required to wear a corrective brace for several years to prevent the foot from regressing. For the first three months the brace is necessary up to 24 hours a day. After that, the child will need to be braced for approximately 12 hours a day. Keeping the brace on while sleeping at night and during naps is likely to be sufficient.

Treatment is considered successful when the foot is functional and pain-free. The patient should be able to stand and walk normally with the foot flat on the ground. The affected foot will remain 1 to 1 1/2 sizes smaller than the other foot, but this should not seriously impact patients. In some cases the body may not react as expected or the deformity may be so severe that more invasive surgical treatment is required. 

Prevention & Prophylaxis

Smoking should absolutely be stopped and exposure to secondhand smoke should be avoided while pregnancy. This may help reduce the risk of having a child with club foot.

Although there are no known methods for preventing idiopathic club foot, families can work together to help ensure that the condition does not reoccur by ensuring that the child continues to wear the brace as required. Corrective shoes and splints may also be needed. Parents must be vigilant to ensure that proper protocol is adhered to, and regular monitoring is recommended until adulthood.