It is three dimensional deformity of foot involving either one or both feet since birth. The affected foot of a child looks like being rotated internally & downward at the ankle. If left untreated, can cause severe gait abnormality during walking as child walk on outer part of sole and ankle. The child further finds it difficult to place the sole of the foot flat on the surface. Ideally treatment of clubfoot should start as early as possible without delay to avoid major problems as the child grows. Early treatment gives better results.
Causes of Clubfoot
The exact cause of clubfoot is still not known (Idiopathic). Other reasons for this could be genetic, position of baby in mother womb, neuromuscular disorders etc. The parents must get the child screened immediately to assess his health condition and identify the exact cause of the congenital deformity. There is no correlation in the deformity and other ritual myths like “GRAHAN”
Symptoms of Clubfoot
Deformity is obvious and apparent and can be diagnosed immediately after birth. The most important symptom of clubfeet is the foot looking deformed and twisted like the club of the golf stick. But the child will experience discomfort and find it difficult to walk if clubfoot is not treated properly and timely. The child may find it difficult to wear shoes and participate in physical activities. Sometimes foot size of affected side appears smaller than normal side.
Dr. Nargesh Agrawal
Child Ortho Care
Child Orthopedic Surgeon & Consultant, Delhi
Diagnosis of Clubfoot
Clubfoot can be diagnosed even before baby born (antenatal) by Ultrasound. Orthopaedic surgeon detects the deformity after birth by observing the appearance and movement of the baby’s feet and legs.
Clubfoot can be treated Non-surgically by serial casting followed by percutaneously done tenotommy with success rate over 90%. Tenotomy is a day care procedure done on OPD basis. After tenotomy child always put on braces for sometimes. In some cases surgery require like relapse, neglected, neuropathic and muscular cause of clubfoot.
The nonsurgical treatment methods require the child to wear special shoes and braces fulltime till the clubfoot is cured. Also, the child has to perform a variety of stretching exercises on a daily basis.
What is Positional Club foot / CTEV?
Positional or Postural Clubfoot /CTEV is a benign form of clubfoot in which because of the position of the child in mother womb or because of mechanical pressure in the mother womb foot remain in atypical position.
It’s a flexible form of clubfoot /CTEV. It is correctable on stretching.
How to manage it?
Gentle stretching exercises are usually sufficient to correct it. More severe form of Positional clubfoot/CTEV may require plaster cast or braces. Results of correction are wonderful with almost 100% correction.
What are the chances of recurrence?
Postural Clubfoot / CTEV is unlikely to recur and does well with stretching exercises.
Dr Nargesh Agrawal is a renowned Paediatric orthopaedic Surgeon specialized in clubfoot treatment. He has eight years of experience in Paediatric orthopaedics. He has treated more than 600 cases of clubfoot till now and has many published research papers on clubfoot to his credit.
FAQ’s (Frequently Asked Questions)
Is it correctable deformity?
Success rate of treatment is more than 90% without surgery by casting + Tenotomy technique.
How many cast will be needed?
Usually 4-5 cast (depend upon severity of foot) followed by tenotomy.
What is tenotomy?
Tenotomy is a day care procedure done under LA/GA. In this we release tight posterior structure.
Any side effect of tenotomy?
No, released structure regenerate spontaneously without any side effect.
What is braces and for how long need to bear?
Braces are used to prevent the recurrence of deformity. Initially put for 23 hours in a day for three months and then at nap time till four years of age.
When should I start treatment for Clubfoot?
Treatment of Clubfoot / CTEV should be started as early as possible as early intervention results in better results. But it doesn’t mean that you are late, whenever you start it’s not too late. Better late than never.
What is the meaning of Clubfoot / CTEV?
Clubfoot is designated for deformity of foot in which shape of the foot looks like a “club”. CTEV stands for Congenital Telepes Equino CavoVarus.
– Congenital means since birth ( It doesn’t mean that it’s Genetic)
– Telepes means if child remain untreated then child will walk on Talus (a foot bone).
– Equino means a foot position in which foot remains down side like a horse.
– CavoVarus means that foot remains in inward direction with small cavity on plantar side of foot.
Is the clubfoot a Genetic disease?
Not proven yet but given literature doesn’t support its genetic etiology and in my experience although I have seen few cases in which there are family history present but those cases are very less say 2-4%. So we can’t say that Clubfoot / CTEV is a genetic disease.
Why plaster is so high and above knee and Can we given plaster below knee?
Clubfoot / CTEV can be corrected with serial plaster casts on weekly basis and should be started as early as possible. Plaster is started from tip of the toe and it extended as high as possible. There are three reasons why plaster should extend as high as possible:
- To reduce the chances of slipping of plaster from leg -> there are high chances of cast slippage when plaster cast size is short or it’s below knee. Cast slippage may create Iatrogenic “Atypical Clubfoot” with deep transverse crease.
- Tibial torsion is reduced in case of Clubfoot and to correct the torsion plaster cast should be given above knee.
- Gastrocnemius muscle (Tendo-achilles) which is very tight in clubfoot and responsible for equines deformity, is attached to calcaneus distally and at femoral condyle proximally (above knee). To stretch it plaster should be given above knee.
What is the tenotomy and can we avoid it? Will it weaken the foot? What will happen to this cut tendon? Will it delay child walking?
Tenotomy means cutting the tight tendon (Tendo-achilles) and not all cases require it. Decision of it’s requirement can be done during the plaster treatment. Purpose of tenotomy is to lengthen the tendon and to correct equines deformity to gain range motion.
Tenotomy will not cause any side effect to the foot and will not cause any weakness in the foot.
Cut Tendon regenerates spontaneously in 12-16 weeks. Regenrated tendon remains same functionally, physiologically, structurally and all of it is proven through USG guided study. Child will walk normally without any weakness in the foot.
Is clubfoot or CTEV is a permanent disability?
No, it’s not a disability at all and in recent times with advanced technology with early detection and intervention it is almost 100% correctable with very good results and good functional outcome.
Is the plaster in clubfoot painful?
No, it’s not a painful procedure but to start with child remains uncomfortable for a while , say one or two days and then child adapts to it.
What are the precautions I need to take during plaster treatment of clubfoot?
Two things to keep in mind:
1. Watch for plaster complications like –
- Toe colour- during the plaster treatment parents should be vigilant for toe colour and it should remain pink or red. Parent can also see perfusion of toes by pressing the toe and see the capillary filling time. It’s easy and effective method.
- Toe swelling – parents should watch for toe swelling as sometime there may be swelling in toe due to plaster tightness, although its rare.
- Toe movements- parents should watch for toe movements
2. Avoid soiling of plaster with urine and stool as plaster is extended as high as possible and very close to genitals. To prevent soiling parents are advised –
- Use proper size of diaper
- Diaper should frequently changed
- Use diaper rash cream whenever diaper is changed.
Will clubfoot delay the walking of my child?
No, child will start walking by his / her natural time and there is no significant delay in walking because of clubfoot. To promote walking parents should not give walker to child in spite of it parents can give tripod for walking assistance of child.
When should I start treatment of Clubfoot / CTEV?
There two school of thoughts one advocate for early start of treatment from day one of life irrespective of maturity of newborn and other (Old generation) advocate for manipulation and stretching exercises for first two weeks of life followed by plaster.
Recent advances suggest for early treatment of plaster cast even from day one of life with following arguments-
- Bone and joints of newborn is soft and stretching is easy so number of plaster required for it may be lesser than older child
- In clubfoot foot size is smaller than normal foot and it become more visible in case of unilateral clubfoot when only one side of foot is involved. Early treatment reduces it’s chances.
- Chances of tenotomy are less
So every effort should be done to start best possible treatment as early as possible with Paediatric Orthopaedic surgeon.
What are the chances of relapse in clubfoot and how I can prevent it?
Clubfoot treatment has very good success rate (more than 95 %) but few cases get relapse. Relapse means deformity recur and foot start bending downward and inward. Equinus is most common and earliest deformity to relapse. There are following reason behind relapse –
- Lack of exercises
- Braces not used properly and regularly
- Tibialis anterior tendon over activity
- Peroneal tendon weakness
First two are most common reason for relapse (Lack of exercises and Braces not used properly). Role of both of these are very important and parents should follow instructions of their doctor for the same.
Tibialis anterior muscle is a strong invertor muscle of the foot and may be hyperactive in clubfoot. It is known as Dynamic Supination (child foot becomes inverted while walking). Majority of these cases resolve spontaneously with time with regular exercises and braces. Few cases are resistant to conventional treatment and may require further treatment like tendon transfer and posterior release. Ideal age for tendon transfer is around four to five year. Tibialis anterior tendon transfer surgery results are very satisfactory and child walks normally.
Peronei are strong evertor of foot and it’s weakness also results in relapse of deformity. Majority of cases resolve spontaneously with time and some case require tendon transfer surgeries with good results.
Parents should do regular stretching exercises and use braces regularly and properly. They should also take regular follow up of their treating paediatric orthopaedic surgeon.
My child is having clubfoot on one side only but why my doctor has given braces on both foot with bar in between?
Braces (DB splint) are most important part of the treatment of clubfoot and is given in both legs with bar in between. Even if your child is having clubfoot on one side. It is because clubfoot has a tendency to relapse and come back to it’s natural position. After completion of plaster treatment we want to keep foot in slightly outside direction and it is possible only when other leg push it outside with the help of the bar in between.
Why braces are given for five long years?
This is a very commonly asked question by parents to me and they ask me if my child will use braces with bar for five years then when will he walk? When will he go to school and play? But I stress on the use of these braces only for night time and nap time, so he will walk and play normally in day time.
What is a CTEV shoe?
CTEV shoes are normal looking shoes with slight modifications without bar in between. Child can walk, run and can do all sports activities with these shoes. It has straight medial border, outer raise with no heel. Not all children require CTEV shoes. Child with dynamic supination can get benefit with these. They are not alternative to DB splint. DB splint will continue at night and nap time as regular.
How I can get DB Splint?
You can get DB splints from your treating Paediatric Orthopaedic surgeon or from Orthotist. It require some sort of angle adjustment before using it. It also requires adjustment of bar length which is equivalent to shoulder distance.