Clubfoot (Talipes Equinovarus)

What clubfoot looks like

In a clubfoot:

• the foot points downward (equinus)
• the heel turns inward (varus)
• the front of the foot curves inward (adductus)
• the arch is high (cavus)
• there may be a deep crease across the sole and at the back of the heel
• the calf and foot on the affected side are often slightly smaller

The foot is stiff and cannot be moved into a normal position. This is different from positional clubfoot, where a normal foot was squeezed in the womb. Positional feet are flexible and correct with stretching or on their own.

Causes

• Idiopathic clubfoot: most cases occur in otherwise healthy babies and have no known cause. Genes play a role: the risk is higher if a parent or sibling had clubfoot. Smoking in pregnancy has been linked to a higher risk.
• Non-idiopathic (syndromic) clubfoot: occurs with other conditions, such as spina bifida, arthrogryposis (multiple joint contractures), and some genetic syndromes. These feet are often stiffer and harder to treat.

Clubfoot is not caused by the baby's position in the womb or anything the parents did.

Diagnosis

• Prenatal ultrasound: clubfoot is often seen on the routine anatomy scan at around 18 to 22 weeks. This gives parents time to meet a pediatric orthopedic team before birth. Not all cases are seen, and occasionally a foot that looks like clubfoot on ultrasound is normal at birth.
• Examination at birth: the diagnosis is made by examining the shape and stiffness of the foot. X-rays are not usually needed.
• Full newborn check: the baby is examined for other conditions, including the hips (hip dysplasia can occur alongside) and the spine.

Treatment: the Ponseti method

The Ponseti method is the standard treatment worldwide. It ideally starts in the first weeks of life.

1. Casting (about 5 to 8 weeks)

Each week, the clinician gently stretches the foot toward the correct position and holds it with a long-leg plaster cast from toes to upper thigh. Each new cast moves the foot a little further. Babies tolerate this well.

2. Achilles tenotomy

Most babies, often more than 8 in 10, need a minor procedure to release the tight Achilles tendon so the foot can point upward. It is a small cut done under local anesthetic, sometimes in clinic. A final cast stays on for about 3 weeks while the tendon heals in a longer position.

3. Bracing (until about age 4 to 5)

After the last cast, the child wears a foot abduction brace: shoes or boots attached to a bar that holds the feet turned outward at shoulder width.

• First 3 months: worn about 23 hours a day.
• After that: worn during night sleep and naps until around age 4 to 5.

Bracing is essential. Most relapses happen when the brace is not worn as prescribed. Children quickly get used to it, and it does not delay sitting, crawling or walking significantly.

If relapse happens

The foot can start to turn in again, most often in the first few years. Relapses are usually treated with more casting, sometimes a repeat tenotomy, and for some children, a tibialis anterior tendon transfer around age 3 to 5 to balance the foot muscles.

Surgery

Extensive surgery to release tight structures was common in the past but leads to more stiffness and arthritis later. It is now reserved for feet that do not respond to the Ponseti method, often in syndromic clubfoot.

Outlook

With Ponseti treatment and good brace use, most children with idiopathic clubfoot have a functional, painless foot and can walk, run, play sports and wear normal shoes. The treated foot is often slightly smaller (by up to about 1 to 1.5 shoe sizes), and the calf thinner, than the other side. Some ankle stiffness, a slightly flat-looking foot or mild in-toeing may remain. Syndromic clubfeet are harder to correct and more likely to need further treatment.

Tips for parents

• Keep casts dry and check the toes daily for color and warmth.
• Use the brace exactly as instructed. Make it part of the bedtime routine.
• Put on cotton socks without seams, and check the skin each day.
• Play with your baby while in the brace: they can kick both legs together, which helps them adjust.
• Ask for support. Parent groups and your clinic team can help with practical problems.

Frequently asked questions

What causes clubfoot?

In most babies the cause is unknown. Genetic factors play a role, since clubfoot runs in some families, and smoking during pregnancy is linked to higher risk. Less often, clubfoot occurs with conditions such as spina bifida or arthrogryposis. It is not caused by anything parents did.

Can clubfoot be fixed?

Yes. The Ponseti method of weekly casting, a minor Achilles tendon release and bracing corrects most idiopathic clubfeet. Children usually walk and play normally. Consistent brace wear until about age 4 to 5 is key to preventing the foot from turning in again.

Is clubfoot painful for babies?

Clubfoot itself does not hurt a baby. Casting is generally well tolerated, and the Achilles tenotomy is done with local anesthetic. If untreated, however, clubfoot causes pain and difficulty walking later in life, which is why early treatment is recommended.

Can clubfoot be seen on ultrasound?

Often, yes. Clubfoot is frequently detected on the routine 18 to 22 week anatomy scan. A prenatal diagnosis lets parents meet the treatment team early. The diagnosis is confirmed by examining the baby after birth, and treatment usually begins within the first few weeks.

How long does a child wear a clubfoot brace?

The brace is usually worn about 23 hours a day for the first 3 months after casting, then during night sleep and naps until around age 4 to 5. Stopping early is the most common reason clubfoot comes back.