Clubfoot

Overview

About 1 in 1,000 babies is born with a foot that twists inward, a condition called clubfoot. It happens when the tendon and ligaments on the back and inside of the foot are too short and tight. This pulls the foot down and in, so the toes point toward the opposite leg – sometimes to the point where the sole faces up. One or both feet may be affected. The condition isn't painful, but it can seriously impair the ability to stand and walk. With timely treatment, starting a week or two after birth, the defect can be fully corrected.

In most cases, it's not clear why a baby is born with clubfoot. (When there's no known cause, the condition is termed "idiopathic.") Clubfoot can run in families, so there may be a genetic component. Boys are at higher risk than girls, as are babies whose mothers smoked during pregnancy. Some children develop clubfoot because of an underlying condition, such as spina bifida, cerebral palsy or arthrogryposis (conditions involving permanently contracted joints).

Signs & symptoms

The severity of clubfoot varies, but the signs are easy to see. They include:

• The affected foot points downward and the toes may curl inward.
• The foot appears to be sideways or even upside down.
• The foot may be abnormally short and wide.
• The calf muscles of the affected leg are smaller than those on the other side.
• The foot may have a limited range of motion.

Diagnosis

Clubfoot may be detected before birth during a routine ultrasound screening. But many children aren't diagnosed until they're born and have a physical exam. If your pediatrician suspects your baby has clubfoot, you'll be referred to a pediatric orthopedist for treatment.

Treatment

The goal of treatment is to correct the positioning of the foot so that the bones, tendons and muscles can grow normally. Ideally, treatment begins in the first month after birth, when these structures are initially developing. Treatment consists of a combination of casting and bracing to rotate the foot into the proper position, an approach known as the Ponseti method.

• Casting. In the first stage of treatment, the doctor stretches and repositions your child's foot, then places the foot, ankle and leg in a cast to maintain the new position. After a week, the doctor removes the cast, repositions the foot and puts on a new cast. This process is repeated every week for five to eight weeks (longer if necessary) until the foot is in the correct position.
• Surgery. After the casting process is complete, almost all babies need a minor surgery called a heel cord tenotomy to lengthen the Achilles tendon (the cord attaching the calf muscle to the heel). The procedure can be done in the operating room or the doctor's office, depending on your preference, the surgeon's preference, and whether your child will tolerate a procedure under local anesthesia (pain controlling injections in the area being treated) or needs to be under general anesthesia (completely asleep). After the heel cord is cut, a cast is put in place for three weeks while the tendon heals.
• Bracing. After the cast is removed, the baby is fitted with special braces designed to hold the feet apart in a turned-out position. The braces are worn essentially full time (23 hours a day) until the baby is pulling to stand (around 9 to 10 months old). At that point, the braces are worn only at night or during naps until the child is 4 years old. If there is a recurrence, the braces are worn until the child is 5. This process can be challenging, because as kids get older they often resist wearing the braces. But adhering to the program is important because not wearing braces as prescribed is the number one reason kids need additional surgery.

Outcomes

If your child has another condition along with clubfoot, the outlook may depend on treatment for the other condition. But when clubfoot is the only issue, most babies who receive timely treatment grow up to have normally functioning feet. They can run, play and wear store-bought shoes; they can even play sports. If only one foot was affected, you may notice that the affected foot is smaller than the other and that the calf muscles of that leg are smaller and less muscular. Your child may need to wear different-sized shoes.