Clubfoot is one of the most common congenital orthopaedic conditions, affecting nearly 1 in every 1,000 newborns worldwide. This condition, also known as congenital talipes equinovarus (CTEV), leads to the abnormal positioning of a baby’s foot, making it turn inward or downward. While clubfoot may seem alarming to new parents, early diagnosis and treatment can help children walk and run normally.

This comprehensive guide will explore this condition extensively.

What Causes Clubfoot?

Several factors during pregnancy may contribute to the development of clubfoot, including genetic predisposition, restricted foetal movement, maternal health, and external influences.

Genetic Factors

Clubfoot can be passed down in families through genetics. If one parent has clubfoot, there is a 3-4% chance of their child having it, while if both parents have it, the risk increases to 15-30%. In some cases, clubfoot can be associated with genetic syndromes such as Trisomy 18, Arthrogryposis, and Spina Bifida.

Restricted Foetal Movement (Oligohydramnios)

Oligohydramnios, or low amniotic fluid levels, can restrict a baby’s ability to move freely in the womb, resulting in abnormal positioning of the feet. This can be caused by conditions such as twin pregnancies or uterine abnormalities.

Maternal Smoking & Alcohol Use

Research indicates that mothers who smoke during pregnancy have twice the risk of having a baby with clubfoot. Alcohol consumption and drug use may also interfere with foetal musculoskeletal development.

Nutritional Deficiencies

Folic acid deficiency during early pregnancy may contribute to congenital deformities, including clubfoot. A lack of essential nutrients such as calcium, magnesium, and vitamin D may also affect foetal bone and muscle development.

Maternal Infections & Health Conditions

Viral infections during pregnancy, such as rubella or cytomegalovirus, have been linked to birth defects, including clubfoot. Chronic conditions such as diabetes and obesity may also increase the risk.

Abnormal Positioning in the Womb

A baby’s position in the uterus, such as being in the breech position, may put pressure on the feet and lead to clubfoot.

Exposure to Environmental Toxins

Certain medications (like some anticonvulsants) and exposure to toxic chemicals may increase the likelihood of congenital conditions.

Types of Club Foot

Not all cases of clubfoot are the same. There are different types of clubfoot, each varying in severity and cause. Let’s understand these types so that you can make informed decisions about its treatment and management.

Idiopathic Clubfoot (Most Common Type)

Idiopathic clubfoot is the most common type of clubfoot, which occurs in otherwise healthy babies with no known underlying medical conditions. It is characterised by a rigid and twisted inward or downward foot, which can affect one or both feet. It is typically detected during prenatal ultrasound or at birth and responds well to treatment using the Ponseti method of casting and bracing. It is more common in boys than girls, and there is a higher risk if there is a family history of clubfoot.

Syndromic Clubfoot (Associated with Genetic Syndromes)

Syndromic clubfoot is a type of clubfoot that is associated with other medical conditions or genetic syndromes, making it stiffer and harder to treat compared to idiopathic clubfoot. It can be linked to conditions such as arthrogryposis, spina bifida, Ehlers-Danlos syndrome, Trisomy 18, and tibial hemimelia.

Syndromic clubfoot is more severe and rigid, often requiring surgery in addition to casting, and may be accompanied by other limb deformities. Relapses are also more frequent with this type of clubfoot.

Positional Clubfoot (Postural-type Clubfoot)

Positional clubfoot is not a permanent deformity, but rather a result of limited space in the womb. It is caused by factors such as breech position, low amniotic fluid, or multiple pregnancies. The foot may appear twisted but is soft and correctable with gentle stretching and physiotherapy. There are no bone abnormalities, just temporary muscle tightness. Typically, positional clubfoot resolves within a few weeks or months after birth.

Atypical Clubfoot (Complex or Resistant Clubfoot)

Atypical or complex clubfoot is a rare and severe form of clubfoot that is difficult to treat. It can be caused by incorrect casting techniques, neuromuscular disorders, or severe stiffness in the foot ligaments and tendons. Characteristics include a rigid and difficult-to-manipulate foot, short tight toes, and a deep crease in the sole. Treatment may require longer or repeated methods, including surgery.

Relapsed Clubfoot

Relapsed clubfoot is when the condition reappears after initial successful treatment. This can happen if the patient does not wear braces as prescribed, does not stretch enough during early treatment, or has underlying muscle or neurological issues. The foot starts to turn inward again after correction and may require repeat casting, bracing, or minor surgery.

Syndromes Associated with Clubfoot

Clubfoot can occur on its own or as part of a larger medical syndrome known as syndromic clubfoot, which is often more severe and difficult to treat. Hence, any discussion of clubfoot is incomplete without touching upon the associated syndromes.

Arthrogryposis Multiplex Congenita (AMC)

Arthrogryposis is a rare condition where multiple joints are stiff and unable to move properly. Babies with AMC often have severe, rigid clubfoot on both feet. Treatment is complex and may involve physical therapy and surgery. Other symptoms include stiffness in multiple joints, weak muscles, and limited movement from birth.

Spina Bifida

Spina bifida is a condition where the spine does not fully develop, causing nerve damage and mobility problems. Around 30-50% of babies with spina bifida also have clubfoot, which is often rigid and may require surgery. Such patients may also experience weakness or paralysis in the legs, loss of bladder and bowel control, and spinal abnormalities.

Trisomy 18 (Edwards Syndrome)

Trisomy 18 is a serious genetic disorder caused by an extra chromosome 18, resulting in various developmental problems. It is often associated with clubfoot, contractures, joint deformities, and low muscle tone, making treatment difficult. A small head and jaw, heart defects, and intellectual disabilities can be additional symptoms.

Larsen Syndrome

Larsen syndrome is a rare genetic disorder that affects joint and bone development, often resulting in clubfoot among babies. Children suffering from Larsen syndrome often face other symptoms such as dislocated hips, knees, and elbows, flattened facial features, and spinal abnormalities. Treatment may involve bracing, physical therapy, and surgery.

Ehlers-Danlos Syndrome (EDS)

Ehlers-Danlos Syndrome affects connective tissues in the body, leading to issues with the skin, joints, and vessels. Babies with EDS may be born with clubfoot due to weak connective tissues, making treatment more challenging. Other symptoms include hypermobile joints, stretchy skin, easy bruising, and a higher likelihood of clubfoot recurrence.

Multiple Pterygium Syndrome (Escobar Syndrome)

Escobar syndrome is a rare genetic disorder that affects skin folds and joint movement. Babies with this syndrome often have severe and rigid clubfoot, which can require multiple surgeries for correction. Webbing of the skin at joints, scoliosis, and respiratory issues are some of the other symptoms experienced in this condition.

Diagnosis of Clubfoot

Clubfoot is usually diagnosed through one or several of the following methods:

• Prenatal Ultrasound – Clubfoot can often be detected during a routine ultrasound between 18-22 weeks of pregnancy.
• Physical Examination at Birth – Doctors check for foot twisting, stiffness, and abnormal positioning right after birth.
• Range of Motion Test – Evaluates foot flexibility to differentiate between positional and structural clubfoot.
• X-rays or Imaging (If required) – Confirms bone alignment and severity, especially in complex cases.
• Assessment for Syndromic Clubfoot – Additional genetic tests or evaluations if clubfoot is linked to a syndrome.

Treatment of Clubfoot in Babies

Early intervention is key to ensuring a good outcome. Several treatment options exist for clubfoot correction, including non-surgical and surgical methods.

Early Diagnosis & Evaluation

Clubfoot is diagnosed at birth through any of the methods we discussed above. Severity is assessed to determine if it is mild, moderate, or severe, and whether it is idiopathic or syndromic clubfoot. Treatment typically starts with non-surgical methods such as the Ponseti method.

Ponseti Method (Gold Standard for Clubfoot Treatment)

The Ponseti method for clubfoot involves gently manipulating and casting the baby’s foot to gradually correct its position. This treatment usually starts shortly after birth and requires weekly cast changes over 4-8 weeks to achieve full correction.

Achilles Tenotomy (Minor Surgical Procedure, If Needed)

This procedure, done in most cases, involves making a small cut in the Achilles tendon to release tightness. It is a quick and simple procedure done under local anaesthesia in a clinic. Following the procedure, a final cast is applied for 3 weeks to allow proper healing.

Bracing Phase (To Prevent Relapse)

The Foot Abduction Brace (FAB) is a special brace worn after casting to maintain correction. Initially worn for 23 hours a day for the first 3 months, then only during sleep for the next 3-4 years (12-14 hours per night). Consistent use of the brace helps prevent relapse and reduces the risk of recurrence.

Physical Therapy & Stretching Exercises

This assists in maintaining flexibility and strength in the corrected foot. Parents are instructed on gentle stretching exercises to enhance mobility.

Surgical Treatment (For Severe or Relapsed Clubfoot)

Surgery is typically considered as a last resort for treating clubfoot, only after the Ponseti method has been unsuccessful or in cases of syndromic clubfoot. Surgical interventions may include tendon lengthening, joint repositioning, or bone realignment to correct the deformity. Following surgery, the child may require bracing, physical therapy, or further corrective procedures to ensure optimal outcomes.

Mild Clubfoot: What to Expect

Mild clubfoot refers to a less severe form of the condition where the foot is slightly turned inward but remains flexible and responsive to gentle manipulation. Unlike severe cases, mild clubfoot may not require extensive treatment and can sometimes be corrected with gentle stretching exercises, physical therapy, or minimal casting. The Ponseti method is still the preferred approach, but fewer casts may be needed.

In some cases, a foot brace or special shoes may be recommended to maintain proper alignment. If diagnosed early, mild clubfoot often responds well to non-surgical treatment, allowing the baby to develop normal foot function without long-term complications. Regular follow-ups with a specialist ensure that the foot remains in the correct position as the child grows.

Sources:

• https://www.mayoclinic.org/diseases-conditions/clubfoot/symptoms-causes/syc-20350860
• https://www.childrensnational.org/get-care/health-library/clubbed-foot
• https://my.clevelandclinic.org/health/diseases/16889-clubfoot
• https://montefioreeinstein.org/patient-care/services/orthopedics/specialties/pediatric/clubfoot
• https://pediatricfootankle.com/foot-conditions/clubfoot-treatment/