Clubfoot, medically known as congenital talipes equinovarus (CTEV), is a common congenital deformity of the foot present at birth. It is characterized by the foot being twisted inward and downward, causing an abnormal positioning where the sole faces somewhat medially and the front of the foot points downward. This condition affects approximately 1 in every 1,000 newborns globally, with about half of the cases involving both feet. It is one of the most common musculoskeletal birth defects worldwide and has a higher prevalence in boys than girls, with a male-to-female ratio of roughly 2:1.
Anatomy and Pathophysiology
In a normally developed foot, the tendons—the connective tissues that attach muscles to bones—maintain balance and positioning by pulling at specific angles. In clubfoot, the tendons on the inside and back of the foot are shorter and tighter than usual. This abnormal shortening leads to the foot being drawn inward (adducted) and downward (equinus), with the heel turned inward (varus). The deformity typically has four main components:
- Midfoot cavus: an exaggerated arch of the foot,
- Forefoot adductus: inward deviation of the front of the foot,
- Heel or hindfoot varus: inward tilting of the heel,
- Hindfoot equinus: downward pointed foot caused by tight Achilles tendon.
Because of these deformities, the foot appears rotated and fixed in an abnormal position that cannot be corrected by simple manipulation. Children with untreated clubfoot often walk on the outer edge or top of the foot, which causes pain, skin sores (calluses), and difficulties with footwear and mobility later in life.
Types and Classification
Clubfoot is generally classified into two categories:
- Idiopathic Clubfoot (Isolated Clubfoot): This is the most common type, accounting for about 80% of cases. It occurs without any other associated abnormalities or neuromuscular disorders. Idiopathic clubfoot is considered a multifactorial condition resulting from a complex interplay of genetic, environmental, vascular, and positional factors during fetal development.
- Non-Isolated (Secondary or Syndromic) Clubfoot: This form, comprising about 20% of cases, occurs alongside other medical conditions such as spina bifida, arthrogryposis (joint contractures), or muscular dystrophy. This type is often more rigid and resistant to treatment and may require longer and more intensive management, including multiple surgeries.
Causes and Risk Factors
The exact cause of clubfoot remains uncertain despite decades of research. Both genetic and environmental factors are believed to contribute:
- Genetic predisposition: Studies show familial tendencies, where having a first-degree relative with clubfoot increases the risk by 25%, and identical twins show a 33% concordance rate. However, no single gene mutation has been conclusively identified.
- Environmental factors: These include maternal smoking, maternal diabetes, alcohol consumption during pregnancy, and unusual intrauterine positioning or physical constraints (e.g., a small uterus or oligohydramnios). Seasonal variations affecting maternal temperature during fetal development have also been suggested.
- Mechanical factors: In some cases classified as extrinsic clubfoot, physical compression during pregnancy may lead to milder, more supple deformities.
Overall, the leading theory is that clubfoot results from disruption in the development or functioning of muscles, tendons, and bones in the lower leg and foot during early pregnancy, leading to joint contractures and deformities.
Diagnosis
Clubfoot is most commonly diagnosed at birth by visual and physical examination of the infant’s feet, revealing the characteristic inward twist and rigidity. Affected feet often have a deep crease on the sole and a smaller calf muscle on the affected side due to muscle underdevelopment. The deformity may be unilateral or bilateral.
Prenatal diagnosis via ultrasound is possible, typically around the 20-week anatomy scan, allowing early planning for treatment at birth. Early identification is important because timely management significantly improves outcomes.
Symptoms and Presentation
The classic signs of clubfoot include:
- Feet turned inward and downward,
- Stiffness and rigidity of the foot with limited range of motion,
- Smaller foot size on the affected side,
- Underdeveloped calf muscles,
- Heel turned inward and possible deep creases on the inner sole.
Affected children, without treatment, develop walking difficulties such as walking on the side or top of the foot, leading to pain, skin breakdown, and impaired mobility
Treatment
Clubfoot requires intervention to correct the deformity, as it does not improve spontaneously. The goal of treatment is to enable normal walking without pain or difficulty wearing regular shoes.
Non-surgical Treatment
The Ponseti method is the gold standard for clubfoot correction, especially effective when started shortly after birth:
- Serial casting: Gentle manipulation and weekly casting to gradually stretch the foot and reposition bones and tendons.
- Achilles tendon lengthening: A minor outpatient procedure (tenotomy) frequently performed near the end of the casting phase to lengthen the tight heel cord.
- Bracing: After correction, a foot abduction brace is worn to maintain the correction and prevent relapse, usually for several years or until the child walks independently.
The Ponseti method has a very high success rate worldwide, particularly when started early.
Surgical Treatment
Surgery may be necessary in more severe or resistant cases, or when treatment begins late. Surgical options involve releasing tight tendons and ligaments, repositioning bones, and lengthening muscles. While surgery can provide correction, it carries risks such as stiffness and weakness if overdone. Therefore, surgery is usually reserved for cases where conservative treatment fails.
Prognosis and Long-Term Outcome
When clubfoot is treated early and effectively, children can expect to lead active, normal lives with well-aligned, functional feet. Untreated clubfoot results in lifelong disabilities, including pain, difficulty walking, and inability to wear normal shoes. Treatment outcome depends on severity, timing, and adherence to bracing protocols post-correction.
Even in cases with associated neuromuscular disorders, ongoing orthopedic care can improve mobility and quality of life.
Global Perspective
Clubfoot disproportionately affects low- and middle-income countries, where access to early diagnosis and treatment may be limited. Worldwide efforts by orthopedic organizations and charities focus on training healthcare providers in the Ponseti method and increasing treatment accessibility to reduce disability from untreated clubfoot.