Clubfoot

Overview

Clubfoot describes a range of foot abnormalities usually present at birth (congenital) in which your baby's foot is twisted out of shape or position. In clubfoot, the tissues connecting the muscles to the bone (tendons) are shorter than usual. Clubfoot is a fairly common birth defect and is usually an isolated problem for an otherwise healthy newborn.

Clubfoot can be mild or severe. About half of children with clubfoot have it in both feet. If your child has clubfoot, it will make it harder to walk normally, so doctors generally recommend treating it soon after birth.

Doctors are usually able to treat clubfoot successfully without surgery, though sometimes children need follow-up surgery later on.

Symptoms

If your child has clubfoot, here's what it might look like:

• The top of the foot is usually twisted downward and inward, increasing the arch and turning the heel inward.
• The foot may be turned so severely that it actually looks as if it's upside down.
• The affected leg or foot may be slightly shorter.
• The calf muscles in the affected leg are usually underdeveloped.

Despite its look, clubfoot itself doesn't cause any discomfort or pain.

When to see a doctor

More than likely your doctor will notice clubfoot soon after your child is born, based on appearance. Your doctor can advise you on the most appropriate treatment or refer you to a doctor who specializes in bone and muscle problems (pediatric orthopedist).

Causes

The cause of clubfoot is unknown (idiopathic), but it may be a combination of genetics and environment.

Risk factors

Boys are about twice as likely to develop clubfoot than girls are.

Risk factors include:

• Family history. If either of the parents or their other children have had clubfoot, the baby is more likely to have it as well.
• Congenital conditions. In some cases, clubfoot can be associated with other abnormalities of the skeleton that are present at birth (congenital), such as spina bifida, a birth defect that occurs when the spine and spinal cord don't develop or close properly.
• Environment. Smoking during pregnancy can significantly increase the baby's risk of clubfoot.
• Not enough amniotic fluid during pregnancy. Too little of the fluid that surrounds the baby in the womb may increase the risk of clubfoot.

Complications

Clubfoot typically doesn't cause any problems until your child starts to stand and walk. If the clubfoot is treated, your child will most likely walk fairly normally. He or she may have some difficulty with:

• Movement. The affected foot may be slightly less flexible.
• Leg length. The affected leg may be slightly shorter, but generally does not cause significant problems with mobility.
• Shoe size. The affected foot may be up to 1 1/2 shoe sizes smaller than the unaffected foot.
• Calf size. The muscles of the calf on the affected side may always be smaller than those on the other side.

However, if not treated, clubfoot causes more-serious problems. These can include:

• Arthritis. Your child is likely to develop arthritis.
• Poor self-image. The unusual appearance of the foot may make your child's body image a concern during the teen years.
• Inability to walk normally. The twist of the ankle may not allow your child to walk on the sole of the foot. To compensate, he or she may walk on the ball of the foot, the outside of the foot or even the top of the foot in severe cases.
• Problems stemming from walking adjustments. Walking adjustments may prevent natural growth of the calf muscles, cause large sores or calluses on the foot, and result in an awkward gait.

Prevention

Because doctors don't know what causes clubfoot, you can't completely prevent it. However, if you're pregnant, you can do things to limit your baby's risk of birth defects, such as:

• Not smoking or spending time in smoky environments
• Not drinking alcohol
• Avoiding drugs not approved by your doctor

Diagnosis

Most commonly, a doctor recognizes clubfoot soon after birth just from looking at the shape and positioning of the newborn's foot. Occasionally, the doctor may request X-rays to fully understand how severe the clubfoot is, but usually X-rays are not necessary.

It's possible to clearly see most cases of clubfoot before birth during a routine ultrasound exam in week 20 of pregnancy. While nothing can be done before birth to solve the problem, knowing about the condition may give you time to learn more about clubfoot and get in touch with appropriate health experts, such as a pediatric orthopedic surgeon and a genetics counselor.

Treatment

Because your newborn's bones, joints and tendons are very flexible, treatment for clubfoot usually begins in the first week or two after birth. The goal of treatment is to improve the way your child's foot looks and works before he or she learns to walk, in hopes of preventing long-term disabilities.

Treatment options include:

• Stretching and casting (Ponseti method)
• Surgery

Stretching and casting (Ponseti method)

This is the most common treatment for clubfoot. Your doctor will:

• Move your baby's foot into a correct position and then place it in a cast to hold it there
• Reposition and recast your baby's foot once a week for several months
• Perform a minor surgical procedure to lengthen the Achilles tendon (percutaneous Achilles tenotomy) toward the end of this process

After the shape of your baby's foot is realigned, you'll need to maintain it with one or more of the following:

• Doing stretching exercises with your baby
• Putting your child in special shoes and braces
• Making sure your child wears the shoes and braces as long as needed — usually full time for three months, and then at night and during naps for up to three years

For this method to be successful, you'll need to apply the braces according to your doctor's directions so that the foot doesn't return to its original position. The main reason this procedure sometimes doesn't work is because the braces are not used as directed.

Surgery

If your baby's clubfoot is severe or doesn't respond to nonsurgical treatments, more-invasive surgery may be needed. An orthopedic surgeon can lengthen or reposition tendons and ligaments to help ease the foot into a better position. After surgery, your child will be in a cast for up to two months, and then need to wear a brace for a year or so to prevent the clubfoot from coming back.

Even with treatment, clubfoot may not be totally correctable. But in most cases, babies who are treated early grow up to wear ordinary shoes and lead full, active lives.

Preparing for an appointment

If your baby is born with clubfoot, he or she will likely be diagnosed soon after birth. In some cases, your baby's doctor may refer you to a pediatric orthopedist.

If you have time before meeting with your child's doctor, make a list of questions to ask. These may include:

• Do you commonly treat newborns with clubfoot?
• Should my child be referred to a specialist?
• What types of corrective treatment are available?
• Will my child need surgery?
• What kind of follow-up care will my child need?
• Should I get a second opinion before beginning my child's treatment? Will my insurance cover it?
• After treatment, will my child be able to walk normally?
• Are there any printed materials that I can have? What websites do you recommend?

In addition, tell your doctor:

• If you have family members — including extended family — who've had clubfoot
• If you had any medical issues or problems during your pregnancy

Preparing and anticipating questions will help you make the most of your time with the doctor.