Clubfoot: Causes, Symptoms, and Treatment

A clubfoot is a defective position of the foot. There are two different types of clubfoot. On the one hand, there is the congenital form, which occurs more frequently, and the acquired form, which is usually caused by disturbances in the nerve supply and is, therefore, also called “neurogenic clubfoot.”

Congenital form

This form belongs to the extremity deformities, but it is a combination of different deformities of the foot. Furthermore, the sole shows an inward rotation inwards (supination), and the lower leg muscles show anomalies. The congenital form of clubfoot occurs with a frequency of 1:1000, with boys being affected about twice as often as girls. This makes clubfoot the second most common congenital malformation after hip joint malposition (hip dysplasia). The cause of this congenital malformation is not yet apparent. It is suspected that the muscles and connective tissue are not formed in the correct proportion.

This results in a muscle imbalance, which alters bone growth and could lead to the development of clubfoot. Another explanation is that the development of the foot stops at an earlier stage and is, therefore, similar to an early embryonic foot. There are several hypotheses for these erroneous developments, such as an unfavorable position of the embryo, a reduction in the amount of amniotic fluid, and the consequence of taking medication such as folic acid antagonists (methotrexate). This foot malposition can occur on one or both sides, but in half of the cases, both feet are affected by the malposition.

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Appearance of the clubfoot

The congenital limb malposition is a combination of several deformities. It is a complex and severe malformation of the entire foot and not only a malposition of the joints. In the case of a clubfoot, there is an inward twisting (supination) of the foot with the sole pointing inwards: Pes varus. Also, the foot is in a pointed foot position, whereby the foot is pulled towards the sole in the upper ankle joint.

As a rule, further malpositioning of the feet can be found: sickle-foot position of the forefoot (Pes adductus) and a hollow foot (Pes excavatus).

This is associated with a shortening of the Achilles tendon. This leads to the fact that affected persons can walk without treatment only on the outer edge of the foot, in particularly severe cases even only on the back of the foot.

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Diagnostics of the clubfoot

The diagnosis is based on the clinical picture of the foot. Another indication can be a skinny and shortened calf. Also, an X-ray of the foot can be taken to determine the angle between the heel and the calcaneus. This angle is also called the talocalcaneal angle and is typically less than 30°. The X-ray image is also needed to plan the therapy optimally and individually and to document the success of the therapy.

Acquired form

In the acquired form of clubfoot, the weakening of the musculus peroneus longus and brevis leads to this malposition. The tibialis posterior muscle gives the foot its typical shape and is, therefore, also called the “clubfoot muscle.”

Treatment of the clubfoot

The treatment depends on the cause and the severity of the malposition, but early treatment is essential in all cases. If the treatment is both started early and carried out consistently, the prognosis is good. The foot position should be controlled until the growth is complete. Without treatment, however, the clubfoot remains, which can lead to pain when walking and standing.

Conservative

A clubfoot plaster is available as a conservative therapy. In the congenital form, this therapy is usually started as soon as possible after birth. As a rule, a thigh cast is applied, not a lower leg cast. This form of therapy is also called regression treatment. In the beginning, the plaster casts must be changed daily, and the foot position must be continuously corrected. Later, it is sufficient to renew the casts at weekly intervals. Physiotherapeutic treatment is recommended to support these treatment measures, as this strengthens and stretches the muscles. Once the malposition of the foot has been corrected, it is still necessary to keep the foot in this position.

This is usually done with night splints and additional insoles. If the malpositioning reoccurs during growth, a final correction can then be made by additionally lengthening the tendon of the “clubfoot muscle.” Another conservative option for the treatment of clubfoot is the correction of the malformation with insoles or the fitting of a so-called Anti-Varus shoe. There are also other different orthoses available, which are individually fitted by an orthopedic technician. In general, an attempt is made to correct the foot when the knee is bent, with a maximum inward bend (raising the outer edge of the foot and lowering the inner one) and lateral abduction.

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Operative

The optimal age to surgically treat all structures is about three months. This involves lengthening the Achilles tendon and correcting the angle between the heel and heel bone. The operation aims to correct all the structures involved, so it may sometimes be necessary to straighten individual bones of the foot.

Forecast

The prognosis of a clubfoot malposition depends on early treatment. If left untreated, the malposition will persist and may even worsen as the foot grows. The bones grow deformed, the joints slip out of their normal position, and the muscles harden. All this leads to an increasing stiffening of the foot and pain when walking and standing, but if an adequate therapy is started immediately after diagnosis, a complete healing can be achieved. In addition to an intensive treatment with a plaster cast, it is often necessary to lengthen the Achilles tendon in operation.

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Summary

The clubfoot is a complex malpositioning of the foot, in which an acquired, and a congenital form can be distinguished. The congenital clubfoot is the second most common congenital malposition after the hip joint malposition, with boys being affected twice as often as girls. The various malformations that together form the clubfoot are a pointed foot, a hollow foot, a sickle foot position of the forefoot, and an inward rotation of the foot. Furthermore, the shortening of the Achilles tendon and a curvature of the calf muscles are typical, hence the name “clubfoot.” In any case, early and intensive therapy is essential. As a rule, a regression treatment is started, whereby the clubfoot is gradually corrected using plaster casts. With consistent treatment, complete healing is possible. However, pain occurs when walking and standing.

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