Information on the following diseases can be found in the Related Disorders section of this report:

• None

There are several types of clubfoot. They are as follows:

EQUINOVARUS The foot is turned inward and downward . If both feet are affected the toes point toward each other instead of straight ahead. The heel cord often is very tight, making it impossible to bring the foot up to a normal position without a specialist's help.

CALCANEAL VALGUS OR VALGUS CALCANEUS This type of clubfoot is more common. The foot is sharply angled at the heel, with the foot pointing up and outward.

METATARSUS ADDUCTUS The front part of the foot is turned inward.

METATARSUS VARUS The front part of the foot is turned inward and inverted. Although present at birth, this form of abnormality may not be diagnosed until the infant is a month to a few months old. With treatment the foot can look better and become more functional.

In general, clubfoot is not painful and doesn't bother the baby until he or she begins to stand and walk. Since the ankle is twisted in place, the foot can't move up and down as it normally would in walking. The child must walk as if he were on a peg leg.

If both feet are affected, the child walks on the balls of his feet. If the feet are badly twisted, the child will walk on the sides or even the top part of the feet instead of the soles. The part that comes in contact with the ground may become ulcerated, hard and lumpy, since it is not protected by the thick skin of the sole of the foot. The entire leg is sometimes unable to grow as it should.

The exact cause of clubfoot is not fully understood. In the past, it was thought to be caused by a twisting of the fetus' feet in the mother's womb. However, this has been found to be true only when the problem resolves spontaneously after birth. Many scientists think the defect starts as early as the eighth week of pregnancy before the fetus is large enough to stay in one position very long.

Clubfoot probably is caused by a combination of hereditary and other factors that may affect prenatal growth, such as infection, drugs, disease or other factors in the environment.

During pregnancy, the tendons on the inside of the lower leg become shortened (for unknown reasons) and this shortening when combined with unusually shaped bones causes the foot to turn inward. The Achilles tendon becomes tense or tightened causing the foot to point downward.

Although most children with clubfoot have no other birth defects, occasionally there are other abnormalities as well. Children with an open spine (spina bifida) sometimes have a form of clubfoot. This is caused by damaged spinal nerves that affect the leg muscles. In other cases, feet that are normal at birth may become twisted as a result of muscle or nerve disease.
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Clubfoot is usually present at birth. Approximately 9,000 babies (about one in 400 live births) are born annually in the United States with this congenital defect. Boys are affected twice as often as girls.

Diagnosis
Clubfoot is usually apparent on physical examination at birth.

Treatment
Treatment of clubfoot is started soon after birth.

There are differences of opinion between "conservative" treatment that consists of the use of plaster casts or their stand-ins, and "radical" treatment that usually makes use of surgery. Within ‘conservative" treatment there are debates about the alternative methods of casting.

Serial casting involves the manipulation of the foot to a position as far forward as far as it can go, followed by plaster casting to hold it in that position. At first, the cast is changed to bring the foot closer to normal through frequent adjustments. After the foot is straightened, it is tilted further upward to stretch the tightened heel cord. It is kept in this over-corrected position for a few weeks. The treatment usually requires three to six months, followed by checkups for many years by an orthopedist.

The Ponseti method involves manipulation, casting and limited surgery.

An evaluation of the two methods for treatment of idiopathic clubfoot showed the Ponseti method to be more effective and economic.

In certain cases, some doctors use adhesive bandaging over a special type of splint instead of hard casts. After the bandages are off (or in some mild forms of clubfoot), the baby sleeps in shoes attached to a metal bar that holds the feet in a corrected position.

Sometimes the heel cord is too tight to be stretched by a cast or bandaging, and the patient must undergo surgery to lengthen it.

Immediate treatment for clubfoot using casts or strapping (not surgery), works in more than half of the cases.

With expert early treatment, most patients grow up to wear regular shoes, can take part in sports, and lead full, active lives.
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Investigators from the Intermountain Unit of Shriners Hospitals for Children, the University of Utah Department of Pediatrics, and the Eccles Institute of Human Genetics are collaborating on a project to map and characterize genes causing multiple congenital contracture disorders and limb deficiency/duplication syndromes. The disorders being studied are: autosomal dominant clubfoot, distal arthrogryposis type I, Gordon Syndrome, Freeman-Sheldon Syndome, Trismus Pseudocamptodactyly, autosomal dominant Multiple Pterygium Syndrome, autosomal ulnar hypoplasia ectrodactyly disorders, ulnar mammary syndrome, Holt-Oram Syndrome, and fibular hypoplasia. For more information, please contact:

Michael Bamshad, M.D.
Eccles Institute of Human Genetics
Building 533 Room 2100
University of Utah Medical Center
Salt Lake City, UT 84112
Tel: (801) 585-3384 office
Tel: (801) 585-3385 lab
Fax: (801) 581-7796
E-mail: mike@thor.med.utah.edu

McKusick VA, Ed. ONLINE MENDELIAN INHERITANCE IN MAN (OMIM). The Johns Hopkins University. Clubfoot. Entry Number; 119800: Last Edit Date; 2/27/2002.

TEXTBOOKS
Jones KL. Ed. Smith's Recognizable Patterns of Human Malformation. 5th ed. W. B. Saunders Co., Philadelphia, PA; 1997.

Skinner HB. Ed. Current Diagnosis and Treatment in Orthopedics. Appleton & Lange. Norwalk, CT; 1995.

Beers MH, Berkow R., eds. The Merck Manual, 17th ed. Whitehouse Station, NJ: Merck Research Laboratories; 1999:.

Berkow R., ed. The Merck Manual-Home Edition.2nd ed. Whitehouse Station, NJ: Merck Research Laboratories; 2003:.

REVIEW ARTICLES
Gore AI, Spencer JP. The newborn foot. Am Fam Physician. 2004;69:865-72.

Noonan KJ, Richards BS. Nonsurgical management of idiopathic clubfoot. J Am Acaad Orthop Surg. 2003;11:392-402.

Morcuende JA, Weinstein SL. Birth Defects Res part C Embryo Today. 2003;69:197-207.

Furdon SA, Donlon CR. Examination of the newborn foot: positional and structural abnormalities. Adv Neonatal Care. 2002;2:248-58.

Dietz F. The genetics of idiopathic clubfoot. Clin Orthop. 2002;(401):39-48.

JOURNAL ARTICLES
Morcuende JA, Dolan LA, Dietz FR, et al. Radical reduction in the rate of extensive corrective surgery for clubfoot using the Ponseti method. Pediatrics. 2004;113:376-80.

Dobbs MB, Rudzki JR, Purcell DB, et al. Factors predictive of outcome after use of the Ponseti method for the treatment of idiopathic clubfeet. J Bone Joint Surg Am. 2004;86-A:22-27.

Heilig MR, Matern RV, Rosenzweig SD, et al. Current management of idiopathic clubfoot questionnaire: a multicentric study. J Pediatr Orthop. 2003;23:780-87.

Ippolito E, Farsetti P, Caterini R, et al. Long-term comparative results inpatients with congenital clubfoot treated with two different protocols. J Bone Joint Surg Am. 2003;85-A:1286-94.

Dobbs MB, Corley CL, Morcuende JA, et al. Late recurrence of clubfoot deformity: a 45-year followup. Clin Orthop. 2003;(411):188-92.

Spiegel DA, Loder RT. Leg-length discrepancy and bone-age in unilateral talipes equinovarus. J Pediatr Orthop. 2003;23:246-50.

Hattori T, Ono Y, Kitakoji T, et al. Effect of the Dennis Browne splint in conservative treatment of congenital club foot. J Pediatr Orthop B. 2003;12:59-62.

Napiontek M. Femoral shortening in clubfeet. J Pediatr Orthop B. 2003;12:56-58.

Mohammed NB, Biswas A. Three-dimensional ultrasound in prenatal counseling of congenital talipes equinovarus. Int J Gynaecol Obstet. 2002;79:63-65.

FROM THE INTERNET
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Fact Sheet. Clubfoot and Other Foot Deformities. March of Dimes. nd. 4pp.
www.marchofdimes.com/professionals/681_1211.asp

Patient Guide to Clubfoot. Johns Hopkins Department of Orthopedic Surgery. 2000. 4pp.
www.hopkinsmedicine.org/orhtopedicsurgery/peds/clubfoot.html

Clubfoot (talipes equinovarus. Orthopaedics. Connecticut Children's Medical Center. 2000. 2pp.
www.ccmckids.org/departments/orthopaedics/orthoed22.htm

Clubfoot. Your Orthopaedic Connection. American Academy of Orthopaedic Surgeons. March 2001. 2pp.
http://orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=161&topcategory=Foot


Price A. Treating Clubfoot: Surgery at younger age now recommended.
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Ponseti Casting Method for Clubfoot. Shriners Hospitals for Children. March 28, 2003. 2pp.
www.shrinershq.org/patientedu/clubfootponseti.html

Anguelov Z, Dietz F. Ponseti Method of Idiopathic Clubfoot Treatment. Currents. Winter 2000. Vol. 1, No. 1. 3pp.
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Ponseti I. Treatment of Congenital Clubfoot. Virtual Children's Hospital. ©1992-2004. 6pp.
www.vh.org/pediatric/provider/orhopaedics/Clubfoot/Clubfoot.html

Herzenberg JE, Radler C, Bor N. Evaluation of Ponseti Versus Standard Casting for Treatment of Idiopathic Clubfoot. AAOS. Poster Board No: PE132. March 2, 2001.
www.aaos.org/wordhtml/anmt2001/poster/pe132.htm

Li YH. Management of Resistant Clubfoot. nd. 3pp.
www.dkch.org/Education/Articles/clubfoot%20management.html

Li YH. Clubfoot (Talipes Equinovarus). nd. 20pp.
www.dkch.org/Education/Articles/clubfoot.html

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