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One child out of every 1000 births will have a clubfoot, and half of those will have both feet affected. Clubfoot is usually diagnosed at birth, and sometimes before birth. In the infant, clubfoot itself is not painful. The heel of the foot turns inward, the foot and toes point down and curve inward. There may be creases above the heel and in the middle bottom portion of the foot. The bones are abnormally shaped and the tendons, muscles, and ligaments are tight. The foot and calf are usually smaller than normal, and the muscles may be weaker and the nerves may be abnormal. Often the blood supply is abnormal as well.
There are four different types of clubfeet:
- A positional clubfoot is a normal foot that was held in an abnormal position in utero. The bony alignment is normal and the foot is usually corrected by stretching or casting.
- A teratologic clubfoot is associated with neurologic disorders such as spina bifida. It almost always requires surgery, although casting does help stretch the soft tissues in preparation for surgery.
- A syndromic clubfoot is associated with an overall genetic syndrome such as arthrogryposis. This type almost always requires surgery as definitive treatment, although casting does help stretch the soft tissues in preparation for surgery.
- A congenital clubfoot is a foot with abnormal bony deformity present at birth but not associated with any neuromuscular cause or syndrome.
Not all clubfeet are the same. Some are flexible while others are stiff. Some deformities are mild yet others are severe. Due to these differences, treatments and outcomes may vary. If untreated, the deformity does not improve on its own. The deformity will actually worsen, and if left uncorrected, will become crippling, leading to children walking on the top rather than the bottom of their foot. This eventually creates skin breakdown, ulceration, and infection, and can ultimately lead to an amputation in the most severe untreated cases.
Treatment begins as soon as possible after birth. This usually involves manipulation of the foot into the best possible position and holding it with a long leg casting. Typically the manipulation and casting are performed once a week (sometimes biweekly) for 6 to 8 weeks.
The majority of feet can be corrected in this manner. If casting is successful, the foot will then be held in either a plastic brace, or a corrective shoe and bar to maintain the correction until the child begins to walk.
If the foot is not completely corrected or if the deformity recurs following correction, surgery is usually suggested. Surgery is usually done between 6 and 9 months of age so that the foot is corrected by the time the child is ready to stand and walk. After surgery the foot is held in a cast for 6 to 12 weeks followed by use of a plastic brace to hold the foot in a corrected position and limit the possibility of recurrence.
There is a 20-25 percent chance of recurrence of the deformity after successful correction (by either casting or surgery). This may require further surgery and/or casting.
No matter what the treatment, the goal is to create a foot with the sole on the ground, which is flexible and pain free. Most children with corrected clubfeet will go onto lead normal lives, but they will still need to be followed. Even after growth is complete, the patient with a clubfoot needs to be seen by a specialist to ensure a well-functioning foot in adulthood.