Clubfoot

Clubfoot is a congenital condition that affects newborn infants.The medical term for clubfoot is Congenital Talipes Equinovarus. This condition has been described in medical literature since the ancient Egyptians. Congenital means that the condition is present at birth and occurred during fetal development. The condition is not rare and the incidence varies widely among different races. In the Caucasian population, about one in a thousand infants are born with a clubfoot. In Japan, the numbers are one in two thousand and in some races in the South Pacific it can be as high as seven infants in one thousand who are born with a clubfoot. The condition affects both feet in about half of the infants born with clubfoot. Clubfoot affects twice as many males as females. 

How does this problem develop?

During the nine months of pregnancy, the fetus undergoes remarkable changes. In the skeleton, these changes include the separation of each individual bone in the body from one mass of bone material. In some cases, this process is flawed. A clubfoot occurs when this failure of separation occurs in the tarsal bones of the foot.

Until recently, most experts believed that the clubfoot deformity was due to the foot being stuck in the wrong position in the womb. As development progressed, the foot could not grow normally because it was turned under and held in that position. Today, most information suggests that clubfoot is hereditary, meaning that it runs in families. It is not clear what genetic defect causes the problem. It is not known yet whether the defect affects the development of the muscles, blood vessels, or bones of the foot.

What treatment options are available?

Treatment for clubfoot usually begins at birth. Treatment in the majority of infants will require both non-surgical treatment and surgery. The foot will never be normal, but treatment can provide a very functional foot that can be used for walking without pain.

Nonsurgical Treatment

The most commonly used non-surgical treatment in the newborn and infant is manipulation and casting. This is started as soon as possible. The foot is manipulated to stretch and loosen the tight structures. The foot is then placed in a cast to hold it in a corrected position. This is repeated every one or two weeks until the deformity is corrected or surgery is performed.

As any parent knows, the newborn grows rapidly after birth. The technique of manipulation and casting the foot is used to guide the growth of the foot towards the normal alignment. Without this guidance, the foot will remain deformed and may actually get worse. The greatest chance for correction of deformity occurs early in life when there is so much growth occurring.

There have been many different techniques proposed for the way the foot is manipulated and the way the casts are applied. Treatment of the infant with clubfoot is definitely one of the arts of medicine. Successful treatment requires patience and attention to detail.
The success of treatment of clubfoot by manipulation and casting alone varies greatly. The majority of infants will eventually require surgery but the manipulation and casting begins the process of guiding the foot towards a more normal form. In the infant that eventually needs surgery, the manipulation and casting are still required to obtain as much correction as possible prior to the surgery.

What should be expected from treatment?
Physiotherapy  after surgery for a clubfoot can begin as soon as your child’s surgeon recommends it.  All treatment, either surgical or non-surgical including physiotherapy, is designed to give the child a foot that can be placed flat on the floor. Another goal of therapy is to assist your child’s walking biomechanics in order to encourage your child to walk as efficiently as possible. Lastly, our goals also include relieving any pain if present, preventing pain in the future, maintaining the flexibility of your child’s muscles and tissues, and preventing any weaknesses around the lower extremities and core from developing.

During your first appointment your Physiotherapist will discuss your child’s foot brace with you and ensure that you are confident putting it on and taking it off.  Your doctor will set the specifications of the brace according to your child’s needs. Your doctor will inform you which activities are safe while in the brace and which ones should be avoided.

The schedule of how long your child will have to wear the brace each day will be set by your child’s surgeon.  At first the time with the brace on will likely need to be most of the day and night. Generally the wearing time is gradually decreased over time so that your child has some awake time without the brace on. In most cases children will need to wear the brace during all sleep times until eventually sleep time is the only time the child is required to wear the brace. Depending on the age of your child, once the brace is discarded during the day, your physiotherapist may incorporate taping techniques of the foot to provide gentle foot positioning guidance.

Your physiotherapist may address any pain issues that your child may be experiencing from the surgical procedure or the deformity itself, depending on the age of your child. Your physiotherapist may use modalities such as ice, heat or massage to try to relieve any pain. In some cases they may even use ultrasound, again depending on your child’s age and the location of their pain.

Maintaining the length of the tissues in your child’s foot is the main goal of any stretching exercises we do with your child or ask you to do with them.  Your child’s age at the time of surgery will largely influence how formal the stretches and strengthening exercises for your child will be. If they are old enough to understand and follow along, your physiotherapist may encourage specific stretches for the back of the calf and Achilles tendon, as well as for the bottom of the foot.  Often, however, children who have had surgery for clubfoot are too young to effectively engage in formal stretches therefore play activities that encourage these types of stretches will be taught.  Ensuring that your child spends time squatting, standing with feet flat, standing on their toes, standing on their heels, walking without the brace, and practicing jumping are ways to encourage proper foot movement. Your physiotherapist will guide you through which of the activities are most important for your child at which time, the proper technique for these activities, and how long they should be performing each activity. 

 You will be taught by your therapist how to apply pressure properly to your child’s foot or leg during these activities in order to encourage normal foot alignment.  If your child is too young to walk or do the higher level activities then your physiotherapist will teach you age-appropriate play activities that encourage the proper positioning of your child’s foot and lower leg.  Range of movement exercises that encourage motion of the foot in all directions away from the clubfoot position will be important.  Of particular importance are passive Achilles tendon stretches, which will be taught to you and will be encouraged frequently.  The Achilles tendon is the thick tendon at the back of the ankle. 

Maintaining the length of the Achilles tendon after casting and surgery to lengthen it prepares the foot and ankle to take the body’s weight for activities such as walking, squatting, and jumping.  It should be noted how important it is to maximize use of the time that your child spends outside of the brace by doing the specified activities that your physiotherapist prescribes as this will train the muscles to hold your child’s new foot position and give the other tissues as much active stretching as possible.  

Formal strengthening exercises for older children will be taught which encourage ankle, calf, hip, and core strengthening as well strengthening for the muscles that pull the foot into a position where the sole of the foot is turned up and out (opposite to the clubbed foot position.) As previously mentioned often the child who has had surgery for clubfeet is too young to perform any formal exercises. Playing is once again the best method to encourage strength development in your child’s feet, legs and core area.

Your physiotherapist will encourage fun play activities and games such as assisted frog jumps or hops on one leg in order to strengthen the appropriate muscles.  Even helping the young child mimic these types of activities can be very useful to strengthen the legs and feet and encourage proper foot position. Any activity they enjoy which encourages the proper motion is useful! Often singing while doing activities or making a game of the exercises is the best method of incorporating rehabilitation into your young child’s world.

Generally children who have had surgery for clubfeet do extremely well with the physiotherapy.  Over the course of your child’s therapy your therapist will liaise closely with your child’s doctor, surgeon, Orthotist, and Podiatrist as well as any other health care professionals that are involved in their care to ensure your child is recovering as quickly and normally as possible.