Clubfoot is a term used to describe a foot deformity in newborns. The name is derived from the appearance of an untreated adult foot, which resembles a club. Typically, the foot is turned inward and downward. It affects both feet in half of all patients.
Several types of clubfeet exist. A positional clubfoot is one where the foot has the characteristic appearance but is quite flexible, secondary to in-utero crowding and not abnormal development. This is the mildest and most easily treated form. The most common form of a clubfoot is the idiopathic variety. “Idiopathic” means that we do not know the cause. A teratologic clubfoot is a more severe form and is associated with a known neuromuscular abnormality like spina bifida.
Although a clubfoot gene has not been identified, there is increased risk with a positive family history. Twenty four percent of individuals with a clubfoot have a positive family history. If there is a first degree relative in the family with a clubfoot, then the odds are 17 times higher than normal that another member of the family has a clubfoot. If a second degree relative has a clubfoot, then the odds are 6 times higher than normal. If a parent has a clubfoot, the chances are 1 in 4 that their children will have a clubfoot.
The true cause of an idiopathic clubfoot is unknown. There are, however, associations that have been made. Mechanical factors and “packing problems” are associated with positional clubfeet but there is considerable debate regarding the importance of crowding in idiopathic clubfeet. Since a clubfoot develops during the first trimester of the pregnancy and there are reports of clubfoot deformity in very young fetuses, it seems clear that there is more involved than simple crowding. Current theories regarding the cause of a clubfoot include arrest of normal development, vascular, muscular and histologic anomalies.
A clubfoot is diagnosed by its appearance. Radiographs may be necessary to evaluate for other foot and leg conditions that can be confused or accompany a clubfoot, but are generally not necessary to make the diagnosis. Radiographs can be used to help guide treatment and the need for surgery. A clubfoot is typically curved along the outside border of the foot and may have deep creases along the middle and back of the foot. The foot and calf are smaller than the other side and the difference in foot length and calf size will continue throughout life and generally causes no functional deficit. There are numerous classifications schemes for clubfeet, but they are unreliable and not very useful as a guide to treatment.
Treatment of a clubfoot begins as soon as the condition is diagnosed. Positional clubfeet may be observed or a stretching program can be used. The initial treatment for the vast majority of clubfeet is serial casting. The foot is stretched for a short period of time in the office and then the foot is held in an improved position with a cast. Fiberglass and plaster casts can be used. The casts include the entire foot and go up to the thigh with the knee bent. The cast is changed frequently, generally once a week, in order to take advantage of a young tissue’s ability to stretch quickly. Fiberglass casts can easily be removed without tools in the office, while plaster cast can be soaked off at home in water or removed with a cast saw. The process is then repeated until the foot is corrected.