Clubfoot, also known as Congenital Talipes Equinovarus, is a complex, congenital deformity of the foot, that left untreated can limit a person’s mobility by making it difficult and painful to walk. It is defined as a deformity characterized by complex, malalignment of the foot involving soft and bony structures in the hindfoot, midfoot and forefoot.
The deformity affects the structure and position of the foot, presenting as an adductus and cavus (an inward turning) of the midfoot and a varus hindfoot. At the subtalar joint, the foot is held in a fixed equinus, or downward pointing position. The foot affected by clubfoot is shorter, and the calf circumference is less than a normal, unaffected foot. On presentation, the clubfoot deformity is not passively correctable and presents with varying degrees of rigidity.
In approximately 80% of cases, clubfoot is idiopathic. The remaining 20% present in association with other disorders, most commonly Spina Bifida, Cerebral Palsy and Arthrogryposis.
The causes of clubfoot are poorly understood. There is almost certainly a genetic component and environmental factors, seasonal variation and in utero positioning have all been suggested as possible causal factors but these have not been consistently demonstrated.
Several theories have been proposed to explain the origin of clubfoot, considering both intrinsic and extrinsic causes, including: intrauterine position of the foetus, mechanical compression or increased hydraulic pressure, interruption in foetal development, viral infections, vascular deficiencies, muscular alterations, neurological alterations, defect in the development of the bones structures and genetic defects.Researchers believe there are both genetic and environmental influences.
According to some studies smoking by mother during pregnancy may be one the most possible causes of clubfoot.It is also believed that if one parent is having this deformity, the newborn baby have the risk of getting it. The risk is even higher if both parents are affected.
Bony prominence visible and palpable over the dorsolateral aspect of the foot represents the head and neck of the talus which are partially uncovered by the navicular
In underdeveloped countries many clinicians are unqualified, inexperienced and untrained in Ponseti method. Some clinician who do not know anything about this deformity, advised parents to keep away from any treatment as it will get better as the child grows up.
Some calls it a deficiency of vitamins.
Some parents seek religious healers.
Some seek for surgery.
many think that just exercises and massage can correct it.
Many children are left untreated as it is believed that it can’t be treated. In short, there is still too much work to be done about this deformity. We need to know what this deformity is. How and when it can be treated? And if not treated what complications can occur in the future?
1.The most widely accepted method being used for clubfoot treatment is the “Ponseti Method”, developed by Ignacio Ponseti (1942-2009). It includes Manipulations by an expert physiotherapist, several serial castings and a minor surgical operation in which the Achilles tendon is released. If applied correctly and in time, individuals with clubfoot can recover up to 90% of normal foot alignment with minor differences when compared to normal foot.
In developed countries a lot of researches, annual conferences and training sessions are arranged to educate people about this deformity, and to train medical professionals for successful treatment of clubfoot. But in underdeveloped countries there is no such a system. Many medical professionals and clinicians do not know about clubfoot, many don’t have the idea of treating it with a method of most accurate outcome.
If there are any hospitals or facilities available to treat clubfoot, they don’t have any qualified or expert medical professionals. As seen in general practice, such children are brought for medical treatment when the deformity has worsened.
Readers may also wish to be aware of the French Functional (Physical Therapy) Method, a less commonly used technique for which there is a much smaller body of supporting research evidence.
The French Method consists of daily manipulations of the infant's clubfoot, stimulation of the muscles acting on the foot to maintain the reduction achieved through manipulation, and foot immobilization using nonelastic adhesive strapping. Treatment usually lasts over a course of approximately two months and is then gradually reduced. Improvement typically occurs within the first three months and is achieved at a slower rate when compared to the Ponseti Method.
Richards et al (2008) compared the Ponseti and French Methods and found after 51.4 months average follow-up that feet managed with the Ponseti Method demonstrated a trend towards a better clinical outcome versus those managed with the French Method (p = 0.31); however, the results were very close. For the Ponseti Method, outcomes were considered 'Good' for 72%, 'Fair' for 12%, and 'Poor' for 16% of the participants, compared to 67%, 17%, and 16%, respectively, for the French Method. The authors report that this may have been attributed to the amount of substantial effort required to train the parents and have them implement the technique reliably (i.e. perform the stretching, taping, and splinting on a daily basis) for up to two years.
Early surgical management of clubfoot in the late 1800’s mainly consisted of different types of soft tissue release but had satisfactory outcomes in as low as 45% of patients treated.
Surgical techniques regained popularity in the 1970’s and were the treatment of choice throughout the 1980’s and 1990’s; many of these were variations on the posteromedial release (PMR) involving extensive release of the soft tissues of the foot.
Turco, whose work was particularly influential in the rise of surgical techniques reported his method of PMR as having excellent or good results in 83% of cases at follow up ranging from 2-15 years after initial treatment.
However, other long-term follow-up studies, notably that by Aronson & Puskarich (1990) found high levels of foot and ankle stiffness and weakness amongst patients ten years after treatment with surgical release.
This and other evidence led to the current stance adopted by most orthopaedic clinicians: that clubfoot should ideally initially be managed non-invasively.
Most commonly, clubfoot is classified as “Idiopathic Clubfoot” meaning there is no known cause for the deformity. In idiopathic clubfoot, there can also be a definite hereditary influence, in that if a person has a relative, parent, or sibling has clubfoot, then they are more likely to have clubfoot or have a child with it (3-10% chance). Within the group of idiopathic clubfeet there is a wide spectrum of impairment depending on severity, as well as whether the clubfoot has been untreated, partially treated, poorly treated, or successfully treated. These are outlined by the Arica Clubfoot Training as follows:
Untreated Clubfoot - all clubfeet from birth up to 2 years of age that have had very little or no treatment can be considered as untreated clubfeet.
Treated Clubfoot - untreated clubfeet that have been corrected with Ponseti treatment are termed “treated clubfeet”. Treated clubfeet are usually braced full-time for 3 months and at night up to age 4 or 5 years.
Recurrent Clubfoot - this is a clubfoot which has achieved a good result with Ponseti treatment, but the deformity has recurred. The commonest reason is due to abandoning the braces early.
Neglected Clubfoot - the neglected clubfoot is a clubfoot in a child older than 2 years, where little or no treatment has been performed. The neglected clubfoot may respond to Ponseti treatment, but also may have bony deformity that requires surgical correction.
Complex Clubfoot - any foot with deformity that has received any type of treatment other than the Ponseti method may have added complexity because of additional pathology or scarring from surgery.
Resistant Clubfoot - this is a clubfoot where Ponseti treatment has been correctly performed but there has been no significant improvement. It is often found that this type of clubfoot is not in fact idiopathic after all and is secondary or syndromic.
“Atypical” Clubfoot - this is a type of clubfoot dealt with in the advanced section of this course . It involves a foot that is often swollen, has a plantarflexed first metatarsal and an extended big toe. It can occur spontaneously but most often occurs after slippage of a cast.
Secondary clubfoot, on the other hand, occurs when there is another disease or condition that is causing or linked to the development of clubfoot. Such conditions are usually Neurological such as Spina Bifida associated with concurrent sensory and or motor impairments or Syndromic Disorders such as Arthrogryposis associated with more global findings and involvement of other musculoskeletal issues.
Physical therapy for Club Foot will be used to stretch the structures of the foot including the tendons, ligaments, and muscles to adjust the foot and keep it in the proper position. If surgery is needed, physical therapy will be initiated after the procedure to ensure that the correction takes hold.
1.Bracing will be a critical component of recovery from a fixed Club Foot.
2.Manual Therapeutic Technique (MTT)
3.Hands on care including soft tissue massage, stretching and joint mobilization by a physical therapist to improve alignment, mobility and range of motion of the foot. The use of mobilization techniques also helps to modulate pain.
4.Therapeutic Exercises (TE)
Including stretching and strengthening exercises to regain range of motion and strengthen muscles of the foot and lower extremity to support, stabilize and decrease the stresses place on joint cartilage and the foot joint.
5.Stretching Of Opposite Group Of Muscle And Strengthening Of Dorsiflexer’s With Evertor’s Or Invertors According To Varus Or Valgus Deformity.
6.ES ( Electrical Stimulation) Mainly SF( Surge Faradic) Group Stimulation in Acuired Deformity show Good Results As Compared To Congenital Deformity.
SF Current Are in Mostly Dorsiflexer’s With Evertor’s Or Dorsiflexer’s With Invertor’s Group Muscle According to Varus Or Valgus Deformity Are Selected.
7.Taping Technique is Also Useful.
8.Neuro-muscular Re-education (NMR)
9.To restore stability, retrain the lower extremity and improve movement techniques and mechanics (for example, walking, gait training, running or jumping) of the involved lower extremity to reduce stress on the joint surfaces in daily activities.
10.Rhythmic and repeated gentle manipulation.
11.Strapping and plaster of Paris (POP) cast.
12.Education and instructions to the mother and/or parents.
13.Modalities including the use of ultrasound, electrical stimulation, ice, cold, laser and others to decrease pain and inflammation of the involved joint.
14.Neurodevelopmental treatment to achieve age-appropriate motor milestones in conjunction with serial casting or splinting.
15.Facilitate weight-bearing while sitting on bench or chair.
16.Facilitate weight-bearing with supported standing or while standing at furniture.
17.Pre-gait training activities and gait training.
18.Manual therapy; mobilize the talonavicular joint by moving the navicular laterally and the head of the talus medially.