Congenital clubfoot

The foot turns in and down, the sole faces the other leg, the heel is drawn up and the outer border is arched: that is clubfoot, one of the commonest congenital differences of the skeleton. It shows up in roughly one baby in a thousand, twice as often in boys, and about half the time it affects both feet. The good news is that the treatment has been transformed over the past thirty years: plaster casts and patience have pushed out the big operations, and almost all of these children grow up walking, running and wearing ordinary shoes. The bad news is that the result is not won in the first few weeks but over the four years of brace wear that follow, and that is exactly where things tend to go wrong.

What the foot looks like

The shape is obvious to the eye and needs no equipment: the foot is rotated inwards, the sole points towards the other leg, the heel is small and sits high, and deep creases stand out along the inner border and above the heel. The calf on that side is often thinner and the foot itself shorter.

It is not simply a short Achilles tendon, as is sometimes written. Clubfoot is an altered position and shape of the bones of the mid and hind foot together with shortened tendons, ligaments and muscles along the inner and back surfaces. That is why it cannot be kneaded out by hand or massaged away: it takes a series of measured shifts, each one held in place by a cast.

A baby feels no pain from it — the foot does not hurt and does not get in the way until the child starts to stand. Left alone, the child ends up weight-bearing on the outer edge and even on the top of the foot, thick painful callus builds up there, walking becomes heavy work, and by adulthood the pain is constant.

Looks similar, is not the same

Some babies arrive with feet turned in simply because there was no room in the womb. Telling that apart from true clubfoot is not hard: a positional foot can be brought calmly and without force into a normal position by hand and even bent a little past a right angle, whereas genuine clubfoot resists stiffly. A positional foot straightens out by itself at two or three months, sometimes with a few physiotherapy sessions, and needs no cast.

Then there is metatarsus adductus, where only the front half of the foot is turned in while the heel sits correctly. That is not clubfoot either and in most cases settles without treatment. Working out which is which is a job for a doctor: getting it wrong is expensive either way — lost time on one side, months of pointless plaster on the other.

Where it comes from

In most cases no cause is ever identified. There is a hereditary element, though it follows no simple rule. The rough figures run like this: once one child has been born with clubfoot, the chance for the next is put at about one in thirty-five; if one parent had it, about one in thirty; if both did, it climbs sharply to roughly one in three. Smoking during pregnancy raises the risk, particularly where the family history is already there.

Something else matters far more: in a proportion of children clubfoot is not a stand-alone problem but a sign that nerves or muscles are involved. Warning signs are feet that barely give at all to stretching, stiffness in other joints too, weak legs, a dimple, a tuft of hair or a swelling over the lower back, and asymmetrical thigh creases with limited hip movement. Behind those may lie spina bifida, arthrogryposis, a neuromuscular disorder or hip dysplasia, which keeps company with clubfoot more often than chance would explain. Such findings change the whole plan: the underlying condition comes first and treatment of the feet runs longer and harder. That is why the examination never stops at the foot — the back, the hips and the movement of every joint are checked as well.

The first weeks: casting the Ponseti way

Treatment starts early, usually in the first or second week of life, while the tissues are soft and willing. The main method carries the name of Ignacio Ponseti and works in weekly steps: the doctor eases the foot into a slightly better position without any jerking, holds it there for a few minutes and locks in the gain with a cast running from the toes to the upper thigh. A week later the cast comes off and the whole thing is repeated, adding a little each time. Five to eight casts are usually needed.

Almost every child then has a very small procedure on the Achilles tendon at the end of that series: it is divided through a needle puncture under local anaesthetic, which lets the heel come down. It takes a matter of minutes, needs no stitches, and afterwards a final cast stays on for about three weeks. In that time the tendon heals back together at the length it should have had.

The brace: where the result is actually decided

Once the last cast is off, the longest and most underrated stage begins. The child is fitted with boots joined by a rigid bar that holds the feet turned outwards. For the first three months or so they are worn nearly all the time, coming off only for bathing and changing, and after that only for naps and overnight, right up to four or five years of age.

The first nights are hard: the child fights it, the bar stops the legs moving the familiar way, and parents feel as though they are tormenting a baby. Within a week or two children get used to it and sleep in the boots quite peacefully. It helps to know what the brace is for: it does not correct the foot, it holds on to what has already been achieved while the child grows. Practically every relapse comes not from the method failing but from the wearing being stopped or cut short.

If the foot does start slipping back, that is neither a disaster nor a return to square one: a few repeat casts and a return to the brace schedule usually cover it. The sooner it is spotted, the shorter the detour, so routine check-ups are worth keeping.

When to call the doctor without waiting for an appointment

A cast on such a small leg needs watching. Get in touch the same day or go to urgent care if:

• the toes turn blue, white or cold, or swell noticeably;
• the toes have slid up inside the cast and can no longer be seen — the cast has shifted and may be squeezing the leg;
• the child cries inconsolably for hours on end with no other explanation;
• there is a bad smell or discharge from under the cast, or the skin at the edge is rubbed raw;
• the cast has got wet, gone soft, cracked or is sliding off;
• a fever appears with no cold to account for it.

Separately, and without delay, the child should be seen if alongside the clubfoot there is weakness or complete lack of movement in the foot and lower leg, a lump over the lower back, or poor weight gain and slow development. That is no longer about the foot but about what is causing it.

What to expect later on

Children treated in time who kept up the brace walk at the usual age, run, play sport and wear ordinary shoes. The foot does not end up perfectly symmetrical: where only one side was affected, it usually stays a size or a size and a half smaller with a thinner calf, and any difference in leg length is small. Some children tire sooner on long walks, but daily life is barely affected.

Follow-up carries on until the foot has finished growing — rarely, the shape starts to return in the school years, and then small procedures may be needed, such as moving a tendon or adjusting the position of a bone. The extensive reconstructive operations once done on almost everyone are now the exception.

Online consultation

Everything that does not need hands-on examination works well remotely: what exactly was seen on the pregnancy scan, how a positional foot differs from true clubfoot, what the treatment timetable looks like and what to ask the orthopaedic surgeon at the first visit. For parents who are already through the casting stage, an online appointment helps most with the brace: how to put it on without tears, what to do about rubbed skin, whether it can be skipped on the day of a long journey, how to tell that the foot is drifting back. Anything to do with the state of the cast or the colour of the toes cannot be settled through a screen — for that, see a doctor straight away.

This material is for information only and does not replace medical advice.