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Clubfoot

  • "Some kids with well-treated club foot are indistinguishable from kids with normal feet. Knowing the problems that would have developed without treatment, it's very satisfying to see how functional and amazing these kids can be with good treatment, bracing and follow-up care."

    --Susan Mahan, MD, MPH, orthopedic surgeon, Boston Children's Hospital

    If your child has been diagnosed with a club foot, you’ll have concerns and questions about his health, treatment, recovery and other issues. It may comfort you to know that Boston Children's Hospital is a world leader in pediatric orthopedics, and we have a wealth of experience treating children with this fairly common and highly treatable condition.

    Illustration of clubfoot

    What to know about club foot

    Club foot (also known as talipes equinovarus) is a congenital (present at birth) foot deformity. It affects the bones, muscles, tendons and blood vessels and can be present in one or both feet.

    In club foot, the heel points downward, while the front half of the foot turns inward. The calf muscles on the affected side are smaller than on the normal side; the leg on the affected side is slightly shorter than on the other side. The foot itself is usually short and wide, and the heel cord (Achilles tendon) is tight.

    • The condition is fairly common, occurring in about one of every 1,000 newborns.
    • It affects boys twice as often as girls.
    • Fifty percent of club foot cases affect both feet (bilateral).
    • A club foot is visible at birth, and is often detected by fetal ultrasound before birth.
    • The “Ponseti”method—manipulating the foot into correct position without joint surgery—is the standard treatment, and usually begins shortly a baby is born. The method involves:
      • a two to three-month regimen of stretching and casting
      • surgery (tenotomy) to release and lengthen the Achilles tendon
      • several years of bracing

    Twenty to 30 percent of kids need additional interventions later on in childhood for tendon tightness or to prevent recurrence of the condition.

    • Most instances of club foot are idiopathic (no apparent cause).
    • A club foot that occurs with some genetic syndromes and birth defects—such as Edwards syndrome (trisomy 18) or spina bifida (myelodysplasia)—can be more fixed, rigid and difficult to treat.
    • Most children who are properly treated for club foot can run, play and live active lives, even though technically their foot and leg remain mildly abnormal.

    How Boston Children's Hospital approaches club foot

    The goal of treatment for club foot is to correct the position of the foot, so that the bones grow normally. Boston Children's doctors take conservative, non-surgical approaches whenever possible, and we have excellent success rates. If a newborn needs surgery, we try to avoid using general anesthesia, which does pose some risk to infants.

    Compared with many other institutions, we offer an especially strong and supportive bracing program. We also have an exceptional prenatal counseling program to help parents anticipate and plan for their baby’s care after birth.

    At Boston Children’s, we recognize the burden of a bracing regimen, which is absolutely necessary to successfully treat club foot, but which places stress on both the child and the family, particularly after a child reaches 2 years old. That’s why we’re initiating a research study to try to predict which children are less likely to have problems with their feet after they’re 2, so that they could reduce or discontinue their bracing programs.

    Club foot: Reviewed by Susan Mahan, MD, MPH

    © Boston Children's Hospital, 2011

  • What is club foot?

    Club foot (talipes equinovarus) is a congenital (present at birth) foot deformity that affects boys twice as often as girls. The condition affects bones, muscles, tendons and blood vessels. It can be present in one or both feet, and there’s a 50 percent chance of its being bilateral (affecting both feet).

    When does club foot show up, and what it does look like?

    Club foot can usually be seen in a prenatal ultrasound, and is readily visible when a baby is born. The baby’s heel points downward, and the front half of the foot turns inward. The calf muscles on the club foot side are smaller than on the normal side, and the leg on the affected side is slightly shorter than on the other side. The foot itself is usually short and wide, and the heel cord (Achilles tendon) is tight.

    What causes club foot?

    Despite a great deal of study, the exact cause of club foot in isolation (not as part of a syndrome or other birth defect) is unknown. There have been some indications of a genetic cause, but these haven’t been confirmed. Most children who are born with a club foot don’t have a family history of the condition.

    What is known is that if a baby boy has a club foot, there’s a 2.5 percent chance that his next-born sibling will have club foot, too. If a girl baby has a club foot, there’s a 6.5 percent chance that her next-born sibling will also have a club foot.

    How common is club foot?

    Club foot is a relatively common deformity, affecting about one of every 1,000 newborns.

    Are there different types of club foot?

    • A true (idiopathic) club foot accounts for the vast majority of cases. This type is stiff or rigid, and very hard to manipulate.
    • The affected foot may be more flexible, with a condition known as positional club foot. This flexible type of club foot is caused by the baby's prenatal position in the uterus (often breech). Positional clubfoot can easily be positioned into a neutral (not curved) position by hand.
    • A third type is syndrome club foot—in which the condition is part of a larger syndrome. This type is usually more severe and difficult to treat, with less positive outcomes.

    How serious is club foot? Can it remain untreated?

    Club foot is serious only if it’s left untreated. A child’s well-treated club foot is very functional, enabling the child to run and play freely. But if left untreated, the condition progresses and limits the child’s mobility.

    Who’s at risk for developing club foot?

    Risk factors may include:

    Babies born with club foot may also be at increased risk of having an associated hip condition, developmental dysplasia of the hip (DDH). In DDH, the top of the thigh bone (femur) slips in and out of its socket because the socket is too shallow to keep the joint intact.

    How does Boston Children’s treat club foot?

    Major surgery is rarely the first choice for treating club foot today. Instead, the Ponseti method (named for its originator, Dr. Ignacio Ponseti) manipulates the foot into correct position without major joint surgery. This is the standard treatment, and it usually begins shortly after birth.

    The Ponseti method involves:

    • a two to three-month regimen of stretching and casting, with weekly changes of the cast in clinic
    • minor surgery (tenotomy) usually under local anesthesia to release and lengthen the Achilles tendon
    • a years-long bracing regimen

    Is my baby in pain?

    No, club foot isn’t usually painful to the baby or child.

    Will my child be OK?

    Babies and children usually do very well today with the Ponseti regimen and good follow-up care. Major surgery is rarely needed to achieve a highly functional foot.

    However, 20 to 30 percent of treated kids need additional intervention sometime in their childhood for tendon tightness, or to prevent recurrence.

    Parents and children can be very heartened to know that some of America’s finest athletes had club foot as children. These include Pittsburgh Pirates infielder Freddy Sanchez; pro soccer star Mia Hamm; Olympic skater Kristi Yamaguchi; and Dallas Cowboys quarterback Troy Aikman.


    Causes

    There are a significant number of ongoing studies to determine the exact cause of club foot, including at Children’s. There may be a genetic cause, but for most children who are born with a club foot, the cause is idiopathic (unknown).

    Signs and symptoms

    • The heel points downward, and the front half of the foot turns inward.
    • The calf muscles on the affected side are smaller than on the normal side.
    • The leg on the affected side is slightly shorter than on the other side.
    • The foot itself is usually short and wide.
    • The Achilles tendon is tight.

    When to seek medical advice

    If your child has club foot, your doctor will have observed the condition either in your fetal ultrasound before your baby’s birth or upon delivery of your baby. Your doctor will initiate treatment immediately after your baby is born.

    Questions to ask your doctor

    If your child is diagnosed with club foot, you may feel understandably anxious. It can be easy to lose track of the questions that occur to you. Lots of parents find it helpful to jot down questions as they arise—that way, when you talk to your child’s doctors, you can be sure that all your concerns get addressed.

    Some of the questions you may want to ask include:

    • Could you describe what’s wrong with my child’s foot (feet)?
    • Are other tests needed to confirm this diagnosis?
    • Is there, or could there be, damage to his tissues or blood vessels?
    • What will my child’s treatment involve? Will he need surgery?
    • How can you prevent recurrence?
    • Could there be long-term effects? Pain? Arthritis?
    • Could this condition affect my child’s ability to walk, run or play sports?
    • How long should my child be followed by her care team?

    Who’s at risk

    Complications

    If a child and his parents strictly follow the doctor’s bracing regimen, treatment of club foot at Children’s usually takes place without complications and is largely complete by about age 4. But 20 to 30 percent of kids need additional treatment later in childhood for tendon tightness or to prevent recurrence.

    Long-term outlook

    Babies and children usually do very well today with the Ponseti regimen and close, consistent follow-up care. Major surgery is rarely needed to give a child a highly functional foot, but 20 to 30 percent of kids need more treatment sometime in their childhood for tendon tightness or recurrence of the condition.

    Parents and children can be very heartened to know that many celebrated athletes had club foot as children: football quarterback Troy Aikman; Olympic skater Kristi Yamaguchi; baseball infielder Freddy Sanchez; and pro soccer player Mia Hamm.

  • At Boston Children's Hospital, we know that the first step to treating your child’s club foot is to form a timely, complete and accurate diagnosis.

    Prenatal diagnosis

    Most of the time, a baby’s clubfoot is diagnosed prenatally (before birth) with ultrasound.* About 10 percent of clubfeet can be diagnosed as early as 13 weeks into pregnancy. By 24 weeks, about 80 percent of clubfeet can be diagnosed, and this number steadily increases until birth.

    If your child isn’t diagnosed prenatally, clubfoot can be seen and diagnosed at birth.

    *One caveat: There’s about a 20 percent false-positive rate with ultrasound diagnosis.

    Diagnosis after birth

    Exams and tests that may help confirm a diagnosis of club foot include:

  • At Boston Children's Hospital's Orthopedic Center, our specialists provide comprehensive treatment—including evaluation, diagnosis, consultation and follow-up care.

    Our standard of care for clubfoot is the “Ponseti” method, in which the foot is manipulated into correct position without joint surgery. Usually begun immediately after birth, the method involves:

    • a two to three-month regimen of stretching/overstretching and repositioning using casts that get changed every few weeks
    • for about 95 percent of babies, when the casting period is over, surgery (tenotomy) to release and lengthen the Achilles heel; this procedure is performed at Children's usually under local anesthesia
    • a bracing regimen (see description, next paragraph) that lasts for several years—a crucially important step, requiring full family attention and compliance

    About bracing

    • Doctors at Boston Children's stress that the bracing component of the treatment for club foot is absolutely critical. The bracing program is full-time (about 22 hours a day) until the baby is about 6 months of age. At 6 months, we generally scale back to bracing just at night and at nap time—about 15 or 16 hours a day—and the baby goes without the brace while he's awake. When the baby is ready to learn how to crawl, and then walk, run and play, the brace is off. 
    • Strictly following the bracing program until the child is about 4 years old (despite the understandable inconvenience) is the best prevention against recurrence and the need for further intervention.

    Tips for care of your child's casts

    • Keep your child's cast clean and dry.
    • Check for cracks or breaks in the cast.
    • Put pads on rough edges to protect his skin from scratches.
    • Don't scratch his skin under the cast by inserting objects inside the cast.
    • Use a hairdryer placed on a cool setting to blow air under the cast and cool down the hot, itchy skin. Never blow warm or hot air into the cast.
    • Cover the cast while your child is eating to prevent food spills and crumbs from falling into the cast.
    • Prevent small toys or objects from being put inside the cast.
    • Elevate the cast above the level of the heart to decrease swelling.
    • Encourage your child to move his toes to promote circulation.

    Coping and support

    At Boston Children's, we understand that a hospital visit can be difficult. So, we offer many amenities to make your child's—and your own—hospital experience as pleasant as possible. Visit the Center for Families for all you need to know about: 

    • getting to Boston Children's
    • accommodations
    • navigating the hospital experience
    • resources that are available for your family

    In particular, we understand that you may have a lot of questions when your child is diagnosed with a club foot. Will my child need surgery? When will his foot be normal? Will it affect him long term? Children's can help you connect with extensive resources to help you and your family through this stressful time, including:

    • patient education: From doctor's appointments to treatment to follow-up, our nurses and physical therapists will be on hand to walk you through your child's diagnosis, treatment and follow-up care. 
    • parent-to-parent: Want to talk with someone whose child has been treated for club foot? Our Orthopedic Center can often put you in touch with other families who've been through the same experience that you and your child are facing. 
    • faith-based support: If you're in need of spiritual support, we'll connect you with the Children's chaplaincy. Our program includes nearly a dozen clergy—representing Protestant, Jewish, Muslim, Catholic and other faith traditions—who will listen to you, pray with you and help you observe your own faith practices during your hospital experience. 
    • social work: Our social workers and mental health clinicians have helped many other families in your situation. We can offer counseling and assistance with issues such as coping with your child's diagnosis, stresses relating to coping with illness and dealing with financial issues.
  • For more than a century, orthopedic surgeons and investigators at Boston Children's Hospital have played a vital role in advancing the field of musculoskeletal research. We’ve developed breakthrough treatments and major advances for children with lower limb and hip problems, as well as for those with scoliosis, polio, tuberculosis and traumas to the hand and upper extremities.

    Our pioneering research helps answer the most pressing questions in pediatric orthopedics today—to provide children with the most innovative care available.

    In Boston Children’s Orthopedic Center we take great pride in our basic science and clinical research leaders, who are recognized throughout the world for their achievements. Our orthopedic research team includes:

    • full-time basic scientists
    • 28 clinical investigators
    • a team of research coordinators and statisticians

    Research study on club foot in preliminary data-gathering stage

    At Boston Children’s, we recognize that the critically-important bracing regimen, which lasts until a child is about 4 years old, poses significant challenges to both a child and his family. For example, a family may find their 2-year-old’s potty training and behavioral issues to be particularly stressful in light of the burdensome bracing regimen. To address that burden, Boston Children’s researchers are initiating a research study to try to predict which children are less likely to have problems with their feet after 2 years old and can therefore reduce or discontinue their bracing programs.

    Orthopedic basic science laboratories

    Some of the foremost musculoskeletal researchers in the America are making new discoveries in Boston Children’s labs, including:

    • Orthopedic basic science research
    • Center for the study of genetic skeletal disorders
    • Sports Medicine research laboratory
    • Matthew Harris lab
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