Foot and ankle: Treatment of idiopathic clubfoot

What is clubfoot?

Clubfoot is a condition that causes the lower leg, ankle and foot to be turned inward and pointed down. The deformity occurs during early development of the fetus and is present at birth (congenital).

Clubfoot affects 1 to 2 children for every 1000 live births. It is twice as common in males as it is in females. Clubfoot can run in families. The exact cause depends on a number of factors, including genetic, though the responsible gene(s) has not yet been found.

Other names for idiopathic clubfoot include congenital clubfoot and talipes equinovarus.

The deformity can occur in one or both feet. Because the muscles, tendons and bones have been growing in an abnormal position, the foot is often quite rigid and requires several stages of treatment.

How is clubfoot treated?

The standard of care treatment globally is the Ponseti Method of casting, a minor surgical procedure and bracing.

Ideally, treatment should begin in the first two months of life, after you and your baby are comfortably settled at home. If a baby is born pre-term, has other important medical needs early on, or if the mother has medical needs after birth, treatment can safely be delayed, without impacting treatment outcomes, until both are healthy. Results of treatment are still excellent even if started a little later.

Broadly, there are three treatment stages:

1. Weekly Ponseti stretching and casting of the foot and leg
2. A minor surgical procedure to release the Achilles tendon
3. Bracing to hold the corrected position

Stage 1: Casting

The first part of treatment involves a specific series of gentle stretching and casting of the affected foot/feet to gradually correct the alignment. This is often referred to as manipulation and casting. The treatment is performed by a physiotherapist and an orthopaedic technologist or orthopaedic surgeon trained in the Ponseti Method.

Casting typically starts within the first two months of life and is repeated every 1 to 2 weeks, for an average of 4 to 8 weeks. The number of casts needed can depend on the stiffness of the foot, your baby or child’s age, and their skin condition and response to casting. If the baby or parent have other medical needs after birth, casting treatment can safely be delayed until both are healthy.

The stretching and casts do not hurt the baby as they are done gently. Since the cast goes to above the knee and up to the thigh, the baby has to learn how to move differently with the cast on. It is normal for them to be a little fussy for 1 to 2 days after casting, but this should settle throughout the week.

Stage 2: Achilles tendon tenotomy (tendon release)

The casting corrects the foot alignment, but in the majority of babies the Achilles tendon (where the calf muscle attaches to the heel) is too strong and prevents full upward motion of the ankle. As the Achilles tendon is very tight, surgery is recommended to release/cut it, rather than continuing to put force on the foot with casting. More than 90% of babies with clubfoot will require this.

The procedure is done by the orthopaedic surgeon in the clinic under local anaesthetic. It involves a very small incision at the back of the ankle and does not require stitches. Babies settle well after the procedure and generally do not require pain medicine. If they are fussier than usual, acetaminophen is recommended. After the tendon is released, the foot will be casted in the fully corrected position for 3 weeks. Babies older than 6 months of age at the time of this procedure typically require the procedure in the operating room under general anesthetic.

Stage 3: Bracing

After the last cast is removed, the baby will need to wear a specific brace to maintain the corrected position. The bracing phase is essential for preventing the deformity from returning and success is dependent on the parents developing a good routine for brace wear!

The brace is called boots and bar (B&B). It includes two boots attached to a bar that holds the feet shoulder-width apart and turned outward, away from the body. This position is natural and comfortable for the baby and prevents the previously tight muscles from pulling the foot back in a downward and inward position.

Your child will need to wear the boots and bar 23 hours a day for the first 3 months. You will be able to take it off once a day for bathing and skin care. If the foot shape remains well corrected, brace wear is then decreased to nighttime only aiming for 12 to 15 hours. The casting, tenotomy, and full-time bracing stages are typically completed within 6 months.

Your child will continue to wear the brace at nighttime only until 4 to 5 years of age. Bracing is necessary for all patients and is essential to prevent relapse of the deformity. Most children will not require any special footwear or bracing for daily function.

The majority of babies with idiopathic clubfoot will experience normal developmental milestones during and following treatment. The average child with idiopathic clubfoot walks by 18 months of age. This is within the normal time frame for all healthy children.

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Response to treatment and follow up care

The Ponseti Method is considered the most effective treatment of idiopathic clubfoot. Each clubfoot is unique, so your child’s response to each phase of treatment will be unique as well. Some clubfeet are more flexible while others are more rigid, requiring more casts than initially predicted or possibly recasting during later phases of treatment. A small percentage of children may require additional surgery at some stage in their treatment if the foot is not correcting well with casting.

Attending all appointments and a commitment to keeping casts and braces on as prescribed are important to achieve and maintain correction of the foot deformity.

Regardless of the severity of the clubfoot, the goal and result of treatment is to achieve a functional and painless foot with good alignment. The affected clubfoot is typically a little smaller than the normal foot and the calf muscle may develop slightly smaller. The affected leg may also be slightly shorter and may toe-in slightly. If both feet are involved, they are usually symmetric. None of these differences will cause pain or affect the child’s growth or function. Your child should be able to walk and run normally and to participate in most physical activities.

Cast care

• The casts will be removed in clinic at the beginning of every appointment.
• The casts must remain clean and dry. Sponge bath only.
• If the top edge of the cast becomes lightly soiled with urine or stool (poop), wipe the area with a slightly damp cloth and apply a small amount of petroleum jelly (no cream) on the skin around the edge of the cast.
• If the cast is heavily soiled, please call the clinic for advice. The cast may need to be replaced.
• The casts are high on the baby’s leg on purpose. Though it may be challenging for diaper changes, they are not too high. They are applied this way to ensure the cast remains in position to achieve the best correction of the foot.

Look out for

• The toes may appear squished or swollen but as long as the toes are pink and warm, the cast is fine. The toes should never be white.
• A quick circulation check with each diaper change is recommended. Apply blanching pressure (skin turns white) to the toes and colour should return quickly (2 to 3 seconds) after pressure is removed.
• The toes should always be as visible at the edge of the cast as they were when the cast was applied. If the toes are disappearing inside the cast, it means the cast is slipping down and the correct molding of the foot is not being achieved.
• Call the clinic immediately if the cast slips. They will likely advise to remove the cast. If you cannot reach the clinic within 3 hours and you are certain the cast slipped, remove it at home.

Safety and circulation

• If your child’s toes appear white, blue, dark purple and/or very swollen:
1. Elevate the feet on a rolled towel or pillow.
2. Gently move the legs to increase circulation.
• If the color does not return, call the clinic immediately AND remove the casts. There is no need to go to the Emergency Deparmtent. Inform the clinic that the casts were removed, so an appointment to recast can be scheduled.

When to remove the cast

• If the toes are white or remain blue/swollen after trying to elevate and move the legs.
• If the baby shows signs of increased pain or irritability that seems to be related to the cast (the baby is otherwise well).
• Toes are disappearing inside the cast.
• The cast is saturated with large amounts of urine or stool.

How to remove the cast

1. The outside layer of the cast is a semi-rigid fiberglass tape. Simply find the end and carefully peel the cast off. It will feel like trying to unroll duct tape.
2. After the outer layer is removed simply soak the plaster portion of the cast in warm water. The cast will soften in 10 minutes and you can peel it off. We leave a “bump” as a starting point.

Clubfoot team

Contact information

Orthopaedic Technologists (Derek, Kim, Kira, Kiaya, Salman): 416-813-5785

For questions or concerns about casts, please leave us a detailed voicemail and we will call you back as soon as possible - Monday to Friday 8 a.m. - 4 p.m.

Clinic Reception

For appointment booking, cancellation or changes call: 416-813-5840, Monday to Friday.

When leaving a message, please state your child’s full name (spell the last name) and date of birth.

Resident on call

For concerns about casts after hours (5 p.m.), call the central locating system at 416-813-1500, option 5, and ask for the orthopaedic resident on call.