Clubfoot
Clubfoot is a congenital deformity in which a baby's foot is turned inwards and downwards at birth. It is treated from the first weeks of life with the Ponseti method (serial casts, tenotomy and an abduction brace), which corrects the vast majority of cases without major surgery.
- Typical age
- From birth
- Also known as
- Congenital talipes equinovarus · Talipes equinovarus · CTEV
What is it?
Congenital clubfoot, also known as congenital talipes equinovarus, is a foot deformity present from birth that affects the shape, position and movement of the foot. It needs assessment by a paediatric orthopaedic specialist.
The foot has a combination of abnormalities that make it point downwards and inwards. It may affect one foot or both and, if not treated properly, can make walking difficult and cause pain, functional limitation and problems with weight-bearing.
It is one of the most common congenital malformations of the musculoskeletal system: it occurs in about 1 in 1,000 newborns, is more common in boys than girls and affects both feet in about half of cases. Its origin is multifactorial. The exact cause is not always known, although genetic factors and musculoskeletal development during pregnancy play a part.
It may occur on its own, without other anomalies, or be associated with certain neuromuscular conditions, genetic syndromes and other congenital malformations.
In most cases it is not caused by anything the parents did during pregnancy, and it cannot be prevented through usual prenatal care.
It must be distinguished from positional clubfoot, a foot position caused by how the baby lay in the womb, which is flexible and corrects easily.
The good news is that most children with clubfoot can achieve a functional, flexible and practically pain-free foot with appropriate treatment started early and followed by long-term monitoring.
In our Paediatric Foot and Ankle Unit we manage clubfoot from birth to adolescence, with particular focus on initial treatment, preventing relapses and managing complex deformities.
Signs parents may notice
- The foot points inwards and downwards and cannot be gently brought into a normal position.
- The heel looks small and “high”.
- These features appear together and to varying degrees. When only one side is affected, the foot is usually shorter and smaller than the other.
- Unlike other positional deformities in newborns, clubfoot does not fully correct with simple passive movement and needs specific treatment.
When to see a specialist
Ideally it should be assessed in the first weeks of life: treatment works better the earlier it starts. If it was seen on a pregnancy scan, you can request a prenatal consultation to learn about the treatment in advance.
How is it diagnosed?
The diagnosis is clinical: it is made by examining the baby. X-rays are not usually needed. The consultation also includes an overall assessment of the baby to rule out other associated problems.
Treatment
Conservative treatment: the Ponseti method
The Ponseti method is the reference treatment worldwide. Dr. Corominas trained in it at the University of Iowa with Dr. Morcuende, at the centre where the method was developed. It has three phases:
1. Serial casts. At each session the foot is gently manipulated following a specific sequence and a cast is applied from the toes to the groin to hold the correction achieved. Casts are usually changed every week. Typically 4 to 5 casts are needed, although the number depends on the severity and how each foot responds.
The correction is gradual and respects the anatomy and flexibility of the structures of the foot. It is not simply a matter of forcing the foot into a normal position.
2. Achilles tenotomy. A large proportion of children need a small procedure, a percutaneous Achilles tendon tenotomy, to correct residual equinus and achieve adequate ankle dorsiflexion. It is a brief procedure carried out at the end of the casting phase, usually in the clinic under local anaesthesia, which functionally lengthens the Achilles–calcaneus complex. The anaesthetic technique is adapted to the patient’s age and characteristics. The tendon heals on its own.
A final cast is then applied for about 3 weeks to let the tendon heal in the corrected position.
3. Abduction brace (boots and bar). This stops the foot from becoming deformed again. It is worn 23 hours a day for the first 4 months, then 18 hours a day until 12 months, and afterwards only during sleep (12–14 hours) until 4–5 years of age. This is the most important phase for preventing relapse: the brace does not just maintain the immediate result, it reduces the risk of the deformity returning during growth.
It is important for families to understand how to put it on, how to check the skin and how to spot possible fitting problems. Persistent discomfort, skin sores or difficulty keeping the brace on should be reported to the medical team.
Relapses and surgical treatment
Clubfoot can relapse during growth, even after a satisfactory initial correction. The risk increases when the brace is not worn as instructed, although relapses can also occur despite good adherence.
Signs to watch for include:
- Walking on the outer edge of the foot again.
- The foot tending to turn inwards.
- Gradual loss of ankle dorsiflexion.
- Toe walking or early heel lift.
- Loss of flexibility or return of the deformity.
If these signs appear, a specialist assessment is advisable without waiting for the deformity to progress.
In many cases an early relapse can be treated with further manipulation and serial casts. Some children need to go back to the brace or change how they wear it.
When a muscle imbalance persists, especially a tendency for the foot to turn up and in (dynamic supination) when walking, a tibialis anterior tendon transfer may be indicated. In selected cases other soft-tissue or bone procedures may also be needed.
Treatment is decided individually, taking into account age, flexibility, walking pattern and previous treatments.
Outlook and recovery
With properly performed treatment and appropriate follow-up, most children with idiopathic clubfoot can achieve a functional foot that allows them to walk, run, play sport and take part in the usual activities for their age.
The aim is not just a normal-looking foot, but:
- Proper weight-bearing on the sole.
- Functional ankle and foot movement.
- Efficient, stable walking.
- No pain, or significantly reduced pain.
- Prevention of residual deformities and relapses.
- The least possible need for extensive surgery.
The affected foot may remain somewhat different in size, muscle bulk or movement from the healthy foot, especially when only one side is affected. These differences do not necessarily mean significant functional limitation.
The outlook depends on the type of clubfoot, its initial severity, associated conditions, response to treatment and follow-up during growth.
Why follow-up until adolescence matters
Clubfoot needs long-term monitoring. Even when the initial correction is satisfactory, new changes in foot position, movement or walking pattern can appear during growth.
Check-ups confirm that the correction is stable, assess musculoskeletal development, detect relapses early and adapt treatment to the needs of each stage.
Follow-up must be tailored to each child and continue throughout growth, with particular attention to periods when clinical or functional changes are detected.
Complex, atypical and syndromic clubfoot
Complex or atypical clubfeet, or those associated with neuromuscular conditions, need more specific planning.
They may be stiffer, have deep skin creases, a shortened foot, persistent deformities or a less predictable response to conventional treatment.
In these patients it is especially important to adapt the manipulation, the casting technique, the follow-up and, where appropriate, the indications for surgery.
Care may require collaboration with specialists in paediatric neurology, genetics, rehabilitation, physiotherapy and other areas, depending on the child’s needs.
Surgery is reserved for cases where a significant deformity persists or there is a functional problem that cannot be adequately corrected by conservative methods.
Frequently asked questions
Does clubfoot hurt my baby?
No. Clubfoot does not cause pain in newborns, and Ponseti casts should not bother them either if they are applied correctly.
Will my child be able to walk and play sport normally?
With well-performed Ponseti treatment and good brace adherence, the vast majority of children walk, run and play sport normally.
Can it be detected before birth?
It is often seen on the second-trimester ultrasound scan. If so, you can request a prenatal consultation to learn about the treatment before your baby is born.
What if clubfoot is associated with a neurological or genetic condition?
In these cases treatment needs to be adapted and the associated conditions assessed. A multidisciplinary approach and closer follow-up may be needed.
This page is for general information and does not replace an assessment by a specialist. If you are worried about your child's foot, talk to their paediatrician or book an appointment.