Club feet (talipes)

Club foot is a congenital abnormality that can affect one or both feet of the developing fetus. It is also known by the medical term Talipes, which is a contraction of the Latin words for ankle (talus) and foot (pes). Sometimes this is followed by a second term, which refers to the altered position of the foot. The most common of these is Talipes Equinovarus, which describes a foot that points down and is turned inward. The condition can affect the ankle, heel and toes, and the affected foot is usually slightly shorter, while the associated calf muscle may also be thinner. If not treated talipes can cause considerable disability, but with the appropriate treatment the club foot can look and function as a normal foot.

What causes club foot?

The incidence of club foot is about 1 in 1000 live births and there is some ethnic variation. About 25% of cases are familial, where more than one family member has been affected, and boys are twice as likely to have the condition as girls. About half the time, both feet are involved (bilateral) and the rest are unilateral (one foot affected).

Talipes can be either positional or structural. Positional refers to a normal foot, which has been forced into a deviated position due to crowding in the uterus – e.g. in multiple pregnancy – or to decreased amniotic fluid around the baby. In such cases, the malposition is usually mild and can be treated successfully with non-surgical techniques, such as physiotherapy and exercises, or splinting.

Structural talipes is a condition in which the foot is fixed into an abnormal position. The tendons in the ankle, such as the Achilles tendon, may be shortened, causing the foot to point down and turn inwards. In most cases, this is an isolated or idiopathic defect and there are no other obvious abnormalities seen in the fetus. In about 20% of cases, though, the club foot is associated with other congenital malformations and genetic conditions, such as spina bifida, cerebral palsy, arthrogryposis and Edwards syndrome (trisomy 18).

How is club foot diagnosed?

Traditionally talipes has been diagnosed by examination of the newborn and confirmed by x-ray of the foot. This is still sometimes the case, but in recent years the condition is often first seen during the second trimester detailed anatomy ultrasound scan. When detected during this scan at 19-20 weeks gestation, the sonographer or fetal medicine specialist can look for other abnormalities, which may be associated. This helps to determine whether it is an isolated defect, or part of another condition.

How is club foot treated?

As mentioned above, positional talipes may only require physiotherapy or splinting. Structural club foot usually entails a longer treatment with surgical and/or non-surgical techniques. Management depends on the degree of rigidity, associated abnormalities and secondary muscular changes, and should be started in the first few months of life, while the tissues are still soft and the baby less mobile. There has been a recent move away from surgery towards conservative treatments using manipulation and immobilization, such as the Ponseti method and the French functional method. The latter involves manipulation by specialized physiotherapists, with immobilization by bandages and pads. The Ponseti method progressively corrects the position of the foot using weekly casts, usually over a six week period.

Minor surgery to lengthen the Achilles tendon is often performed after this, followed by splinting – initially 23 hours a day, then nighttime only – for a total of three to four years. If conservative treatment is not appropriate, or does not provide full resolution of the deviated position, then surgery to release the shortened tendons of the ankle (including the Achilles) is required. Further corrective surgery may be needed in later childhood, which can involve minor reshaping of the bones in the ankle or foot.

What is the prognosis?

Initial conservative treatment – e.g. Ponseti – and/or surgery gives excellent results in about 90% of cases. Non-compliance with splinting is the most common cause for relapse. The vast majority of children treated get a good cosmetic result and normal function of their feet.

Many high level athletes were born with a club foot, including the Olympic gold medalist figure skater Kristi Yamaguchi, Dallas Cowboy quarterback Troy Aikman and the world’s most successful female football (soccer) player Mia Hamm. Stephen Gerrard, one of the current best international football players, as well as captain of both Liverpool Football Club and the England national team, also started life with this condition.

More information:

http://clubfootclub.org/
http://www.ponseti.info/ponseti-method.html
Huntley JS; Optimising the management of congenital talipes. Practitioner. 2013 Oct;257(1765):15-8.

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