CONGENITAL TALIPES EQUINOVARUS (CTEV)

Mayank Pushkar. BPT, MSAPT*

INTRODUCTION deformities- Equinus, Varus, Adductus and cavus4.

The ‘equinus’ deformity is present at the ankle joint,
Congenital telipesequinovarus (CTEV) is a
TCN joint and forefoot. The ‘varus’ component
common congenital limb deformity involving one
occurs primarily at TCN joint and the hind foot is
foot or both1. “Congenital” means a deformity that is
rotated inward. The ‘adductus’ deformity takes place
present at birth, “Telipes” means simply the foot and
at the talonavicular and the anterior subtalar joints.
ankle, and “Equinovarus” refers to position of the
The ‘cavus’ component involves forefoot plantar
foot, which points downward and inward. CTEV is
flexion, which contributes to the composite equinus.
also known as “Clubfoot”. An estimated 30000
children born with CTEV every year in India2,
although a rate of 1.24 or greater have been reported
in UK. It is a common birth defect, occurring in
about 1/1000 live births. Almost half of the cases of
CTEV are bilateral. Male children are more affected
than female children with a ratio of approximately
2:13. Fig- 1- Showing CTEV in both the foot.

PATHOANATOMY AETIOLOGY

Genetic factors play an important role in

The true clubfoot is characterized by different

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 ISSN: 2277-1700 ● Website: http://www.srji.info.ms ● URL Forwarded to: http://sites.google.com/site/scientificrji
inheritance of CTEV as a polygenic multifactorial
trait5. Maternal Hyperthermia is also one of the
causes for CTEV6, as maternal hyperthermia acts as
adverse environmental factor in the sensitive period
of intrauterine development.
Mainly there are 3 broad categories responsible
for CTEV deformity in newborn7-
1. NEUROLOGICAL DAMAGE
2. MUSCULO-SKELETAL DEFORMITY
3. POSTURAL DEFORMITY
1.NEUROLOGICAL DAMAGE: Spina bifida
overta with failure of development of the sacral part
of the spinal cord but normal proximal development
can results in an equinovarus deformity of the foot.
2. MUSCULO-SKELETAL DEFORMITY:
CTEV can results because of composite intrinsic
pathology of muscle and the bone. There are
varieties of other conditions which affectthe
peripheral musculoskeletal tissues and cause an
equinovarus deformity.
3. POSTURAL DEFORMITY: Some children
born with equinovarus deformity of the feet, if they
have been tightly packed in the utero with the feet
fixed in an equinovarus position for some week prior
to birth.
TYPES OF CTEV
1. STRUCTURAL CTEV: This type of CTEV is
caused by genetic factors such as- a genetic defect
with 3 copies of chromosome 18, which is known an
“Edward Syndrome”. Compartment syndrome,
Larsen’s syndrome, congenital heart defect and
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neural tube defect are some of the other causes of
structural CTEV4.
2. POSTURAL CTEV: This type of CTEV is
caused due to the compression in utero with the feet
held in equionovarus position in final trimester.
CLINICAL FEATURES OF CTEV
Idiopathic clubfoot is characterized by a bean-
shaped foot prominence of the head of Talus, medial
plantar cleft, deep posterior cleft, absence of normal
creases over the insertion of tendon achilies,
calcaneal tuberosity situated at a higher level and
atrophy of calf muscle4. Three major components of
deformities, those are, equinous, varus and adducts,
are obvious on examination. Presence of other
anomalies implies a non-idiopathic type of clubfoot.
Hypertrophy of calf muscle is present and
dorsiflexion and eversion are limited. Lateral
malleolus is very prominent while the medial
malleolus is buried in a depression because of the
inversion at the subtalar joint. There is also
exaggeration of longitudinal arch of the foot.
ASSESSMENT OF CTEV
ANTENATAL DIAGNOSIS: The clubfoot can be
diagnosed at 18-20 weeks of gestation with the
advert of Ultrasound. Amniocentesis is made at < 20
weeks to check for the high incidence of associated
genetic anomalies7,8.
POSTNATAL DIAGNOSIS: The child as well as
foot must be carefully assessed at birth.
The early assessment of CTEV can be carried out by
two methords9:
1. Photographic Assessment
 Scientific Research Journal of India ● Volume: 2, Issue: 1, Year: 2013

2. Radiological Assessment CTEV is the correction of the deformity followed by

1.PHOTOGRAPHIC ASSESSMENT: Photograph
of resting forefoot supination is recommended at
birth. The focus of the camera is centred at the level
of the ankle joint and an assistant holds the knee
between finger and thumb and rotates the leg
outward until the forefoot is superimposed upon the
line of tibia. From the photograph it is then possible
to measure an angle subtended by the forefoot on the
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line of the tibia (Fig. 2). Children with more than 90
of resting forefoot supination at birth were more
resistant to surgical correction.
maintenance of the in the corrected position.
The management of CTEV can be conservative
(Non-operative) method as well as operative
depending on the severity of deformity and age of
child.
CONSERVATIVE TREATMENT
The conservative method comprises of
manipulation with or without strapping or corrective
plaster casts. The goal of physiotherapy management
of CTEV consisted of short term and long term
goals14. The short term goal is to correct the
deformity so that ankle assumes plantigrade
positioning by the time the child would be 3 months.
The long term goal is to maintain the corrected ankle
in the situ and follow up the maintained correction
until the child start walking.

MEANS OF PHYSIOTHERAPY
MANAGEMENT

1. Rhythmic and repeated gentle

manipulation10

Fig. 2- Showing the measurement of angle. 2. Strapping and Plaster of Paris

2.RADIOGRAPHIC ASSESSMENT: A standard 3. Education and instruction to the mother

lateral soft tissue radiograph of the lower leg can be and/ or parents10

used for the assessment of CTEV. But X-Rays are

1. RHYTHMIC AND REPEATED GENTLE
not routinely prescribed at birth as few bones in the
MANIPULATION: To provide gentle
foot are ossified4. Also there is not much of clinical
manipulation, the PT placed the knee at 900 of
use of radiographic assessment as it does not make
flexion to prevent the damage to the lower end of
any difference in management of CTEV.
tibia and fibular epiphysis and the ankle joint. To

MANAGEMENT OF CTEV correct the adduction, the soft tissue of foot is

passively stretched as- the forefoot is uncurled so
The main principle of the management of that it moves away from epsilateral heel i.e. forefoot

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abduction. To correct the inverted foot, the foot is correction by this technique is 20.4.
turned such that the sole face outward i.e. eversion.
Ponseti’s Technique4: In Ponseti’s technique, first 2
Finally, to correct the equinus, the heel is cupped
casts are applied with the supination of forefoot so
with the one hand from the front of the foot and an
as to bring into alignment with the hind foot12. The
upward pressure is applied, which brings the ankle
third cast is applied with the forefoot abducted and
into dorsiflexion. The entire procedure is repeated 3-
simultaneous counterpressure over the head of talus.
4 times in each foot.
In the fourth cast, the forefoot is further abducted.
2. STRAPPING AND PLASTER OF PARIS: This Before the application of fifth cast, the degree of
can be useful for fairly mild cases and should be dorsiflexion is assessed and if the dorsiflexion is not
started at birth. Strips of adhesive strapping are possible beyond neutral, then a “Percutaneous
passed around the foot, up the side of legs, and over AchiliesTenotomy” is required, this is done under
the top of the knee, to hold the foot in a corrected local anaesthesia. The casts are changed weekly
position. This is usually done weekly, followed by intervals, before tenotomy, while the cast after the
some manipulation by the physiotherapist. tenotomy is removed at the end of 3 weeks. After the
removal of cast the patient is placed in modified
According to the “International Clubfoot Study
“Foot Abduction Orthosis (FAO)”. FAO is initially
Group (2003)”, Kite’s, Ponseti’s and Bensabel’s
used 23 hrs.a day for 4 months and then
techniques have been approved as the standardized
subsequently for night-time for 3 years13. The
conservative regimes for the management of
average number of casts required with this technique
CTEV11.
is 5.4.
Kite’s Technique4: This technique was derived from
French Technique4: This technique involves daily
the concept of three-point pressure. In this method,
manipulation of the child’s clubfoot by
the manipulation can be started soon after birth. The
Physiotherapist for 30 minutes, followed by
forefoot is grasped and distracted while the other
stimulation of muscles (especially Peroneal muscle)
hand holds the heel. The counterpressure is applied
around the foot and then adhesive strapping is
over calcaneocuboid joint and the navicular is
applied. Daily treatment is required for
pushed laterally. The heel is everted as the foot is
approximately 2 months and then reduced to 3
abducted. This is followed by application of slipper
sessions per week for an additional six months.
cast, which is extended to below the knee with the
Tapping is continued until the patient is ambulatory.
foot everted with gentle external rotation. Once the
Once the child starts ambulation, then night-time
adduction and varus are corrected, then the foot is
splint is given for additional 2 to 3 years.
pushed into dorsiflexion to correct the equinous. The
casts are changed every week. Following full 3. EDUCATION AND INSTRUCTION TO THE
correction, the foot are placed in a “Denis Brown MOTHER: The mother should be assured and
Bar”. The average number of cast required for reassured that with her co-operation, consistency and

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 Scientific Research Journal of India ● Volume: 2, Issue: 1, Year: 2013

compliance to treatment, the deformity could be prevent stiffness, which can be done with following
corrected. She should be taught how to mobilize the physiotherapy interventions15.
feet in the absence of strap10. She is advised to take
• Movement of toe, hip and knee in the plaster
care and observed every time when a fresh strapping
cast only, by tickling or by holding child
or plaster is applied and also to prevent the plaster or
high in suspension.
strapping from being wet or soiled either by water or
any other fluid. • To improve strength and stability gradual
active non-weight bearing and resisted foot
SURGICAL/ OPERATIVE MANAGEMENT
and ankle exercises are given, followed by
The operative treatment is required once the progression to weight-bearing exercises.
conservative treatment fails or the chance of
• To maintain the correction and avoid
correction of deformity with conservative
recurrence, Night splint are provided. Some
management is very less. Different operative
of the splints used in the management of
procedures are performed based on the age of child.
CTEV are-
At 9 months – 3 years: A Postero-medial soft tissue
1. CTEV Splint
release (PMR), which was introduced by Turco14 is
performed and followed by “Dennis Brown splint” 2. Dennis Brown Splint (Fig-4)
for 2 years. In this technique, the correction of the
3. CTEV Shoes (Fig-5)
abnormal tarsal relationship is prevented by rigid
pathological soft tissue contracture. • Gait training with proper foot position is

At 3 years- 8 years: At this age, soft tissue release taught to the patient.

along with Wedge Osteotomy of cuboid bone, which

• Special CTEV shoes are given to the
is known as EVANS is performed.
patients. The shoes got straight inner borer,

At 8- 12 years: At this age, the Wedge Osteotomy which prevents forefoot adduction, outer

of calcaneum (Dwyer’s Operation) along with shoe raise to prevent inversion and no heel

wedge osteotomy of tarsal bone is performed. to avoid equinus.

Above 12 years: A triple arthrodesis of 3 joints of • An effective training is given to the mother

foot (i.e. subtalar, calcaneo-cuboid and talo- or both parents for home care programme to

navicular joint) is performed. maintain the correct position of the limb and
how to give the exercise in correct way.
POST-OPERATIVE PHYSIOTHERAPY
MANAGEMENT

The main objective of physiotherapy after surgical

procedure is to keep the other joints mobile and

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Fig-3- CTEV Splint

Fig-5- CTEV Shoes Splint

Fig-4- Dennis Brown

REFRENCES

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6. Edwards, M.J. The experimental production of clubfoot in guinea pigs by maternal hyperthermia during
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7. Katz K, Meizner I, Mashiach R, Soudry M. The contribution of prenatal sonographic diagnosis of clubfoot to
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8. Roye, B.D., Hyman J., Roye, D.P. Jr. Congenital idiopathic talipesequinovarus. Pediatr Rev, 2004;25:124-30.

9. Porter, R. Club foot. The foot,1997;7: 181-193.

10.Ezeukwu, A.O. and Maduagwu, S.M. Physiotherapy management of an infant with bilateral congenital
talipesequinovarus. African Health Science, 2011;11(3): 444-448.

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11. Bensahel, H., Guillaume, A., Czukonyi, Z. andDesgrippes, Y. Results of physical therapy for idiopathic
clubfoot: A long term8follow up study. J Pediatr Orthop,1990;10:189-92.

12. Ponseti IV, Campos J. Observations on pathogenesis and treatment of clubfoot. ClinOrthop, 1972;84:50-60.

13. Ponseti IV. Congenital clubfoot: Fundamentals of treatment. Oxford University Press: Oxford, England; 1996.

14. Turco VJ. Clubfoot. Churchill Livingstone: New York; 1981.

15. Goel RN. Goel’s Physiotherapy.Shubham Publication- Bhopal, Vol II, 2000.

CORRESPONDING AUTHOR:

* Email: physio.mayank.pushkar@gmail.com

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