Deformities The deformities affecting joints of the foot occur at three joints of the foot to varying degrees.

They are [2]

Inversion at subtalar joint Adduction at talonavicular joint and equinus at ankle joint, that is, a plantarflexed position, making the foot tend towards toe walking.[3]

The deformities can be remembered using the mnemonic, "InAdEquate" for Inversion, Adduction and Equinus.[4] Causes There are different causes for clubfoot depending on what classification it is given. Structural cTEV is caused by genetic factors such as Edwards syndrome, a genetic defect with three copies of chromosome 18. Growth arrests at roughly 9 weeks and compartment syndrome of the affected limb are also causes of Structural cTEV. Genetic influences increase dramatically with family history. It was previously assumed that postural cTEV could be caused by external influences in the final trimester such as intrauterine compression from oligohydramnios or from amniotic band syndrome. However, this is countered by findings that cTEV does not occur more frequently than usual when the intrauterine space is restricted.[5] Breech presentation is also another known cause.[citation needed]cTEV occurs with some frequency in Ehlers Danlos Syndrome and some other connective tissue disorders, such as Loeys-Dietz Syndrome. TEV may be associated with other birth defects such asspina bifida cystica. Prenatal Screening Screening for club foot prenatally is a debatable topic. However, this is commonly done as it is easily identified using a ultrasound scan. Most fetuses undergo a 20 weeks

gestation fetal abnormality scan [6] in which club foot is one of the abnormalities that can be picked up. Some doctors have argued that club foot may occasionally be associated with a syndromic disease and should therefore be screened. If no syndromic association is found prenatally, most fetuses with club foot are born and can live a normal life with medical treatment. Clubfoot is treated with manipulation by podiatrists, physiotherapists, o rthopedic surgeons, specialist Ponseti nurses, or orthotists by providing braces to hold the feet in orthodox positions, serial casting, or splints called knee ankle foot orthoses (KAFO). Other orthotic options include Dennis-Brown bars with straight last boots, ankle foot orthoses and/or custom foot orthoses (CFO). In North America, manipulation is followed by serial casting, most often by the Ponseti Method. Foot manipulations usually begin within two weeks of birth. Even with successful treatment, when only one side is affected, that foot may be smaller than the other, and often that calf, as well. Extensive surgery of the soft tissue or bone is not usually necessary to treat clubfoot; however, there are two minimal surgeries that may be required: 1. Tenotomy (needed in 80% of cases) is a release (clipping) of the Achilles tendon minor surgery local anesthesia 2. Anterior Tibial Tendon Transfer (needed in 20% of cases) where the tendon is moved from the first ray (toe) to the third ray in order to release the inward traction on the foot. Of course, each case is different, but in most cases extensive surgery is not needed to treat

clubfoot. Extensive surgery may lead to scar tissue developing inside the child's foot. The scarring may result in functional, growth and aesthetic problems in the foot because the scarred tissue will interfere with the normal development of the appendage. A child who has extensive surgery may require on average two additional surgeries to correct the issues presented above. In stretching and casting therapy the doctor changes the cast multiple times over a few weeks, gradually stretching tendons until the foot is in the correct position of external rotation. The heel cord is released (percutaneous tenotomy) and another cast is put on, which is removed after three weeks. To avoid relapse a corrective brace is worn for a gradually reducing time until it is only at night up to four years of age. Surgical treatment On occasion, stretching, casting and bracing are not enough to correct a baby's clubfoot. Surgery may be needed to adjust the tendons, ligaments and joints in the foot/ankle. Usually done at 9 to 12 months of age, surgery usually corrects all clubfoot deformities at the same time. After surgery, a cast holds the clubfoot still while it heals. It is still possible for the muscles in the child's foot to try to return to the clubfoot position, and special shoes or braces will likely be used for up to a year or more after surgery. Surgery will likely result in a stiffer foot than nonsurgical treatment, particularly over time. Without any treatment, a child's clubfoot will result in severe functional disability, however with treatment, the child should have a nearly normal foot. He or she can run and play without pain and wear normal shoes. The corrected clubfoot will still not be perfect, however; a clubfoot usually stays 1 to 1 sizes smaller and somewhat less mobile than a normal foot. The

calf muscles in a leg with a clubfoot will also stay smaller. Long-term studies of adults with post-club feet, especially those with substantial numbers of surgeries, may not fair as well in the long term, according to Dobbs, et. al.,[12] A percentage of adults may require additional surgeries as they age, though there is some dispute as to the effectiveness of such surgeries, in light of the prevalence of scar tissue present from earlier surgeries. Definition Clubfoot describes a range of foot abnormalities usually present at birth (congenital) in which your baby's foot is twisted out of shape or position. The term "clubfoot" refers to the way the foot is positioned at a sharp angle to the ankle, like the head of a golf club. Clubfoot is a relatively common birth defect and is usually an isolated problem for an otherwise healthy newborn.Clubfoot can be mild or severe, affecting one or both feet. Clubfoot will hinder your child's development once it's time for your child to walk, so treating clubfoot soon after birth is generally recommended. Treatment is usually successful, and the appearance and function of your child's foot should show improvement. Symptoms In most cases, clubfoot twists the top of your baby's foot downward and inward, increasing the arch and turning the heel inward. The foot may be turned so severely that it actually looks as if it's upside-down. Also, the calf muscles in your child's affected leg are usually underdeveloped, and the affected foot may be up to 1 centimeter (about .4 inches) shorter than the other foot. Despite its look, however, clubfoot itself doesn't cause any discomfort or pain.

When to see a doctor More than likely your doctor will notice clubfoot soon after the birth of your child. Your doctor can then advise you on the most appropriate treatment. Causes The cause of clubfoot isn't known (idiopathic). But scientists do know that clubfoot isn't caused by the position of the fetus in the uterus. In some cases, clubfoot can be associated with other congenital abnormalities of the skeleton, such as spina bifida, a serious birth defect that occurs when the tissue surrounding the developing spinal cord of a fetus doesn't close properly. Environmental factors play a role in causing clubfoot. Studies have strongly linked clubfoot to cigarette smoking during pregnancy, especially when a family history of clubfoot is already present. Risk factors Risk factors include: Sex. Clubfoot is more common in males. Family history. If you, your spouse or your other children have had clubfoot, your baby is more likely to have it as well. Smoking during pregnancy. If a woman with a family history of clubfoot smokes during pregnancy, her baby's risk of the condition may be 20 times greater than average. Complications Clubfoot typically causes no problems until your child starts to stand and walk. While your child's mobility may be slightly limited and the affected foot may be up to 1 1/2 shoe sizes smaller than the unaffected foot, treating clubfoot generally ends with your child having a relatively normal foot, both in the way it looks and functions. Left untreated, however, clubfoot can become a burden. Not only is your child likely to have arthritis, but the unusual appearance of the foot may make body image a concern during the teen years.

The twist of the ankle may not allow your child to walk on the soles of the feet. To compensate, he or she may walk on the balls of the feet, the outside of the feet or even the top of the feet in severe cases. These adjustments may inhibit natural growth of the calf muscles, cause large sores or calluses on the feet, and result in an awkward gait. Preparing for your appointment If your baby is born with clubfoot, he or she will likely be diagnosed soon after birth. In some cases, your baby's doctor may refer you to a pediatric orthopedist, a doctor who specializes in bone and muscle (musculoskeletal) problems. If you have time before meeting with your child's doctor, it's a good idea to make a list of questions. Your time with the doctor may be limited and appointments can go fast, so it helps to be prepared. Here are some questions to consider asking: What types of corrective treatment are available for my child's condition? Will my child need surgery? What kind of follow-up care will my child need? Should I get a second opinion before beginning my child's treatment? Will my insurance cover it? Can you tell how complete a recovery my child will have and whether he or she will have a normal gait? Are there any brochures or other printed material that I can take with me? What websites do you recommend? In addition, tell your doctor: If you have family members including extended family who've had clubfoot If you had any medical issues or problems during your pregnancy It's also a good idea to ask your doctor if he or she commonly treats newborns with clubfoot, or

if you should get a referral to another doctor. Tests and diagnosis Most commonly, a doctor recognizes clubfoot after birth just from looking at the shape and positioning of the newborn's feet. The doctor may request X-rays to fully understand the severity of the deformity. It's possible to clearly see some cases of clubfoot before birth during a baby's ultrasound examination. If clubfoot affects both feet, it's more likely to be apparent in an ultrasound. While nothing can be done before birth to solve the problem, knowing about the defect may give you time to learn more about clubfoot and get in touch with appropriate health experts, such as a genetic counselor or an orthopedic surgeon. Treatments and drugs Because your newborn's bones and joints are extremely flexible, treatment for clubfoot usually begins soon after birth. The goal of treatment is to restore the look and function of the foot before your child learns to walk, in hopes of preventing long-term disabilities. Treatment options include: Stretching and casting (Ponseti method). This treatment entails manipulating the foot into a correct position and then placing it in a cast to maintain that position. Repositioning and recasting occurs every week for several weeks. After the shape of the foot is realigned, it's maintained through stretching exercises, special shoes or splinting with braces at night for up to three years. For this method to work effectively, you'll need to apply your child's braces according to your doctor's specifications so that the foot doesn't return to its original position. Stretching and taping (French method). This approach involves daily manipulation of the foot, followed by the use of adhesive

tape to maintain the correct position until the next day. After two months, treatments are reduced to three times each week until the baby is 6 months old. Once the foot's shape is corrected, parents continue to perform daily exercises and use night splints until their baby is walking age. This method requires commitment to very frequent appointments for six months. Some providers combine the French method and the Ponseti method. Surgery. In some cases, when clubfoot is severe or doesn't respond to nonsurgical treatments, your baby may need surgery. An orthopedic surgeon can lengthen tendons to help ease the foot into a more appropriate position. After surgery, your child will need to wear a brace for a year or so to prevent recurrence of the deformities. Even with treatment, clubfoot may not be totally correctable. But in most cases babies who are treated early grow up to wear normal shoes and lead normal, active lives. Prevention Because the cause of clubfoot is unknown, you can't take absolute measures to prevent it. However, if you're pregnant, you can take steps to limit your baby's risk of birth defects, such as clubfoot. These steps include not smoking or spending time in smoky environments, not consuming alcohol, and avoiding drugs not approved by your doctor. Casting A series of plaster or fiberglass casts are applied to the foot and lower limb these are replaced every few weeks, which each cast progressively moving the foot towards a more corrected position. The number of times the cast needs to be replaced will be determined by the severity of the clubfoot (but several months is not unusual). Most activities are not hampered by wearing a cast.

Surgery If cast treatment fails or the clubfoot is rigid, surgery may be needed. This is not usually done until the child is between four and eight months of age. There are a variety of surgical procedures which may be done in isolation or in combination:

Soft tissue surgery that releases the tight tissues around the joints and results in lengthening of tendons so the foot can assume a more corrected position Bony procedures such as breaking bone and resetting the bone to correct deformities, or fusing joints together to stabilize joints to enable the bones to grow solidly together. Tendon transfers to move the tendons to a different position, so they can move the foot into a corrected position.