Clubfoot

Clubfoot is an abnormality of the ankle and foot that is usually present at birth. The foot points downward and the toes turn inward. The tendon in the heel and ankle is often very tight, making it impossible for the foot to be in a normal position.

Clubfoot happens in about one to three of every 1,000 births, with boys slightly outnumbering girls. One or both feet may be affected.

What are the risk factors for clubfoot?

Risk factors may include:

• Family history of clubfoot
• Multiple gestations (twins or triplets)
• Increased occurrences in those children with neuromuscular disorders, such as cerebral palsy (CP) and spina bifida
• Oligohydramnios (decreased amount of amniotic fluid surrounding the fetus in the uterus) during pregnancy

Babies born with clubfoot may also be at increased risk of having a related hip condition known as developmental dysplasia of the hip (DDH). DDH is a condition of the hip joint in which the ball at the top of the thigh bone slips in and out of the hip. Learn more about developmental dysplasia of the hip (DDH).

How is clubfoot diagnosed?

Your child’s doctor makes the diagnosis of clubfoot at birth with a physical exam. During the examination, your child’s doctor obtains a complete prenatal and birth history of the child and asks if other family members are known to have clubfoot. An X-ray may also be used to confirm a diagnosis of clubfoot.

How is clubfoot treated?

The goal of treatment is to straighten the foot so that it can grow and develop normally. We specialize in the Ponseti method, which uses gentle manipulation and casting to correct clubfoot. Though the method is not used for every child, it is recommended that Ponseti treatment be started as soon as clubfoot has been diagnosed, even as soon as one week of age. Most infants with clubfoot can be corrected with gentle manipulation and casting. If standard treatment does not work, or the deformity reoccurs, surgery may be needed.

Casting

A cast will be applied to the child that goes from the toes to the upper part of the thigh. The cast causes the feet and ankles to turn a certain way. A new cast in a new position will be placed every week for about six weeks. Before the final cast, a procedure called a tenotomy often needs to be done. The tight tendon in the ankle may need to be released surgically, so that the foot can move upward in the cast. This is a sterile procedure done in the office or clinic with a local anesthetic (pain medication). The final cast is applied right after the procedure and stays on for three weeks. Learn more about casting at CHOC.

Bracing

Following casting and the tendon release, a foot abduction brace is often prescribed to prevent clubfoot from reoccurring. This brace, commonly called Denis Browne Bar Shoes, consists of an adjustable bar that connects two footplates, which are attached to shoes.

The brace is to be worn 23 hours a day for three to four months, except during baths. The brace is then worn at night and during naps for three to four years. The duration will be decided by your child’s doctor; it’s important not to end treatment early.

Wearing Instructions

• Always use cotton socks that cover the foot everywhere the shoe touches. Your baby’s skin may be sensitive after the cast, so you want to use two pairs of socks for the first two days.
• To put the brace on, insert the more affected foot first, then the less affected foot. If your baby tends to kick a lot, try inserting the less affected foot first.
• Hold the foot in the shoe and tighten the strap. The strap helps keep the heel firmly down inside. Check that the child’s heel is down in the shoe by pulling up and down on the lower leg. If the toes move backward and forward, the heel is not down, so you must retighten the strap. A line should be on the insole of the shoe, indicating where a child’s toes should be at or beyond when the shoe is on properly.
• Lace the shoes tightly. Do not cut off circulation. Remember: the strap is the most important part. The laces are only used to help hold the foot in the shoe.
• Be sure all of the baby’s toes are out straight and that none of them are bent under. Until you are certain of this, you may want to cut the toes out of a pair of socks so you can clearly see all the toes.

Replacing the Shoes

• The brace will be set up initially by our clinic technicians. However, you may be responsible for changing the shoes and widening the bar as your child grows.
• Change the shoes only when the baby’s toes completely curl over the edge of the shoe. If you don’t know what size of shoes was used originally, measure the length of the shoe and contact our office. New shoes will be two sizes larger than the current shoes.
• Mark the joints on the bar before changing the shoes to ensure a return to the proper alignment.
• Attach the shoes with the buckles toward the inside. You should adjust the width of the bar at this time. Measure the distance between the outside of your child’s shoulders. Lengthen the bar to match your measurement.
• Mark a line for the location of the toes the first time the new shoes are worn, so you will know if the heel is down.

More Tips

• Expect your child to be fussy in the brace for the first two days. This is not because they are in pain, but because they are wearing something new and different.
• Play with your child in the brace. This is key to getting over their irritability quickly. Your child is unable to move his or her legs independently of each other, so you must teach your child that he or she can kick and swing the legs simultaneously. You can do this by gently flexing and extending the knees and pushing and pulling on the brace’s bar.
• Children do better if you make their treatment a routine. During the second stage, when your child wears the brace during the night and naps, be sure to put the brace on any time your child goes to their sleeping spot. They will figure out that they need to wear the brace at those times of the day. Your child is less likely to fuss if you make this part of their routine.
• Pad the bar. A bicycle handle bar pad works well for this. By padding the bar, you will protect your child, yourself and your furniture from being hit.
• Some redness is normal with the use of the brace. Never use lotion on any red spots on the skin. Lotion may make the problem worse. Bright red spots or blisters, especially on the back of the heel, indicate that the shoe is not being worn correctly. Make sure the heel stays down in the shoe. If you notice bright red spots or blistering, contact your child’s doctor.
• Be sure to periodically tighten the screws on the bar, using the tools provided.
• If your child repeatedly escapes from the brace, try the following. After each step, check to see that the heel is down. If not, proceed to the next step.
  • Tighten the strap by one more notch.
  • Tighten the laces.
  • Remove the tongue of the shoe. Use of the brace without the tongue will not harm your child.
  • Lace the shoes from top to bottom, so that the bow is by the toes.