Clubfoot (Congenital Talipes Equinovarus, CTEV) is a congenital deformity of the foot and ankle in which the foot is turned inward and downward. This condition involves a combination of forefoot adduction (inward turning), hindfoot varus (inward tilt), midfoot cavus (high arch), and ankle equinus (upward bending). If untreated, it can lead to long-term disability, gait abnormalities, and complications such as skin ulcers and arthritis. Early intervention is key to achieving functional foot alignment and preventing permanent deformity.
How Common It Is and Who Gets It? (Epidemiology)
Clubfoot affects approximately 1–2 per 1,000 live births worldwide.
- Males are affected twice as often as females.
- Bilateral involvement (both feet) occurs in 50% of cases.
Most cases are idiopathic, meaning no specific cause is identified, although genetic factors and family history may play a role. Syndromic clubfoot, associated with conditions such as arthrogryposis or spina bifida, is less common but can lead to more severe deformities and treatment challenges.
Why It Happens – Causes (Etiology and Pathophysiology)
The causes of clubfoot are complex and multifactorial:
- Idiopathic clubfoot results from developmental malalignment of the foot and soft tissues.
- Neuromuscular clubfoot is associated with systemic conditions like cerebral palsy or myelomeningocele, where muscle imbalances exacerbate foot deformity.
- Genetic factors: Some cases run in families, indicating a genetic predisposition.
- Intrauterine factors: Conditions such as oligohydramnios (low amniotic fluid) or intrauterine compression may increase risk.
How the Body Part Normally Works? (Relevant Anatomy)
The foot and ankle are formed by a complex arrangement of bones, ligaments, tendons, and muscles.
- The talus bone connects the lower leg to the foot.
- The calcaneus, navicular, cuboid, and metatarsals form the arch and contribute to foot motion.
- In clubfoot, the talus is medially rotated, and the Achilles tendon and posterior capsule are often shortened, leading to restricted movement and abnormal foot positioning.
What You Might Feel – Symptoms (Clinical Presentation)
Symptoms of clubfoot include:
- A foot that is inwardly rotated and pointed downward, resembling a “club” shape.
- Limited ability to straighten the foot.
- Deformity of the ankle, often associated with a smaller calf muscle.
- Asymmetry between the affected and unaffected foot.
- In severe cases, the foot may become rigid with an inability to move the toes and ankle.
Symptoms are often pain-free at birth, but if untreated, deformity and functional limitations can worsen over time.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis is primarily based on physical examination at birth, where the foot’s abnormal position is visible.
- Prenatal ultrasound can detect clubfoot as early as 12–16 weeks of gestation.
- X-rays are performed after birth to evaluate bone alignment and rule out other skeletal anomalies.
- MRI or CT scans may be used in recurrent or complex cases to assess the soft tissues and bony structures more clearly.
Classification
The Pirani scoring system is used to assess the severity of clubfoot at birth:
- Score 0-2: Mild deformity
- Score 3-4: Moderate deformity
- Score 5-6: Severe deformity
The Dimeglio classification further categorizes deformity into flexible, rigid, or severe rigid forms, which helps guide treatment strategies.
Other Problems That Can Feel Similar (Differential Diagnosis)
- Positional clubfoot: Occurs due to intrauterine positioning and is flexible, unlike true clubfoot.
- Metatarsus adductus: A milder foot deformity where the forefoot is inwardly curved but not as severe.
- Hip dislocation: May present with a similar foot position but is accompanied by other joint abnormalities.
- Neuromuscular conditions (e.g., cerebral palsy) may cause abnormal foot positioning that mimics clubfoot but requires different treatment.
Treatment Options
Non-Surgical Care
The Ponseti method is the gold standard for treating idiopathic clubfoot and aims to correct the deformity through gentle manipulation and casting:
- Weekly casting is done for 6–8 weeks to correct the forefoot adduction, hindfoot varus, and midfoot cavus.
- Achilles tenotomy (cutting the Achilles tendon) is required in 80% of cases to allow correction of the equinus (toe-down position).
- After casting, a foot abduction brace (Denis Browne bar) is worn 23 hours/day for 3 months, then nightly until 4–5 years of age to maintain correction.
Other methods include Kite casting and physical therapy for stretching and strengthening.
Surgical Care
Surgery is indicated for rigid clubfoot, recurrence, or syndromic cases that do not respond to casting:
- Soft tissue releases: Includes posterior release (for the Achilles tendon) and release of other contracted ligaments.
- Tendon transfers: May include tibialis posterior tendon transfer to help correct foot positioning.
- Osteotomy: In older children with fixed deformities, to realign the bones.
- Triple arthrodesis: Fuses three midfoot joints (naviculocuneiform, calcaneocuboid, and subtalar) in severe deformities.
Surgical methods aim to restore functional alignment and preserve foot mobility, although recovery is longer than non-surgical methods.
Recovery and What to Expect After Treatment
- Non-surgical recovery: The Ponseti method allows for rapid improvement in the first 2–3 months. However, brace compliance is essential for long-term success.
- Surgical recovery: Following soft tissue release or tendon transfer, children usually begin weight-bearing after 4–6 weeks in a cast or boot. Full recovery and return to regular activity typically occur within 6–12 months.
Continuous follow-up with a pediatric orthopedist is necessary to monitor for recurrence and ensure proper growth alignment.
Possible Risks or Side Effects (Complications)
- Recurrence of deformity, often due to noncompliance with bracing protocols.
- Residual deformity or stiffness in some cases.
- Overcorrection leading to planovalgus (flatfoot with outward tilt) or rocker-bottom foot.
- Infection or delayed wound healing after surgery.
- Soft tissue scarring may limit mobility or flexibility.
Long-Term Outlook (Prognosis)
With early intervention, the prognosis for idiopathic clubfoot is excellent.
- Ponseti method results in >90% success for achieving a pain-free, flexible foot that supports normal walking.
- Surgical outcomes are generally favorable, but severe cases may require multiple procedures and extensive rehabilitation.
- Lifelong follow-up is essential to detect and treat any recurrence or growth-related deformities.
Out-of-Pocket Costs
Medicare
CPT Code 27650 – Soft Tissue Releases (Posteromedial Release, Achilles Tendon Lengthening, Tendon Transfer): $154.99
CPT Code 28735 – Bony Procedures (Osteotomy or Triple Arthrodesis): $181.60
Medicare Part B covers 80% of the approved cost for these procedures once your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans, such as Medigap, AARP, or Blue Cross Blue Shield, typically cover the remaining 20%, resulting in minimal or no out-of-pocket expenses for Medicare-approved surgeries. These supplemental plans are structured to work in coordination with Medicare to fill the coverage gap.
If you have Secondary Insurance through TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it acts as a secondary payer. These plans usually cover the remaining coinsurance or deductible amounts, which typically range from $100 to $300 depending on your plan and provider network.
Workers’ Compensation
If your clubfoot treatment is related to a work-related injury, Workers’ Compensation will cover all surgical and rehabilitation costs, including soft tissue releases and bony procedures. You will not have any out-of-pocket expenses, as the employer’s insurance carrier directly covers all medical costs.
No-Fault Insurance
If your clubfoot surgery or related complication is due to an automobile accident, No-Fault Insurance will typically cover the full cost of your treatment, including surgery and follow-up care. The only possible out-of-pocket expense may be a small deductible or co-payment based on your insurance policy.
Example
Isaac Clark developed clubfoot and required Achilles tendon lengthening and soft tissue release (CPT 27650) followed by a triple arthrodesis (CPT 28735). His estimated Medicare out-of-pocket cost for the soft tissue release was $154.99. Since Isaac had supplemental coverage through Blue Cross Blue Shield, his remaining balance was covered, leaving him with no out-of-pocket expenses for both procedures.
Frequently Asked Questions (FAQ)
Q. What is congenital talipes equinovarus (CTEV)?
A. Congenital talipes equinovarus, also known as clubfoot, is a congenital deformity where one or both feet are twisted out of shape or position.
Q. How common is congenital talipes equinovarus?
A. It occurs in about 1 in every 1,000 live births and is more common in boys than girls.
Q. What causes clubfoot?
A. The exact cause of clubfoot is unknown, but it is believed to involve both genetic and environmental factors.
Q. Is clubfoot painful for infants?
A. Clubfoot itself is not painful for infants, but if left untreated, it can lead to significant disability and discomfort as the child grows.
Q. What are the visible signs of clubfoot?
A. The foot is usually turned inward and downward, and the calf muscles on the affected leg are often underdeveloped.
Q. Can both feet be affected by clubfoot?
A. Yes, clubfoot can affect one or both feet, with bilateral involvement being common.
Q. How is clubfoot diagnosed?
A. Clubfoot is typically diagnosed at birth through physical examination, and it can sometimes be detected through prenatal ultrasound.
Q. What is the initial treatment for clubfoot?
A. The Ponseti method, which involves gentle manipulation and casting, is the most common initial treatment.
Q. How many casts are usually needed in the Ponseti method?
A. Usually, 5 to 7 casts are required to correct the deformity gradually.
Q. Is surgery required for all clubfoot cases?
A. Most cases respond well to the Ponseti method, but some may require a minor surgical procedure to release the Achilles tendon.
Q. What happens after the casting phase?
A. After casting, the child typically wears a brace to maintain correction and prevent recurrence.
Q. How long does a child need to wear the brace after treatment?
A. The brace is worn full-time for the first few months and then during naps and nighttime for several years.
Q. What if clubfoot is not treated?
A. Untreated clubfoot can lead to permanent disability, pain, and difficulty with walking.
Q. Can children with treated clubfoot lead normal lives?
A. Yes, with proper treatment, most children with clubfoot can walk, run, and participate in regular activities without limitations.
Q. Is recurrence of clubfoot possible after treatment?
A. Yes, recurrence can happen, especially if bracing is not followed properly, which is why regular follow-up is important.
Q. Are there long-term complications of clubfoot?
A. With successful treatment, long-term complications are minimal, though some children may have slightly smaller or less flexible feet.
Q. Does clubfoot have any impact on intelligence or brain development?
A. No, clubfoot is a structural condition of the foot and does not affect brain development or intelligence.
Q. What causes clubfoot?
A. It is usually a congenital deformity, but in some cases, it may be associated with neuromuscular diseases or other systemic conditions like spina bifida.
Q. How is clubfoot treated?
A. The Ponseti method is the standard treatment, involving serial casting and Achilles tendon release, followed by bracing. Surgery may be required for severe or recurrent cases.
Q. How long does the Ponseti method take to work?
A. Casting usually takes 6–8 weeks, followed by bracing for several months to several years to maintain correction.
Q. Can surgery be avoided?
A. Yes, with early intervention and proper brace compliance, many children achieve full correction without the need for surgery.
Q. What happens if clubfoot is left untreated?
A. Untreated clubfoot leads to lifelong deformity, difficulty walking, and potential joint arthritis.
Summary and Takeaway
Clubfoot is a congenital deformity that can be effectively treated with the Ponseti method if caught early. This involves serial casting, Achilles tendon release, and brace use. For severe or recurrent cases, surgery may be necessary to restore normal foot function and prevent disability. Early and consistent treatment leads to long-term success, allowing children to walk and live pain-free.
Clinical Insight & Recent Findings
A 2024 study from the Journal of the West African College of Surgeons evaluated the effectiveness of the Ponseti protocol for treating idiopathic clubfoot at Lagos University Teaching Hospital. Involving 82 children (128 feet), the study found an 84.4% success rate at six months, confirming the Ponseti method as a highly effective, low-cost treatment for congenital clubfoot.
The average initial Pirani severity score was 3.6, and most cases required about six casts to achieve correction. Over half (51.6%) of patients needed an Achilles tenotomy, typically those with more severe deformities. Importantly, compliance with the foot-abduction brace after casting was crucial—noncompliant patients had a 69% relapse rate, compared to only 2% among those who followed the brace protocol.
The study reinforces that early, consistent, and properly supervised Ponseti treatment leads to excellent outcomes in most children with CTEV. (“Study on Ponseti method outcomes in clubfoot – see PubMed.”)
Who Performs This Treatment? (Specialists and Team Involved)
Treatment is typically provided by orthopedic foot and ankle surgeons or podiatric surgeons. Radiologists assist in imaging interpretation, and physical therapists guide postoperative rehabilitation and gait training.
When to See a Specialist?
You should see a specialist if you notice persistent toe curling, pain, or pressure sores, especially if you have diabetes or reduced sensation in your feet.
When to Go to the Emergency Room?
Seek immediate medical attention if:
- The ulcer is deep or bleeding heavily
- You have fever, redness, or pus indicating infection
- You cannot walk or experience sudden pain, swelling, or deformity.
What Recovery Really Looks Like?
Healing requires consistent care: daily wound cleaning, offloading, and blood sugar monitoring. Patients often wear special shoes or casts to protect the foot during recovery. Full healing can take several weeks to months, but deep infections may require prolonged treatment.
What Happens If You Ignore It?
Neglecting a diabetic ulcer can lead to serious infection, including osteomyelitis or abscess formation. Chronic cases may require surgery and long-term antibiotics.
How to Prevent It?
- Inspect your feet daily for blisters, redness, or sores
- Keep blood sugar, cholesterol, and blood pressure under control
- Wear properly fitting, breathable shoes
- Avoid walking barefoot
- Visit a podiatrist regularly for preventive monitoring.
Nutrition and Bone or Joint Health
A balanced diet rich in lean proteins, vitamin C, zinc, and omega-3 fatty acids supports tissue repair. Maintaining proper hydration and glucose control also enhances wound healing.
Activity and Lifestyle Modifications
During recovery, minimize walking on the affected foot and use supportive footwear. Resume normal activity gradually once the wound has healed completely.
Dr. Mo Athar
