Club foot

• Congenital talipes equinovarus (CTEV)

• 754.51 Congenital talipes equinovarus

• Q66.0 Congenital talipes equinovarus

• 4B: Impaired Joint Mobility, Motor Function, Muscle Performance, and ROM Associated with Impaired Posture

Description

• Three malformations of the foot/ankle complex seen at birth
  • Plantarflexion (ankle or hindfoot equinus)
  • Inversion (rearfoot varus)2
  • Adduction (forefoot varus or metatarsus adductus)2

Essentials of Diagnosis

• Idiopathic, though can be hereditary
• Neurogenic
• Associated with syndromes such as arthrogryposis and Larsen syndrome3
• Postural or positional; not a true club foot

General Considerations

• Two categories: flexible or rigid
• Results from abnormally shaped tarsal bones that cause ligament and joint changes
• Often associated with myelomeningocele4
• May result from arthrogryposis

Demographics

• Incidence 1 to 2 per 1000 infants
• 2:1 male-to-female ratio
• Hispanics at greater risk
• Asians at least risk
• 50% bilateral
• Occurs most often in first-born infants

Signs and Symptoms

• Either flexible or rigid deformities of the foot including plantarflexion, adduction, and inversion
• Contracted intrinsic muscles of the foot
• Vertical talus

Functional Implications

• Unable to stand with flat foot or bear weight on the involved side

Possible Contributing Causes

• Genetic: siblings 30 times more likely to also have club foot
• Environmental: in-utero complications, such as too little amniotic fluid (oligohydramnios) or abnormal fetal positioning
• Dwarfism
• Myelomenigocele
• Polio
• Cerebral palsy

Differential Diagnosis

• Metatarsus adductus
• Postural club foot
• Tarsal coalitions
• Skew foot
• Streeter’s dysplasia

Imaging

• X-ray to assess bone alignment

• All patients with CTEV should be referred to an orthopedic surgeon for possible
  • Serial casting5
  • Stretching and splinting
  • Surgical repair (15 to 50%)
  • Ponseti method involving manipulation and casting6
  • Night splint after correction

• Unable to stand independently
• Unable to ambulate
• Decreased passive and active ROM for dorsiflexion, abduction, and eversion

• Goniometric measurements

• Serial casting
• Gentle passive ROM to stretch soft tissue and correct alignment
• Neurodevelopmental treatment to achieve age-appropriate motor milestones in conjunction with serial casting or splinting
  • Facilitate weight-bearing while sitting on bench or chair
  • Facilitate weight-bearing with supported standing or while standing at furniture
• Pre-gait training activities and gait training
• Manual therapy; mobilize the talonavicular joint by moving the navicular laterally and the head of the talus medially

• Patient will be able to:
  • Demonstrate full passive and active ankle and foot ROM to maximize function
  • Stand at furniture for 5 to 10 minutes while playing
  • Cruise at furniture to increase mobility
  • Ambulate with 2 hands held for household mobility
  • Ambulate with 1 hand held as primary method of mobility
  ...