Positional Clubfoot

positional clubfoot

Positional Clubfoot or Talipes (from the Latin compound of “talus” meaning ankle and “pes” meaning foot) is a widely misunderstood, misrepresented and many times mistreated condition which affects approximately 1 in 1,000 children. For most, the term Clubfoot brings to mind a bony deformity, a structural anomaly that requires intensive and often aggressive intervention.  

But Positional Clubfoot refers to a flexible foot that was held over time in an abnormal position in utero. When the child is born, due to the prolonged positioning, they may present with one or both feet in an atypical resting position. Bony alignment is not impacted and foot position is likely corrected by conservative treatment (involving a comprehensive program of stretching, range of motion, weight bearing and massage).

Management requires time and attention to undo the positional constraints imposed during the baby’s compressed time in utero. Long term prognosis of Positional Clubfoot reveals the fact that most cases resolve without gait abnormalities as the child matures and develops.

This leaves us to question, is the label “Positional Clubfoot” causing confusion? Could we relabel this truly benign condition to better emphasize its meaning?

With such a great prognosis coupled with the fact that children with Positional Clubfoot respond so well to conservative strategies, this should be a diagnosis presented with reassurances about outcomes. Collaborative care focused on working directly with families to teach helpful interventions, and assistance in building strategies into the child’s daily routine will ensure the best possible outcomes. So why are we hearing time and again from families that recommendations for serial casting and even Achilles tenotomy have been made by respected Pediatric Orthopedists and Orthopedic Surgeons, for the very children that we are discussing?

positional clubfoot
Children with Positional Clubfoot can typically achieve full passive range of motion of ankle

Children with Positional Clubfoot typically exhibit unrestricted passive range of motion of forefoot and ankle. And yet, many medical professionals are pushing for invasive strategies initiated early in infancy, without introducing or entertaining the idea of more conservative strategies, let alone consultation with a Pediatric Physical Therapist. Labels can be misleading and the diagnosis of Clubfoot spans conditions which differ widely in presentation, anatomy, neurologic involvement, severity and prognosis.

These different presentations require very different interventions. Treating all children with the general diagnosis “Clubfoot” in the same manner is both wrong and potentially harmful!

positional clubfoot
Congenital Clubfoot presentation

Classification of Clubfoot:

  1. Positional Clubfoot (or Positional Talipes) refers to a flexible, typically developed foot which due to prolonged positioning in utero presents in internally rotated manner at rest. This presentation lacks any true anatomic abnormality. Often associated with a restrictive uterine environment (for instance, in multiples, larger babies, oligohydramnios, or uterine anomalies).
  2. Idiopathic Clubfoot (also referred to as Congenital Talopes Equinovarus – CTEV) refers to an isolated congenital condition, featuring a rigid foot with abnormal bony deformity present at birth, but not associated with any neuromuscular cause or syndrome.
  3. Neurologic Clubfoot refers to a presentation associated with concurrent sensory and or motor impairments, as in the case of a child with Spina Bifida.
  4. Syndromic Clubfoot refers to a presentation associated with more global findings and involvement of other musculoskeletal issues, as in the case of Arthrogryposis.

While positional clubfoot has an excellent prognosis with conservative management, idiopathic, neurologic and syndromic clubfoot require a completely different approach based entirely on each child’s individual presentation. 

positional clubfoot

Research Review

Unfortunately there is an extreme lack of evidence based research regarding treatment for Positional Clubfoot. In fact, in my review of the literature, I found only one reference in direct relation to the treatment of Positional Clubfoot (which they refer to as postural clubfoot) in the May 2012 Journal of the Australian Family Physician explain, “No treatment is required for most cases of postural clubfoot. Resolution often occurs within the first few weeks of life. However, severe cases which do not resolve within one month may actually represent mild structural clubfoot and referral to a Pediatric Physiotherapist is recommended.” There is no mention of any aggressive therapy, simply stating if the situation does not improve consult with a Physical Therapist.

Even in my investigation of research regarding the more structurally impaired Congenital Clubfoot or Congenital Talipes Equino Varus (CTEV) diagnosis, evidence supporting aggressive management is lacking. Despite this dearth of evidence, there has been a push for early invasive management when anatomical expectations are not met. The efficacy of further interventions beyond conservative measures have not been adequately demonstrated. The few studies which have demonstrated success are based on anatomical and radiographic findings. When functional based outcomes are measured, children treated with invasive procedures perform worse. A 2011 review article in the Journal of Experimental and Clinical Medicine sums it up well,

“There should be two simple long term goals in the treatment of children with clubfoot. First, the foot should be free of pain during activities of daily living. Second, the foot should allow the child to walk as close to normal as possible, run with peers, and to participate in the typical activities of childhood, adolescence and finally adulthood. While studies reporting that radiographic measures may reflect correction of the clubfoot deformity, they have poor correlation with how the foot actually works in allowing normal function of the child.”

And yet these invasive treatments are still being performed and presented as the only options for children with clubfoot. It is important to note that most of these procedures are not without their own serious adverse effects. Early casting can cause: discomfort, skin breakdown and blistering, impede early motor milestones, reduce sensory feedback, and cause unnecessary stress and anxiety for the family.

Surgical interventions such as Achilles tenotomy, in which the heel cord is cut and lengthened with the expectation that elongating the muscle will release any restriction of ankle movement and allow for a “shoe-able” foot, can lead to motor delays and gait impairments in the child, not to mention the dangers that come with general surgery for young children.

I have spoken to many families whose children were diagnosed with Positional Clubfoot, and had been told that all Clubfoot is treated uniformly (despite the individual presentation), pushing for aggressive unnecessary interventions in these young infants (casting, bracing and surgery), without allowing this benign and often fully reversible condition the time to resolve itself with far more conservative treatment.

positional clubfoot
Ponseti Casting for Clubfoot
positional clubfoot
Tenotomy Model

Clinical decisions are usually impeded by a lack of adequate and convincing long term reviews of treatment based on prospective assessment and unbiased comparisons of different techniques. A 2009 publication from the Association of Bone and Joint Surgeons entitled, “Update on Clubfoot: Etiology and Treatment”, explains that in relation to treating Congenital Clubfoot,

“Avoidance of extensive soft tissue release operations in the primary treatment phase should be the priority, and the use of surgery for clubfoot correction should be considered only conservative methods fail.”

Operative vs. Non-Operative Strategies

Gait analysis data supports the application of nonoperative strategies for Congenital Clubfoot, such as Physical Therapy and taping (as in the French Functional Physiotherapy program). Studies by Muratli et al and Davies et al, both found that ankle motion, power and strength were diminished in children treated with surgical release, and that knee hyperextension and genu valium were more common in the surgical intervention group. This lack of ankle motion led to more compensatory abnormalities found in proximal portions of lower extremity in further follow up studies.

A 2005 study published in the Journal of Pediatric Orthopedics, examined children treated with PT vs. those treated with more invasive measures. The authors reported that improved gait dynamics were found more in the PT group, with more findings of impaired biomechanics in the surgical group. A 2009 study published in the Journal of Bone and Joint Surgery, compared Ponseti casting to Physical Therapy interventions for Idiopathic Clubfoot. They looked at long term follow up of nonoperative measures (5 years post) and reported decreased internal rotation, improved dorsiflexion and plantar flexion in both nonoperative groups, with more children continuing to present with in-toeing in the casting group as compared to the PT group.

Positional Clubfoot

Dobbs Clubfoot Bar Brace

Another recommendation commonly made for young infants diagnosed with positional clubfoot is the use of restrictive bracing like the Dobbs Clubfoot bar brace. As a 2010 review entitled, Bracing in the Treatment of Children with Clubfoot Past, Present and Future points out in relation to bracing, “Evidence in the literature regarding biomechanics effects, clinical outcomes, functionality and patient adherence is limited.”

An article by Bensahel et al from the Journal of Pediatric Orthopedics explains that “correction is not obtained by splints or strapping”. The authors explain that they have worked with many hundreds of children with clubfoot and have found that though early conservative treatment is stressed in the literature, few studies explain the parameters of a Physical Therapy program that are pivotal to the management of clubfoot. They highlight the benefit of early range of motion and stretching with child comfortable and relaxed and discuss that it is preferable that the child be free of splints during the pre-weightbraing stage of infancy as, “muscle imbalances may be present but correct themselves with time”. With participation free of bracing, mild forms of clubfoot will respond to active weight bearing and reverse foot deviations on their own. Bracing the foot so early on, prevents active movement and the crucial sensory feedback and input gained during a child’s early motor development. Not to mention, the undue stress and anxiety it causes families.

Treatment Focus

Our goal when treating children with Positional Clubfoot should be to restore each child to their maximal functional ability. All while providing the families with the tools and resources needed, as they are an integral part towards the success of the treatment. By grouping all cases of Clubfoot together, and not understanding how vastly different the underlying components of each case may be, we are causing more harm than benefit.

We need to treat Positional Clubfoot as the unique condition it is, and avoid intensive and aggressive treatments which have not shown to demonstrate any modicum of success in this population. Early commencement of Physical Therapy,  thorough education, family involvement, and an individualized plan of conservative management are essential aspects of Positional Clubfoot care.

Proposed Physical Therapy Treatment of Positional Clubfoot

 1. Range of Motion Exercises:

  • Attempt exercises after each diaper change, should be done when child is relaxed and comfortable
  • None of these exercises should hurt! Use gentle graded pressure for sustained stretch
  • Build up tolerance and extend length of stretch as indicated by child’s level of comfort

a. Ankle Range of Motion:

Starting Position: With child on his or her back.

Movement: Place one hand on child’s flexed knee. Grasp foot with palm of other hand, cupping above the heel. Gently flex the ankle up into dorsiflexion and extend down into plantar flexion. Cycle through the motion of the ankle 10x. After range of motion of ankle, move into sustained stretch.

Dorsiflexion Stretch:  With foot flexed up at ankle joint, hold for 15 second intervals, 5x.

positional clubfoot
positional clubfoot

b. Forefoot Range of Motion:

Starting Position: With child on their back

Movement: Stabilize with one hand on leg just above ankle, use other hand cupping around base of big toe, to turn foot in and out. Cycle through motion of forefoot 10x. After range of motion of forefoot, move into sustained stretch.

Inversion Stretch: With hand supporting forefoot turned inward hold for 15 second intervals, 5x.

positional clubfoot
positional clubfoot

2. Weightbearing Exercises:

  • Allow sensory input and feedback through feet, and provide child ability to maintain contact with surface with full plantar surface.
  • Try to position child into neutral foot position prior to weight bearing.
positional clubfoot
a. Supine Weightbearing:

Starting Position: With child on their back, knees bent and feet contacting floor.

Movement: Stroke outer edge of foot to encourage foot to move into more neutral alignment (with toes facing forward and ankle bent). Gently provide downward pressure through knees so that heel and forefoot maintain full contact with surface. Hold for 15 seconds, repeat 5x.

positional clubfoot
b. Supported Sitting Weightbearing

Starting Position: With child supported on your lap or seated on slightly elevated surface (1-2″), allow for knee and ankle flexed to 90 degrees with firm surface underneath.

Movement: Position foot in neutral and gently provide downward pressure through knees or top of foot, so that feet are fully contacting surface. Hold for 15 seconds, repeat 5x.

positional clubfoot

3. Massage:

Starting position: With child on his or her back or in your arms

Movement: Gently massage plantar surface and into arch of foot. Can use circular motion of thumb to release tight muscles.positional clubfoot

4. Tactile/Proprioceptive Input

  • Introduce different textured surfaces to child, placing under feet to allow child to feel and engage with them (soft blanket, rubber mat, dyna disc).
  • Can promote weight bearing with different surfaces underneath as well.
  • For added input, can use tactile ball, slowly roll along full surface of foot.
  • Will release muscle tightness and provide necessary proprioceptive input/feedback to foot.

positional clubfoot

5. Other Tips:

  • Allow child lots of time to freely kick and move lower extremities.
  • Encourage child to have sensory experiences (in bath, exposing feet to different surfaces, tickling).
  • Avoid tight leggings, socks or shoes so baby is able to actively move feet and lower extremity.
  • If you are swaddling, ideally keep feet out so they are not confined.

Learn more about Pediatric Gait Presentations and Treatment Strategies here!

pediatric gait

Learn more about Dinosaur Physical Therapy!

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References:

  1. Bensahel H, Guillaume A, Czukonyi Z, Desgrippes Y. Results of physical therapy for idiopathic clubfoot: a long-term follow-up study. J Pediatr Orthop 1990;10:189e92.
  2. Davies TC, Kiefer G, Zernicke RF.  Ankle and first metatarsophalangeal joint dorsiflexion in children with clubfoot.  J Pediatric Orthop 2001; 21:727e30.
  3. Desair L, Oprescu F. Bracing in the Treatment of Clubfoot: Past, Present and Future.  Iowa Orthop J. 2010; 30: 15-23.
  4. El-Hawary R, Karol L, Jeans K, Richards S.  Gait analysis of children treated for clubfoot with physical therapy or the Ponseti cast technique.  J Bone Joint Surg 2008; 90-A:1508e16.
  5. Gray K, Gibbons P.  Clubfoot: Advances in Diagnosis and Management.  Australian Family Physician.  May 2012; 41(5): 299-301.
  6. Karol L, Jeans K.  Assessment of Clubfoot Treatment Using Movement Analysis.  J Exp Clin Med 2011; 3(5):228-232.
  7. Karol L, O’Brien S, Wilson H, Johnstron C, Richards B.  Gait analysis in children with severe clubfeet early results of physiotherapy versus surgical release.  J Pediatr Orthop 2005;25:235e40.
  8. Muratli H, Dagli C, YavuzerG, Celebi L, Bicimoglu A.  Gait characteristics of patients with bilateral clubfeet following posteromedial release procedure.  J Pedatr Orthop 2005; 14:206e11.
  9. Ponseti I.  Treatment of congenital clubfoot.  J Bone Joint Surg Am 1992; 3: 448e54.

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  • Thank you for this blog. Very informative. I would also add that some of the exercises you are showing also help integrate primitive reflexes, feeds the proprioceptive system and prepares them for creeping (commando crawl)…

    • Liane, Thank you for your comments! You are absolutely correct we are definitely tapping into the proprioceptive system and allowing the child that essential input with both our massage and weight bearing activities. This is extremely important to promote motor development.

  • Very good read. Probably the most information I have read to date on understanding club foot in layman’s terms. My son was born with bilateral congenital club feet among other conditions. They tried to tell me it was positional and I disagreed because he moved more than any of my other kids. Still does. Anyway, he was incorrectly casted where I live and we went to Iowa to get it done by Ponseti himself but was out of office as we were a day late due to bad weather. We had Morcuende fix his feet through casting and the boots and bar. We kept them on for 4 years. He was good until this last year where his left foot is relapsing. So instead of another series of casting, we are going to try the stretch and massage method. We are just trying to get back to neutral. This is very helpful information. Thanks for sharing.

    • Hi Marie, Thank you for sharing your story! I am so sorry you have had such an arduous journey! I wish you and your son only the best for the future! Feel free to reach out via email at info@dinopt.com to speak further! More than happy to be a source of information for your family. Best wishes, Rebecca

  • Most detailed and informing article I’ve read comparing the different treatments. My daughter born with unilateral clubfoot. We had an amazing orthopedic doctor who recommended the Ponseti method. He hoped she wouldnt need an Achilles tenotomy, but decided she did. After the last casting after her procedure we received her boots and bar. Our doctor also showed us an exercise of manipulating the foot out and up using the palm of your hand. He emphasized that this exercise was most important for our daughters treatment. He said to do it as often as she would let us or as long aspossible. Also, to think of the shoes as maintenance and the exercise as her true treatment. He did warn us to do it regularly, stoping, and going days with out would be like staring over and will make it painful for the child. My daughter is 13 months and walking. We have moved and no longer have our initial ortho doctor. We are seen at Texas Scottish Rite hospital which does indicate different treatments for club feet but I wish I had known more in the beginning. Although, they are supposed to be leaders in this field, none of the other parents I’ve talked to say they were ever recomended any kind of physical exercises. Makes me question a little. My biggest fear is her foot regressing. She only wears the shoes at night to sleep now and it’s even harder to get her to do the exercise, she’s so busy! They haven’t indicated to us that we should be doing more, so I’m glad there is more info out there for us to also make and educated decision on her treatment.

  • Thank you so so much for this post. I have a week old newborn with bilateral clubfoot and after looking up and reading about the treatment methods using serial casting and braces for so long and how hard it is for babies and families to adjust to it, I sobbed thinking we were left with no choice. It made me upset that orthopedic doctors would just do the norm without really investigating each individual case. But your article makes so much more sense to me and my usband as we work closely with bodies being yoga teachers. You’ve helped us understand so much and gave us hope that casting is not the only way and the negative impacts of casting makes so much sense to me as well. We will do these stretches and exercises religiously and hopefully we can find a pediatric physical therapist in our area (Los Angeles) that can help with our son. Again, I appreciate your research and this post so so much. Thank you!