History and Physical Examination

Seek a detailed family history of clubfoot or neuromuscular disorders, and perform a general examination to identify any other abnormalities. Examine the feet with the child prone, with the plantar aspect of the feet visualized, and supine to evaluate internal rotation and varus. If the child can stand, determine whether the foot is plantigrade, whether the heel is bearing weight, and whether it is in varus, valgus, or neutral.

Similar deformities are seen with myelomeningocele and arthrogryposis. Therefore, always examine for these associated conditions. The ankle is in equinus, and the foot is supinated (varus) and adducted (a normal infant foot usually can be dorsiflexed and everted, so that the foot touches the anterior tibia). Dorsiflexion beyond 90° is not possible.

The navicular is displaced medially, as is the cuboid. Contractures of the medial plantar soft tissues are present. Not only is the calcaneus in a position of equinus, but also the anterior aspect is rotated medially and the posterior aspect laterally.

The heel is small and empty. The heel feels soft to the touch (akin to the feel of the cheeks). As the treatment progresses, it fills in and develops a firmer feel (akin to the feel of the nose or of the chin).

The talar neck is easily palpable in the sinus tarsi as it is uncovered laterally. Normally, this is covered by the navicular, and the talar body is in the mortise. The medial malleolus is difficult to palpate and is often in contact with the navicular. The normal navicular-malleolar interval is diminished.

The hindfoot is supinated, but the foot is often in a position of pronation relative to the hindfoot. (See the image below.) The first ray often drops to create a position of cavus. The Ponseti method of closed management of clubfeet through manipulations and casting describes the elevation of the first metatarsal as a first step, even if it means seemingly exacerbating the supination of the foot.

Spontaneous correction of hindfoot varus by abducting forefoot and allowing calcaneum to rotate freely under talus.

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The tibia often has internal torsion. This assumes special importance in the casting management of clubfeet, where care should be taken to rotate the feet into abduction, avoiding spurious tibial rotation through the knee. (See the images below.) Even after correction, the foot often remains short and the calf thin.

Never forcibly evert or pronate foot during clubfoot casting.

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Traditional manipulation and casting methods fail, as they do not allow free rotation of calcaneum and talus.

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Workup

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Media Gallery

Posteromedial release for clubfoot.
Complications of manipulation treatment. Rocker-bottom foot.
Ilizarov distraction for arthrogrypotic clubfoot.
Schematic representation of posteromedial release.
Traditional manipulation and casting methods fail, as they do not allow free rotation of calcaneum and talus.
Never forcibly evert or pronate foot during clubfoot casting.
Spontaneous correction of hindfoot varus by abducting forefoot and allowing calcaneum to rotate freely under talus.

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Author

Minoo Patel, MBBS, PhD, MS, FRACS Senior Lecturer, Monash University; Director, Centre for Limb Reconstruction and Deformities, Epworth Centre; Chairman, Cabrini Hospital Orthopaedic Surgery Specialty Group; Orthopaedic Adult/Pediatric Surgeon, Epworth Hospital; Fellowship Director, Epworth Kleos Upper Limb and Limb Reconstruction Fellowship; Consulting Adult/Pediatric Orthopedic Surgeon, Department of Orthopedic Surgery, Monash Medical Center, Australia

Minoo Patel, MBBS, PhD, MS, FRACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Australian Association of Surgeons, Australian Medical Association, Australian Orthopaedic Association, Royal Australasian College of Surgeons, Orthopaedic Research Society, AO Foundation, Orthopaedics Overseas, Indian Orthopedic Association, Bombay Orthopedic Society, Shoulder and Elbow Society of Australia, Australian Paediatric Orthopaedic Society, Australian Limb Lengthening and Reconstruction Society, Victorian Hand Surgery Society, Victorian Shoulder and Elbow Society

Disclosure: Nothing to disclose.

Coauthor(s)

John Herzenberg, MD, FRCSC Head of Pediatric Orthopedics, Director of International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore

John Herzenberg, MD, FRCSC is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine, Pediatric Orthopaedic Society of North America, Limb Lengthening and Reconstruction Society, American Academy of Orthopaedic Surgeons

Disclosure: Received educational grant from Smith and Nephew, EBI, Orthofix for none.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS Professor of Orthopedic Surgery, Chief, Division of Foot and Ankle Surgery, Director, Foot and Ankle Fellowship Program, Department of Orthopedic Surgery, University of Texas Medical Branch School of Medicine

Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Texas Orthopaedic Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Styker.

Additional Contributors

John S Early, MD Foot/Ankle Specialist, Texas Orthopaedic Associates, LLP; Co-Director, North Texas Foot and Ankle Fellowship, Baylor University Medical Center

John S Early, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Texas Medical Association

Disclosure: Received honoraria from AO North America for speaking and teaching; Received consulting fee from Stryker for consulting; Received consulting fee from Biomet for consulting; Received grant/research funds from AO North America for fellowship funding; Received honoraria from MMI inc for speaking and teaching; Received consulting fee from Osteomed for consulting; Received ownership interest from MedHab Inc for management position.

Clubfoot (Talipes) Clinical Presentation

History and Physical Examination

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