Cleft lip and palate are congenital conditions in which the two sides of a baby’s top lip or roof of the mouth do not join up during foetal development. Surgery is normally performed to correct the condition, usually between the ages of six months and two years.…
Talipes (club foot)
What is clubfoot (talipes)?
Clubfoot (talipes) occurs when a baby is born with a foot and ankle twisted out of shape or position. One of the more well-known forms of talipes is clubfoot (talipes equinovarus). However, there are other forms of the condition.
Talipes is a common condition and its diagnosis can be very worrying for parents. However, less serious cases may get better as the baby grows, while for more serious cases there are effective treatments available, so most children will be able to walk normally.
Talipes is not painful and may affect one or both feet. Babies with talipes are more likely to also have developmental dysplasia of the hip.
In babies with talipes, the position of the foot can be abnormal in a number of ways. It may be:
- Pulled or contracted downwards (equinus) leading to 'tiptoe walking', or be pulled or contracted upwards (calcaneus);
- Turned inwards (varus) or outwards (valgus), and/or;
- Excessively flexed or arched (cavus).
Some of the more common foot abnormalities that can occur in newborn babies include:
In clubfoot, also known as talipes equinovarus, the foot is:
- Pulled downwards;
- Turned inwards, and;
- Excessively arched.
In severe cases, the foot can be so twisted that it appears to be upside down. The foot may also be smaller than the unaffected foot, the leg shorter and the leg muscles below the knee underdeveloped.
In talipes calcaneovalgus, the foot is:
- Pulled upwards and;
- Turned outwards.
Frequently in this condition, the foot can be pulled upwards and outwards so far that the back of the foot and toes touch the shin.
In metatarsus varus (also called metatarsus adductus), the tendency to turn inwards is restricted to just the front part (or tarsal bones) of the foot.
If the position of the baby's foot is restricted while in the uterus, this can lead to 'positional' talipes, in which the soft tissues develop abnormally, but the bones develop normally. For this reason, with positional talipes, the baby's foot can usually be gently moved into a more normal position.
In congenital talipes, bones in the foot and ankle develop abnormally, as well as the soft tissues. In many cases, the cause of congenital talipes is not clear.
Congenital talipes is not due to the position of the foot in the uterus during pregnancy. The foot may be stiff and can generally not be moved back into a normal position. Congenital talipes requires much more intensive treatment than positional talipes.
When congenital talipes occurs as part of a wider range of developmental abnormalities, it may be described as syndromic talipes.
Risk factors for talipes include:
- Gender - boys are more likely to be born with clubfoot (talipes equinovarus), while girls are more likely to develop talipes calcaneovalgus;
- Birth order - first-born children are more likely to be born with positional talipes because the uterus tends to be tighter in a first pregnancy;
- Birth defects such as spina bifida, cerebral palsy and arthrogryposis;
- Genetics - a family history of congenital clubfoot increases the chance a baby will develop the condition;
- Conditions in the mother that prevent normal movement of the developing baby in the uterus, such as oligohydramnios, in which there is not enough amniotic fluid in the uterus;
- Ethnicity - babies of Polynesian and Maori heritage are at increased risk of clubfoot, and;
- Maternal smoking and recreational drug use during pregnancy - this can increase the risk of the baby developing clubfoot.
Methods for diagnosis
Talipes is usually diagnosed when a baby is physically examined after birth. X-rays may be recommended to evaluate how severe the condition is, but are usually not required for a diagnosis.
In some cases, talipes may be diagnosed during pregnancy with an ultrasound. However, it is important to remember that an ultrasound can give a 'false positive' for talipes, particularly late in pregnancy. There is no treatment to correct talipes during pregnancy, but a diagnosis can give parents a chance to learn about the condition before the baby is born.
Babies with talipes will generally be assessed for developmental hip dysplasia, because they can be at greater risk of having this condition.
Types of treatment
Treatment will depend on the type and severity of talipes. In mild cases of positional talipes, the condition may get better on its own as the baby grows and develops. However, it is best to follow the directions of your child's medical professionals, because early treatment is more likely to be effective.
Exercises and massage for positional talipes
Parents and carers of babies with positional talipes may be instructed on how to perform a series of gentle exercises and massage to help the baby's foot move into a more normal position. To be effective, these exercises need to be done regularly (for example, when the baby's nappy is changed) and in a way in which they do not hurt the baby.
It is important that they are done under the supervision of a medical professional such as a doctor, nurse or physiotherapist. These exercises are not effective for congenital talipes, where the bones have developed abnormally and need more intensive treatment to be straightened.
Casting and stretching
A course of stretching the affected foot into a more normal position and then using a plaster cast for several weeks to encourage the foot to stay in position may be recommended for cases of talipes in which the foot is stiff and exercises are unlikely to be effective. This may need to be repeated several times.
The Ponseti technique
An example of casting and stretching is the Ponseti technique, which is the most commonly-recommended treatment for congenital clubfoot (talipes equinovarus). It is quite intensive and often continues until the child is four years old.
The initial phase involves placing the affected leg or legs in plaster casts that extend from the baby's toes to their groin for 4-6 weeks. These casts are changed about weekly, with the foot being gently manipulated before each new cast is put on, to gradually help it move into a more normal position.
At the end of this time, a device called an abduction brace (which is attached to shoes that hold the feet in an outward position) is prescribed. The baby wears the brace for 23 hours a day for the next three months.
After this, wear will be reduced to around 14-16 hours a day (worn mostly overnight while sleeping), until the child is four years old.
In order for the Ponseti technique to be effective, it is necessary for the child to wear the brace as directed by the doctor. If this does not occur, the foot could return to the abnormal position and surgery is more likely to be required.
The French method
An alternative to the Ponseti technique is the French method, which involves stretching and taping the baby's foot into position every day, and the use of a machine that moves the baby's foot continuously as they sleep. This is an intensive method that requires a lot of time from carers, and ongoing exercises for the child.
In cases where other treatments have not been effective in correcting the foot's position, or talipes has come back, surgery may be recommended.
Surgeries for talipes include:
- Posterior medial release, in which tendons and ligaments that are too tight are loosened ('released'), in order to help the foot take up a more normal position, and;
- Stabilizing or fusing joints within the ankle. Techniques such as triple arthrodesis and subtalar fusion may be used to help stabilize the ankle and improve the position of the foot.
If congenital talipes is not correctly treated, the abnormal foot position may persist or return after treatment. This may interfere with walking and running.
Stretching and casting
During stretching and casting, complications can include:
- Pressure sores;
- Fractures to the bones of the foot;
- The plaster cast slipping, which means it may not be effective, and;
- Failure to improve because of the foot being incorrectly positioned within the cast.
Most children with talipes will walk normally with appropriate treatment. When talipes is associated with other serious conditions, such as spina bifida or cerebral palsy, it may be more difficult to treat and it is more likely there will a permanent problem with the foot that may affect walking.
Most talipes cannot be prevented, although avoiding smoking and recreational drug use during pregnancy may reduce the risk of the baby developing clubfoot (talipes equinovarus).