Parents of infants born with clubfeet may be reassured that their baby, if otherwise normal, when treated by expert hands will have normal looking feet with normal function for all practical purposes. The well-treated clubfoot is no handicap and is fully compatible with a normal, active life.
DEFINITION
Congenital clubfoot (talipes equinovarus (CTEV), also known as pes equinovarus (PEV)) is the most common congenital musculoskeletal disorder in children, characterized by a complex foot deformity.
It is not an embryonic but a developmental malformation. A normally developing foot "transforms" into a clubfoot during the second trimester of pregnancy, rather than immediately after fertilization in the early embryonic stage when organs form (organogenesis). In congenital clubfoot, all internal foot structures are properly developed (similar to a healthy foot), but at some point, the foot begins to acquire clubfoot characteristics for an unknown reason.
"Congenital" means that the condition is fully present and easily observable at birth. It also indicates that the deformity developed during the fetal period and is not the result of any external intervention during or immediately after birth.
WHY “CLUBFOOT”?
A clubfoot closely resembles the end of a golf club in shape. This resemblance led to the English term “clubfoot” (club meaning “[golf] club” and foot). In Czech and Slovak, the condition is referred to as golfová noha, which would translate literally as golf foot.
WHERE DOES THE NAME “PES EQUINOVARUS” COME FROM?
The term “pes equinovarus” is a literal translation of the Latin. The Latin adjective equinus (equina, equinum) is derived from the noun equus (equi), meaning “a horse” while varus refers to a condition where a limb is turned inward.
In a horse’s hind leg, the calcaneus (heel bone) and talus (ankle bone) are positioned very high in relation to the metatarsal and forefoot bones. A similar structure is seen in clubfoot, where the heel bone moves upward due to the shortening of the Achilles tendon, giving the foot a comparable position. A horse’s hoof corresponds to human toes. Just as a horse stands on its hoof with its heel raised high, a child with this condition stands on their toes, with the heel elevated and not touching the ground at all.
CHARACTERISTICS
Clubfoot is the result of several overlapping components, and only their combined presence confirms the correct diagnosis of the condition.
The abnormal anatomy of clubfoot, which is structurally advanced, is reflected in the foot’s distinct and highly specific appearance. The four main characteristics of clubfoot are summarized by the acronym CAVE:
C
cavus - excessive elevation of the foot medial longitudinal arch
A
adductus - foot adduction
V
varus - heel varus
E
equinus - equine position of the calcaneus
excessive elevation of the medial longitudinal arch of the foot
CAVUS – excessive elevation of the longitudinal arch of the foot
The medial border of the foot is excessively raised due to the strong pull of contracted tendons, which position the metatarsal bones in plantar flexion (especially the first metatarsal). This gives the appearance as if the foot were “broken” in the middle.
adduction
heel varus
VARUS - varus. The calcaneus is positioned inward, causing the foot to rest on its lateral side. This alignment leads to excessive inversion of the calcaneus, which may result in the sole of the foot being almost turned upward.
equine position of the calcaneus
calf thinning
CALF THINNING – muscular atrophy of specific muscle groups in the calf
A significant reduction in muscle tissue volume in the calf on the affected side leads to noticeable thinning of the lower leg. Muscle atrophy primarily affects the posterior and medial calf muscles. The gastrocnemius muscle and posterior tibial muscle become fibrotic (with an excessive amount of connective tissue compared to muscle tissue), shorter, smaller, and reduced in volume. The difference in calf size and volume is most noticeable in children with unilateral clubfoot.
CLASSIFICATION
Clubfoot can be classified from multiple perspectives, depending on the criteria we choose to consider. If we focus on range of motion and morphological structure, we can distinguish: postural (positional, habitual) clubfoot, which is a completely idiopathic variant of the deformity. It is characterized by a full range of motion and no anatomical abnormalitie or structural clubfoot, sometimes referred to as "true clubfoot." This form exhibits structural changes in the soft tissues, bones, their alignment, as well as the biomechanics of the foot and calf.
Clubfoot can also be classified based on the severity of the deformity, its rigidity, and its ability to be corrected, using the four-grade Dimeglio scale or the six-grade Pirani scale.
Additionally, clubfoot can be classified based on its etiology, meaning the potential cause of its development. Potential, because numerous hypotheses exist regarding its origin, but none have been definitively confirmed so far. This leads to the following classifications:
ISOLATED/IDIOPATHIC - meaning "of unknown cause". A child with this type of deformity has no other congenital anomalies or medical conditions—the foot deformity is not a result of any syndrome or systemic disease. The child is otherwise completely healthy and has only clubfoot. A variation of this type is the previously mentioned THE POSITIONAL CLUBFOOT.
SYNDROMIC - the deformity is associated with genetic mutations that lead to congenital anomalies. Therefore, it results from an underlying syndrome. This type of clubfoot often occurs alongside a sequence, e.g., Pierre-Robin sequence or a complex, e.g., diastrophic dysplasia or arthrogryposis multiplex congenita (AMC) or a syndrome, e.g., Möbius syndrome, Larsen syndrome, Beckwith-Wiedemann syndrome, etc.
NEUROGENIC - this type of clubfoot is associated with other congenital neurological disorders, such as cerebral palsy (paralysis cerebralis infantium), spina bifida and its variations (MC/ MMC), tethered cord syndrome or other forms of paralysis. Neurogenic clubfoot is often more challenging to treat due to its neurological connections, which can be unpredictable in their progression.
TERATOGENIC - the deformity occurs as part of developmental disorders arising during pregnancy, for example, due to drug use (e.g., amphetamines), medication intake, or smoking.
From a visual perspective, clubfoot can be divided into typical/ standard clubfoot, which exhibits the standard characteristics described earlier (CAVE) and atypical clubfoot, which presents additional distinct features that are clearly visible, such as atypical clubfoot or complex clubfoot.
Atypical clubfoot and complex clubfoot are distinct variations of clubfoot deformity. Unfortunately, these terms are often used interchangeably, leading to confusion in differentiating these two types.
In addition to the standard CAVE characteristics, both types have additional features, including: a deep crease above the heel and on the sole of the foot, the big toe in hyperextension, while the other toes may be in plantar flexion, in atypical clubfoot, toes often have a weak response to stimulation, the foot is in severe plantar flexion and equinus position. The primary distinguishing factor is the timing of occurrence: atypical clubfoot is present at birth, before any treatment and complex clubfoot results from improper casting techniques and complications during casting, such as: frequent slipping of casts, leaving displaced casts on the leg, swelling and deformities, including a flattened heel due to incorrectly applied casting. Atypical clubfoot is rare, occurring in less than 5% of children with congenital clubfoot. Complex clubfoot is more common.
Atypical clubfoot is usually of neurological origin, often linked to motor deficits and reduced dorsiflexion response. Complex clubfoot can result from any of the previously mentioned causes. A dedicated article discusses both ATYPICAL AND COMPLEX CLUBFOOT, along with their treatment approaches, as these are highly specific deformities requiring specialized care.
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In the order of appearance on the page:
- 1-3: Own/Goodwill People
- 4: AI Generated
- Clubfoot Components: Own
- Other: Own/Goodwill People