NOT COMPLETELY...
„The baby has clubfoot because there wasn’t enough space in the womb.” – Perhaps this statement was made by a nurse, doctor, physiotherapist, or even a close relative? This opinion is widespread yet medically inaccurate. It is a common myth.
Congenital clubfoot develops after the 12th week of pregnancy. At 12 weeks, the fetus has plenty of space in the womb for unrestricted movement, unless severe oligohydramnios is diagnosed at such an early stage, which would naturally lead to pregnancy termination. Therefore, at this stage of pregnancy, the fetus can develop completely normally and does not experience intrauterine crowding. Dr. Ignacio Ponseti explains it as follows:
We know that the foot grows normally for the first several weeks in the pregnancy and then something happens that we don't understand yet, and the foot twists.
Congenital and true clubfoot, meaning the structural type, is not caused by the positioning of the feet inside the womb. Although there was a theory proposed by Dr. Sir Denis Browne suggesting that a mechanical obstruction limits foot movement, causing it to become stuck in a certain position, this theory has been disproven with advances in science, medical knowledge, and research.
DEFINITION
Positional clubfoot, also known as habitual or postural clubfoot, is a very mild foot deformity that externally resembles congenital clubfoot but is characterized by a full range of motion. This means the foot can move freely in all directions.
This deformity develops between the 14th and 16th weeks of pregnancy, when the fetus still has plenty of space in the womb and an ample amount of amniotic fluid, allowing for unrestricted movement. It may be visible in a standard prenatal ultrasound, but the exact type of deformity and the accuracy of the DIAGNOSIS can only be confirmed after birth.
In response to a parent's question about what causes this type of deformity, Dr. Ignacio Ponseti explained:
(...) may be due to an anomaly in the myosin (the protein of the muscles in the posterior tibialis and gastrosoleus). This error in the myosin causes a contracture of the muscles and twists the foot in and down. (...) Incidentally the defect in the myosin is limited to the myosin of the flexor muscles of the foot. (...) After birth (...) the fetal myosin is replaced by normal myosin and the foot is normal for life.
Factors that may contribute to positional clubfoot include:
- limited space in the uterus, caused by conditions such as oligohydramnios (low amniotic fluid levels)
- twin pregnancy
- mechanical obstruction (e.g., umbilical cord entanglement)
- maternal trauma during pregnancy, leading to pressure on the abdomen
It is difficult to determine whether these factors are primary or secondary - and whether their occurrence leads to myosin-related issues in muscles that are not actively functioning.
Fetal movement is crucial for maintaining overall body condition. Restricted movement can lead to various complications, such as contractures. Movement also plays a vital role in proper muscle development, preventing growth limitations that arise from inactivity. Active muscle fibers continue to work and develop when movement is unrestricted.
CHARACTERISTICS
A positional clubfoot has a normal size and slender shape. Unlike structural clubfoot, there is no difference in the length or width of the feet. The bones within the foot may be slightly shifted relative to each other, but their shape and structure remain normal. The Achilles tendon has the correct attachment, length, and width, and its functions are fully preserved. Evidence of this includes the ability to freely achieve dorsiflexion of the foot and the presence of normal skin creases above the heel, which are identical to those in a healthy foot. The calf muscles in positional clubfoot are not fibrotic or smaller, so the calf circumference is comparable to that of a healthy leg. Any potential irregularities related to myosin do not result in THE CHARACTERISTIC PATHOLOGICAL ANATOMY seen in structural clubfoot.
A positional clubfoot is passively manipulable, meaning that during an examination, the person moving the foot does not need to apply significant effort. However, the child does not move the foot on its own by consciously using muscle strength. When the foot is stimulated, for example, by touching the lateral edge, it responds easily to the stimulus, demonstrating abduction, eversion, and dorsiflexion of the foot and toes.
A positional foot can be freely moved in any direction: it can be easily abducted to the side and effortlessly lifted upward (dorsiflexion). The foot has FULL RANGE OF MOTION, with inversion, eversion, supination, and pronation being easy to achieve. The movement of the toes is active and unrestricted.
TREATMENT
A positional clubfoot generally does not require treatment, as it resolves on its own in a short time after birth, or by the third month of life, or when the child starts standing and walking, bearing weight on the foot (or feet), around the ninth month of life. It should be monitored until the end of the second year of life. Typically, the results of simple physiotherapy or the lack of treatment show similar outcomes. If treatment is necessary, the foot responds well, and the effectiveness of conservative treatment is high. The foot develops normally after correction, and there is no recurrence of the deformity.
However, some cases fall between a rigid, yet still positional, deformity and a mild, idiopathic, and structural clubfoot.
Because the habitual deformity is relatively mild, and the boundary between it and a mild clubfoot deformity (grade I on the Dimeglio scale) is very thin, some doctors believe that nothing should be done and mistakenly downplay the issue, while others may overuse casting treatments. It is crucial to distinguish between these two conditions, as the treatment approach for each is quite different. In some cases, a slightly stronger positional deformity may require the use of a cast, as well as a derotation splint for a period of time, but this duration is significantly shorter than for a structural clubfoot.
Positional clubfoot is a molding deformity which resembles clubfoot. The foot is in mild equinus, in adduction and is rotated inwards. However, the foot is passively fully flexible with dorsiflexion well above neural and no sign of the rigid deformities seen in true clubfoot. Positional clubfoot usually responds to stretching and massage. However, some cases are somewhere between severe positional clubfoot and mild idiopathic clubfoot and should be followed to at least two years of age. Whenever a cast is needed for correction, abduction bracing as for clubfoot should be performed for a limited amount of time.
Positional clubfoot
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- Radler C.: „Foot Disorders of Newborns”
- Anand A., Sala D.A.: „Clubfoot: Etiology and treatment.”
- Furdon S.A., Donlon C.R.: „Examination of the newborn foot: positional and structural abnormalities.”
- Chaweerat R. et al.: „The effectiveness of parent manipulation on newborns with postural clubfoot: a randomized controlled trial.”
- Huntley J.S.: „Optimising the management of congenital talipes.”
- Cady R. et al.: „Diagnosis and Treatment of Idiopathic Congenital Clubfoot.”
- Canavese F., Dimeglio A.: „Clinical examination and classification systems of congenital clubfoot: a narrative review.”
- Carroll S.G.M. et al.: “Outcome of fetal talipes following in utero sonographic diagnosis.”
- Rondonuwu G. et al.: “Physical Medicine and Rehabilitation Management in Pediatric Patient with Postural (Positional) Clubfoot: A Case Report.”
- 1-4: Own/Goodwill People
- Radler C.: „Foot Disorders of Newborns”