Foot Problems

Clubfoot

Introduction

Talipes equinovarus (Talus = ankle, pes = foot, equino = heel is elevated, varus = turned inward), also known as clubfoot, refers to a developmental deformity of the foot in which one foot or both feet are excessively plantar flexed, with the forefoot swung medially and the sole facing inward. Clubfoot (seen below) can be classified as an extrinsic (supple) type, which is essentially a severe positional or soft tissue deformity, or intrinsic (rigid) type, where manual reduction is impossible. While most cases (80%) are idiopathic, genetics and intrauterine factors are suggested to play a role in causing clubfoot.

clubfoot.png         Image 1 adapted from Gore AI and Spencer JP. The Newborn Foot. Am Fam Physician. 2004 Feb 15;69(4):865-872.

Epidemiology

  • Clubfoot occurs in 1-2 per 1000 live births overall
  • Incidence is higher in Hispanics and lower and Asians
  • Male fetuses are primarily affected, with a 2-to-1 male to female ratio
  • Clubfoot is bilateral in 30-60 % of cases

Risk Factors

Major risk factors for clubfoot are family history of clubfoot, multiple gestations, oligohydramnios, breech position, certain genetic disorders, or fetal neuromuscular abnormalities.

Diagnosis

Diagnosis can occur prenatally through the use of a transvaginal ultrasound as early as 12-13 weeks gestation. Confirmation of the diagnosis is made clinically by examining the patient’s feet at birth. On examination one may note pronounced tightness of the achilles tendon with little dorsiflexion, which differentiates clubfoot from metatarsus adductus. On radiography one may note “stacking” and parallel axes of the talus and calcaneus (seen below).

footxray.png                                          Image 2 adapted from Gore AI and Spencer JP. The Newborn Foot. Am Fam Physician. 2004 Feb 15;69(4):865-872.

Treatment

  • Extrinsic (supple) type: The extrinsic type involves serial plaster casts using either the Ponseti method or Kite method. Of note, some success has been noted with persistent plaster casts. The Kite's method of manipulation (center of rotation of malaligned foot and fulcrum on cuboid) was modified by Ponseti (fulcrum on head of talus). While still controversial, many research studies have shown the Ponseti method to be more effective.
  • Intrinsic (rigid): Start with plaster casts, but typically require achilles tenotomy or tibial tendon transfer.

 

Metatarsus Adductus

Introduction

Metatarsus Adductus (MTA) is a transverse plane deformity in the tarsometatarsal joints, in which the metatarsals are deviated medially. Bilateral MTA (seen below) is the most common cause of an intoeing gait in infants. The pathogenesis of MTA is not well understood, but it is thought to be caused by infant’s position in the womb.

MTA.png
Image 3 adapted from Gore AI, Spencer JP. The newborn foot. Am Fam Physician. 2004 Feb 15;69(4):865-72. PubMed PMID: 14989573

Epidemiology

  • Occurs in 2 per 1000 live births
  • More common in females than males
  • Left sided MTA is slightly more commonly affected than right sided MTA

Risk Factors

Major risk factors include being the first born child, multiple gestations, family history of MTA, and arrested fetal development of the foot.

Diagnosis

MTA is a clinical diagnosis and is characterized by medial deviation of the forefoot (V test, seen below) and prominence of the fifth metatarsal. Physicians should assess using heel bisector and assess the degree of flexibility in the forefoot.

  vtest.png
Image 4 adapted from Gore AI, Spencer JP. The newborn foot. Am Fam Physician. 2004 Feb 15;69(4):865-72. PubMed PMID: 14989573. - V test: Foot is observed from plantar aspect. Observe for medial deviation of forefoot: positive for MTA if  forefoot deviates away from middle finger

Treatment

In contrast to clubfoot,  >90% of all cases of MTA resolve without intervention. The only indications to treat are moderate-to-severe decreases in the flexibility of the affected foot. Treatment mainly consists of passive stretching starting at birth, however one may consider use of orthotic splints or corrective shoes if uncorrected by 4-6 years of age.

References

  1. Magriples U et al. Prenatal diagnosis of talipes equinovarus (clubfoot). UpToDate. Aug 2015.
  2. Rijal R, Shrestha BP, Singh GK, et al. Comparison of Ponseti and Kite's method of treatment for idiopathic clubfoot. Indian J Orthop. 2010 Apr;44(2):202-7.
  3. Gore AI and Spencer JP. The Newborn Foot. Am Fam Physician. 2004 Feb 15;69(4):865-872.
  4. Hart ES, Grottkau BE, Rebello GN, et al. The newborn foot: diagnosis and management of common conditions. Orthop Nurs. 2005 Sep-Oct;24(5):313-21; quiz 322-3.