Foot deformities

Clubfoot (talipes equinovarus)

• Pathology & Clinical Features (“CAVE”):

  • Cavus: Elevated medial longitudinal arch.
  • Adductus: Forefoot turned inward.
  • Varus: Hindfoot (calcaneus) inverted.
  • Equinus: Fixed plantarflexion due to tight Achilles tendon.
  • Hallmark: Rigid deformity that cannot be passively dorsiflexed/corrected to neutral.
  • Associations: Myelomeningocele (spina bifida), arthrogryposis, oligohydramnios, and developmental dysplasia of the hip (DDH) (requires hip and spine exam).

• Diagnosis:

  • Clinical exam at birth (screening via 2nd-trimester prenatal US; imaging not routinely required).

• Key Differential Diagnoses:

  • Metatarsus adductus: Forefoot adduction only, hindfoot normal; fully flexible / passively correctable (reassurance/observation).
  • Positional clubfoot: Flexible deformity 2/2 intrauterine crowding; easily reduced to neutral passively.
  • Congenital vertical talus (“rocker-bottom foot”): Rigid midfoot dorsiflexion with convex sole; associated with Trisomy 18.

• Management Hierarchy:

  1. 1st-Line: Ponseti method (serial manipulation and weekly long-leg casting started immediately after birth). c
  2. Adjunct: Percutaneous Achilles tenotomy (needed in ~90% of cases for residual equinus prior to final cast).
  3. Maintenance: Foot abduction orthosis (boots and bar) worn up to age 4–5 to prevent relapse.
  4. Refractory/Late: Surgical soft tissue release / tendon transfer.

• High-Yield Exam Pearl:

  • The most common cause of recurrence/relapse is non-adherence to the post-casting bracing regimen.

Metatarsus adductus, curved foot (metatarsus varus)

• Etiology & Associations:
  • Most common congenital foot anomaly; caused by intrauterine crowding (primigravida, oligohydramnios, breech).
  • Must screen for associated Developmental Dysplasia of the Hip (DDH) with hip exam (Barlow/Ortolani).
• Clinical Features:
  • Medial forefoot deviation with a convex, “C-shaped” lateral border and prominent 5th metatarsal base.
  • Hindfoot is completely normal (neutral or valgus) with full, unrestricted ankle ROM (normal dorsiflexion).
• Key Differential (Clubfoot / Talipes Equinovarus):
  • Clubfoot involves forefoot adduction plus hindfoot varus and fixed equinus (plantarflexion) contracture; cannot be passively dorsiflexed.
• Diagnosis:
  • Purely clinical; heel bisector line deviates lateral to the 2nd/3rd interdigital space.
  • XR unnecessary unless rigid, surgical candidate, or evaluating for alternative bony pathology.
• Management (Algorithm by Flexibility):
  • Flexible (overcorrects past midline): Observation & reassurance (85-90% resolve spontaneously by age 1).
  • Partially flexible (corrects to midline only): Passive stretching exercises by parents at each diaper change ± corrective shoes.
  • Rigid (cannot reach midline) or persistent after 6–9 months: Serial below-knee casting (best if initiated before 12 months).
  • Refractory/Late presentation (>3–4 years): Delayed surgical correction (metatarsal osteotomy).