Club Feet (Congenital Talipes Equinovarus (CTEV))

Club Feet (Congenital Talipes Equinovarus (CTEV))

CTEV is a short form of Congenital Talipes Equinovarus. It is a congenital (since birth) deformity which affect one or both the feet of a child. It can be asymmetrical / symmetrical in presentation  

Incidence / prevalence

• 1 in 1000 live births
• It affects boys more than girls and the ratio is approximately 2:1

Symptoms / Clinical Signs of CTEV
The symptoms or signs varies according to the age of the child and severity of the problems

In the initial stage ( First Phase)
The forefoot is twisted downward and inward which ultimately increase the arch and turn the heel inward. Sometimes, the foot is so turned that it looks like the up side down.

In the later stage (Second Phase)
The affected leg has underdeveloped calf muscles and the foot may be shorter than the unaffected foot. In case of bilateral involvement, it may have some asymmetry

Types / Kinds of CTEV
CTEV can be classified as

• Idiopathic CTEV
• Secondary CTEV
• Postural CTEV
• Structural CTEV

Causes / Etiology of CTEV In most of the cases, the exact cause of the deformity is not known

• Edward Syndrome, Compartment Syndrome, Ehler’s-Danlos Syndrome and Loeys-Dietz Syndrome, etc have associated CTEV
• Children with Spina bifida may have CTEV
• Family history with CTEV increases the chances of having a child with CTEV
• According to reports, the chances of CTEV increases if the mother smokes during pregnancy
• Insufficient amniotic fluid in pregnancy has been reported one of the risk factors.

Associated disorders with CTEV
Following problems are occasionally associated with CTEV 

• Spina Bifida
• Below knee atrophy
• Hyperactive- due to SPD

Diagnosis making / Tests and Investigations for CTEV
CTEV is commonly identifies at birth. The delivery team of doctors can recognize the disorder just looking at the shape of the foot / feet. To know the severity of the disorder, the doctor will ask for X-ray of the foot / feet.
In fact bilateral CTEV can be detected by ultrasound during pregnancy also. Although nothing can be done in the pregnancy but parents become aware of the condition which helps the family to cope with the problem easily.
In most of the cases, a club foot is an isolated condition but it can be an associated disorder of other problem like Spina bifida.

Assessments and evaluations of CTEV
While treating a child with CTEV, holistic assessment and evaluation is done as

• Look for spina bifida, if any
• Assessment of hips to look for sign of development dysplasia of the hip
• Assessment of Cervical spine, head and face for signs of 
• Both lower limbs including limb length, range of movement, tone and deformity
• Both upper limbs and hands for range of movement, tone and deformity

Pirani Score
The Pirani score is a simple, easy to use tool for assessing the severity of each of the components of a clubfoot. It is extremely useful for assessing and monitoring patients’ progress.
Other assessments tools are also used in practice such as
Roye Score
Bangla Tool

Management / Treatment of CTEV
As the condition is detected at birth only, the management starts from birth itself. Although, there is no specific medicine available which can help the deformity to be corrected but lots of other treatment systems are available. Ponseti Method is the best available management technique for correcting CTEV

Ponseti Method
It is a combination technique of casting (use of plaster) and physiotherapy where the child gets intermittent stretching and casting for a few months. When the foot becomes enough align, a splint called Denis Browne Bar with Boot is used. After Denis Browne Bar with Boot splint, the foot is put under Custom Made Foot Orthosis (CMFO) rather Ankle Foot Orthosis (AFO). Generally the CMFO is modified according to the need of the feet and changed in 3-4 months interval. 80% of the children benefit from this method and rarely require orthopedic surgery.

Surgical Treatment
Few cases of CTEV which are not fully corrected may need Tenotomy. Generally, Tenotomy of the Achilles tendon is done. Tenotomy is done under local anesthesia. In some cases, the child requires a series of surgery on the basis of the severity to get optimal correction.

Botulinum Injection Therapy (Botox)
Botulinum Toxin Injection has been used as one of the treatment techniques these days. It is used to relax the stiff muscles. When the stiff muscles are relaxed, it becomes easy to fit the CMFO and stretching of the muscles without much pain. Botox can be used along with Ponseti Method before the surgical procedure.
  
Prognosis and Employment Opportunities
Most of the children with CTEV get deformity correction with available treatment technique and lead normal life. If the child is not treated well, the child will get problem with mobility. The child may have problem with shoe if it is unilaterally affected. Severely affected children can get problems of arthritis in the long run. The scientifically treated children can lead a productive life as others. In case of Spina bifida and other syndromes, the treatment is less successful.

If you have any query about a child with club feet, please contact us for guidance and support

Mail at: helpicd@gmail.com  Whatsapp at: +91-7838809241     Voice Call at +91-11-41012124