Clubfoot: Causes, Symptoms & Treatment Guide

What Is Clubfoot?

Clubfoot is a congenital birth defect where one or both feet are twisted inward and downward at birth. The heel points upward (equinus), the forefoot turns inward (adduction), and the sole faces inward (varus). It affects approximately 1-2 babies per 1,000 live births worldwide and is twice as common in males.

Clubfoot, medically known as congenital talipes equinovarus (CTEV) or PEVA (from the Latin pes equinovarus adductus), is one of the most common congenital musculoskeletal abnormalities. The condition involves a complex deformity of the foot and ankle that is present at birth. Without treatment, clubfoot causes significant disability, but with modern treatment methods, particularly the Ponseti technique, outcomes are excellent.

The deformity consists of four main components that physicians remember using the acronym CAVE: Cavus (high arch), Adductus (forefoot turned inward), Varus (heel turned inward), and Equinus (foot pointed downward like a horse's hoof). These abnormalities involve not just the bones, but also the ligaments, tendons, and muscles of the foot and ankle.

In approximately 50% of cases, both feet are affected (bilateral clubfoot). When only one foot is affected (unilateral clubfoot), that foot and calf may remain slightly smaller than the unaffected side throughout life, though this rarely causes functional problems. The condition is approximately twice as common in males as in females, and the reasons for this gender difference are not fully understood.

Types of Clubfoot

Clubfoot is classified into two main categories based on its underlying cause, which has implications for treatment and prognosis:

Idiopathic clubfoot accounts for about 80% of cases and occurs as an isolated birth defect with no identifiable cause. These cases typically respond very well to the Ponseti method, with success rates exceeding 95%. The foot is otherwise normal anatomically, and children achieve excellent functional outcomes.

Syndromic or neuromuscular clubfoot occurs in association with other conditions such as spina bifida, arthrogryposis, or various genetic syndromes. These cases may be more rigid, more likely to recur, and may require additional surgical interventions. However, the Ponseti method is still the first-line treatment and achieves good results in many syndromic cases as well.

What Causes Clubfoot in Babies?

The exact cause of idiopathic clubfoot remains unknown, but it appears to involve a combination of genetic and environmental factors. Family history is the strongest known risk factor, with the condition being more common if a parent or sibling is affected. Males are twice as likely to be born with clubfoot as females.

Despite decades of research, the precise cause of clubfoot remains elusive. The current understanding suggests that clubfoot results from a complex interplay between genetic susceptibility and environmental influences during fetal development. Unlike some birth defects, clubfoot is not typically caused by anything the parents did or did not do during pregnancy.

The genetic component of clubfoot is well-established. If one parent has clubfoot, the risk of their child having the condition is approximately 3-4%, compared to 0.1-0.2% in the general population. If a sibling has clubfoot, the risk for subsequent children is about 2.5%. If both a parent and sibling are affected, the risk rises to approximately 10-20%. Several genes have been implicated in clubfoot susceptibility, including those involved in muscle development and limb formation.

Environmental factors that may contribute to clubfoot risk include reduced amniotic fluid (oligohydramnios), which restricts fetal movement, and maternal smoking during pregnancy, which has been associated with a modestly increased risk. Some studies suggest that early amniocentesis (before 15 weeks) may also increase risk, though this remains controversial.

Theories About Clubfoot Development

Several theories attempt to explain how clubfoot develops during fetal growth. The arrest theory suggests that normal foot development is halted at a critical stage (around 9-10 weeks of gestation) when the foot naturally passes through a clubfoot-like position. The retrogenic theory proposes that an already normally-formed foot becomes deformed due to abnormal muscle or nerve development. Most current evidence supports a combination of these mechanisms, with primary abnormalities in the muscles and connective tissues leading to secondary bony changes.

Research has identified abnormalities in the muscles and connective tissues of clubfoot that are present from early fetal life. The muscles on the inner (medial) side of the leg and foot are shorter and more fibrotic than normal, while muscles on the outer (lateral) side are often underdeveloped. These soft tissue abnormalities are thought to be the primary problem, with the bony deformities developing secondarily due to the abnormal mechanical forces.

What Are the Symptoms of Clubfoot?

Clubfoot is visible at birth with the foot turned inward and downward. The heel points upward, the forefoot curves toward the body's midline, and the bottom of the foot faces inward. The calf muscles are underdeveloped, and the foot cannot be moved into a normal position. Half of all cases affect both feet.

Clubfoot is typically diagnosed immediately at birth based on the characteristic appearance of the foot. The deformity is usually obvious and cannot be corrected to a normal position by passive manipulation. In some cases, clubfoot may be detected before birth on prenatal ultrasound, typically during the second trimester screening around 18-22 weeks of pregnancy.

The key features of clubfoot include several distinct components that together create the characteristic appearance:

• Equinus: The foot is pointed downward at the ankle, with the heel drawn up. The baby cannot flex the foot upward toward the shin.
• Varus: The heel is turned inward, so the sole of the foot faces toward the midline of the body rather than facing downward.
• Adductus: The forefoot (front part of the foot) curves inward toward the body's centerline, creating a C-shaped or bean-shaped appearance.
• Cavus: The arch of the foot is abnormally high, creating a visible crease on the sole.

The Achilles tendon (heel cord) is typically tight and shortened, contributing to the equinus position. The muscles of the calf (particularly the gastrocnemius and soleus) are smaller and weaker than normal, and this calf muscle underdevelopment persists to some degree even after successful treatment. The affected leg may be slightly shorter than the unaffected side.

Severity Assessment

Physicians use scoring systems to assess the severity of clubfoot and monitor response to treatment. The most widely used is the Pirani score, which evaluates six clinical signs on a scale of 0 (normal) to 1 (severely abnormal), with a maximum total score of 6. The signs assessed include the curvature of the lateral border, the medial crease, the posterior crease, the rigidity of the equinus, the empty heel pad, and the coverage of the head of the talus bone.

Some clubfoot is more flexible and easier to correct (the foot can be partially manipulated toward a normal position), while other cases are more rigid and resistant to correction. However, even rigid clubfoot can be successfully treated with the Ponseti method; it may simply require more casts before correction is achieved.

How Is Clubfoot Diagnosed?

Clubfoot is diagnosed through physical examination at birth based on the characteristic appearance of the twisted foot. No imaging tests are typically needed. Prenatal ultrasound can detect clubfoot during pregnancy, usually around 18-22 weeks, allowing parents to prepare and plan for treatment.

The diagnosis of clubfoot is primarily clinical, meaning it is made through physical examination rather than laboratory or imaging tests. The characteristic appearance of the foot at birth—turned inward and downward with the heel pointing up—is usually unmistakable to healthcare providers experienced in newborn care. The foot cannot be passively corrected to a neutral position, distinguishing true clubfoot from positional deformities.

During the examination, the physician will assess the flexibility of the deformity, check for any other associated abnormalities, and evaluate neurological function. It is important to determine whether the clubfoot is isolated (idiopathic) or associated with other conditions, as this affects prognosis and may influence treatment approach.

Prenatal Detection

Clubfoot can often be detected before birth during routine prenatal ultrasound examinations. The characteristic position of the foot can be visualized as early as 12-14 weeks gestation, but detection is most reliable during the second-trimester anatomy scan around 18-22 weeks. However, prenatal ultrasound has limitations: it may miss some cases of clubfoot, and it cannot distinguish between true clubfoot and positional deformities that will resolve on their own.

When clubfoot is detected prenatally, parents have the opportunity to learn about the condition and its treatment before their baby is born. This can help reduce anxiety and allow families to connect with orthopedic specialists who will manage treatment. Prenatal counseling should emphasize that clubfoot is highly treatable and that children can expect normal function after successful treatment.

X-rays and Other Imaging

X-rays are generally not necessary for diagnosing or treating clubfoot in newborns. The bones of the foot are largely cartilaginous (not yet calcified) at birth, so they do not show up well on standard X-rays. Clinical examination provides all the information needed to begin treatment.

X-rays may occasionally be used later in treatment, particularly if there are concerns about the correction achieved or if surgery is being considered. MRI studies have been used in research to better understand the anatomy of clubfoot but are not part of routine clinical care.

How Is Clubfoot Treated?

The Ponseti method is the gold standard treatment for clubfoot, achieving 90-95% success without major surgery. It involves weekly gentle manipulation and casting for 5-7 weeks, followed by a minor Achilles tendon release in most cases, and then bracing until age 4-5 years. Treatment ideally begins within the first week or two of life.

The treatment of clubfoot has been revolutionized by the Ponseti method, developed by Dr. Ignacio Ponseti at the University of Iowa in the 1940s-1950s. This technique has become the global standard of care because it achieves excellent results with minimal intervention. Before the Ponseti method became widely adopted, extensive surgical releases were common, but these often led to stiff, painful feet in adulthood. The Ponseti method produces more flexible, functional feet with better long-term outcomes.

The key principles of the Ponseti method include gentle manipulation to gradually stretch the tight structures, serial casting to maintain the correction achieved, a minor procedure to lengthen the Achilles tendon when needed, and long-term bracing to prevent recurrence. Each component is essential—skipping or shortening any phase significantly increases the risk of relapse.

Serial Casting Phase

Treatment optimally begins within the first 1-2 weeks of life when the newborn's connective tissues are most pliable. However, the Ponseti method can be effective even when started later, including in older children and even adults, though more casts may be required.

Each week, the orthopedic specialist gently manipulates the foot toward the corrected position, then applies a plaster cast to hold the foot in its new position. The cast extends from the toes to the upper thigh, with the knee bent at 90 degrees. This position helps keep the cast in place and relaxes some of the muscles contributing to the deformity.

The manipulation follows a specific sequence: first, the cavus (high arch) is corrected by elevating the first metatarsal. Then the forefoot is gradually abducted (turned outward) around the talus bone while maintaining slight flexion. The adduction and varus components are corrected simultaneously through this maneuver. The equinus (pointed-down position) is addressed last, after the other components are corrected.

Most babies require 5-7 weekly casts to achieve adequate correction of the forefoot adduction and heel varus. Some cases may require fewer or more casts depending on severity and flexibility. Parents often notice dramatic improvement after just 2-3 casts, which can be very encouraging.

Achilles Tenotomy

After serial casting corrects most of the deformity, approximately 80-90% of babies still have residual equinus (the foot still points downward) because the Achilles tendon is too tight to allow the foot to flex upward adequately. This is addressed with a minor procedure called a percutaneous Achilles tenotomy.

The tenotomy is a simple procedure that can be performed in a clinic setting under local anesthesia. The physician makes a tiny incision and cuts the Achilles tendon, which allows the foot to be brought up into proper position. A final cast is then applied and worn for 2-3 weeks while the tendon heals. During this time, the tendon regenerates at a longer length, allowing improved ankle flexibility.

Parents are sometimes apprehensive about this procedure, but it is safe, takes only a few minutes, and is essential for achieving full correction in most cases. Avoiding the tenotomy when it is needed leads to incomplete correction and a high risk of recurrence.

Bracing Phase

The bracing phase is perhaps the most critical component of clubfoot treatment for long-term success. After the final cast is removed, the baby is fitted with a foot abduction brace (also called boots and bar, or Denis Browne splint). This device consists of special shoes attached to a metal bar that holds the feet in an outwardly rotated position.

The bracing protocol is demanding but essential:

• First 3 months: The brace is worn 23 hours per day (full-time), removed only briefly for bathing and diaper changes.
• After 3 months until age 4-5 years: The brace is worn for 12 hours at night plus 2-4 hours during daytime naps, totaling 14-16 hours daily.

Compliance with bracing is the single most important factor in preventing recurrence. Studies show that recurrence rates are as low as 6% when bracing protocols are followed correctly, compared to 80% or higher when bracing is discontinued prematurely. Parents should understand that the bracing does not hurt the baby when fitted correctly, and most babies adjust quickly.

Long-term Follow-up

Regular follow-up appointments continue throughout childhood, typically until age 8 or older. The orthopedic team monitors for signs of recurrence, which is most common between ages 2-5 years when the foot is growing rapidly and bracing compliance may wane. Early detection of recurrence allows prompt intervention, usually with additional casting.

Some children (approximately 10-30%) develop dynamic supination, where the front of the foot turns inward when walking due to muscle imbalance. This is usually treated with a surgical procedure called tibialis anterior tendon transfer, typically performed between ages 4-6 years. In this procedure, the tibialis anterior tendon is moved from the inner side of the foot to the middle, helping to balance the foot during walking.

What Is the Long-term Outlook for Clubfoot?

Children treated for clubfoot with the Ponseti method can expect to walk, run, and participate in sports normally. The foot may appear slightly different (smaller, thinner skin over the ankle) and the calf may be somewhat smaller, but these differences are usually minor and do not affect function. Long-term outcomes are excellent when bracing protocols are followed.

The prognosis for clubfoot treated with the Ponseti method is excellent. Multiple long-term studies following patients into adulthood have demonstrated that properly treated individuals have feet that function normally, with good flexibility, strength, and endurance. Most can participate in any physical activity without limitation, including competitive sports.

Some differences may persist even after successful treatment:

• The affected foot may be slightly smaller (approximately half a shoe size) than the unaffected foot in unilateral cases.
• The calf muscles on the affected side are typically somewhat smaller and may remain so throughout life.
• The skin over the outer ankle may be thinner and the lateral malleolus (outer ankle bone) may be more prominent.
• The affected leg may be 1-2 cm shorter in some cases, though this rarely requires treatment.

These physical differences are usually subtle and do not cause functional problems. Children with properly treated clubfoot typically achieve all their motor milestones (sitting, crawling, walking) at normal ages. Parents should be reassured that their child can expect to live a fully normal, active life.

Recurrence and Its Management

Recurrence of the deformity is the main challenge in clubfoot treatment. Even with proper treatment, some degree of recurrence occurs in approximately 20-30% of cases, most commonly between ages 2-5 years. The risk is highest when bracing is not followed as prescribed—recurrence rates exceed 80% when bracing is stopped prematurely.

When recurrence is detected early, it can usually be managed with additional casting using the Ponseti technique. This re-correction is typically successful and avoids the need for surgery. More advanced or late recurrences may require surgical intervention, but even these cases usually achieve good outcomes.

What Happens If Clubfoot Is Not Treated?

Untreated clubfoot results in severe disability. The child walks on the outside or top of the foot, causing pain, calluses, and infections. The deformity worsens over time as bones develop abnormally. Untreated clubfoot is a leading cause of physical disability in developing countries where treatment access is limited.

Without treatment, clubfoot does not resolve on its own—the deformity persists and worsens as the child grows. The child learns to walk on the outer edge or even the top of the affected foot, which leads to multiple problems:

• Painful calluses and skin breakdown on the abnormally weight-bearing surfaces
• Recurrent infections from skin breakdown and wounds
• Progressive bony deformity as the bones develop in abnormal positions
• Arthritis and joint pain from abnormal mechanics
• Difficulty walking and limited mobility
• Inability to wear normal footwear

In many parts of the world, untreated clubfoot remains a significant cause of physical disability due to limited access to specialized care. Organizations like MiracleFeet and CURE International work to bring Ponseti treatment to underserved areas, dramatically improving outcomes for affected children globally.

Even in cases where treatment is delayed—whether due to late diagnosis, lack of access to care, or previous incomplete treatment—the Ponseti method can still be effective, though it may require modifications and additional procedures. It is never too late to seek treatment for clubfoot.

When Should You Seek Medical Care?

Clubfoot is typically identified at birth and treatment should begin within the first 1-2 weeks of life. If your baby is born with an abnormally positioned foot, notify your healthcare provider immediately. Prenatal detection on ultrasound allows families to prepare and arrange for early treatment with a Ponseti-trained specialist.

Clubfoot is usually obvious at birth, and newborn screening should identify the condition. If you notice that your newborn's foot appears twisted or positioned abnormally, bring this to the attention of your healthcare provider immediately. Early referral to an orthopedic specialist trained in the Ponseti method is essential.

Contact a healthcare provider if:

• Your newborn has a foot that appears twisted, turned inward, or pointing downward
• Prenatal ultrasound suggests possible clubfoot
• Your child has previously treated clubfoot and you notice the foot turning inward again
• Your child has difficulty wearing the foot abduction brace
• You notice skin problems under the brace or cast

If your child has been treated for clubfoot, continue regular follow-up appointments as recommended—typically until age 8 or longer. Recurrence is most easily treated when caught early, so don't hesitate to seek evaluation if you notice any changes in foot position or gait.