Clubfoot

Confirm antenatal findings but diagnose clinically after birth. Ask about family history, reduced fetal movement, other scan abnormalities and pregnancy exposures without implying parental cause. Inspect both feet, calves, knees, hips and spine. Note deep medial and posterior creases, small heel and calf and whether the foot can be gently corrected. Check active toe and ankle movement, perfusion, tone, reflexes and sacral skin. Bilateral clubfoot can still be idiopathic.

Describe severity with a reproducible score such as Pirani or Dimeglio rather than simply mild or severe. Pirani assesses hindfoot and midfoot signs, including posterior crease, empty heel, rigid equinus, medial crease, curved lateral border and talar-head coverage. Scores track response but do not replace experienced examination. Positional talipes is supple and often resolves with movement; true clubfoot resists correction and requires direct Ponseti referral.

Start Ponseti treatment in the first weeks when practical, after family bonding and medical stability. The clinician manipulates gently and applies a well-moulded long-leg cast with knee flexed to prevent slippage. At weekly changes, cavus is corrected by aligning the forefoot, then the foot is abducted beneath a stabilised talar head. The heel corrects through coupled calcaneal rotation; directly pushing the heel or pronating the forefoot creates deformity.

Equinus is addressed only after the foot has abducted and the heel is neutral or valgus. If ankle dorsiflexion remains limited and the heel feels empty, percutaneous Achilles tenotomy is performed with age-appropriate analgesia or anaesthesia in the trained service. A final cast holds correction for about three weeks while the tendon heals. Ultrasound or radiography is not routinely required for idiopathic diagnosis or tenotomy when clinical landmarks are clear.

Bracing preserves rather than creates correction. Fit bilateral boots connected by a bar, with the treated foot set in the prescribed external rotation and enough dorsiflexion. The brace is commonly worn 23 hours each day for three months, then for nights and naps until four or five years. Check heel seating, sock creases and skin. Address sleep, fitting and family barriers collaboratively because unrecognised practical difficulty appears as non-adherence and relapse.

Review dorsiflexion, heel position, lateral border, passive abduction and dynamic gait. Early loss of range or recurrent adduction responds best to repeat manipulation and casting, followed by resumed brace use. A repeat tenotomy may be needed for recurrent equinus. Once the child walks, dynamic supination during swing with lateral-border landing reflects tibialis-anterior imbalance; after restoring passive correction, transfer to the lateral cuneiform can rebalance selected children.

Syndromic and neuromuscular feet are stiffer, need more casts and relapse more often. Coordinate neurological, spinal, hip and developmental assessment and set realistic functional goals. Limited posterior release or more extensive surgery is reserved for resistant deformity that cannot become plantigrade with expert Ponseti treatment. Repeated extensive soft-tissue releases should be avoided where possible because scar, weakness and painful stiffness accumulate.

Teach families that a corrected foot remains smaller and the calf slimmer, but the goal is a flexible plantigrade pain-free foot in ordinary shoes. Provide urgent cast advice for colour, swelling, smell, dampness, slipping and reduced movement. Continue follow-up through brace years and growth. At every relapse, ask how the brace fits and is being used before blaming the family; repair equipment, education and support alongside mechanical recorrection.