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A Literature Review of Non-Surgical Intervention for the Treatment of Idiopathic Talipes Equinovarus: A Podiatric Perspective

by Janet McGroggan, BSc(Hons)1 , Gloria Dunlop2

The Foot and Ankle Online Journal 3 (10): 2

This article aims to discuss the current surgical and non-surgical interventions in the treatment of idiopathic talipes equinovarus. It examines the literature from 1964 to the present day and includes a detailed anatomical description of the condition. The treatment of this condition has evolved from complicated surgical procedures with low long term success rates to less traumatic closed treatments with good outcomes. The latter, specifically the Ponseti Method of treatment, has been practiced by orthopaedic surgeons in the United Kingdom for seven years now and this article examines the podiatrist’s potential role in the management of this lower limb complaint.

Key Words: Clubfoot, Idiopathic talipes equinovarus

Accepted: September, 2010
Published: October, 2010

ISSN 1941-6806
doi: 10.3827/faoj.2010.0310.0002

Idiopathic talipes equinovarus (ITEV) is characterised by the ankle in a plantarflexed and inverted position with the heel, midfoot and forefoot adducted and inverted producing a cavus deformity. [1] The Achilles tendon acts as an invertor [2] and the calf muscles are shortened. [3] ITEV, more commonly known as clubfoot, is a disorder affecting one or both lower limbs with fifty percent of cases being bilateral. Worldwide statistics show an incidence ratio of 1.2 babies affected in every 1,000 live births [4] with a 2:1 male:female ratio. [5] Bakalis, et al., reported in their retrospective study that of 103,228 routine ultrasound foetal scans taken between January 1991 and October 2000 in three separate London teaching hospitals, 0.1% (n=107) showed talipes equinovarus.

The scans were observed at 18-23 weeks of foetal gestation with occurrence being bilateral in 64 cases and unilateral in 43. The researchers reported 51.4% of these cases were idiopathic and 48.6% were associated with other pathologies.6 Idiopathic talipes equinovarus has a familial link and displays clear racial prevalence [7] however, the reason for the abnormal development is still unkown. [4] In third world countries ITEV is frequently left untreated and affected people will suffer diminished mobility, ulcerations from abnormal weight bearing and be socially ostracised. In the United Kingdom (UK) ITEV has historically been treated primarily through orthopaedic surgery until around 2003 when non surgical methods became more widely available.

ITEV is a congenital dysplasia which affects all tissue below the knee. [4] In a two part anatomical study [8,9] Windisch, et al., dissected seven foetal feet affected with ITEV aborted in weeks 27-36 of gestation and compared the pathoanatomy with two anatomically normal feet in weeks 27 and 36 of gestation. When describing the bone and joint relationships the authors reported a talar neck-troclea angle of 37° to 41° in ITEV compared to 27° to 33° in normal feet. Deviation of the talar neck relative to the body was 28° to 43° in ITEV compared to 22° to 24° in normal feet. The posterior surface of the talus was flat and triangular with the subtalar joint unattainable. The talar head turned along a longitudinal axis opposite to that in the normal foot.

The researchers found the anterior surface of the calcaneus to be flat, medially twisted and orientated upwards, although there was no significant difference in its angle of torsion to that of a normal foot. They concluded that an ossification disturbance of the calcaneus was the primary fault which then influences the varus position of the foot. The soft tissues merely conform to the misshapen bones. The medial ligaments are shortened and thickened, and depending on the severity of the club foot, the tendons of tibialis posterior, flexor hallucis longus and flexor digitorum longus can be wrapped up in a fibrotic mass.

In contrast, Bensahel, et al., found that the midtarsal joint played a major role in ITEV. [10] They noted that the tibialis posterior turns the talo-navicular joint towards supination with the mid and forefoot following the deviation. This allows the talus to become unstable and the calcaneus to be deviated towards an equinus and varus position. Again the surrounding soft tissues contracts and increases the deformity. Calf muscle atrophy is usual in a limb affected by ITEV [4,5] with the triceps surae and the tibialis posterior affected the most. [7] Measurements ranging from 1.25 cm to 10cm difference in the circumference of the calf muscle have been reported between the affected limb and the unaffected limb in unilateral cases. [2]

In her research Whynne-Davis [2] reported an average limb length discrepancy of 2.5cm in 47 unilateral cases of ITEV as a result of shortened bones. This shortening may occur in any one site: femur, tibia, fibula and any of the bones of the foot. Less than half the males studied were affected but all the females were affected in this study which likely is due to the earlier closing of the female epiphyses. Further studies have reported associated musculoskeletal abnormalities occurring in patients with ITEV such as internal tibial torsion and internal femoral torsion. [11]

Eighty nine to ninety percent of ITEV cases present with an absent or reduced anterior tibial artery. [12,13] In such cases the artery is always hypoplasic and stops at the level of the distal tibial epiphysis.

This phenomena is only seen in up to 3.5% of normal feet although difficulties have been reported in interpreting the arteriograms due to the rotation of the feet. [14] Preservation of four persistent primitive arteries have also been reported ‘the embryonic interosseus, tibial posterior superficialis, peronea posterior superficialis and ramus communicans inferior arteries.’ [13] There may also be absence or reduction of the posterior tibial artery and in these cases the peroneal artery becomes dominant. [11] Research shows not only are the distal vessels affected by hypoplasia, [15] but the proximal deep femoral and popliteal arteries also display circulatory disturbances. It is possible that an arterial aberration in the sixth and eighth week of gestation is related to the positioning of the calcaneus in equinus. [16] All foetal feet resemble ITEV at this point of development and although some previous studies have reported no vascular anomalies in still born infants with ITEV, [12] other research studies have identified an interruption in foot development during the ninth week of gestation. [17,18] which may provide defective positional information preventing the foot from de-rotating into a normal position. Researchers have claimed that limbs affected show fewer fibroblasts, smaller cells and less cytoplasmic volume suggesting cellular hypoplasia. [19] It has also been suggested that ITEV may result from growth of the anterolateral foot growing round the stunted posteromedial foot. [17] This theory suggests a neural abnormality may be present, since muscle fibre type is neurally determined.

Surgical interventions for ITEV

Surgical intervention is normally carried out before the child is twelve weeks old. [20] A complete subtalar release [21] is an extensive soft tissue surgical procedure that is only advised when the foot is at least eight centimetres long. During surgery the talus and calcaneus are repositioned and post operatively the limb is cast with the knee flexed at 90° and the foot externally rotated at a 10 degree angle to the knee. The limb is then elevated for 10 days. Further casts are applied as an outpatient until six weeks after the procedure. Foot orthoses are then worn at night and straight last shoes during the day.

The parents will perform physiotherapy on the affected limb for two years post operatively. Advantages of the subtalar release are to produce a high degree of correction as well as alignment between the foot and leg. Disadvantages include post operative scarring which may be so extensive that subsequent soft tissue procedures are difficult. There is also a tendency to over correct with the subtalar release and rarely (less than 1/1,000) ischemic necrosis post operatively may develop due to the poor vascular perfusion of the affected limb. [22]

The posteriomedial release is an alternative soft tissue surgical procedure in which the tendo calcaneus is lengthened leaving its lateral attachment intact. Posterior excision of the ankle capsule and the talocalcaneal capsule, including cutting the calcaneofibular ligament, and the tibialis posterior tendon is divided. If necessary the flexor hallucis longus tendon is lengthened and the plantar fascia released including any small muscles arising from the calcaneum. The posterior component of the medial ligament of the ankle is brought forward. Post operatively the limb is cast with the knee in flexion and the foot in dorsiflexion for five days. The limb is then strapped for seven to ten days until 20°of dorsiflexion is attained. At this point splints are applied and worn continuously until the child is walking. Splints are then reduced to sleep times. [20] This procedure aims to prevent the pes cavus and metatarsus adductus deformities which occur as a result of over correction after a complete subtalar release. [23] The reported success rates of the posteriomedial release vary from 50% – 84%. [23,24,25] This can be compared to a reported poor result in 15% of cases treated with a complete subtalar release. [23] A 30 year follow up of 73 feet treated with extensive soft tissue release concluded that repeated surgery can result in a stiff, painful and arthritic foot causing significant impaired quality of life. [26]

Non Surgical Interventions for ITEV

The French Functional method is a non surgical method of correction commonly used today. [27] This method was developed in the 1970’s [28] and consists of daily gentle mobilization and stretching of contracted tissues in order to stimulate and strengthen weakened muscles. Taping and splinting are used to maintain the correction’. [29] The treatment aims to obtain full correction in five months. The parents are taught the technique to continue at home until the child is walking. A splint is then used until the child is two or three years old to prevent relapse.

The Ponseti method of correction is currently the most popular closed technique. [27,30] Gentle sequential manipulation of the foot is performed to achieve a plantigrade, functional foot. [29] (See images: Images and description courtesy of www.Global_HELP.org.) Photographs and images describe the foot before, during and after treatment. Before treatment, the navicular is displaced to the medial side of the head of the talus. Note how this relationship normalizes during cast treatment. Similarly, the cuboid becomes aligned with the calcaneus during the same cast treatment (Images and description courtesy of www.Global_HELP.org.) (Fig. 1) The deformities are dealt with in the following order, cavus, adductus, varus, equinus, and serial casting, with casts used to immobilise the knee at right angles while the leg is rotated to correct tibial torsion. [31] This process is repeated weekly for five or six weeks until the anterior calcaneus can be abducted from underneath the talus allowing the foot to be safely dorsiflexed without crushing the talus. At this point a Achilles tenotomy may be required to completely correct the equinus deformity producing an average improvement in the lateral tibiocalcaneal angle of 16.9°. [32] The foot is then cast again for three weeks by which time the defect in the tendon should be healed. [33] The child must then wear ‘boots and bar’ splints (Denis-Browne splints) day and night for 10 weeks and then during sleep until the child is four years old to prevent relapse. [33] The result is a foot which may appear overcorrected however as the child grows and walks this overcorrection relaxes into a normal foot.

Figure 1   The foot before, during and after treatment. Before treatment, the navicular is displaced to the medial side of the head of the talus. Note how this relationship normalizes during cast treatment. Similarly, the cuboid becomes aligned with the calcaneus during the same cast treatment. Images and description courtesy of www.Global_HELP.org .

Complications may result with the Ponseti method if the practitioner does not manipulate sequentially. [34] Such an error can usually be corrected with further serial casting if detected early enough. However, if the talus gets crushed or a rocker bottom deformity develops, [35] surgery will be required. Lack of compliance precedes the majority of relapses as the child may have trouble sleeping wearing the Denis-Brown splints therefore parental education is vital. [34] Other closed methods such as the ‘extra space cast correction technique’ have been documented [36] however the Ponseti method is emerging as the most popular manageable treatment routine which has an average 70% success rate [27,29] and produces positive long term results in foot function and aesthetics. [27,37,38] Abnormalities such as knee hyper-extension, equinus gait and foot drop are not reported with the Ponseti method but have been reported with other manipulation techniques.

Currently clinics providing the Ponseti treatment generally comprise of an orthopaedic surgeon, physiotherapists, nurses and an orthotist at the stage of splinting. However the Ponseti method has been extended to other healthcare professionals which has already been trialled successfully in the UK within two separate secondary care settings. [39,40] Kampa, et al., [40] used a multidisciplinary team comprising of junior doctors, physiotherapists, nurses and plaster technicians or orthotists. They concluded that the combined approach of a multidisciplinary team and a surgeon when necessary was a success. Docker, et al., [39] used a team of trained physiotherapists who referred only to the orthopaedic surgeons in the case of complications or the need for a tenotomy. Tenotomies in this study were carried out under general anaesthetic although a local anaesthetic is recommended. [41] A significant difference in the number of tenotomies required between the two groups was reported in favour of the physiotherapy department. The authors hypothesised that this may be due to the treatment initiating at an earlier stage.

The Ponseti method would be equally relevant and applicable to podiatry practice as Podiatrists already treat patients with surgically corrected ITEV as part of routine clinical practice, already work in multidisciplinary teams, have extensive specialist knowledge in anatomy and biomechanics of the lower limb and foot, and care on a regular basis for patients with a broad range of physically disabling conditions. The adaptation and the inclusion of current podiatry skills in biomechanical diagnosis, foot casting and orthoses manufacture into the multidisciplinary approach to the Ponseti method, is highly likely to augment delivery of the treatment technique and improve the availability of Ponseti clinics. Having multidisciplinary clinics available at a local level has the potential to reduce the weekly journey time for parents and children making the experience less stressful. As parent education is key to the treatment’s success, having podiatrists available close to home for mid week visits to respond to problems when they arise is likely to reduce the long waiting times in out patients departments which is already a problem cited by both Docker, et al., [39] and Kampa, et al., [40] Docker, et al., also suggested that the earlier intervention of the multidisciplinary team reduced the number of tenotomies required, again cutting the overall healthcare costs.

Halananski, et al., [42] compared the resource utilization between the Ponseti method and the standard surgical routes and found a significant difference in the use of resources between the two methods. He did however highlight difficulties in the study as non monetary resources were difficult to quantify. A similar in depth study would be proposed to compare the costs of a surgically led Ponseti clinic with a multidisciplinary Ponseti clinic which ideally should also included a podiatrists as a member of the team.


It is proposed that the inclusion of podiatry skills to the Ponseti method for the treatment of ITEV, would enhance the continuity of care for the patients in the long term in the assessment and monitoring of post operative care and in identifying further intervention if and when necessary.

Using podiatrists to practice the Ponseti method in a multidisciplinary setting has the potential to develop a more foot focused, cost effective, and patient centred practice and it is proposed that future research into the efficacy and the cost efficiency of the Ponseti method will include the professional and clinical skills of the podiatrist.

The authors invite other clinicians to write in expressing their views on podiatry and the Ponseti method and discuss research results pertaining to this literature review.


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16. Crider RJ, Hootnick DR, Dobbs MM, Seimon L. Do talipes equinovarus (TEV) and congenital vertical talus (CVT) have a common aetiology? In: Bensahel H, Kuo KN, Lehman. Fifth Annual Clubfoot Congress IFPOS & ICFSG, August 27-28, 2008, Hong Kong. J Childrens Orthopaedics 2009 3:67-83.
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21. Simons GW. Complete subtalar release in club feet. Part 1 – A preliminary report. JBJS 1985 67A: 1004-1055.
22. Hootnick DR, Dobbs MB, Crider RJ. Review of ischemic necrosis following clubfoot surgery with case of retained primitive arterial rete. In: Bensahel H, Kuo KN, Lehman. Fifth Annual Clubfoot Congress IFPOS & ICFSG, August 27-28, 2008, Hong Kong. J Childrens Orthopaedics 2009 3: 67-83.
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28. Bensahel H, Bienayme B, Jehanno P. History of the functional method for conservative treatment of clubfoot. J Childrens Orthopaedics 2007 1: 175-176.
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30. Changulani M, Garg NK, Rajagopal TS, Bass A, Nayagam SN, Sampath J, Bruce CE. Treatment of idiopathic clubfoot using the Ponseti method. JBJS 2006; 88B: 1385-1387.
31. Ponseti IV, Smoley EN. Congenital club foot: the results of treatment. JBJS 1964 45: 261-344.
32. Radler C, Manner HM, Suda R, Burgardt R, Herzenberg JE, Ganger R, Grill F. Radiographic evaluation of idiopathic clubfeet undergoing Ponseti treatment. JBJS 2007 89A: 1177-1183.
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34. Goksan SB. Treatment of congenital clubfoot with the Ponseti method. Acta Orthopaedica Traumatologica Turcica, 2002 36: 281-287.
35. Wicart P, Koureas, G Seringe R. Rocker bottom deformity: a complication of idiopathic congenital clubfoot conservative treatment. In: Bensahel H, Kuo KN, Lehman. Fifth Annual Clubfoot Congress IFPOS & ICFSG, August 27-28, 2008, Hong Kong. J Childrens Orthopaedics 2009 3: 67-83.
36. Baindurashvili AG, Rumyantsev NJ, Omarov GG. Extra space casting technique in clubfoot: 20 years of experience. In: Bensahel H, Kuo KN, Lehman. Fifth Annual Clubfoot Congress IFPOS & ICFSG, August 27-28, 2008, Hong Kong. J Childrens Orthopaedics 2009 3: 67-83.
37. Ippolito E, Farsetti P, Caterini R, Tudisco C. Long-term comparative results in patients with congenital clubfoot treated with two different protocols. JBJS 2003 85A: 1286-1294.
38. El-Hawary R, Karol LA, Jeans KA, Richards BS. Gait analysis of children treated for clubfoot with physical therapy or the Ponseti cast technique. JBJS 2008 90A: 1508-1516.
39. Docker CEJ, Lewthwaite S, Kiely NT. Ponseti treatment in the management of clubfoot deformity – a continuing role for paediatric orthopaedic services in secondary care centres. Annals of the Royal College of Surgeons of England 2007 89(5): 510-512.
40. Kampa R, Binks K, Dunkley M, Coates C. Multidisciplinary management of clubfeet using the Ponseti method in a district general hospital setting. J Childrens Orthopaedics 2008 2: 463-467.
41. Bor N, Katz Y, Vofsi O, Herzenberg JE, Zuckerberg AL. Sedation protocols for Ponseti clubfoot Achilles tenotomy. J Childrens Orthopaedics 2007 1: 333-335.
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Address correspondence to: Janet McGroggen janetmcgroggan@hotmail.co.uk

Private Practice, Instep Podiatry Ltd, 26 Greenwood Street, Altrincham, Cheshire, WA14 1RZ.
Lecturer, School of Health Sciences, Subject area of Podiatry, Queen Margaret University, Edinburgh.

© The Foot and Ankle Online Journal, 2010

Aberrant Tendo-Achilles Tendon in Club Foot: A case report

by J. Terrence Jose Jerome, MBBS, DNB (Ortho), MNAMS (Ortho)1, Mathew Varghese, M.S. (Ortho)2, Balu Sankaran, FRCS, FAMS3, Rajendra Kumar Gupta4, Simon Thomas, MBBS, DNB (Ortho), MNAMS (Ortho)5, Amit Mittal6

The Foot & Ankle Journal 2 (2): 2

This case report discusses the presentation and treatment of a baby boy with club foot deformity. He was initially treated by Ponseti’s method of weekly plaster of paris casting. The club foot did not reduce after 6 weeks of serial casting. The boy then underwent percutaneous Achilles tendon lengthening and placed in a Steinbek Splint. After 12 weeks, the equinus persisted and we decided to perform an open Achilles lengthening. An aberrant tendo-achilles tendon was discovered during open tenotomy and this was released. Once the aberrant tendon was released, the club foot reduced and at 9 months, the baby could walk with good heel strike and the foot was supple with no residual deformity.

Key words: Aberrant tendo-Achilles tendon, club foot, talipes equinus, Ponseti’s casting method

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot & Ankle Journal (www.faoj.org)

Accepted: January, 2009
Published: February, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0202.0002

Congenital club foot is a complex deformity that is difficult to correct. It has a tendency to recur until the age of six or seven years. While there may be a so-called recurrence in an adolescent, this is usually associated with incomplete initial correction rather than being secondary to growth alone. We present a case report of a 15 day-old boy with aberrant tendo-Achilles tendon of the right side which caused an incomplete correction of club foot.

Case Report

A 15 day- old baby was referred by a pediatrician for the management of right clubfoot. The baby was a full-term, normal delivery in a governmental hospital. On examination the baby was found to have a 3-dimensional deformity (CAVE) with four components in the right foot (Figs. 1)


Figures  1   A 15 day- old baby presents with right club foot deformity.  The deformity is 3-dimensional with 4 components including cavus, forefoot adduction, heel varus and equinus (CAVE).

C-Cavus-increased longitudinal arch of foot.
A-Adduction-tarsal bones are directed towards the median plane
V-Varus-inversion and adduction of calcaneum
E-Equinus-increased plantar flexion of foot

The spine and pelvis were clinically normal. The baby was treated by Ponseti’s method of weekly POP (plaster of paris) cast. Simultaneous correction of the three components of deformity (Cavus, Forefoot, Adduction and heel varus) was achieved in 6 weeks. (Fig. 2)

Figure 2   The baby is treated with serial casting  by Ponseti’s method of weekly plaster of paris cast.

The baby had persistent equinus (Fig. 3A) after 6 weeks of serial POP casting. The foot could be abducted and externally rotated to 60 degrees.A percutaneous tenotomy of the tendo-Achilles was done under local anesthesia. Postoperatively, toe to groin cast with knee in 90 degrees of flexion to maintain the corrected position and to allow tendon healing was applied for 3 weeks. Then the foot was maintained in 60-70 degrees of abduction, external rotation and 15-20 degrees of dorsiflexion by Steinbek Splint (open toe high top straight shoes attached to bar of length equal to shoulder width). This splint is usually worn 23 hours/day for the first 3 months and 14-16 hours/day up to 3-4 years of age.

Twelve weeks later, the parents were complaining that their baby touches the floor only with tip of the right toe. On examination, the heel cord was found tight. (Fig. 3B)


Figures 3A and 3B  The boy presents with persistent equines following 6 weeks of serial casting. (3A)  After 12 weeks, the heel cord was still found to be tight and open Achilles tendon lengthening was planned. (3B)

Equinus was found to be persistent. We decided to do an open tendo-Achilles lengthening. Intra-operatively, we found an aberrant tendo-Achilles tendon (Fig. 4) attaching just posterior to the tendo-Achilles tendon and the calcaneal tuberosity. This was released from the calcaneum and the foot could be dorsiflexed to 20 degrees on the operating table. The baby was given an above- knee POP cast for 3 weeks and followed with Steinbek Splint in 70 degrees of abduction, external rotation on affected side and 45 degrees on normal side with 15 degrees of dorsiflexion.

Figure 4  An aberrent tendo-Achilles tendon was discovered during open tenotomy.  The aberrent tendon was located just posterior to the Achilles tendon and calcaneal tuberosity.

At 9 months, the baby could walk with a good heel strike and the foot was supple with no residual deformity. (Fig. 5) At 18 months follow up the baby was found to have a pain-free, plantigrade foot, with good mobility. (Fig. 6) The parents were advised to continuously use the brace for the baby, 14 to 16 hours a day until 3 to 4 years of age.

Figure 5  At 9 months, the boy could walk with good heel strike and the foot was supple with no deformity.

Figure 6  At 18 months follow-up, the baby was found to have a pain-free, plantigrade foot, with good mobility.


Club foot deformity has four components [3-5,6,14,15]: equinus, varus, adductus, and cavus. The goal of treatment is to reduce or eliminate these four deformities so that the patient has a functional, pain-free, plantigrade foot, with good mobility and without calluses, and does not need to wear modified shoes. The most severe deformities in a club foot occur in the hind part of the foot. The talus and calcaneus are generally deformed and in severe equinus, the calcaneus is in varus angulation and medially rotated, and the navicular is severely displaced medially. [2,11,12,17,18,20,21] These components of the deformity are inextricably inter-related. The ligaments of the posterior aspect of the ankle and of the medial and plantar aspects of the foot are shortened and thickened. The muscles and tendons of the gastrocnemius tibialis posterior, and toe flexors are shortened. [4,14,15,20]

Most orthopedists have agreed that the initial treatment of a club foot should be non-operative. [4,5,8,11,12,14,15] The preferred method is manipulation and application of a plaster cast at weekly intervals. Less favored methods of initial treatment are use of a Denis Browne splint, stretching and adhesive strapping, and physiotherapy. Manipulation and serial application of casts, supported by limited operative intervention, yielded satisfactory functional results in 89 percent of the feet. [8,14,15] However, at other institutions, manipulative treatment has resulted in increased cavus deformity, rocker-bottom deformity, a longitudinal breach, flattening of the proximal surface of the talus, lateral rotation of the ankle, and increased stiffness of the ligaments and joints. [1,2,3,4] To avoid these distressing outcomes, early and even primary operative treatment of club foot is practiced in some centers [5,7,9,10,12,15,19,23], often with equally disturbing failures and complications, such as wound infection, necrosis of the skin, severe scarring, stiff joints, overcorrection and under correction, dislocation of the navicular, flattening and beaking of the talar head, talar necrosis, and weakness of the plantar flexors of the ankle with major disturbances of gait.

The reported results of operations in newborns have been either short term and not encouraging. Early operative treatment often results in reduced motion of the ankle and foot, whereas manipulation and the application of plaster casts with proper technique lead to greater mobility and less disability. [7,9,10,13,15]

Most orthopedists have agreed that an operation [3,4,5,11,12,15,21] should be considered only after manipulation and serial application of casts have failed to obtain correction in a specified period of time, preferably not more than three months. The poor results of manipulative treatment of most club feet in many clinics suggest that the attempts at correction have been inadequate or that the technique has been faulty. [8,14,15] Books and papers on pediatric orthopedics have devoted scant space to manipulative technique in the treatment of this deformity, and often the descriptions have been incorrect. The correction of the cavus component of the deformity is usually not addressed. [14,15] The equinus is corrected by dorsiflexion of the foot with the heel in valgus after the adduction of the foot and the varus deformity of the heel has been corrected. The correction entails stretching of the tight posterior capsules and ligaments of the ankle and subtalar joints and the tendo-Achilles. [4,5,8,12,14,15] Two or three plaster casts that carefully mold the heel, applied after manipulation, are usually needed to correct the equinus deformity. Care should be taken not to cause a rocker-bottom deformity, which can occur when dorsiflexion of the foot is attempted with pressure under the metatarsals rather than under the mid-part of the foot, particularly when the varus deformity of the heel has not been corrected. [1,8]

A simple subcutaneous tenotomy of the tendo-Achilles, performed with the patient under local anesthesia, facilitates correction of the equines. [8,14,15] This tenotomy is done in about 70 percent of patients, when 15 degrees of dorsiflexion has not been obtained with the use of the casts. Dorsiflexion of the ankle to more than 10 to 15 degrees is rarely possible because of the talar and calcaneal malformations and tight ligaments. A posterior capsulotomy of the ankle and subtalar joint is rarely done, because the few additional degrees of correction that are obtained may be completely lost later due to retraction of the scar tissue. [4,5,13,14,15]

Regardless of treatment, a club-foot deformity tends to relapse until the child is about seven years old. [3,4,5,8,12,14,15] To prevent relapse, some orthopedists hold the foot in maximum correction with a series of plaster casts or with splints. Denis Browne splints and high-top shoes with well-molded heels that hold the feet in lateral rotation are the most effective means for maintenance of the correction. The splints are worn full time for two to three months and thereafter at night for two to four years. The splint should maintain the foot in 60 to 70 degrees of external rotation, to prevent recurrence of varus deformity of the heel, adduction of the foot, and in-toeing. [8,14,15] With careful supervision and with cooperative and responsible parents who follow instructions faithfully; relapse can be prevented in about 50 percent of patients. In the other 50 percent, a relapse will occur between the ages of ten months and seven years (average age, two and one-half years). A relapse is detected when slight equinus and varus deformity of the heel is observed, usually without increased cavus and adduction deformity of the fore foot. [16,18,22,23]

The original correction may be recovered in four to eight weeks with manipulations followed by application of a toe-to-groin plaster cast, with the foot held in marked lateral rotation, every ten to fourteen days. This treatment is often followed by lengthening of the tendo-Achilles, if the tendon prevents dorsiflexion of the ankle to at least 15 degrees, and by use of the Denis Browne splint at night. [3,4,5,8,12,14,15] A large proportion of club feet that are treated with this procedure found the correction of the equinus, varus deformity of the heel, was obtained with manipulation and application of casts. If this can be maintained, the anteroposterior talocalcaneal angle will become normal. Cavus component of the club-foot deformity rarely recurs. [8,14,15] When this deformity is resistant to manipulation, it should be treated with plantar fasciotomy and recession of the extensor hallucis longus tendon to the neck of the first metatarsal. The adductus component of the club-foot deformity does not recur in patients who have received good treatment and follow-up care. When proper treatment with manipulation and casting has been started shortly after birth, operative release of the tarsal joints is seldom needed. [19]

An early operation (not later than the second month of life) is indicated only in the small percentage of patients who have short, rigid feet, with very severe equino varus deformity, that do not respond to proper manipulations. Many orthopedists also favor release of the tarsal joints in less rigid feet when manipulations have failed to completely correct the displacement of the navicular and the talocalcaneal alignment to a normal talocalcaneal index. Extensive posteromedial release, with or without internal fixation of the tarsal bones, is the preferred procedure, but there has been much disagreement about the timing of the operation. Recently, more radical [19,22,23] techniques have been tried in younger patients. The objective of all of these operations is release of the tight capsules and ligaments of the ankle and tarsal joints, and lengthening of the shortened tendons of the foot to facilitate placement of the tarsal bones in normal alignment.

The baby in this case report had a persistent eqinus deformity even after percutaneous tenotomy. Intra-operatively an aberrant tendo-Achilles was noted and was released from its calcaneal attachment. This could be the reason for the resistant equinus deformity. The literature rarely describes the aberrant tendo-Achilles tendon and the management.


The initial treatment of club foot should be non-operative. Corrective manipulation and serial application of casts, followed by calcaneal tenotomy and release of an aberrant tendo-Achilles tendon if found, should be successful in at least 85 percent of patients who are initially treated a few days after birth. High index of suspicion for an aberrant tendon should be there, if there is a resistant equinus deformity alone, especially after manipulation, POP cast correction and percutaneous tendo-Achilles tenotomy.

The orthopedist and podiatrist must have a thorough understanding of the deformity and be highly skilled with regard to manipulation and the application of plaster casts. Most relapses can be treated successfully with additional manipulations and applications of casts for four to eight weeks. Operative correction of a club foot is indicated when the deformity has not been treated successfully with proper manipulation and serial application of casts, supported by limited operative intervention. Most of these resistant club feet can be corrected with the use of an extensive posteromedial release and release of aberrant tendo-Achilles tendon with satisfactory functional results.


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Address correspondence to: Dr. J. Terrence Jose Jerome, MBBS.,DNB (Ortho), MNAMS (Ortho)
Registrar in Orthopedics, Dept. of Orthopedics
St. Stephen’s Hospital, Tiz Hazari, Delhi 54, India

Registrar in Orthopedics, Department of Orthopedics, St. Stephens Hospital, Tiz Hazari, Delhi, India.
Head Professor, Department of Orthopedics, St. Stephens Hospital, Tiz Hazari, Delhi, India.
Professor Emeritus, Orthopedics, St. Stephens Hospital, Tiz Hazari, Delhi, India. E-mail: pasle@bol.net.in
Consultant in Orthopedics, Department of Orthopedics, St. Stephens Hospital, Tiz Hazari, Delhi, India. Phone: 991-23966021-27.
5-6  Registrar in Orthopedics, Department of Orthopedics, St. Stephens Hospital, Tiz Hazari, Delhi, India. Phone: 991-23966021-27.

© The Foot & Ankle Journal, 2009