Club Foot (CTEV)

Club foot (medically termed Congenital Talipes Equinovarus or CTEV) is one of the most common congenital musculoskeletal conditions, occurring in approximately 1 in 1,000 live births. The foot is twisted inward and downward — the sole faces inward and the toes point down.

The deformity has four components remembered by the acronym CAVE: Cavus (high arch), Adductus (forefoot turning inward), Varus (hindfoot tilting inward), and Equinus (foot pointing downward). Club foot is bilateral in about 50% of cases and is more common in boys.

• Idiopathic (most common): No identifiable cause in the majority of cases — likely multifactorial with genetic and environmental components
• Genetic factors: Positive family history increases risk — siblings have a 3–4% risk; children of an affected parent have a higher risk
• Neuromuscular conditions: Spina bifida, arthrogryposis, and cerebral palsy can cause secondary club foot (more rigid and harder to treat)
• Intrauterine factors: Oligohydramnios (reduced amniotic fluid) restricting fetal movement
• Club foot can often be detected on routine antenatal ultrasound scan from around 20 weeks of pregnancy

• Foot visibly twisted inward and downward at birth — often detected by midwife or paediatrician at delivery
• The entire foot from heel to toe is involved — the heel is small and pulled up, the forefoot turns inward
• The calf muscles on the affected side are thinner than on the normal side
• The deformity is rigid — unlike positional deformities, it cannot be passively corrected to neutral position
• If undetected and untreated — as the child begins walking, weight is borne on the outer border of the foot causing painful calluses and severe functional impairment

• Clinical examination at birth to confirm diagnosis and assess severity using the Pirani or Diméglio scoring system
• Differentiation from positional club foot (flexible, corrects easily) and postural talipes (corrects with gentle manipulation)
• X-rays are not routinely required initially but may be used to assess bony relationships in older children or atypical presentations
• Ultrasound may assist in very young infants before bones are ossified
• Assessment for associated neuromuscular conditions — spine MRI if neurological cause suspected

Treatment should begin within the first week of life to take advantage of the plasticity of infant ligaments and cartilage:

• Ponseti serial casting (gold standard): A weekly casting programme begins within days of birth. Each cast gently corrects one component of the deformity at a time — cavus first, then adductus and varus, then equinus. Typically 5–7 casts over 5–7 weeks
• Percutaneous Achilles tenotomy: In about 90% of cases, a minor procedure to cut the Achilles tendon is performed after the final cast to fully correct the equinus. The tendon heals and lengthens within the final cast over 3 weeks
• Foot Abduction Brace (FAB): After casting, the child wears a boots-and-bar brace for 23 hours/day for 3 months, then nights and naps until age 4–5. Brace compliance is critical — it prevents relapse
• Tibialis anterior tendon transfer (TATT): For children over 2.5 years with dynamic supination (foot turning inward during walking due to muscle imbalance) — the tendon is transferred to the lateral border of the foot to balance pull
• Surgical soft tissue release: For resistant or relapsed cases not amenable to re-casting — a more extensive posterior medial release may be required