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Congenital talipes equinovarus (CTEV) or clubfoot is a common foot abnormality found in males generally present at birth. In babies with clubfoot the tissues connecting the muscles to the bones are shorter than usual causing their feet to be twisted. The ankle can be twisted at a sharp angle making the foot resemble a golf club, hence the name. The severity of clubfoot can range from mild to severe with half of affected babies having both feet affected.

Symptoms

Besides being unable to walk properly there are other symptoms that your child can show.

•	The top of the foot may be twisted downward and inward, causing the arch to increase and turn the heel inward. •	The foot can look as though it’s upside down due to the severity of the turn. •	The calf muscles of the affected foot are typically underdeveloped. •	The affected foot may be up to 1/2 inch shorter when compared to the normal foot.

Though clubfoot may look painful, it actually does not cause any pain or discomfort for the baby. The foot affected will also be visibly smaller since the muscles in the foot cannot be utilized at its fullest potential. This may also lead to developing arthritis in the foot. Though the affected foot may seem smaller, your child may still need bigger a bigger shoe size to accommodate the curvature of the foot.

Causes

Though clubfoot has been around for many decades, its exact etiology is still unknown. Some cases of clubfoot can be blamed on abnormalities in the bones. Scientists do not believe that the position of the fetus while gestation is a cause. They instead blame environmental factors as possible causes for clubfoot. Cigarette smoking during pregnancy is a common link thought increases chances of a baby having clubfoot, especially if there is already a genetic predisposition to inheriting the disease.

Genetics

Though clubfoot has been around for many decades, its exact etiology is still unknown. Hippocrates was the first to make a hypothesis about the cause around 400 B.C. and still to this day there are many other hypotheses for clubfoot pathogenesis. Most of the studies have concluded that clubfoot may be caused by environmental factors, genetics, or a combination of both. There was not one study that was able to pinpoint an exact root for clubfoot, but most of findings agreed on one thing, “It is likely there is more than one different cause and at least in some cases the phenotype may occur as a result of a threshold effect of different factors acting together”

Taking a look in the early development stages of humans, some researchers hypothesized that clubfoot is formed by a malfunction that occurred while gestating in the womb. Amniocentesis is believed to increase the rates of this deformity because there is an increase in possible amniotic leakage during the procedure. Underdevelopment of the bones and muscles in the embryonic foot may be another underlying cause to clubfoot. This underdevelopment of the foot does not allow the fetus’ foot to rotate medially leaving it in the club formation after birth. A widely accepted hypothesis in the early 1900’s that further supports the foot not being able to rotate medially is one where the fetal foot development is constricted due to the uterus.

Underdevelopment of the bones also affects the muscles and tissues of the foot. Abnormality in the connective tissue causes, “The presence of increased fibrous tissue in muscles, fascia, ligaments and tendon sheaths,”. Affected individuals have smaller than normal legs even after corrected. This brought up another hypothesis where it suggests that there are variations in genes that influence muscle development are risk factors for clubfoot. Further evidence showed that mutations in genes components encoding the muscle contractile complex (MYH3, TPM2, TNNT3, TNNI2, and MYH8) cause congenital contractures, including clubfoot, in distal arthrogryposis (DA) syndromes

Modern technology advances in genetic mapping techniques, development of mouse models, improved understanding of the control of developmental processes and genetic epidemiology studies have led to a more recent hypothesis that is said to be the closest in finding the etiology of clubfoot. Its inheritance pattern is explained with a polygenic threshold model as a heterogenous disorder. The PITX1-TBX4 transcriptional pathway has become key to the study. PITX1 and TBX4 are uniquely expressed in the hind limb. Further studies duplicating this pathway in models need to be conducted to hopefully find what genetic abnormalities cause clubfoot.

Diagnosis

Clubfoot is usually instantaneously diagnosed immediately after birth just by looking at the foot. It is then up to the doctor whether or not to x-ray the foot(s) to further see how they are positioned. In some cases it may be possible to detect the disease prior to birth during the ultrasound. It may be more prominent if both feet are affected. The ability to possibly identify clubfoot before live birth can prove beneficial to the child as different treatments can be explored. .

Treatment

Once your child has been diagnosed with clubfoot treatment can be approached at many different angles. Treatment should start at an early age usually within a week or two after diagnosis to take full advantage of the flexibility in the baby’s bones and joints. This will allow easy manipulation to try to achieve a normal foot.

French Method The French method also known as the functional method or physiotherapy method is easiest to do with such supple bones. A physical therapist will direct parents to stretch and tape their child’s foot. Little by little move the child’s foot to achieve the right position then hold it in place with tape. Then in the evenings the child’s foot is hooked up to a machine where it continuously moves the foot while the child sleeps. Treatment can be lessened to three times a week after two months of continuous use. Once the foot has a regular shape to it, daily exercises should be performed and splints should be worn to bed until the baby is ready to walk. This method is not considered the most common because it is so time consuming.

Ponseti Method The most common treatment is done by the doctor. This treatment requires stretching and casting, but is better known as the Ponseti method. The foot is repositioned to the normal position then a cast is placed on top of it. The baby’s foot is then continually repositioned and placed back into a cast once or twice a week for several months. Towards the end of the process after being in a cast, the doctor will then go in and surgically lengthen the Achilles tendon. After the foot has been realigned, maintenance is kept by doing routine stretching. The child also has to wear special shoes or braces full time for three months then just nightly for three years after. This method can be compared to wearing braces on your teeth. Parents’ have to follow the doctor’s orders for when to wear and not wear the brace to keep the foot corrected. Failure will occur if parents don’t follow directions and the foot will return back to its odd shape. .

Surgery In severe cases, surgery may be the only option to correct the foot after trying all other non-invasive methods for treatment. Surgery does not ensure full recovery, but most babies who underwent the surgery have maintained their normal feet. A surgeon will go in and lengthen the muscles and tendons to ease the foot into position. After surgery when the cast is removed, a brace is to be worn to prevent the foot from returning to the old position.