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Mayank Pushkar, Congenital Talipes Equinovarus (CTEV), Scientific Research Journal of India (SRJI) Vol- 2, Issue- 1, Year- 2013
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35
CONGENITAL TALIPES EQUINOVARUS (CTEV)
Mayank Pushkar. BPT, MSAPT*
INTRODUCTION
Congenital telipesequinovarus (CTEV) is a
common congenital limb deformity involving one
foot or both1. “Congenital” means a deformity that is
present at birth, “Telipes” means simply the foot and
ankle, and “Equinovarus” refers to position of the
foot, which points downward and inward. CTEV is
also known as “Clubfoot”. An estimated 30000
children born with CTEV every year in India2,
although a rate of 1.24 or greater have been reported
in UK. It is a common birth defect, occurring in
about 1/1000 live births. Almost half of the cases of
CTEV are bilateral. Male children are more affected
than female children with a ratio of approximately
2:13.
PATHOANATOMY
The true clubfoot is characterized by different
deformities- Equinus, Varus, Adductus and cavus4.
The ‘equinus’ deformity is present at the ankle joint,
TCN joint and forefoot. The ‘varus’ component
occurs primarily at TCN joint and the hind foot is
rotated inward. The ‘adductus’ deformity takes place
at the talonavicular and the anterior subtalar joints.
The ‘cavus’ component involves forefoot plantar
flexion, which contributes to the composite equinus.
Fig- 1- Showing CTEV in both the foot.
AETIOLOGY
Genetic factors play an important role in
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inheritance of CTEV as a polygenic multifactorial
trait5. Maternal Hyperthermia is also one of the
causes for CTEV6, as maternal hyperthermia acts as
adverse environmental factor in the sensitive period
of intrauterine development.
Mainly there are 3 broad categories responsible
for CTEV deformity in newborn7-
1. NEUROLOGICAL DAMAGE
2. MUSCULO-SKELETAL DEFORMITY
3. POSTURAL DEFORMITY
1.NEUROLOGICAL DAMAGE: Spina bifida
overta with failure of development of the sacral part
of the spinal cord but normal proximal development
can results in an equinovarus deformity of the foot.
2. MUSCULO-SKELETAL DEFORMITY:
CTEV can results because of composite intrinsic
pathology of muscle and the bone. There are
varieties of other conditions which affectthe
peripheral musculoskeletal tissues and cause an
equinovarus deformity.
3. POSTURAL DEFORMITY: Some children
born with equinovarus deformity of the feet, if they
have been tightly packed in the utero with the feet
fixed in an equinovarus position for some week prior
to birth.
TYPES OF CTEV
1. STRUCTURAL CTEV: This type of CTEV is
caused by genetic factors such as- a genetic defect
with 3 copies of chromosome 18, which is known an
“Edward Syndrome”. Compartment syndrome,
Larsen’s syndrome, congenital heart defect and
neural tube defect are some of the other causes of
structural CTEV4.
2. POSTURAL CTEV: This type of CTEV is
caused due to the compression in utero with the feet
held in equionovarus position in final trimester.
CLINICAL FEATURES OF CTEV
Idiopathic clubfoot is characterized by a bean-
shaped foot prominence of the head of Talus, medial
plantar cleft, deep posterior cleft, absence of normal
creases over the insertion of tendon achilies,
calcaneal tuberosity situated at a higher level and
atrophy of calf muscle4. Three major components of
deformities, those are, equinous, varus and adducts,
are obvious on examination. Presence of other
anomalies implies a non-idiopathic type of clubfoot.
Hypertrophy of calf muscle is present and
dorsiflexion and eversion are limited. Lateral
malleolus is very prominent while the medial
malleolus is buried in a depression because of the
inversion at the subtalar joint. There is also
exaggeration of longitudinal arch of the foot.
ASSESSMENT OF CTEV
ANTENATAL DIAGNOSIS: The clubfoot can be
diagnosed at 18-20 weeks of gestation with the
advert of Ultrasound. Amniocentesis is made at < 20
weeks to check for the high incidence of associated
genetic anomalies7,8.
POSTNATAL DIAGNOSIS: The child as well as
foot must be carefully assessed at birth.
The early assessment of CTEV can be carried out by
two methords9:
1. Photographic Assessment
Scientific Research Journal of India ● Volume: 2, Issue: 1, Year: 2013
37
2. Radiological Assessment
1.PHOTOGRAPHIC ASSESSMENT: Photograph
of resting forefoot supination is recommended at
birth. The focus of the camera is centred at the level
of the ankle joint and an assistant holds the knee
between finger and thumb and rotates the leg
outward until the forefoot is superimposed upon the
line of tibia. From the photograph it is then possible
to measure an angle subtended by the forefoot on the
line of the tibia (Fig. 2). Children with more than 900
of resting forefoot supination at birth were more
resistant to surgical correction.
Fig. 2- Showing the measurement of angle.
2.RADIOGRAPHIC ASSESSMENT: A standard
lateral soft tissue radiograph of the lower leg can be
used for the assessment of CTEV. But X-Rays are
not routinely prescribed at birth as few bones in the
foot are ossified4. Also there is not much of clinical
use of radiographic assessment as it does not make
any difference in management of CTEV.
MANAGEMENT OF CTEV
The main principle of the management of
CTEV is the correction of the deformity followed by
maintenance of the in the corrected position.
The management of CTEV can be conservative
(Non-operative) method as well as operative
depending on the severity of deformity and age of
child.
CONSERVATIVE TREATMENT
The conservative method comprises of
manipulation with or without strapping or corrective
plaster casts. The goal of physiotherapy management
of CTEV consisted of short term and long term
goals14. The short term goal is to correct the
deformity so that ankle assumes plantigrade
positioning by the time the child would be 3 months.
The long term goal is to maintain the corrected ankle
in the situ and follow up the maintained correction
until the child start walking.
MEANS OF PHYSIOTHERAPY
MANAGEMENT
1. Rhythmic and repeated gentle
manipulation10
2. Strapping and Plaster of Paris
3. Education and instruction to the mother
and/ or parents10
1. RHYTHMIC AND REPEATED GENTLE
MANIPULATION: To provide gentle
manipulation, the PT placed the knee at 900 of
flexion to prevent the damage to the lower end of
tibia and fibular epiphysis and the ankle joint. To
correct the adduction, the soft tissue of foot is
passively stretched as- the forefoot is uncurled so
that it moves away from epsilateral heel i.e. forefoot
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abduction. To correct the inverted foot, the foot is
turned such that the sole face outward i.e. eversion.
Finally, to correct the equinus, the heel is cupped
with the one hand from the front of the foot and an
upward pressure is applied, which brings the ankle
into dorsiflexion. The entire procedure is repeated 3-
4 times in each foot.
2. STRAPPING AND PLASTER OF PARIS: This
can be useful for fairly mild cases and should be
started at birth. Strips of adhesive strapping are
passed around the foot, up the side of legs, and over
the top of the knee, to hold the foot in a corrected
position. This is usually done weekly, followed by
some manipulation by the physiotherapist.
According to the “International Clubfoot Study
Group (2003)”, Kite’s, Ponseti’s and Bensabel’s
techniques have been approved as the standardized
conservative regimes for the management of
CTEV11.
Kite’s Technique4: This technique was derived from
the concept of three-point pressure. In this method,
the manipulation can be started soon after birth. The
forefoot is grasped and distracted while the other
hand holds the heel. The counterpressure is applied
over calcaneocuboid joint and the navicular is
pushed laterally. The heel is everted as the foot is
abducted. This is followed by application of slipper
cast, which is extended to below the knee with the
foot everted with gentle external rotation. Once the
adduction and varus are corrected, then the foot is
pushed into dorsiflexion to correct the equinous. The
casts are changed every week. Following full
correction, the foot are placed in a “Denis Brown
Bar”. The average number of cast required for
correction by this technique is 20.4.
Ponseti’s Technique4: In Ponseti’s technique, first 2
casts are applied with the supination of forefoot so
as to bring into alignment with the hind foot12. The
third cast is applied with the forefoot abducted and
simultaneous counterpressure over the head of talus.
In the fourth cast, the forefoot is further abducted.
Before the application of fifth cast, the degree of
dorsiflexion is assessed and if the dorsiflexion is not
possible beyond neutral, then a “Percutaneous
AchiliesTenotomy” is required, this is done under
local anaesthesia. The casts are changed weekly
intervals, before tenotomy, while the cast after the
tenotomy is removed at the end of 3 weeks. After the
removal of cast the patient is placed in modified
“Foot Abduction Orthosis (FAO)”. FAO is initially
used 23 hrs.a day for 4 months and then
subsequently for night-time for 3 years13. The
average number of casts required with this technique
is 5.4.
French Technique4: This technique involves daily
manipulation of the child’s clubfoot by
Physiotherapist for 30 minutes, followed by
stimulation of muscles (especially Peroneal muscle)
around the foot and then adhesive strapping is
applied. Daily treatment is required for
approximately 2 months and then reduced to 3
sessions per week for an additional six months.
Tapping is continued until the patient is ambulatory.
Once the child starts ambulation, then night-time
splint is given for additional 2 to 3 years.
3. EDUCATION AND INSTRUCTION TO THE
MOTHER: The mother should be assured and
reassured that with her co-operation, consistency and
Scientific Research Journal of India ● Volume: 2, Issue: 1, Year: 2013
39
compliance to treatment, the deformity could be
corrected. She should be taught how to mobilize the
feet in the absence of strap10. She is advised to take
care and observed every time when a fresh strapping
or plaster is applied and also to prevent the plaster or
strapping from being wet or soiled either by water or
any other fluid.
SURGICAL/ OPERATIVE MANAGEMENT
The operative treatment is required once the
conservative treatment fails or the chance of
correction of deformity with conservative
management is very less. Different operative
procedures are performed based on the age of child.
At 9 months – 3 years: A Postero-medial soft tissue
release (PMR), which was introduced by Turco14 is
performed and followed by “Dennis Brown splint”
for 2 years. In this technique, the correction of the
abnormal tarsal relationship is prevented by rigid
pathological soft tissue contracture.
At 3 years- 8 years: At this age, soft tissue release
along with Wedge Osteotomy of cuboid bone, which
is known as EVANS is performed.
At 8- 12 years: At this age, the Wedge Osteotomy
of calcaneum (Dwyer’s Operation) along with
wedge osteotomy of tarsal bone is performed.
Above 12 years: A triple arthrodesis of 3 joints of
foot (i.e. subtalar, calcaneo-cuboid and talo-
navicular joint) is performed.
POST-OPERATIVE PHYSIOTHERAPY
MANAGEMENT
The main objective of physiotherapy after surgical
procedure is to keep the other joints mobile and
prevent stiffness, which can be done with following
physiotherapy interventions15.
• Movement of toe, hip and knee in the plaster
cast only, by tickling or by holding child
high in suspension.
• To improve strength and stability gradual
active non-weight bearing and resisted foot
and ankle exercises are given, followed by
progression to weight-bearing exercises.
• To maintain the correction and avoid
recurrence, Night splint are provided. Some
of the splints used in the management of
CTEV are-
1. CTEV Splint
2. Dennis Brown Splint (Fig-4)
3. CTEV Shoes (Fig-5)
• Gait training with proper foot position is
taught to the patient.
• Special CTEV shoes are given to the
patients. The shoes got straight inner borer,
which prevents forefoot adduction, outer
shoe raise to prevent inversion and no heel
to avoid equinus.
• An effective training is given to the mother
or both parents for home care programme to
maintain the correct position of the limb and
how to give the exercise in correct way.
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Fig-3- CTEV Splint
Fig-4- Dennis Brown
Fig-5- CTEV Shoes Splint
REFRENCES
1.Macnicol M. F.The management of Clubfoot: Issues for debate. J Bone Joint Surg[Br],2003;167-170.
2. Global clubfoot initiative. Last assessed on 15th May 2012 at: http://globalclubfoot.org/countries/india/
3. Macnicol M. F. and Murray A. W. Changing Concepts in the management of congenital
talipesequinovarus.Paedetrics and child health,2008; 272-277.
4. Anand, A. and Sala, D.A. Clubfoot: Etiology and treatment. Indian J Orthop,2008;42:22-28.
5. Lehman, W.B. The clubfoot. JB Lippincott: New York; 1996
6. Edwards, M.J. The experimental production of clubfoot in guinea pigs by maternal hyperthermia during
gestation. J Pathol, 1971;103:49-53.
7. Katz K, Meizner I, Mashiach R, Soudry M. The contribution of prenatal sonographic diagnosis of clubfoot to
preventive medicine.J Pediatr Orthop,1999;19:5-7
8. Roye, B.D., Hyman J., Roye, D.P. Jr. Congenital idiopathic talipesequinovarus. Pediatr Rev, 2004;25:124-30.
9. Porter, R. Club foot. The foot,1997;7: 181-193.
10.Ezeukwu, A.O. and Maduagwu, S.M. Physiotherapy management of an infant with bilateral congenital
talipesequinovarus. African Health Science, 2011;11(3): 444-448.
Scientific Research Journal of India ● Volume: 2, Issue: 1, Year: 2013
41
11. Bensahel, H., Guillaume, A., Czukonyi, Z. andDesgrippes, Y. Results of physical therapy for idiopathic
clubfoot: A long term8follow up study. J Pediatr Orthop,1990;10:189-92.
12. Ponseti IV, Campos J. Observations on pathogenesis and treatment of clubfoot. ClinOrthop, 1972;84:50-60.
13. Ponseti IV. Congenital clubfoot: Fundamentals of treatment. Oxford University Press: Oxford, England; 1996.
14. Turco VJ. Clubfoot. Churchill Livingstone: New York; 1981.
15. Goel RN. Goel’s Physiotherapy.Shubham Publication- Bhopal, Vol II, 2000.
CORRESPONDING AUTHOR:
* Email: physio.mayank.pushkar@gmail.com
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