Congenital Foot Deformities: A Guide To Conservative Care

By Mark A. Caselli, DPM

The early recognition and treatment of congenital foot deformities is essential in order to ensure optimal functioning of the foot. In regard to joint deformities caused by contracture of muscles and capsule, one can achieve correction via methods including: repeated gentle manipulation stretching of the tight structures; cast immobilization of the joints in the position of correction; and shoe/splint therapy. These forms of conservative therapy are of particular value in the correction of such congenital deformities as talipes equinovarus or clubfoot, metatarsus adductus and talipes calcaneovalgus.

When one initiates and properly performs these procedures in a timely manner, podiatric physicians can expect to correct at least 50 percent of talipes equinovarus deformities and over 90 percent of the feet affected by metatarsus adductus and talipes calcaneovalgus. In regard to conservative management of congenital foot deformities, the goals are reducing the need for surgery and, when surgery is inevitable, limiting its extent as much as possible.

Stretching exercises are most often recommended as the first line of treatment for congenital foot deformities. To be effective, patients must do the exercises aggressively and frequently, and as soon after birth as possible. In all cases, however, a careful clinical assessment should precede any form of conservative therapy.

When it comes to a thorough clinical assessment of a patient with a talipes equinovarus deformity, the examiner must feel the calcaneal contour to determine whether the calcaneus is in place or not. With this deformity, the calcaneus is usually pulled proximally away from the heel pad with the small heel being drawn up and rolled in under the talus in an inverted position. Clinicians can palpate the talar head dorsolaterally at the midfoot. It is usually lined up with the patella but may be plantarflexed. The examiner should try to reduce the foot deformities in the horizontal (adduction), sagittal (equinus) and frontal (varus) planes in order to assess the reducibility of the foot as doing so is essential to success. One must also evaluate overall muscle tone since signs of spasticity can significantly increase the difficulty in obtaining correction.

Key Insights On Manipulation Therapy
Classifying the clubfoot is often useful in monitoring the effectiveness of the treatment. When it comes to clubfoot, there are four classification categories: benign, moderate, severe and very severe. Benign indicates totally reducible feet. Moderate clubfoot denotes reducible, partially resistant feet. With severe clubfoot, podiatrists are looking at resistant, partially reducible feet. Very severe clubfoot denotes irreducible feet.

The success of manipulations increases as the foot becomes reducible. This classification system allows us to monitor the evolution of reducibility throughout treatment.

While manipulation therapy is most commonly used in the United States as a prelude to applying a cast for the correction of a clubfoot deformity, the therapy, as developed by Bensahel with Guillaume and the staff of Robert Debre Hospital, has met with some success as the primary treatment for this condition. In either case, manipulation of a clubfoot requires a good deal of experience. Indeed, the practitioner should have a strong understanding of the anatomic pattern of the clubfoot.

In order to correct the deformity via manipulation therapy, one must make the following three changes.

• Move the navicular from its set medial position on the medial malleolus.
• Mobilize the distal part of the calcaneus, which is associated with the head of the talus.
• Displace the posterior part of the calcaneus proximally and laterally. One must bring the posterior part back medially and distally.

Hold the talus firmly throughout manipulation. This functional manipulation method is sequential and includes the decoaptation of the navicular from the medial malleolus, abduction of the calcaneo-forefoot component around the talus and correction of equinus.

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