This assignment is due 2/25/2021

nothing less than 300 words.

PLEASE READ THE INSTRUCTIONS AND THE ATTACHED ARTICLE 

COMMENTARY Open Access

What a paediatrician should know about
congenital clubfoot
Daniela Dibello1, Valentina Di Carlo1, Giulia Colin2, Egidio Barbi1,2 and Anna M. C. Galimberti2*

Clubfoot is the most frequent congenital malformation of the foot, affecting more than 1–2 subjects per 1.000
newborns. Without appropriate treatment, a child with congenital clubfoot will never be able to walk
physiologically with a dramatic impact on the quality of life. In the last decades, different corrective solutions have
been proposed, and there is rising scientific evidence that the Ponseti non-invasive method is safe and effective in
the treatment of the clubfoot. So, what should a general paediatrician know about this condition and what should
he concretely do in the suspect of a congenital clubfoot?

Keywords: Clubfoot, Talipes, Equinovarus, Management, Pediatric

The talipes equinovarus congenital foot, also known
as congenital clubfoot, is the most common congeni-
tal malformation of the foot. One or two, per 1000
newborns are affected [1], with a male to female ra-
tio of 1 to 2. This condition is particularly frequent
in Developing Countries (80% of overall cases). In
50% of cases, it affects both feet [2]. Without ad-
equate treatment children with congenital clubfoot
will not walk physiologically and will not be able to
live a normal life. Paediatricians have a critical role
in the early detection of this condition, starting from
the first evaluations of the newborn. The prompt re-
ferral to the specialist is crucial for these children to
obtain a plantigrade and functional foot. This article
aims to provide the general paediatrician with essen-
tial knowledges for proper clubfoot management.
The scientific literature supports the efficacy of Pon-
seti method for this pathology, and we tried to sim-
plify and explain the therapeutic process and the
general management.

What is clubfoot?
Congenital clubfoot is a malformation characterized by a
torsion of the longitudinal axis of the foot, secondary to
a malalignment of the calcaneo-talar-navicular complex.
The foot’s sole is rotated medially and this leads the
child to walk on the foot sides (Fig. 1). We can detect
four different anomalies; CAVE is a mnemonic tip to re-
member them all (Fig. 2):

1. Midfoot cavus deformity (the sole of the foot
“looks” upwards).

2. Metatarsus adductus (the fingers point inside with
concavity of the medial foot margin).

3. Hindfoot varus deformity (medial deviation of the
longitudinal axis of the calcaneus).

4. Hindfoot equinus deformity (extreme plantar
flexion).

There are two main types of congenital clubfoot: idio-
pathic (80% of cases) and secondary clubfoot (20% of
cases). The idiopathic congenital clubfoot is a multifac-
torial condition that includes environmental, vascular,
positional, and genetic factors. Clubfoot has a tendency
to segregate in families: the risk of developing congenital
clubfoot is 25% when a first-degree relative is affected.

© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
changes were made. The images or other third party material in this article are included in the article’s Creative Commons
licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons
licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
data made available in this article, unless otherwise stated in a credit line to the data.

* Correspondence: annamachigalimberti@gmail.com
2University of Trieste, Piazzale Europa 1, Trieste, Italy
Full list of author information is available at the end of the article

Dibello et al. Italian Journal of Pediatrics (2020) 46:78
https://doi.org/10.1186/s13052-020-00842-3

http://crossmark.crossref.org/dialog/?doi=10.1186/s13052-020-00842-3&domain=pdf

http://orcid.org/0000-0003-0063-5754

http://creativecommons.org/licenses/by/4.0/

http://creativecommons.org/publicdomain/zero/1.0/

mailto:annamachigalimberti@gmail.com

Several studies and observations suggest the exist-
ence of different genes and inheritance patterns in-
volved [3]. On the other hand, up to 20% of cases of
congenital clubfoot is associated to other anomalies
(e.g., myelomeningocele) and could be secondary to
a specific genetic condition such as Moebius syn-
drome, neurofibromatosis and multiple congenital
arthrogryposes [4]. The congenital clubfoot could
also show more complex anatomic features that typ-
ically present a shorter and more rigid foot, in which
there is a marked curvature of the midfoot (metatar-
sal equinism) with deep skin folds. In these cases we
talk about an “atypical clubfoot” [5]. Clinical features
of clubfoot may already emerge in prenatal diagnos-
tics, but its ultrasonographic diagnosis appears more
likely between the 18th and the 24th week of preg-
nancy [6].

How to perform a focused examination?
The foot needs to be evaluated in their complexity:
general morphology, presence of skin folds, muscu-
lar and tendon malleability and flexibility of the

Fig. 1 Frontal and posterior view of congenital idiopathic clubfoot

Fig. 2 Severe clubfoot. legend: severe clubfoot (Pirani 6, Manes-Costa 3)

Dibello et al. Italian Journal of Pediatrics (2020) 46:78 Page 2 of 6

deformation. Flexibility is the most relevant element
that influences the prognosis: the more malleable
and easy to move the foot, the better the prognosis.
There are several classification systems of the club-
foot, for example Manes-Costa’s classification, Pira-
ni’s score (Fig. 3) or Dimeglio classification. These
scores are valid prognostic tools and can be used in
the follow-up process. A high score at presentation
may indicate that a longer and more complex treat-
ment will be required. Whenever a congenital club-
foot is detected, a complete examination is
mandatory to rule out other neuro-musculoskeletal
problems, such as signs of occult spinal dysraphism,
developmental dysplasia of the hip (DDH) or con-
genital torticollis.
It is essential to differentiate clubfoot from two

other disorders: postural equino-varus foot and
metatarsus adductus. The postural equino-varus is a
functional malposition of the foot caused by the de-
formed position that the fetus used to hold in the
maternal womb. In this case, there may be some

degrees of forefoot adduction, but it will be flexible
at the manipulation, and there will be no Achilles
tendon contracture. Generally, the postural equino-
varus resolves spontaneously; nevertheless, it is good
practice to monitor the progression (in premature
newborn, a clubfoot can sometimes hide behind a
postural equino-varus) [7]. The adductus metatarsus
is another common deformity characterized by an
adducted forefoot with a curvature of the lateral
edge of the foot, but without the other features of
clubfoot. Also, this disorder is secondary to the
intrauterine postural modeling of the feet and gener-
ally resolves spontaneously (casting may be necessary
if the deformity is rigid).

Which therapy?
Over the decades the surgical treatment of congeni-
tal clubfoot has mostly been abandoned, as it was
associated with complications, with the final result
of a foot that would hardly reached full functional-
ity, due to retractions and scars, secondary to the

Fig. 3 Pirani clubfoot- score. legend: this is a 6-item scale, in which every point has a 0 to 1 score (0 if normal, 0.5 if moderate-mild deformity is
present, 1 with a severe malformation); the higher the score is, the worst is the deformity

Dibello et al. Italian Journal of Pediatrics (2020) 46:78 Page 3 of 6

surgery itself. Although some complex and atypical
clubfeet still need surgical treatments at first [7],
the available evidence has definitively confirmed the
effectiveness of the Ponseti non-invasive method [1,
8, 9]. It consists of gentle manipulations of the foot
followed by the application of plaster casts, which
are kept in place for 5-7 days, during which muscles
and ligaments adapt to the new position. At the end
of the 5-7 days period, the cast is removed, the foot
(which would become softer and more prone to be
moulded) is revaluated and progressively manipu-
lated to maintain, through the application of a new
cast, a new position [2, 8]. The procedure is re-
peated until normal foot alignment is achieved (on
average, about five to six plaster casts are required).
Percutaneous Achille’s tenotomy (Fig. 4) could be
required if equinus deformity persists at the end of
the casting phase. The procedure takes about 5 min
and consists of a millimetric posterior skin incision
through which the tendon section is achieved. After
the tenotomy, plaster is applied to allow the tendon
to heal in elongation for about 20 days. In order to
maintain the correct position of the foot,it is neces-
sary to wear, an orthopedic brace until 5 years of
age. The brace must be worn for 23 h a day for the
first 3 months. Over time, the child may gradually
decrease the use of the brace during the day:: after
the first months, it is necessary to wear the cast for
at least 18–19 h with a gradual reduction in the use
of 1 h per month up to a maximum of 12 h without
the brace. When the patient begins to walk inde-
pendently, the brace is usually only held overnight
until the age of five.. Compliance with the splinting

programme is crucial to prevent recurrences [10],
and the general paediatrician has a critical role in
supporting the family during the brace-phase.
To conclude, the treatment of an “atypical clubfoot” is

more challenging and difficult and often requires a
higher number of plaster casts.

What management should a paediatrician provide?
Radiological diagnostic evaluations, such as foot X-
rays or ultrasounds, are usually not necessary in
addition to the clinical assessment. In the case of
very complex clubfoot, it could be reasonable to
evaluate the possibility of an underlying process or
other associated malformation. A co-existent hip
dysplasia, myogenic torticollis, or other orthopedic
conditions should always be ruled out. The paedia-
trician also has to evaluate the child to exclude a
systemic condition (such as a neuromuscular disease
or a syndromic illness – see Table 1). Paediatricians
are also in charge of preparing the family for the
therapeutic process. Reassurance and providing a
direct link to an experienced centre are the first
steps. Operational timeliness is essential in terms of
outcomes so the newborn needs to be referred to
the specialist as soon as possible, e.g., in the very
first days of life. The relapses of the clubfoot are
not uncommon (about 5–10%), either with conser-
vative and surgical methods. Consequently, paedia-
tricians should play a relevant role in supporting
the family and monitoring compliance with the con-
stant use of the orthopedic brace, which represents
the main factor in preventing the recurrence of
malformation.

Four golden rules for an adequate approach

1. The earlier, the better: if you detect a clubfoot
contact a local orthopedic surgeon who can take
care of the referral to a clubfoot center, preferably
within 48 h but not more than 1 week after the
delivery [7];

2. Motivate the parents: to improve the compliance
with the use of the brace to minimize the
recurrences [7];

3. In case of a severe clubfoot: inform the parents of
the increased risk recurrences;

4. Clubfoot is diagnosed through clinical evaluation,
and usually, a radiological evaluation is not
necessary. The orthopedic surgeon can choose to
perform a radiological evaluation in selected
cases (e.g., in front of a weak response to
treatment or severe relapses) [7].

Fig. 4 Percutaneous tenotomy of the Achille’s tendon

Dibello et al. Italian Journal of Pediatrics (2020) 46:78 Page 4 of 6

Clubfoot is a highly invalidating condition all over the
world; the absence of an adequate treatment will lead
to dramatic consequences on the quality of life of the
patients, with a high social burden. The rapid recog-
nition of deformity and immediate reference to the
orthopedic specialist are the key elements for effective
treatments.

The authors thank Martina Bradaschia for the English revision of the
manuscript.

All authors contributed and approved the final manuscript.

None.

Not applicable.

Not applicable.

Obtained.

The authors declare that they have no competing interests.

1Institute for Maternal and Child Health IRCCS Burlo Garofolo, Via dell’Istria
65/1, Trieste, Italy. 2University of Trieste, Piazzale Europa 1, Trieste, Italy.

Received: 27 March 2020 Accepted: 25 May 2020

1. Balasankar G, Luximon A. Ponseti method in the management of clubfoot

under 2 years of age: A systematic review. PLoS One. 2017;12(6):e0178299.
2. Balasankar G, Luximon A. Current conservative management and

classification of club foot: A review. J Pediatr Rehabil Med. 2016;9(4):257–64.
3. Basit S, Khoshhal KI. Genetics of clubfoot; recent progress and future

perspectives. Eur J Med Genet. 2017;61(2):107–13.
4. Pavone V, et al. The etiology of idiopathic congenital talipes equinovarus: a

systematic review. J Ortho Surg Res. 2018;13(1):206.

Table 1 from B. Sadler, C. A. Gurnett, and M. B. Dobbs “The genetics of isolated and syndromic clubfoot”, Journal of Children
Orthopaedics Jun 2019

Condition/syndrome name Known genes

Autosomal Dominant Larsen Syndrome, Recessive spondylocarpotarsal syndrome FLNB

Barth Syndrome TAZ

Bruck Syndrome PLOD2, FKBP10

Carey-Fineman-Ziter Syndrome MYMK

Catel-Manzke Syndrome TGDS

Charcot-Marie-Tooth Disease Type 4D NDRG1

Diastrophic dysplasia SLC26A2

Ehlers-Danlos Syndrome, Musculocontractural type 1 CHST14

Ehlers-Danlos Syndrome, Musculocontractural type 2 DSE

Ehlers-Danlos Syndrome, vascular type COL3A1

Epileptic Encephalopathy AARS

Joubert Syndrome ATXN10, TCTN2

Loeys-Dietz Syndrome TGFBR1, TGFBR2, SMAD3, TGFB2, TGFB3

Marfan Syndrome FBN1, TGFBR, TGFBR1, TGFBR2, SMAD3, TGFB2, SKI

Moebius Syndrome PLXND1, REV3L

Multiple Epiphyseal Dysplasia COL9A1, COL9A2, COL9A3, COMP, MATN3, SLC26A2

Multiple Synostosis Syndrome GDF5

Peroxisome biogenesis disorder 7A PEX26

Recessive axonal Charcot-Marie-Tooth Disease LMNA, GDAP1

Recessive Larsen Syndrome, Humero-Spinal Dysostosis, Spondyloepiphyseal dysplasia CHST3

Richieri-Costa – Pereira Syndrome EIF4A3

Santos Syndrome WNT7A

Saul-Wilson Syndrome COG4

Schpritzen-Goldberg Syndrome SKI

TARP Syndrome RBM20

Van Maldergem Syndrome 2 DCHS1, FAT4

Dibello et al. Italian Journal of Pediatrics (2020) 46:78 Page 5 of 6

5. Van HJP B. Challenging clubfeet: the arthrogrypotic clubfoot and the
complex clubfoot. J Child Orthop. 2019;13(3):271–81.

6. Faldini C, et al. Prenatal Diagnosis of Clubfoot: A Review of Current
Available Methodology. Folia Med. 2017;59(3):247–53.

7. Besselaar AT, Sakkers R. JB et al. guideline on the diagnosis and treatment
of primary idiopathic clubfoot. Acta Orthopaedica. 2017;88(3):305–9.

8. Chu A. Treatment of Idiopathic Clubfoot in the Ponseti Era and Beyond.
Foot Ankle Clin. 2015;20(4):555–62.

9. Morcuende JA, Dolan LA, Dietz FR, Ponseti IV. Radical reduction in the rate
of extensive corrective surgery for clubfoot using the Ponseti method.
Pediatrics. 2004;113(2):37680.

10. Staheli L, Ponseti I, Morcuende JA, et al. Clubfoot: Ponseti management. 3th
edition, Global HELP Ed, 2009.

Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.

Dibello et al. Italian Journal of Pediatrics (2020) 46:78 Page 6 of 6

Abstract
Background
What is clubfoot?
How to perform a focused examination?
Which therapy?
What management should a paediatrician provide?
Four golden rules for an adequate approach
Conclusion
Acknowledgements
Authors’ contributions
Funding
Availability of data and materials
Ethics approval and consent to participate
Consent for publication
Competing interests
Author details
References
Publisher’s Note