CTEV: Congenital Talipes Equinovarus (Clubfoot)

• Cavus: high medial arch due to plantar-flexed first ray
• Adductus: forefoot deviated medially
• Varus: heel inverted
• Equinus: ankle plantar-flexed due to tight tendo-Achilles

Etiology

CTEV
 │
 ├─ Idiopathic / isolated clubfoot
 │    └─ Most common
 │       • Multifactorial inheritance
 │       • Genetic susceptibility + environmental influences
 │
 ├─ Intrinsic / neuromuscular causes
 │    ├─ Spina bifida / myelomeningocele
 │    ├─ Arthrogryposis
 │    ├─ Cerebral palsy
 │    └─ Peripheral nerve or muscle abnormalities
 │
 ├─ Syndromic causes
 │    ├─ Chromosomal disorders
 │    └─ Skeletal dysplasias / connective-tissue disorders
 │
 └─ Extrinsic / positional factors
      └─ Intrauterine constraint, oligohydramnios, uterine anomalies

Clinical features

NEWBORN WITH FOOT TURNED INWARD AND DOWNWARD
                  │
                  ▼
             Look for CAVE
                  │
    ┌─────────────┼──────────────┐
    ▼             ▼              ▼
 Cavus       Forefoot          Hindfoot
 High arch   adduction         varus
    │             │              │
    └──────────► Equinus ◄───────┘
              Ankle plantar-flexion

Examination findings

• Foot is small, rigid and difficult to correct passively.
• Sole faces medially and upward.
• Medial and posterior skin creases may be deep.
• Heel is small, inverted and poorly palpable.
• Calf on the affected side may be smaller, especially in unilateral CTEV.
• Can be unilateral or bilateral.
• Assess severity using Pirani score or Dimeglio classification.
• Examine the spine, hips, neurologic status, and the rest of the limbs to exclude associated neuromuscular or syndromic disease.

Investigations

• Usually a clinical diagnosis.
• X-rays are not routinely needed in a typical newborn with isolated CTEV.
• If obtained, radiographs may show a reduced talocalcaneal angle and persistent equinus. POSNA diagnostic notes

Management flow chart

DIAGNOSIS OF CTEV
        │
        ▼
Assess:
• Idiopathic vs syndromic/neuromuscular
• Severity: Pirani/Dimeglio score
• Associated anomalies
• Age and prior treatment
        │
        ▼
START EARLY, IDEALLY SOON AFTER BIRTH
        │
        ▼
PONSETI METHOD: FIRST-LINE TREATMENT
        │
        ▼
Weekly gentle manipulation + above-knee plaster cast
        │
        ▼
Correct deformities in this order: C → A → V → E
Cavus → Adductus → Varus → Equinus
        │
        ▼
After approximately 4-7 casts:
Is adequate ankle dorsiflexion achieved?
        │
   ┌────┴─────┐
   │          │
 YES          NO, residual equinus
   │          │
   ▼          ▼
Foot-abduction  Percutaneous Achilles tenotomy
brace           + final cast for about 3 weeks
   │                    │
   └────────────┬───────┘
                ▼
Foot-abduction brace
• 23 h/day for first 3 months
• Then during sleep and naps
• Continue until about 4-5 years of age
                │
                ▼
Regular follow-up for relapse
                │
    ┌───────────┴────────────┐
    ▼                        ▼
No relapse                Relapse/residual deformity
Continue brace            Reassess brace adherence
and surveillance                 │
                                 ▼
                       Repeat Ponseti casting
                                 │
                     ┌───────────┴───────────┐
                     ▼                       ▼
              Dynamic supination        Rigid/severe relapse
              in walking child                 │
                     │                       ▼
                     ▼             Limited surgery / tendon
       Tibialis anterior tendon     transfer / osteotomy /
       transfer, usually >2.5 yr    gradual correction in
                                    selected older children

Core principles of Ponseti treatment

1. Do not correct equinus first. Correct in the sequence CAV(E).
2. Use long-leg casts, changed weekly, to prevent tibial rotation.
3. In most infants, residual equinus requires a percutaneous Achilles tenotomy.
4. The correction is maintained with a foot-abduction brace. Non-adherence is the most important preventable cause of recurrence.
5. Extensive posteromedial soft-tissue release is now reserved for resistant or recurrent rigid deformity because it can lead to a stiff, painful foot later. AAOS patient guidance

Exam-oriented summary

CTEV = CAVE
Cavus + Adductus + Varus + Equinus

Treatment = Ponseti
Manipulation + weekly long-leg casts
      ↓
Achilles tenotomy for residual equinus
      ↓
Foot-abduction brace until 4-5 years
      ↓
Relapse: repeat casts ± tibialis anterior tendon transfer

Clinical features of CTEV in detail

1. CAVE deformities

Important: The deformities occur together. It is not merely “in-toeing.” The hindfoot is fixed in varus and equinus.

Typical appearance on inspection

Anterior / medial view
        ↓
Toes point medially and the sole faces medially and upward
        ↓
Forefoot adduction + cavus
        ↓
Deep medial skin crease

Posterior view
        ↓
Heel is drawn upward and inward
        ↓
Hindfoot varus + equinus
        ↓
Deep posterior ankle crease

Other local signs

• Small foot on the affected side, particularly in unilateral CTEV.
• Small, underdeveloped calf muscles on the affected side. This may persist even after successful correction.
• Shortened Achilles tendon with a prominent heel cord.
• Heel appears small and “empty” because the calcaneus is pulled upward and lies in varus.
• Deep medial crease over the medial aspect of foot.
• Deep posterior crease above the heel.
• The lateral border is convex, while the medial border is concave.
• The talar head may be palpable prominently on the dorsolateral aspect of the foot.
• The foot is usually rigid, with limited passive correction.

Assessment of rigidity

Idiopathic structural CTEV

• Foot cannot be fully corrected by gentle passive manipulation.
• Hindfoot varus and equinus are fixed.
• Resistance is felt on attempting dorsiflexion and abduction.
• Requires treatment with serial manipulation and casting.

Positional talipes

• Foot may look like clubfoot but is flexible.
• Can usually be passively corrected to normal or near-normal position.
• There is no major fixed contracture, deep crease, or severe calf wasting.
• It commonly resolves with observation, stretching, or limited splintage.

Later clinical features in an untreated child

Untreated CTEV
      ↓
Child starts walking
      ↓
Weight borne on lateral border / dorsolateral surface of foot
      ↓
Callosities, abnormal gait, shoe-wear difficulty
      ↓
Painful and stiff foot in later childhood or adult life

• Walking occurs on the lateral border or dorsolateral surface of the foot rather than the sole.
• Callosities develop over the lateral border, dorsum, or head of talus.
• Shoe fitting is difficult.
• Gait is abnormal, often with in-toeing and limp.
• Progressive stiffness and pain may develop with age.

Later clinical features after treatment or in relapse

• Reappearance of adductus, varus, or equinus
• Reduced ankle dorsiflexion
• Heel rising early during gait
• Foot slipping repeatedly out of the brace
• Dynamic forefoot supination during swing phase or walking
• Weight bearing on the lateral border

Systemic examination and associated abnormalities

Examine for

• Spine: sacral dimple, tuft of hair, swelling, scoliosis, signs of spina bifida or tethered cord
• Neurologic function: spontaneous toe movement, foot sensation, muscle power and tone
• Hips: screen for developmental dysplasia of the hip
• Other limbs: arthrogryposis, limb deficiency, constriction bands
• Other congenital anomalies: facial, cardiac, renal, gastrointestinal, and chromosomal abnormalities where syndromic CTEV is suspected

Clinical severity assessment: Pirani score

• 0: normal
• 0.5: moderately abnormal
• 1: severely abnormal
• Total score ranges from 0 to 6.
• A higher score indicates a more severe, rigid deformity and often predicts the need for more casts and Achilles tenotomy.

One-line examination answer

CTEV presents at birth as a small, rigid foot turned downward and inward, with cavus, forefoot adduction, hindfoot varus and ankle equinus, deep medial and posterior creases, tight tendo-Achilles, a small heel, and calf wasting on the affected side.