What is Clubfoot?
The medical definition of the condition commonly referred to as Clubfoot or Talipes is Congenital Talipes Equinovarus (CTEV).
Adults Living with Surgically Treated Clubfoot:
Pre-Ponseti Treatment for Clubfoot
Modern treatment for clubfoot follows the Ponseti Method, a mainly non-surgical treatment involving weekly massage and plaster cast application to gradually improve the position of the foot. This is usually followed by a minor procedure known as a tenotomy and fitting of a foot abduction brace to maintain the correction.
Before the Ponseti method, clubfoot was often treated with extensive surgery on the bones to alter the position of the foot. This was common practice in the 70’s, 80’s and 90’s.
There were many different surgical approaches to correcting clubfoot, and most were focussed on correcting the bone deformity and improving the appearance and functionality of the foot. Common approaches before the widespread use of the Ponseti Method included:
- Postero-medial release (PMR), was an extensive surgery to release tight/contracted soft tissues associated with clubfoot.
- A patient specific, surgical approach; aimed at gradually correcting each aspect of the bone deformities associated with the condition.
Ryan’s Personal Story:
Effects of Surgical Clubfoot Treatment
As patients reached adulthood, surgically treated feet often became painful and stiff. In some cases, some patients developed early arthritis of the ankle.
Studies show that, following the introduction of the Ponseti Method the number of surgeries associated with the condition were considerably lower, and any surgery performed was less extensive.
It is advised that adults treated surgically who are experiencing issues such as pain and stiffness wear supportive comfort shoes, good quality shoes that support the ankle. Many adults with surgically treated clubfoot seem to do very well with MBT footwear and more recently, shoe companies such as FitFlops (www.fitflops.com) have increased their range to covered shoes as well as flip flop type. These are made with supportive sole pieces and therefore can be extremely comfortable for wearers.
A podiatrist may offer advice on footwear and suggest insoles or orthoses where appropriate. You may need to be referred to a podiatrist by your GP although in some areas, it is possible to self-refer. If you need to wear safety boots for work, perhaps take them to your podiatry appointment to see if suitable orthoses can be added.
Physiotherapist and Occupational Therapist
Treatment by a physiotherapist may also help to relieve symptoms and a treatment plan may include exercises to perform at home, such as stretches to the Achilles tendon and plantar fascia (the ligament along the sole of the foot which joins the toes and heel). A transcutaneous electrical nerve stimulation (TENS) machine can also be used to relieve painful joints. This involves sending electrical pulses through the painful area and increasing pain tolerance.
If individual joints hurt, then simple measurers such as steroids can be effective in the short to medium term to get a foot back under control from pain. Newer treatments using artificial join flued (hyaluronidase) injections are being tried in the foot and ankle after many successful reports for treatment of the hip and knee.
Pain relief should be considered if pain is becoming more persistent and intrusive. Non-steroidal anti-inflammatory drugs (NSAIDs) may ease pain, reduce inflammation and may help prevent further damage to the ankle joint. Some NSAIDs are available as a cream/gel, however if you are already taking other versions of NSAIDs, always speak with your doctor before starting any new treatment.
Some adults have residual deformities and surgery can be remarkably effective even in adulthood, especially if there is a residual deformity that has not been completely corrected. In other cases, when painful degeneration in the joints is present, an arthrodesis or fusion may be the best treatment to manage pain.
Surgery to the ankle is usually only considered when all other treatments have been ineffective. There are several options for ankle surgery;
Ankle fusion, where the joint is fused in a standing position and pinned. It may be possible to perform the procedure using keyhole surgery. A cast would need to be worn for several weeks and following this, it should be possible to wear everyday shoes and walk normally.
Triple fusion involves the fusion of three joints (the talonavicular, subtalar and calcaneocuboid joints) which are pinned using plates or screws.
An ankle replacement replaces the worn out ends of the tibia and talus bones with plastic or metal and will still allow for the movement of the ankle joint. It may be necessary to use crutches for a few weeks following surgery. The procedure isn’t as common as hip or knee replacement, but it is thought the new joint can last for ten to fifteen years.
Opting for a surgical approach to ankle pain has advantages and disadvantages; it can offer long-lasting pain relief, reduce the need for regular medication and improve foot function and mobility. However, replacement joints are not long lasting and further surgery may be required.
Ankle fusion surgery restricts joint movement but may offer greater mobility due to a reduction in pain. Occasionally an ankle fusion may lead to a ‘non-union’, where the bones do not join properly, and further surgery may be required. Crutches may be required for several weeks after surgery and some operations, such as ankle fusion require reduced weight bearing for several months, which may impact on day to day life and work. Other complications include excessive swelling, increased stiffness or possible infection.
The combination of treatment options most suited to an individual will vary and depend on the severity of the impact on a person’s life. Some options may not be suitable for everyone and the hospital or GP will be able to advise on the best course of action for your individual circumstances.
Non-impact activities are generally particularly good for adults with surgically treated feet. Activities such as swimming, cycling and cross training as well as walking are recommended.
Running and other impact activities are more likely to generate symptoms therefore it is advisable to avoid these types of activities, especially if you have experienced pain in your foot or feet.
Maintaining a healthy weight may also improve ankle pain by reducing pressure on the joint.
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