Paediatric Foot Deformity

Also known as: Clubfoot, Talipes equinovarus, In-toeing, Tarsal coalition, Toe walking, Curly toes

Most of what worries parents about a child's feet is normal and resolves with growth. The job of the first consultation is to separate the small number of feet that need treatment from the large number that need nothing but an explanation.

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Feet that need reassurance, not treatment

A large part of paediatric foot practice is confirming that something is normal. These are the common ones:

Flexible flatfoot. Normal in young children and in a good proportion of adults. See the flatfoot page.
In-toeing. Comes from the foot, the shin or the hip depending on the child's age, and resolves with growth in nearly all cases. Braces and corrective shoes do not help.
Out-toeing, which follows the same pattern.
Curly and overlapping toes. Usually painless, usually improve, and rarely need surgery in a young child.
Idiopathic toe walking, once a neurological cause has been excluded.
Growing pains, when the pattern is typical: both legs, in the evening, relieved by rubbing, and a completely normal child by morning.

Explaining why these are normal, and what to watch for, is genuinely the treatment.

Feet that do need attention

Clubfoot (talipes equinovarus). Present at birth, with the foot turned down and in. Treated from the first weeks of life with the Ponseti method: a series of weekly plaster casts, a small percutaneous Achilles release in most babies, then a boots-and-bar brace worn at night for several years. Correction is highly reliable. Adherence to the brace is what prevents relapse.

Congenital vertical talus. A rigid rocker-bottom flatfoot present at birth, often associated with other conditions. It needs early treatment with serial casting and a limited surgical release.

Tarsal coalition. An abnormal bony or cartilaginous bridge between two hindfoot bones, which typically becomes symptomatic in adolescence as the bar ossifies. It presents as a stiff, painful flatfoot with repeated ankle sprains. Diagnosed on CT or MRI, and treated with a period of immobilisation, then resection of the bar where symptoms persist.

Accessory navicular. An extra ossicle on the inner side of the foot, painful where the posterior tibial tendon attaches. Often settles with rest and an orthosis, occasionally needs excision.

Osteochondroses, such as Sever disease at the heel and Kohler disease of the navicular. Self-limiting, managed with activity modification and time.

Neuromuscular foot deformity, in cerebral palsy, spina bifida and hereditary neuropathies. These feet deform progressively and need a plan that follows the child through growth rather than a single operation.

When to seek an opinion

The problem affects one side only
The foot is stiff rather than flexible
There is pain, particularly pain that wakes the child
The deformity is getting worse, not better, with growth
The child is losing skills they previously had, or walking is deteriorating
There is a family history of a neurological or skeletal condition

Typical recovery after surgery

A typical course. Your own plan is set at your visit and depends on the operation.

Clubfoot, weeks 0 to 8Weekly casts, each one taking the correction a little further (Ponseti method).
Clubfoot, around week 8A small percutaneous release of the Achilles tendon in most babies, followed by three weeks in a final cast.
Clubfoot, to age 4 or 5A boots-and-bar brace, full time for three months and then at night. This phase is where relapses are prevented.
Tarsal coalition, weeks 0 to 6 after surgeryBoot or cast, then progressive weight-bearing and movement.

Common questions

My child walks with their feet turned in. Will they grow out of it?

In the great majority of cases, yes. In-toeing comes from one of three levels: the foot itself in a baby (metatarsus adductus), the shin in a toddler (internal tibial torsion), or the hip in a young child (femoral anteversion). Each has a typical age at which it appears and resolves. Special shoes, braces and twister cables do not speed this up and are no longer used. Assessment is warranted if it is only on one side, if the child trips constantly, or if it is getting worse rather than better.

My child walks on tiptoe.

Idiopathic toe walking is common and often familial, and many children stop on their own. It matters to check that the calf is not tight and that there is no underlying neurological cause, particularly cerebral palsy, or a tethered spinal cord. Persistent toe walking with a tight calf is treated with stretching, casting, or lengthening if those fail.

How successful is treatment for clubfoot?

The Ponseti method corrects the great majority of clubfeet without major surgery, and it has changed the outlook for this condition completely. The correction is reliable. What decides the long-term result is the bracing phase: relapse is common if the brace is not worn as prescribed, and almost all relapses trace back to that.

My teenager has a stiff, painful flat foot after minor sprains.

This picture, a rigid flatfoot in an adolescent with recurrent ankle sprains and pain in the outer hindfoot, suggests a tarsal coalition, an abnormal bar of bone or cartilage between two hindfoot bones. It is diagnosed on CT or MRI and is treatable, often by resecting the bar.

This page is for patient information and does not replace an examination by a doctor.