The foot is undeniably the pedestal for human balance and
ambulation. Humans depend on the complex
interaction of the many joints and ligament structures in the foot to hold up
their weight, propel them forward, stop their momentum and cushion their
landings. The emphasis on proper foot
function is so strong that it has fostered a billion dollar footwear and
orthotics industry that governs what we wear (and don’t wear) and how we play
and live.
Because of this overarching significance, great care is
placed in early childhood in getting the foot to grow as “normal” as
possible. This care is especially seen
in the congenital deformities of the foot, such as talipes equinovarus, also
known as clubfoot.
The understanding of clubfoot continues to evolve. Most experts no longer think that clubfoot is
simply a positional abnormality from months of in utero molding. Although a small subset may be due to
extrinsic issues like multiparous conditions, breech positioning and fibroid
uterus, the vast majority of clubfeet are now recognized to be a true
disruption of the neural axis into the foot, probably arising from the
brainstem or even the brain itself. In other
words, clubfoot is a true neuromuscular condition.
The treatment of clubfoot is evolving as well. Not so many decades ago, the emphasis of
early treatment was on loosening the ligaments up so that a child could be more
easily repositioned during surgery. Mixed
long-term functional results from surgery as well as the need for non-surgical
options in developing countries led to the advent of rigorous casting and
bracing protocols, sometimes lasting for many months or longer. Although there is no clear consensus that the
casting techniques are the final word in treatment, nevertheless most children
with clubfoot now have an extended course of casting and/or bracing.
It is important to give special attention the motor development
in these children throughout the treatment process. There is a tendency to keep the children lying
on their back throughout the treatment to “protect the casts”, but this is both
unnecessary and potentially harmful. Parents need to understand not only that
milestones may be somewhat delayed by the treatment, but also that they should
not be passive about the child’s positioning and function during the
treatment. It is essential, despite
casting to allow as much of the child’s general function to develop as
possible.
There are a number of strategies which I have incorporated
into my treatment protocols which hopefully will minimize the developmental
effect of the casting. First and
foremost, I have tried to engage the parents in the child’s positioning as much
as possible. A lot of the early postural
development need not be lost to the casting regimen. Since the casts are typically placed with the
knees bent, the all-important curving forward of the body and limbs into what
is termed the flexor position need not be disturbed. Also, the child will still be able to explore
side positioning and rolling, although the parents may have to be more active
in helping the child position and in clearing the casts over the other leg
during rolling.
Since positioning on the baby’s stomach (prone-lying) is so
important for the development of arm and hip/ pelvis position and function, I
try to place the casts so that there is some active movement available in the
knees. The child should be able to bring
the legs under while in the prone position and push off with the arms and hips
to get the full benefit of the ground reactive force.
Another important point is to make full use of whatever time
out of the casts might be available. In
point of fact, since it is not the casting, but the interval stretching before
casting that is the actual treatment, I find that these timeouts are actually
very important in the regimen. I try to
encourage the parents to take full advantage of the time away from
immobilization to have the child rolling and prone and to do as much
facilitating as possible in the brief respites.
In the early stages of the casting, I will use a material that the
parents can remove the day before the next stretching/ casting treatment. This not only allows the parents to bathe the
child thoroughly but also give an extended period of attention to motor stimulation. I have also talked to parents about specific
techniques like brushing to stimulate the child’s awareness of the feet during
the periods out of the casts. These same
techniques can also be done while the child is the cast since the toes and
forefoot are exposed.
An interesting technique I have incorporated recently has
been cast application in a bouncy seat.
Not only does this help the child to relax during the cast
application. It also allows the child to
maintain a flexor posture better than placement of the cast in the fully flat position
typically used. My hope is that the
child will accommodate to the cast as part of the more natural flexor
positioning. Early results in terms of
acceptance of the cast by the child and maintenance of leg function have been
encouraging.
In summary, the most important point is to not
allow the casting regimen to dominate the child’s function. The parents can and should be instructed to
be as active in the child’s development as they would be if the child were not
casted. And special exercises and
activities should be used to take advantage of every moment that the child is
freely mobile.
