Club Foot

Club foot is a rather common occurrence, affecting approximately 1 in 1000 newborns.  The causes are unknown though club foot can be detected via ultrasound in the second trimester.  The foot or entire limb already appears twisted in utero though the bones appear to be normal.

Distorted or restricted space in the uterus may contribute to club foot formation.

The fact that clubfoot is detectable at such an early stage suggests that something in the uterine environment contributes to this development.  The entire body of the fetus is still developing and hence very pliable.  It easily adapts to the spacial dimensions of the womb.

However, this accommodation may come at a price in the form of club foot or other restrictions in the joints such as the sacroiliac joints or the hip joints.

It’s not uncommon for children to have problems with the alignment of their lower extremities.  A much milder from of “club foot” comes to mind.  We call it being pigeon toed.  One or both feet are turned inward to some degree, just not to the extreme as in club foot.

CLub foot is not restricted to the foot.

If one looks closely, the inward rotation, of the foot continues upward to the knee, the hip, and even the sacrum.  Thus, being pigeon toed is not limited to the feet and ankles but involves the entire leg up to the sacrum.  The same applies to the club foot condition.

Unfortunately, stretches and strengthening exercises appear to be focused on “straightening out” the foot and ankle, rather than helping the body to release the restrictions of the entire leg, from the sacrum to the toes.

Both the Ponsetti and the French Functional Method employ casts and stretching exercises to help realign the foot and ankle, as well as achilles tenotomy (partially cutting the achilles tendon).  The success rate is quite high If the parents and child can accommodate these intense forms of therapy.

Casts are periodically adjusted and applied after stretches and manipulation of the feet to maintain the new position.  Wearing a cast for many hours each day, initially almost all day and night long, seems to be crucial to the success of either therapy.  Often, clipping the achilles tendon (achilles tenotomy), a minimally invasive surgery, is necessary as well.

More complex surgery that involves repositioning of tendons in the foot tend to have a poor outcome in the long run.   30-year studies show that surgeries cause deformities, mostly due to scar tissue formation, a common problem with any kind of surgery, and of course the repositioning of the tendons, which affects muscular action and coordination of the foot.

Everything is connected via connective tissue (ligaments, tendons, fascia, meninges).

Anyone who has ever tried to mimic clubfoot on one of their own feet, even a mild form of it, will notice, that turning the foot inward exerts a pulling and twisting effect on the calf muscles, the knee, outer thigh, and the hip.

This is no surprise, as these parts of the legs are connected to one another by the ligaments that hold together the bones at the joints.  Moreover, the tendons of the muscles cross these joints as well.  In fact, the tendons of many muscles of the leg cross two joints, one above and one below.  Thus a shortened muscle can cause a chain reaction up and down the leg.

Another type of connective tissue connecting all the body parts is the fascia, which wraps around each muscle fiber, around groups of muscle fibers, the entire muscle itself, and the entire group of muscles, including the bones.  It also contains the blood and lymph vessels, nerves, and meridians (energy pathways).

Restrictions anywhere in the fascia puts a sort of stranglehold on all the structures it envelops, resulting in impaired blood and lymph flow, disturbed nerve conduction, and erratic flow of energy.

Since everything is packaged together, hangs together, and moves in unison, it’s important to take this dynamic into consideration when designing a therapy to promote healing.

Let’s look at the individual parts and see how they hang together and interact with one another.

The foot is a highly complicated structure.

The five toes (phalanges–3 bones each in four toes, 2 bones in the big toe) connect to the  five metatarsals (long bones) of the foot, which articulate directly with three cuneiform bones and the cuboid bone., which connect either to the navicular bone, the calcaneus (heel bone), or the talus (sits on top of the calcaneus) or more than one of them.

Moreover, the cuneiform, navicular, and cuboid bones, as well as the talus and calcaneus are highly irregularly shaped bones, giving the foot a unique ability to adjust to irregular as well as smooth surfaces.

However, this complicated arrangement also renders it vulnerable to distortion of the connective tissue (ligaments, tendons, fascia) that holds all these bones together.  As the tissue tightens or becomes stretched or twisted by injuries, infection, or postural issues, the bones can easily become misaligned and locked up, resulting in pain and stiffness.  Further, the foot loses its ability to adjust to the various surfaces its on, affecting balance and agility.

I invite anyone to take a close look at all these structures to appreciate the intricacy and beauty of their arrangement.

Movement of the foot depends on the muscles of the calf, as well as the muscles inside the foot.

The tendons of the calf muscles cross the ankle to allow various movements of the foot, such as dorsiflexion (pulling foot upwards), plantar flexion (pointing foot downward), putting weight on the outer edge of the foot (inversion) or the inner edge (eversion), and rotate the foot inward (medial rotation) or outward (lateral rotation).

The tendons of one major muscle of the posterior calf, the gastremius muscle, crosses the ankle via the achilles tendon, and the knee joint above.  Thus, a tight gastremius muscle can affect dorsiflexion of the foot, as well as the extension (straightening out) of the leg at the knee joint.

The small muscles (intrinsic muscles) of the foot allow us to grip the surface we are on for traction, wiggle our toes, point them downward, or raise them.

We need all these muscles to walk, skip, run, jump, dance, or just stand.  Moreover, we need the connective tissue in form of ligaments to stabilize the ankle, as well as the numerous small joints inside the foot between all the small bones of the foot.

But wait!  We can’t do all these things if we have a bum knee, hip, or sacrum.

If the tibia (shin bone), fibula (parallel to shin bone), femur (thigh bone), or sacrum are misaligned at the joints, we experience pain, stiffness, tightness, weakness, and lack of balance.  While we may experience these symptoms only locally, the performance of the entire leg is adversely affected, down to the foot.  High performance athletes know this all too well.

Conversely, any imbalance in the foot makes itself noticeable in how we use the rest of the leg, all the way up to the sacrum.

Through the ligamentous linking of the bones, forces move up and down the leg.  Any misalignment anywhere along the way is transmitted to all other parts of the leg.

Why should this be different for club foot?

It isn’t.

Therefore, if we want to help the body to realign the foot with the ankle, we need to design a therapy that includes work with the entire leg, from the toes up to the sacrum.

This therapy needs to encourage the body to utilize natural movement around the joints to improve the coordination of muscles that work together (synergists) and help it to balance the action of pairs of muscles that oppose each other’s movement (antagonists).

The turning inward of the foot at the ankle indicates a gross imbalance between the muscles that bring the foot to the midline, i.e. pointing it straight forward, indicating that muscles that allow inward rotation and inversion of the foot dominate the muscles that allow the opposite movement.

The dominant muscles shorten over time and the weaker muscles lengthen over time, as they are no longer able to counteract the force of the dominant ones.  Moreover, the fascia, which envelops the muscles shrink wraps around the new position. A “balance” of imbalance becomes the new status quo.

The body wants to, and needs to, move.

The current two major therapies, the Ponsetti method and the French Functional Method, do employ stretching of the dominant muscles to lengthen them and then confining the leg to a cast to maintain this new position.  However, this approach forces the body into inaction while so confined.

In reality, the body moves all the time to maintain a basic tonus of the muscles, and to encourage movement around the joints for lubrication and mobility.  This is expecially important during the developmental years of infancy and toddlerhood.  Watch how infants move their entire bodies all the time while they’re awake.  The arms, hands, fingers, neck, head, torso, legs, feet, and toes are all being engaged almost nonstop.

The body is constantly changing, in size and proportion.  It establishes the neck curve and lumbar curve not through passivity but through action.  Gravity is a natural and great force to work against.  Lifting the head while laying on the tummy, pushing off the ground with the arms to raise the chest or rolling over, sitting up, standing up, walking upright are all done against gravity.

Babies become cranky and restless when they are not allowed to move, for a good reason.  It’s unnatural and restricts their growth and development.  They need the stimulus of the environment, and their loved ones, to thrive.

Casts inhibit muscle movement.

Employing casts for any length of time stunts the development of muscle and joint action.

While the Ponsetti and French Funtional methods enjoy a high rate of success if the parents and child adhere to a strict regimen without fail, there are relapses, requiring often repeated clipping of the achilles tendon to help align the foot and ankle.

Perhaps the over-reliance on the passive action of confining the foot and leg to a cast for extended periods of time, which forces the foot and ankle into a neutral position, actually contributes to the weakening of all leg muscles but doesn’t contribute much to balanced action between these muscles.

Thus, once the cast is off, the foot returns to its former position because the balance of muscle action has not been corrected.  Moreover, the connective tissue (fascia, ligaments, and tendons) hasn’t released its restrictions yet, holding the muscles hostage.

Neuromuscular feedback disrupted in the womb can lead to a club foot condition.

When the leg becomes trapped inside the womb during the course of pregnancy, the opportunity for movement and neuromuscular feedback to the brain of the movement is very restricted.

The brain basically learns to neglect the muscles of the calf and foot that allow outward (external) rotation and eversion of the foot.  Hence, as the infant grows it continues to ignore these muscles.  Thus when time comes to stand up and walk,  the most convenient surface for holding itself upright is the outer edge of the foot.

While not exactly comfortable, perhaps even painful,  the infant’s soft tissues adapt to this condition amazingly well.  Some children are quite fleet footed despite their handicap, which for them, of course, is “normal”.

The body learns through neuromuscular feedback.

This simply means that the body responds to stimuli in its environment.

When we learn a new skill, whether in the area of sports, music, art, crafts, or any other occupation, we repeat the movements involved in this new skill over and over again.  We not only develop the large and small muscles necessary to execute the skill but we also learn to fine tune our movements for efficiency, coordination, ease, and grace.

With each muscle movement the brain receives messages through the neural pathways about the various aspects such as force, speed, pressure, vibration, direction of force, resistance, and so forth.  The brain processes this information and responds to it through the neural pathways, allowing us to adjust all these variables for ultimate efficiency and harmony of motion.

Incorporating play sessions to allow the baby to use its legs and feet will enhance therapeutic value and success.  With some creativity, the therapist, parents, and other care takers can provide gentle stimulus to the bottom of the feet to allow the infant to push against gentle resistance of a hand, the persons’ body, or any other object.

The more stimulus to the bottom of the feet in a playful way, the more the child is encouraged to use all the small muscles of the foot as well as those of the calf muscles, in fact, all the muscles of the leg.  This kind of activity, interspersed throughout the day, will provide plenty of opportunity for neuromuscular feedback to the brain to remind it that the weaker muscles are still available to do work.

Energetic unwinding enhances neuromuscular feedback.

Energetic unwinding of the spine, joints & muscles is a therapy that intuitively combines craniosacral therapy, acupressure, and soft tissue work to help the body to release restrictions from old and new injuries, illnesses, postural issues, and extended periods of immobility.

This therapy is utmost gentle and encourages the body to do its own healing work through vibrational atunement by the therapist.  It’s dynamic in that the therapist responds to the impulses of the patient’s body to re-establish musculoskeletal balance through movement.

Energetic unwinding offers the possibility of much increased therapeutic potential as a stand alone and in combination with other therapies.