Congenital Talipes Equinovarus (CTEV): Causes, Symptoms, Treatment and Cost

Congenital Talipes Equinovarus (CTEV), more commonly known as clubfoot, is a congenital deformity where one or both of the feet are twisted out of their normal position.

It involves the small bones, muscles, tendons and ligaments in the feet and lower leg which can cause either a flexible or rigid clubfoot. Clubfoot can occur in isolation with no other signs of abnormalities or it can be associated with other conditions such as spina bifida or Down syndrome.

There are three types of CTEV:-

• Simple CTEV: In this type, the deformity is most commonly isolated to a non-synostotic isolated first ray contracture which can lead to claw or cocktail toes with rocker bottom heel or a flat foot deformity.
• Complex CTEV: In this type, the deformity is multiplanar from ligamentous laxity and possible synostoses of the tarsal bones with associated cavovarus or calcaneovalgus positions of hindfoot with dorsiflexed forefoot position which leads to substantial forefoot abduction and eversion (clawing).
• Syndromic CTEV: This type occurs in combination with other congenital anomalies such as Down Syndrome and certain chromosomal abnormalities, craniofacial malformations, genitourinary abnormalities, central nervous system malformations and cardiorespiratory defects.

• The exact cause of CTEV remains unknown, though factors such as genetic predisposition, intrauterine position, and immobility are believed to be involved.
• Other risk factors include having an expecting mother who smokes, lacks folic acid or has diabetes during pregnancy.
• CTEV can also be caused by metabolic disorders or chromosomal abnormalities such as Down syndrome or hereditary diseases like Ehlers-Danlos syndrome (EDS).

• Symptoms of CTEV include feet that point downward, inward pointing heels and toes, a tight Achilles tendon and an arch on top of the foot that is absent or flat.
• In addition, affected babies may have difficulty standing or walking due to their limited range of motion in the ankle joint and foot muscles.

• Regular education for all pregnant women about the possible causes, risk factors and preventive measures for CTEV.
• Advice pregnant women to maintain a healthy balanced diet and regular physical exercise to maintain good health during pregnancy.
• Advise proper prenatal care and ensure ultrasounds during pregnancy to identify any problems early.
• Educate parents on detection of signs of foot deformity after childbirth and advice timely intervention if signs are visible or something feels wrong with the baby’s feet position at birth or soon afterwards.
• Advise against wearing footwear such as shoes or boots which exacerbate foot deformity in babies with CTEV by pushing the feet out further and reducing natural movement of feet while the baby is learning to walk and gain balance.

• Physical examination: Your doctor may ask you to stand and walk to get an idea of your foot or ankle function, observe your feet and ankles while you are standing and moving, or look for any signs of imbalance.
• Electromyography (EMG): EMG is used to measure muscle activity in order to check for nerve damage.
• Ultrasound: Ultrasound can be used to diagnose CTEV before birth by showing the position of the baby’s feet in utero (in the womb).
• CT scan: A CT scan is often used in more severe cases of CTEV because it can provide more detailed images than X-rays or ultrasound scans can offer about the bones and muscles of a baby’s feet and ankles.
• MRI: MRIs provide a three-dimensional image that helps doctors assess deformities in greater detail than other imaging technology does, which is useful in complex cases of CTEV when assessing positions, angles, deformities, etc., may be difficult with other forms of imaging technology alone.

• Muscle Deformity: CTEV may result in a 'clubfoot' deformity, where the foot is smaller, twisted, and bent downward.
• Difficulties with Walking: People born with CTEV may experience difficulty walking.
• Joint Stiffness: Due to limited mobility and movement in the affected joint, people with CTEV may experience stiffness.
• Arthritis: Long Term complications of CTEV can include arthritis in the affected joints.
• Chronic Pain: Over time, chronic pain may develop due to tight tendons and connective tissue that causes muscle imbalance and pressure on nerves and blood vessels affecting day-to-day life activities.

• Massages with warm sesame oil: Massage of the affected foot with warm sesame oil helps to relax the tendons and muscles of the foot, thus providing relief from pain.
• Herbal poultice: Application of a poultice made up of equal parts of hornet’s nest ash, mung bean flour and barberry root can help provide relief from the symptoms of CTEV.
• Padhyadhanam: It is a type of Ayurvedic massage technique which involves massaging areas from toes to thighs in order to enhance circulation, strengthen the bones and reduce symptoms associated with CTEV.
• Balaguggulu: Intake of Ayurvedic preparation such as Balaguggulu helps in strengthening tendons, ligaments, bones and muscles which are essential for movement for CTEV afflicted children.

• A balanced diet with plenty of fruits, vegetables, whole grains, lean meats, and low-fat dairy products.
• Calcium-rich foods such as yogurt, milk, and cheese.
• Foods high in omega-3 fatty acids such as salmon, walnuts and flaxseed.
• Omega-6 fatty acids from foods like avocados and olive oil.
• Vitamin C rich foods such as oranges and bell peppers.
• Protein sources including legumes, nuts, lean meats, fish and poultry.

• Raw or undercooked meats and fish: These can increase the risk of food borne illness.
• High sugar foods and drinks: These can interfere with calcium absorption and worsen the deformity.
• Fried and processed foods: These can be inflammatory and aggravate swelling in the feet.
• Spicy or highly seasoned foods: Certain spices may cause further inflammation in the feet and worsen symptoms of CTEV.
• Processed grains, sugar, and refined carbohydrates: These can lead to increased weight gain, which may make it more difficult to manage CTEV symptoms.

• Splinting & Casting: The feet can be manipulated into a better position and placed in a cast or splint. This helps stretch tight muscles as well as hold the foot in a better position while it heals.
• Appropriate Footwear: Wearing shoes that fit properly is important for treating and preventing CTEV recurrence. Shoes that provide support and cushioning can improve walking gait by reducing pressure on certain areas of the foot.
• Exercises & Stretches: Certain exercises and stretches help strengthen afflicted muscles, which can help hold the feet in proper position to prevent future recurrences.
• Soft Tissue Release: This involves releasing the tightness of some of the muscles and tendons in the foot and ankle to allow for better foot mobility.
• Osteotomy: During this surgical procedure, bones in the heel and midfoot are cut and repositioned to help restore a more normal foot shape.
• Tendon Lengthening: This operation is done to increase skeletal length by lengthening shortened tendons or muscles located around the ankle and foot joints.
• Arthrodesis: In order to improve alignment or prevent further deformity of CTEV-related conditions, arthrodesis may be necessary; it’s essentially a fusion surgery in which two medical-grade implants are used to fuse bones together while existing joint functions are preserved as much as possible during fusion healing process.

Most commonly an orthopedic surgeon will be consulted for the treatment of Congenital Talipes Equinovarus (CTEV).

The surgeon may also refer to an orthotist for evaluation, as bracing and/or casting may be necessary.

Physical therapists trained in CTEV are also key in helping a child gain strength and movement as well therapeutic shoes or inserts to appropriate support the foot.

Below are some classes of drugs used to treat CTEV:

• Non-steroidal Anti-inflammatory Drugs (NSAIDs): These medications work by reducing inflammation in order to improve mobility and reduce pain associated with CTEV. Examples include ibuprofen, naproxen sodium, and acetaminophen.
• Corticosteroids: These medications reduce inflammation and can reduce swelling in affected areas. They are typically injected directly into affected muscles or joints around the foot and ankle to provide relief from painful symptoms of clubfoot. Examples include prednisone, methylprednisolone, and triamcinolone acetonide.
• Muscle Relaxants: These drugs help relax tight muscles around the ankles and feet which can occur due to CTEV. Common muscle relaxants used include baclofen, cyclobenzaprine hydrochloride, carisoprodol, tizanidine hydrochloride, metaxalone, and chlorzoxazone hydrochloride.

The recovery time for Congenital Talipes Equinovarus (CTEV) varies from person to person depending on the age of the affected individual and the severity of their condition.It typically takes up to a year for most patients to reach full correction, although younger patients or those with mild cases may reach full correction in as little as six months.

Generally, surgical options for treating CTEV can range anywhere from Rs 20,000-60,000 approximately.

Non-surgical treatments may be less expensive, and fees may also vary depending on whether a patient opts for cast or splint application.Other associated medical costs such as medications, post-operative care and follow-up visits must also be taken into account when determining the overall cost of treatment for CTEV in India.

• CTEV treatments can lead to potential side effects, such as pain, swelling, tenderness, and nerve damage.
• Other complications may include infection, scarring of tissue, bone instability and over-correction of the deformity.
• In rare cases, more serious side effects such as joint dislocation may occur.

If you are suffering from any complications relating to Congenital Talipes Equinovarus (CTEV) then you should consult a doctor nearby as they can cause complications like 'muscle deformity, joint stiffness, arthritis' in which treatment course can range from a few months to years depending on the severity of the situation.