SLR - May 2015 - Luiza Assis

The Contralateral Foot in Children with Unilateral Clubfoot, is the Unaffected Side Normal?

Reference: Cooper A, Chhina H, Howren A, Alvarez C. The contralateral foot in children with unilateral clubfoot, is the unaffected side normal? Gait Posture. 2014 Jul; 40(3):375-80.

Scientific Literature Review

Reviewed By: Luiza Assis, DPM
Residency Program: Botsford Hospital

Podiatric Relevance: In children with unilateral clubfoot, the unaffected foot is often considered “normal” and therefore the control for interventions correcting the clubfoot deformity. However, there have been a few studies that have noted differences in the unaffected foot when compared to children without clubfoot. This has been a limitation since many of these patients are treated with Ponsetti casting prior to surgical interventions. The study goal was to evaluate the pedobarographic parameters of unaffected unilateral clubfoot and compare those results to children who were not affected by clubfoot.

Methods: Patients were selected from the British Columbia Children’s Hospital clubfoot database and only those with unilateral deformities were included in this study. Any child who had other gait altering conditions such as idiopathic toe walking, cerebral palsy, peroneal nerve palsy, or structural abnormalities of the foot or leg were excluded. The remaining cases were divided into three groups based on age; Group 1(<2 years), Group 2(2-5 years), Group 3(>5 years). The treatment for each group included the MCB method which is a modification of the Ponsetti method where Botulinum Type A toxin is used instead of a percutaneus tenotomy, casting and manipulation alone, and surgical interventions which included: tendo-Achilles lengthening, tendon transfers, posterior medial release, midfoot osteotomies, and hindfoot osteotomies. The pedobarographic measurements were taken at least three months post Botulinum toxin injection and at least six months post surgical intervention. Normal control were defined as children who did not have foot deformity or motor dysfunction and were recruited from the British Columbia Children’s Hospital Health Centers.

Results: In Group 1(<2 years) the pedobarographic pressures indicated that there was significantly greater pressure over the lateral forefoot of the unaffected foot and that this occurred later in stance phase when compared to the control. In addition, during stance phase time spent on the lateral forefoot was only 32 percent when compared to 74.4 percent in the normal population. In Group 2(2-5 years) the maximum percentage of force in the unaffected forefoot was significantly less in the heel and lateral forefoot but significantly higher in the midfoot when compared to normal controls. Also during stance phase, the amount of time spend on the medial midfoot in the unaffected foot was significantly greater than normal controls, 66.2 percent compared to 38.9 percent respectively. In Group 3 (>5 years) there was significant more force applied to the heel in the unaffected foot compared to the control and again it was seen that there was a significant increase in force to the medial midfoot in the unaffected foot compared to normal control.

Conclusions: When a unilateral clubfoot deformity is present it is important to understand that the unaffected foot does not function like a normal foot. Pedobarographic measurements indicate that it functions more like a planovalgus foot type and caution should be taken when the unaffected side is used as the “normal” for correcting the clubfoot deformity. These differences could require monitoring as the child matures as pathologies could develop in the affected side due abnormal gait pattern present from a very young age.

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