PreClinical Clubfoot Deformity
The PreClinical Clubfoot Deformity is an inherited abnormal foot structure in which both the calcaneus and talus have not completed their normal ontogenetic torsional development and remain in Supinatus (structurally twisted inward) 1 2 3. When this foot structure is placed into its standing anatomical neutral position (where the articular margins of the subtalar joint are congruous), the bottom surface of the calcaneus is inverted (turned inward) relative to the ground and the hallux (big toe) and first metatarsal head are elevated off the ground 4 5
The Preclinical Clubfoot Deformity is one of the most common causes of abnormal (gravity drive) pronation. 6 At heel contact, as weight is applied to the bottom of the foot, gravity pulls the elevated heel bone downward and outward until the entire bottom surface is resting on the ground. This downward and outward twisting motion of the heel bone forces the inner longitudinal arch (ILA) of the foot to flatten . The more severe the heel Supinatus, the more the heel bone twists. The more the heel bone twists, the flatter the ILA 7.
Flattening of the ILA places a stretch (tension) on the intrinsic foot muscles and spring ligament supporting the ILA. This can result in arch pain. Placing an arch support underneath the ILA in patients with a PreClinical Clubfoot Deformity will prevent the ILA from flattening. This diminishes the arch pain. However, at the same time, supporting the ILA weakens the foot muscles (analogous to a leg cast weakening the muscles in the leg).
As the muscles in the feet become weaker, the unsupported arches (when arch supports are not worn) become flatter 8. As the arches become flatter, the foot pain increases. In essence, the patient becomes addicted to wearing the arch supports to control the pain.
This becomes a vicious cycle. Arch supports are used to control the foot pain, but at the same time make the foot muscles weaker and weaker. Hence, long term arch support therapy in patients with the PreClinical Clubfoot Deformity is not indicated.
Screening for the PreClinical Clubfoot Deformity
The Heel to Toe Raise Test is a screening tool that the healthcare provider can use to help determine if their patient may have the PreClinical Clubfoot Deformity: The height of the ILA is observed at heel contact, flatfoot and heel lift. The test is positive (e.g., high probability of a PreClinical Clubfoot Deformity) if the ILA flattens at mid-stance, but is intact at heel contact and toe off 9.
Clinically, the PreClinical Clubfoot Deformity has been implicated as a common cause of chronic musculoskeletal pain. The symptoms can start in children as young as 3 or 4 and by the time the individual reaches their late 30s, early 40s, the pain can be debilitating and constant 10 11
PreClinical Clubfoot Deformity vs Rothbarts Foot
Both of these embryological foot types distort the signals being generated from the foot to the cerebellum (brain). Both of these foot structures result in postural distortions that frequently result in chronic debilitating muscle and joint pain. And both of these foot structures are treated using Rothbart Proprioceptive Therapy. However the type proprioceptive insole used in treating Rothbarts Foot is very different than the type of proprioceptive insole used to treat the Preclinical Clubfoot Deformity.
Hence it is very important to make a differential diagnosis (determine which foot structure is present) before therapy is initiated.
The Knee Bend Test is used to help make this differential diagnosis.
When the body's weight is over the heel bones (e.g., the knees are straight), foot twist (pronation) is observed only in the Preclinical Clubfoot Deformity.
When the body's weight is over the front part of the foot (e.g., the knees are bent), foot twist (pronation) is observed in both the PreClinical Clubfoot Deformity and Rothbarts Foot.
For more information regarding Rothbarts Foot and the PreClinical Clubfoot Deformity, read Medial Column Foot Systems: An Innovative Tool for Improving Posture.
1. Rothbart BA, 2002. Medial Column Foot Systems: An Innovative Tool for Improving Posture. Journal of Bodywork and Movement Therapies (6)1:37-46
2. Rothbart BA, 2009. What exactly is a Flatfoot? Are there different types? Podiatry Review, Vol 66(6):4-6.
3. Rothbart BA, 2010. The Primus Metatarsus Supinatus (Rothbarts) Foot and the PreClinical Clubfoot Deformity. Podiatry Review, Vol. 67(1):4-5
4. Chaitow L, DeLany J 2005. Clinical Applications of Neuromuscular Techniques, 27(3). Elsevier Chruchill Livingstone Publishers
5. Cummings GS, Higbie EJ 1997. A weight bearing method for determining forefoot posting for orthotic fabrication. Physio Research Intern, Vol 2(1):42-50
6. Rothbart BA, 2010. Gravity Drive. Research Website
7. Rothbart, BA 2010. Gait Analysis of PreClinical Clubfoot Deformity. Research Website
8. Rothbart BA 2010. Arch Supports Wearken the Intrinsic Muscles in the Feet. Research Website
9. Rothbart BA 2010. Heel to Toe Raise Test. Research Website
10. Rothbart BA, Liley P, Hansen, Yerrat M, 1995. Resolving Chronic Low Back Pain. The Foot Connection. The Pain Practitioner (formerly American Journal of Pain Management) 5(3):84-49
11. Rothbart BA, Esterbook L, 1988. Excessive Pronation. A Major Biomechanical Determinant in the Development of Chondromalacia and Pelvic Lists. Journal Manipulative Physiologic Therapeutics 11(5):373-379