Forefoot Adduction Malformation

What is forefoot adduction?

Forefoot adduction is a common condition between metatarsus adductus, Z-shaped foot, and residual clubfoot.

This deformity is located in a pure transverse plane at Lisfranc’s joint.

(29) Forefoot adduction is a positional deformity in which the metatarsals deviate in the transverse plane when compared with the longitudinal axis of the lesser tarsus; this deformity is located at Lisfranc’s joint in a pure transverse plane (29), where the metatarsals are regularly adducted, with a normal position of the hindfoot under the ankle joint.

In literature, the incidence of metatarsus adductus in the population varies from 8.8% to 15% as reported by Cornwall et al.

(30), while others suggested much higher levels (31). Heredity accounts for only 2 to 4% of all cases of metatarsus adductus (32); the theory of abnormal intrauterine position is mostly accepted as etiology of metatarsus adductus (33,34), supported by several studies showing a disproportionate number of affected infants in prima gravida mothers (35).

Male preponderance is approximately 1.3:1 ratio as reported by most authors. Historically, several names were given to this forefoot deformity such as metatarsus adductus, metatarsus varus (36), metatarsus adductors (37), pes adductus, metatarsus supinates (38), forefoot adducts (39), and hooked forefoot (40), all these names are given to media deviation of the forefoot

In forefoot adduction, the front part of a child’s foot turns inward. There is no known cause of forefoot adduction. Forefoot adduction is a very common foot condition in children.

Most cases of metatarsus adductus resolve without treatment. (1) However, in up to 14% of affected children, the deformity persists to adulthood.

(3, 4) Many pediatricians regard forefoot adduction as a cosmetic issue of minor functional significance. (5) However, it is well documented that unresolved forefoot adduction may require further treatment. (6-11)

Epidemiology of Forefoot addutcion

This deformity occurs in approximately 1 in every 12 births and has an equal frequency in males and females. The deformity is bilateral in approximately 60% of cases.

There is an increased incidence in late pregnancy, first pregnancies, twin pregnancies, and oligohydramnios. Associated conditions include DDH (15-20%) and torticollis. (2,16).

Although most cases of forefoot adduction resolve by the time of skeletal maturity, the persistence of the deformity has been associated with the development of valgus (HV). The incidence of MA in patients with HV was reported to be 21.6% to 29.5%. (17)


Forefoot adduction is thought to be caused by the infant’s position inside the womb. Risks may include that the baby’s bottom was pointed down in the womb (breech position) or the mother had a condition called oligohydramnios, in which she did not produce enough.

There may also be a family history of the condition. (20)


This malformation can be diagnosed through a physical exam. Telltale signs of this condition include the high arch and a visibly curved and separated big toe.

During the examination, the doctor will obtain a complete birth history of the child and ask if other family members were known to have forefoot adduction. (20)

Diagnostic procedures are not usually necessary to evaluate forefoot adduction. However, X-rays (a diagnostic test that uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film) of the feet are often done in the case of nonflexible forefoot adduction. (21)

An infant with forefoot adduction has a high arch and the big toe has a wide separation from the second toe and deviates inward.

Flexible t adduction is diagnosed if the heel and forefoot can be aligned with each other with gentle pressure on the forefoot while holding the heel steady. This technique is known as passive manipulation.

If the forefoot is more difficult to align with the heel, it is considered a nonflexible, or stiff foot. (21)

Forefoot adduction Treatment

Specific treatment will be determined by your child’s doctor based on your child’s age, overall health, and medical history, the extent of the condition your child’s tolerance for specific medications, procedures, or therapies, expectations for the course of the condition and your opinion or preference.

In light of reports that 10–14% of forefoot adduction cases persist to adulthood and some require surgical intervention, a more proactive approach is advocated by some authors for rigid, severe deformities (18,19)

The goal of treatment is to straighten the position of the forefoot and heel. Treatment options vary widely from watchful follow-up, passive stretching, bracing, serial casting, and, rarely, surgical correction (12) Studies have shown that forefoot adduction may resolve spontaneously (without treatment) in the majority of affected children.

It gets further complicated by the notion that early intervention, before 8 to 9 months of age, when spontaneous improvement is more likely, carries a better chance for deformity improvement.

(13) When more severe, less flexible forefoot adduction is present, bracing or serial casting is often recommended with reported long-term success rates of approximately 90%. (14,15)

A doctor or nurse may instruct you on how to perform passive manipulation exercises on your child’s feet during diaper changes.

More Essential Tips

A change in sleeping positions may also be recommended. Suggestions may include side-lying positioning. In rare instances, the foot does not respond to the stretching program, long leg casts may be applied. Casts are used to help stretch the soft tissues of the forefoot. The plaster casts are changed every 1 to 2 weeks by your child’s pediatric orthopedist.

If the foot responds to casting, straight-last shoes may be prescribed to help hold the forefoot in place. Straight last shoes are made without a curve in the bottom of the shoe.

For those infants with very rigid or severe forefoot adduction, surgery may be required to release the forefoot joints. Following surgery, casts are applied to hold the forefoot in place as it heals.

There are several outcome studies of forefoot adduction, with most patients presenting with benign and self-limiting forefoot adduction (22-25).

However, there are numerous reports of unresolved issues treated surgically (26, 27). Therefore, it would seem that before surgical intervention, most children with resistant forefoot adduction should be actively treated with casts or orthoses, potentially decreasing the need for subsequent surgical procedures.

A recent meta-analysis emphasized the importance of an accurate initial determination of the severity to be able to decide the appropriate treatment strategy.

For mild, flexible forefoot adduction, observation is suggested. More rigid forefoot adduction should be treated with casting/bracing. This study also stresses the lack of perspective, randomized clinical trials (28)

Treatment of Forefoot Adduction

Forefoot adductionThere are two main methods to treat Forefoot adduction:

1- Serial Casting.

2- The UNFO Brace.

Both methods work fine and the casting series is still the most common treatment option worldwide because the UNFO brace is a revolutionary treatment that was approved by the FD and the CE only in 2018.

Both treatment methods take approximately 2-4 months total and have excellent results.

Serial casting is very unpleasant for the infant, the baby can suffer a lot and develop some wounds due to the casting, also it’s very challenging to take a shower because the cast should be done from the feet to the crotch.

The UNFO shoes are a great alternative to casting that has been used in medical words in the last 200 years and gives excellent results within 10-14 days, you can verify it with our thousands of success stories.

UNFO is more expensive but it’s a much easier treatment for the baby, the parents, and the pediatric orthopedics.


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  16. Prevalence of Metatarsus Adductus in Symptomatic Hallux Valgus and Its Influence on Functional Outcome – Bryan Loh, Jerry Yongqiang Chen, Andy Khye Soon Yew, Hwei Chi Chong, Malcolm Guan Hin Yeo, Peng Tao, Kevin Koo, Inderjeet Rikhraj Singh, 2015 (
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  23. The Treatment of Rigid Metatarsus Adductovarus with the Use of a New Hinged Adjustable Shoe Orthosis – William D. Allen, Dennis S. Weiner, Patrick M. Riley, 1993 (
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The natural history of hooked forefoot | The Journal of Bone and Joint Surgery. British volume