Club Foot Treatment
Information For Parents
What is clubfoot?
Clubfoot is the most common deformity of the foot bones and joints in newborns. It occurs in about 1 in 1,000 babies. The cause of clubfoot is not exactly known, but it is most likely a genetic disorder and not caused by anything the parents did or did not do. Therefore, there is no reason for parents to feel guilty about having a child with clubfoot. The chances of having a second child with a clubfoot are approximately 1 in 30.
Parents of an otherwise normal infant who is born with clubfoot can be reassured that their baby, when treated by an expert in this field, will have a normal-looking foot with essentially normal function. The well-treated clubfoot causes no handicap and the individual is fully able to live a normal active life.
The foot is gently manipulated for about 1 minute every week to stretch the short and tight ligaments and tendons on the inside, back, and bottom of the foot. A cast that extends from the toes to the groin is then applied. The cast maintains the correction< obtained by the manipulation and relaxes the tissues for the next manipulation. In this manner, the displaced bones and joints are gradually brought into correct alignment. Treatment should begin during the first week or two of life to take advantage of the favorable elasticity of the tissues at that age.
Current Ponseti Management
Is Ponseti management now accepted as optimal treatment worldwide?
Over the past decade Ponseti management has become accepted throughout the world as the most effective and least expensive treatment of clubfoot.
How does Ponseti management correct the deformity?
Keep in mind the basic clubfoot deformity. Compare the normal relationships of the tarsal bones with that of the clubfoot . Note that the alus is deformed and the navicular is medially displaced. The foot is rotated around the head of the talus . Ponseti correction is achieved by reversing this rotation. Correction is achieved gradually by serial casts. The Ponseti technique corrects the deformity by gradually rotating the foot around the head of the talus over a period of weeks during cast correction.
When should treatment with Ponseti management be undertaken?
When possible, start soon after birth (7 to 10 days). However, most clubfoot deformities can be corrected throughout childhood using this management.
When treatment is started early, how many cast changes are usually required?
Most clubfoot deformities can be corrected in approximately 6 weeks by weekly manipulations followed by plaster cast applications. If the deformity is not corrected after six or seven plaster cast changes, the treatment is most likely faulty.
How late can treatment be started and still be helpful?
The goal is to start treatment in the first few weeks after birth. However, correction can be achieved in many cases until late childhood.
Is Ponseti management useful if treatment is delayed?
Management that is delayed until early childhood may be started with Ponseti casts. In some cases, operative correction will be required, but the magnitude of the procedure may be less than would have been necessary without Ponseti management.
Ponseti Cast Correction
The setup for casting includes calming the child with a bottle or breast feeding. When possible have a trained assistant. Sometimes is necessary for the parent to assist. The treatment setup is important. The assistant holds the foot while the manipulator performs the correction.
Manipulation and casting
Start as soon after birth as possible. Make the infant and family comfortable. Allow the infant to feed during the manipulation and casting processes.
Exactly locate the head of the talus
This step is essential . First, palpate the malleoli with the thumb and index finger of hand A while the toes and metatarsals are held with hand B. Next , slide your thumb and index finger of hand A forward to palpate the head of the talus in front of the ankle. Because the navicular is medially displaced and its tuberosity is almost in contact with the medial malleolus, you can feel the prominent lateral part of the talar head barely covered by the skin in front of the lateral malleolus.
The anterior part of the calcaneus will be felt beneath the talar head.
While moving the forefoot laterally in supination, you will be able to feel the navicular move ever so slightly in front of the head of the talus as the calcaneus moves laterally under the talar head.
The manipulation consists of abduction of the foot beneath the stabilized talar head. Locate the head of the talus. All components of clubfoot deformity, except for the ankle equinus, are corrected simultaneously. To gain this correction, you must locate the head of the talus, which is the fulcrum for correction.
Reduce the cavus
The first element of management is correction of the cavus deformity by positioning the forefoot in proper alignment with the hindfoot. The cavus, which is the high medial arch [1 yellow arc] is due to the pronation of the forefoot in relation to the hindfoot. The cavus is always supple in newborns and requires only elevating the first ray of the forefoot to achieve a normal longitudinal arch of the foot [2 and 3].
The forefoot is supinated to the extent that visual inspection of the plantar surface of the foot reveals a normal appearing arch–neither too high nor too flat. Alignment of the forefoot with the hindfoot to produce a normal arch is necessary for effective abduction of the foot to correct the adductus and varus.
Steps in cast application
Dr. Ponseti recommends the use of plaster material because it is less expensive and more precisely molded than fiberglass.
Preliminary manipulation: Before each cast is applied, the foot is manipulated. The heel is not touched to allow the calcaneus to abduct with the foot .
Applying the padding: Apply only a thin layer of cast padding  to allow molding of the foot. Maintain the foot in the maximum corrected position by holding the toes with counterpressure applied against the head of the talus while the cast is being applied.
Applying the cast: First apply the cast below the knee and then extend the cast to the upper thigh. Begin with three to four turns around the toes , and then work proximally up to the knee . Apply the plaster smoothly. Add a little tension to the turns of plaster above the heel. The foot should be held by the toes and plaster wrapped over the “holder’s” fingers to provide ample space for the toes.
Indication for tenotomy
Tenotomy is indicated to correct equinus when cavus, adductus, and varus are fully corrected but ankle dorsiflexion remains less than 10 degrees above neutral. Make certain that abduction is adequate for performing the tenotomy.
Bracing is essential
At the end of casting, the foot is abducted to an exaggerated amount, which should measure 60 to 70 degrees (thigh-foot axis).
After the tenotomy, the final cast is left in place for 3 weeks. Ponseti’s protocol then calls for a brace to maintain the foot in
abduction and dorsiflexion. This is a bar attached to straight-last open-toe shoes. This degree of foot abduction is required to
maintain the abduction of the calcaneus and forefoot and prevent relapse. The medial soft tissues remain stretched out only
if the brace is used after the casting. In the brace, the knees are left free, so the child can kick them “straight” to stretch the
The abduction of the feet in the brace, combined with the slight bend (convexity away from the child),
causes the feet to dorsiflex. This helps maintain the stretch on the gastrocnemius muscle and heel-cord tendon. Ankle-foot
orthoses (AFO’s) are not useful because they only keep the foot straight with neutral dorsiflexion.
Three weeks after the tenotomy, the cast is removed and a brace is applied immediately. The brace consists of open-toe hightop
straight-last shoes attached to a bar. For unilateral cases, the brace is set at 60 to 70 degrees of external rotation on the
clubfoot side and 30 to 40 degrees of external rotation on the normal side. In bilateral cases, it is set at 70 degrees of external
rotation on each side. The bar should be of sufficient length so that the heels of the shoes are at shoulder width. A common
error is to prescribe too short a bar, that the child finds uncomfortable. A narrow brace is a common reason for a lack of
compliance. The bar should be bent 5 to 10 degrees with the convexity away from the child, to hold the feet in dorsiflexion.
The brace should be worn full time (day and night) for the first 3 months after the last cast is removed. After that, the child
should wear the brace for 12 hours at night and 2 to 4 hours in the middle of the day, for a total of 14 to 16 hours during each
24-hour period. This protocol continues until the child is 3 to 4 years of age.
Occasionally, a child will develop excessive heel valgus and external tibial torsion while using the brace. In such instances,
the physician should reduce the external rotation of the shoes on the bar from approximately 70 degrees to 40 degrees.
Importance of bracing
The Ponseti manipulations combined with the percutaneous tenotomy regularly achieve an excellent result. However, without
a diligent follow-up bracing program, relapse occurs in more than 80% of cases. This is in contrast to a relapse rate of only 6%
in compliant families (Morcuende et al.).
When to stop bracing
How long should the nighttime bracing protocol continue? As it is often difficult to determine severity, we recommend that all
feet should be braced for to 3 to 4 years. Most children get used to the bracing, and it becomes part of their lifestyle. If after 3
years of age compliance becomes a problem, it may become necessary to discontinue the bracing. The child is closely followed
for evidence of relapse.
Should early relapse be observed, bracing should be promptly started again.
In my practice we make use of the Mitchell shoes and Ponseti bar. The shoes are made of a very soft leather and a plastic sole that is moulded to the shape of the childs foot, making this shoe very comfortable and easy to use.
Wearing instructions for the foot abduction brace
Always use cotton socks that cover the foot everywhere the shoe touches the baby’s foot and leg. Your baby’s skin may
be sensitive after the last casting, so you may want to use two pairs of socks for the first 2 days only. After the second day, use
only one pair of socks.
If your child does not fuss when you put the brace on, you may want to focus on getting the worst foot in
first and the better one in second. However, if your baby tends to kick a lot when putting on the brace, focus on the better foot
first, because the baby will tend to kick into the second shoe.
Hold the foot into the shoe and tighten the ankle strap first. The strap helps keep the heel firmly down into the shoe. Do
not mark the hole on the strap that you use because, with use, the leather strap will stretch and your mark will become meaningless.
Check that the child’s heel is down in the shoe by pulling up and down on the lower leg. If the toes move backward and
forward, the heel is not down, so you must retighten the strap. A line should be marked on the top of the insole of the shoe
indicating the location of the tips of the child’s toes; the toes will be at or beyond this line if the heel is in proper position.
Lace the shoes tightly but do not cut off circulation. Remember: the strap is the most important part. The laces are used to
help hold the foot in the shoe.
Be sure that all of the baby’s toes are out straight and that none of them are bent under. Until you are certain of this,
you may want to cut the toe portion out of a pair of socks so you can clearly see all the toes.