Ignacio Ponseti, MD

Department of Orthopedic Surgery, University of Iowa Stead Family Children's Hospital
Last Revised: May 2017

Parents of infants born with clubfeet may be reassured that their baby, if otherwise normal, when treated by expert hands will have normal looking feet with normal function for all practical purposes. The well-treated clubfoot is no handicap and is fully compatible with a normal, active life.

Figure 1 Clubfoot2-day-old baby with bilateral clubfeet  

The majority of clubfeet can be corrected in infancy in about six to eight weeks with the proper gentle manipulations and plaster casts. The treatment is based on a sound understanding of the functional anatomy of the foot and of the biological response of muscles, ligaments and bone to corrective position changes gradually obtained by manipulation and casting.

Ideally, treatment should begin at two weeks of age in order to take advantage of the favorable elasticity of the tissues forming the ligaments joint capsules and tendons.  Using the Ponseti method, these structures are stretched with weekly, gentle manipulations. A plaster cast is applied after each weekly session to retain the degree of correction obtained and to soften the ligaments. Thereby, the foot bones are gradually brought into the correct alignment. Treatment can also be successful when started later if other issues may be present

Figure 2 ClubfootFourth plaster cast applied after manipulation  

Five to seven plaster casts extending from the toes to the upper thigh with the knees at right angle should be sufficient to correct the clubfoot deformity. Even the very stiff feet require no more than eight or nine plaster casts to obtain maximum correction. Before applying the last plaster cast, which is to be worn for three weeks, the Achilles tendon is often cut in an office procedure to complete the correction of the foot. By the time the cast is removed the tendon has regenerated to a proper length. Treatment can be shortened by changing the plaster casts every five days.

Figure 3 Clubfoot2 1/2 months, the baby's feet are corrected  

After casting, bracing is crucial to maintain the correction and prevent relapses of the clubfoot deformity.  When the last plaster cast is removed a splint must be worn full time for two to three months and thereafter at night up to five years of age. The brace consists of a bar (the length of which is the distance between the baby's shoulders) with  shoes attached at the ends of the bar in about 60 degrees of abduction.  The baby may feel uncomfortable at first when trying to alternatively kick the legs. However, the baby soon learns to kick both legs simultaneously and feels comfortable. In children with only one clubfoot, the shoe for the normal foot is fixed on the bar in 30 degrees of abduction. During the daytime, the children wear regular shoes. Shoes attached to the bar may cause pressure blisters and sores. Education on proper brace application and troubleshooting for skin issues is discussed with parents prior to bracing.

Figure 4 ClubfootShoes and bar  

Once the bracing period is complete (approx. age 5) or difficulties with compliance of bracing occur, a simple operation may be needed when the child is over 3 years of age. The operation consists of transferring the anterior tibial tendon to the third cuneiform.

Poor results of cast and manipulative treatments of clubfeet in many clinics indicate that the attempts at correction have been inadequate because the techniques used are flawed. Without a thorough understanding of the anatomy and kinematics of the normal foot and of the deviation of the bones in the clubfoot, the deformity is difficult to correct. Poorly conducted manipulations and casting will further compound the clubfoot deformity rather than correct it making treatment difficult or impossible.

Figure 5 Clubfoot38-year-old, normal-looking feet with normal function and no pain  

Surgeons with limited experience in the treatment of clubfoot should not attempt to correct the deformity. They may succeed in correcting mild clubfeet, but the severe cases require experienced hands. Referral to a center with expertise in the non-surgical correction of clubfoot should be sought before considering surgery.

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