Clubfoot Correction (Ponseti Method)

Clubfoot correction using the Ponseti method is a non-surgical treatment that gradually reshapes a newborn or young child's foot that was born turned inward and downward into a normal, functional position.

A baby born with clubfoot has tendons (the tough cords connecting muscle to bone) and ligaments (the bands connecting bone to bone) around the foot and ankle that are tighter than normal, pulling the foot into an abnormal shape. The Ponseti method works by gently stretching these soft tissues a little at a time. A specialist carefully moves the foot toward the correct position by hand, then holds it there with a plaster cast. This is repeated every week or so. Over several weeks, the foot gradually reaches a normal shape. In most children, a small procedure to release the Achilles tendon (the cord at the back of the heel) is also needed at the end of casting, followed by a period of wearing a special brace to keep the foot in the corrected position as the child grows.

The Ponseti method is used to treat clubfoot (also called talipes equinovarus), a condition present at birth in which one or both feet point downward and inward. It is suitable for most children when treatment is started early, ideally within the first weeks of life, though older infants and toddlers can also benefit.

• Congenital clubfoot (present at birth) in newborns, infants, and young children
• Isolated clubfoot with no other known underlying cause (called idiopathic clubfoot)
• Clubfoot associated with certain conditions such as spina bifida (incomplete closure of the spine) or arthrogryposis (stiffness in multiple joints from birth), though these may require a modified approach
• Clubfoot that has relapsed (come back) after earlier treatment
• Older children with untreated or partially treated clubfoot, assessed case by case

The Ponseti method is generally not suitable, or may need to be modified, in the following situations:

• Children who have already had extensive surgical release of the foot, as scar tissue can make casting less effective
• Cases where severe underlying neurological (nerve) or skeletal conditions make gradual stretching unsafe or ineffective
• Situations where the family cannot commit to the full course of casting and brace-wearing, since the treatment only works if completed

The Ponseti method is one of the safest treatments in paediatric orthopaedics (children's bone and joint surgery), and serious complications are uncommon. The small Achilles tendon release procedure at the end of casting carries its own minor risks.

• Skin irritation, pressure sores, or blisters under the cast — the most frequently reported issue, usually resolved by adjusting the cast
• Swelling of the toes, which is monitored closely after each cast is applied
• Relapse (the foot returning to a turned-in position) — the most common long-term concern, most often linked to stopping brace wear too early
• Discomfort during stretching and casting, particularly in older children
• For the Achilles tendon release: minor bleeding, a small scar, or, rarely, incomplete release requiring a repeat procedure
• Infection at the small cut made for the Achilles tendon release — rare, and treated with antibiotics
• In very rare cases, a cast applied too tightly can briefly reduce blood flow to the foot; parents are taught warning signs to watch for

The casting phase of the Ponseti method does not require fasting, anaesthesia (medicine to make the child sleep or numb), or any special preparation for each weekly session. However, the small Achilles tendon release procedure usually requires a brief local anaesthetic (numbing medicine) or, in very young babies, no anaesthetic at all because the tendon has very few nerve endings at that age. The doctor will advise what, if anything, to prepare before this step.

Before the first appointment, it is helpful to bring any previous imaging (X-rays or ultrasound scans) of the foot, a summary of the child's birth history, and notes on any other medical conditions the child has. No medications need to be stopped before routine casting sessions. If a procedural step is planned, the doctor will give specific guidance about feeding pauses for very young infants before any sedation (medicine to calm the child).

Here is what typically happens during the treatment course:

• Step 1 — Assessment: The doctor examines the foot, checks its flexibility, and scores its severity using a standard scale (most commonly the Pirani score) to plan the number of casts needed.
• Step 2 — Gentle manipulation: With the child lying comfortably, the doctor slowly and carefully stretches and rotates the foot toward the correct position. This usually takes only a few minutes.
• Step 3 — Cast application: A soft padding is wrapped around the foot, ankle, and leg, followed by plaster or fibreglass cast material that holds the foot in the new position. The cast typically runs from the toes to the upper thigh to prevent it from slipping.
• Step 4 — Weekly repeat: The cast is removed at the next visit (usually by soaking or a cast saw), the foot is gently stretched a little further, and a new cast is applied. This continues for several weeks until the foot is nearly corrected.
• Step 5 — Achilles tendon release (tenotomy): When the foot has reached the right shape but the heel cord is still tight, a small cut is made under local anaesthetic to release the tendon. The foot is then placed in a final cast for a few weeks to allow the tendon to heal in the lengthened position.
• Step 6 — Brace fitting: Once the final cast is removed, the child is fitted with a foot abduction brace (a special bar connecting two shoes that hold the feet turned outward). Wearing this brace consistently, especially during sleep, is the most important step in preventing relapse.

After each casting session the child can usually return home the same day. After the Achilles tendon release, a short observation period at the clinic is typical before discharge. The longest and most important phase of aftercare is brace wearing, which continues for several years and requires close follow-up with the orthopaedic (bone and joint) team.

• Cast care between visits: Keep the cast dry. Avoid putting anything inside the cast. Check the toes daily — if they look blue, are very cold, or the child is unusually upset, contact the treating team immediately.
• Brace wearing after the final cast: In most protocols, the brace is worn for a large part of the day and night at first, then gradually reduced to night and nap time only as the child grows. The exact schedule is set by the doctor.
• Brace care: The shoes and bar should be checked at each follow-up visit for fit and wear. Children grow quickly, so the brace will need to be replaced periodically.
• Follow-up visits: Regular check-ups with the paediatric orthopaedic surgeon are needed throughout the brace-wearing years and beyond, to catch any sign of relapse early.
• Physical activity: Once the final cast is removed, most children can move their foot freely. There is usually no need to limit normal play or later sports, though the doctor will guide the family based on the individual child's progress.
• Watching for relapse: The foot turning inward again is the main long-term concern. Signs to watch for include the child walking on the outer edge of the foot, the heel rising, or the forefoot (front part of the foot) curling inward. Early reporting to the doctor allows prompt treatment.
• Skin care: After a cast is removed, the skin may be dry or flaky. Gentle moisturising is usually recommended. Any redness, blistering, or sores should be shown to the doctor.
• Emotional support: Wearing a brace for years can be challenging for children and families. Many treatment centres have support resources; parents are encouraged to ask about these.