Approach

Treatment of clubfoot deformity begins with recognizing the deformity and referring the patient to a pediatric orthopedic surgeon familiar with nonoperative treatment. The Ponseti method is the most common management approach and is used worldwide.[12]​​[22]​​[29][32]​​[33][34]​​ Guidelines recommend that the patient should be treated by an experienced pediatric orthopedic surgeon trained in the Ponseti method.[21][22]​​[26]​​​ However, treatment by a physical therapist may be equally effective. Hip evaluation can be undertaken at the same time. 

Results can be poor if the Ponseti method is not implemented correctly.

Other nonoperative methods are available but are not commonly used.[35][36][37][38] 

Manipulation

The foot is gently manipulated by using the talus as the fulcrum. The thumb is placed on the talar head while the forefoot is gently supinated and abducted. Global HELP: clubfoot: Ponseti management Opens in new window

Casting

The first cast is applied using plaster-bandage material with the forefoot in supination and mild abduction.[39] Manipulation and casting is then repeated every 4 to 7 days until full correction is obtained.[22] Subsequent abduction is increased. 

The first cast improves the cavus and the adductus deformities. The remaining casts correct the varus deformity and eventually equinus (which is corrected last). Usually between 4 and 6 casts are needed, but if more than 6 or 7 are needed then the practitioner should seek onward referral.[22][40]​​ Casting is occasionally indicated for postural clubfoot (not a true clubfoot), but only 1 or 2 casts are needed. Analgesia is usually not required.

Achilles tenotomy

In >85% of patients, the equinus contracture does not improve acceptably and a percutaneous tenotomy is required.[22] Dorsiflexion is then improved by an additional 20° to 25°. The final cast is placed in abduction and dorsiflexion for 3 weeks.[41] This may be done in the office setting under local anesthesia or in the operating room under general anesthesia.[42][43]

Bracing

Following manipulation/casting and Achilles tenotomy, patients should be placed in a brace full time for 3 months, then for nights/naps until 5 years of age.[22] Many braces are on the market, including the Ponseti brace with Mitchell shoes, Denis Browne bars with Markell shoes, or dynamic orthoses such as the Dobbs bar.[44] These allow active extension and flexion in a single plane. Ankle-foot orthoses have custom-molded inserts. The dynamic foot abduction orthosis includes features that make it easier for the parents to apply the device.[44]​

The shoes are applied shoulder-width apart at the heel with the affected side being externally rotated 70° and the unaffected side externally rotated 40° (if unilateral deformity).[22]

Relapse

The first sign of relapse is the development of equinus, or a tight heel cord. An intoeing gait develops with increased adduction of the forefoot, varus of the heel, and loss of heel strike.[21]

The main reason for relapse is not being compliant with the bracing.[21][31] Relapses should first go through recasting to regain the correction, followed by rebracing as before. The follow-up schedule should include checks for compliance and relapse.

Anterior tibialis transfer may be needed in about 30% of clubfeet treated by the Ponseti method. Usually this is performed with dynamic metatarsus adductus (when children are not walking, the foot appears straight; when they begin walking, forefoot supination is noted).[31] An additional cast may be needed to correct any fixed deformities in children with relapse. The tibialis anterior tends to pull the forefoot into adductus when it fires, and the transfer involves moving the tendon off its insertion on the medial cuneiform. It is then transferred under the retinaculum and placed in a drill hole in the lateral cuneiform.

Posteromedial release and tendon lengthening

This is considered classic clubfoot surgery. It may need to be used in patients with comorbidities (e.g., polio, cerebral palsy), as they may be resistant to nonoperative treatment. Patients who present for treatment as older children or adolescents will also require surgery instead of nonoperative treatment.

French method

The French method is not widely used because of the extensive time constraints.[21] It involves daily stimulation of the muscles around the foot and ankle. Then a nonelastic adhesive is used to maintain the correction that was obtained by passive manipulation. The treatments are continued for 2 months, followed by an additional 6 months of stretching 3 days a week. Taping is continued until the child is walking, followed by night-time splinting for 2 to 3 years.

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