Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

at initial diagnosis

1st line – manipulation + casting

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ACUTE
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at initial diagnosis
1st line – 

manipulation + casting

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.

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

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.[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 4 to 6 casts are needed, but if more than 6 or 7 are needed then the practitioner should seek onward referral.[22][40]​​

Consider – Achilles tenotomy + final casting

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ACUTE
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at initial diagnosis
Consider – 

Achilles tenotomy + final casting

Treatment recommended for SOME patients in selected patient group

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°. Achilles tenotomy can be done under local anesthesia in the clinic.[42][43] The final cast is placed in abduction and dorsiflexion for 3 weeks.[41]

Plus – bracing

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ACUTE
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at initial diagnosis
Plus – 

bracing

Treatment recommended for ALL patients in selected patient group

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-moulded 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]

Plus – posteromedial release and tendon lengthening

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ACUTE
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at initial diagnosis
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comorbidities or older child
Plus – 

posteromedial release and tendon lengthening

Treatment recommended for ALL patients in selected patient group

Considered classic clubfoot surgery. 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 also require surgery instead of nonoperative treatment.

relapse

1st line – recasting + rebracing

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ACUTE
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relapse
1st line – 

recasting + rebracing

The main reason for relapse is not being compliant with bracing.[21][31] These patients 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.

Consider – tibialis anterior tendon transfer

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ACUTE
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relapse
Consider – 

tibialis anterior tendon transfer

Treatment recommended for SOME patients in selected patient group

May be needed in about 30% of clubfeet treated by the Ponseti method. Usually performed with dynamic metatarsus adductus (when the child is not walking the foot appears straight; when beginning walking, forefoot supination is noted). 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.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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