Clubfoot Casting Red Flags

The following red flags are meant to give you information about what to keep an eye out for, as well as a listing of things that every clubfoot parent should know about.

If you feel that your doctor is modifying the Ponseti Method, and you wish to find a doctor who doesn't modify, please let us know and we will help you find a skilled doctor in your area if at all possible.

These conditions might indicate that your doctor is modifying the Ponseti Method. You may not be able to make your doctor practice an un-modified Ponseti Method, but you can often find a doctor who doesn't modify the Method.

The following are red flags that the doctor or caregiver is not following the method properly, and the result could be that your child's feet are damaged instead of corrected. Red flags like these are all very good reasons to seek out a second opinion from a qualified Ponseti Method practitioner.

Fiberglass Casts

Some doctors are very skilled with fiberglass casts. Most are not.

• If your doctor uses fiberglass casts, it is important for that doctor to be able to provide you with data proving their success rates with fiberglass casts. There is a very good reason that Dr. Ponseti always used plaster and required all his students and Ponseti Certified caregivers to always use plaster. It is easier to mold and hold the foot securely in each manipulated position. Fiberglass does not have that ability unless the doctor or caregiver is very, very skilled.
• Fiberglass is often called a "soft cast".
• Most slipped casts are fiberglass, although some are plaster.
• It is usually considered a modification of the Ponseti Method for a caregiver to use fiberglass or soft casts.
• We always recommend finding a doctor who will use plaster and who does not modify the Ponseti Method.
• Any casting material that is not plaster should be considered a modification of the Ponseti Method.

Slipped Casts

• Slipped casts, no matter what media they consist of, are an emergency and should be removed as soon as the first millimeter of slipping is noticed.
• You can use a pen (Sharpie) to mark where the edge of the cast is on your child's toes. This should be done as soon as your child is handed to you after each casting.
• Watch for slipping. Most casts slip "down", they almost never slip "up".
• If you see the cast slipping, do not hesitate to remove it. For information about removing casts see our cast removal page.
• It is important to never leave a slipped cast on. Do not worry about your doctor's wrath. If the doctor has any issue with you removing the cast when it slips (take pics before and after to prove your position), this doctor should not be correcting clubfoot.
• Any good doctor knows what happens when a cast slips. It is the prevailing cause of complex clubfoot. If the doctor doesn't know this, you should find a new doctor.

Modified Bracing Schedule - 23/7 to 12hr reduction, for clubfoot

• Dr. Ponseti's bracing schedule is not the same as many doctors in the US prescribe after the first three months of 23/7 wear, at the time of this writing (2021).
• The Foot Abduction Brace (FAB, BNB) should be worn for 23 hours a day for 3 months, and then the schedule reduced by a couple hours at a time, every 2-3 months over the first year.
• The final hours per day being "nights and naps", which for most kidlets is 12-14 hours a day up till the age of 5 or so.

**Many doctors are using a modified bracing schedule that this site's owner feels likely contributes to relapse, as well as intolerance of the brace.

We have experienced anecdotally that some kids are resistant to a sudden reduction in hours from 23/7 to what many docs tell parents is only "12" hours. Part of the success of the Ponseti Method is the bracing protocols. Some doctors feel that they do not need to follow Dr. Ponseti's bracing protocols and use this sudden weaning. It can cause issues with bracing, and this site's owner believes that it is a leading cause for relapse before the age of 2yo.

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Clubfoot Bracing Schedule for Ponseti Method checklist (infant to 1yo):

1. 3 months 23/7 - take one hour off every day to bathe, snuggle, play, and enjoy!
   1. Reduce 2-3 hours daily, for the next 2-3 months.
   1. Reduce again, 2-3 hours daily for the next 2-3 months.
   1. Etc. every 2-3 months, every 2-3 hours. (It isn't set in stone, and it works out to be about 1 year old, down to nights and naps [12-14hr daily])
2. Eventually you arrive at 12-14 hours/day, at or around 1 year old. This can be maintained till 4-7 years old depending on your kid and their feet and how everyone feels about it. This child is used to bracing, and will be happy to wear their braces every night till they are ready to talk their way out of them, or into them (some parents report kiddos asking for their brace to sleep well after they are "done"). Long term bracers could tell some stories!

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Some studies about
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC65980...

Good things:

Bracing Hours and Years for Ponseti Method

Bracing should be considered the MAIN FACTOR in clubfoot correction. Fixing the foot is only the beginning. Without bracing, and specifically the Foot Abduction Brace or BNB (Boots n Bar) the foot will likely relapse. The foot can relapse quite swiftly if not braced full time for the first 3 months.

After the first 3 months, the hours should be reduced 2-3 hours at a time, every 2-3 months slowly over the first year. Eventually settling on 12-14hr/day till 4-6yo.
Infants who are unable to receive treatment early should adjust the hours as needed with that one year goal, and also modify bracing protocols to match. Ponseti bracing is as much a part of the method as the casting protocols are.

• – Fiberglass "soft" casts. Fiberglass casts are difficult to mold. Very few providers are so skilled with fiberglass that they can achieve the same results as plaster casts are capable of providing. Plaster is easier to mold and shape and this is important for the Ponseti Method.
• –  Slipped casts indicate improper casting and should not be ignored. More than single slipped cast is a serious problem and indicates that the person applying the cast does not have the skills necessary to correct clubfeet.
• – Casts not bent at least 90 degrees at the knee. It is ok (and actually better) to do 100 degrees as well. 90 degrees means an L shape, or a right angle.
• – Casts that do not allow the toes (all 10) to be free and mobile outside of the cast. The toes should not be squished or bent or molded inside the cast and they should be flat. Not rounded or squashed in any way. Casts that do not allow the toes to be free and outside of the cast often will cause the toes to become curled, and they are very difficult to know if the cast has slipped. <>brAlways mark your baby's toes with a pen at the edge of every cast and take pictures of the cast right after it is applied to compare with a suspected slipped cast. 
• – Casts that make the toes or upper leg swell beyond the confines of the cast
• – Casts not following the Ponseti casting guidelines for the first cast. First casting position often is skipped. This is a modification of the Method. The Cavus part of clubfoot must be corrected first.