The Ponseti Method of correcting clubfoot involves 5-7 weekly thigh high plaster casts bent at the knee 90 degrees or more. The last cast is usually after a minor surgical procedure called anAchilles Tenotomy that stays on for 3 weeks after the procedure. This cast can sometimes become too small and need to be replaced midway through the 3 weeks, but this is rare. For most babies, this cast stays on the full 3 weeks. After the last cast is removed, the baby wears the Foot Abduction Bar or "Boots & Bar" (BnB) for 4-6 years. Please see our Bracing pages for more information about the FAB/BnB and all things bracing.
We are working on the potential ramifications of Dr. reviews as associated of our pages of recommended doctors, but right now the Red Light/Green Light List is the best we can provide.
Clubfoot treatment over 4-6 weeks
Plaster Ponseti Casts - Shows knee bend and abduction
The Stages of Clubfoot Correction
Clubfoot casting is not something every Orthopedic Surgeon knows how to do. It is not a surgery, and that is often not worth their time. Beware of any Orthopaedic Surgeon who makes you feel like they are not interested in treating clubfoot without surgery (disinterested in casting, others do the casting, insisting slipped casts are the baby's fault, etc.). Do not just take the recommendation from your pediatrician, or anyone in your insurance network.
Not all doctors are created equal, and when it comes to clubfoot, it's extremely important that you find the right doctor for your child. Many parents travel for the proper care because it's not available locally.
Finding a qualified and skilled Ponseti Method doctor is your child's best chance at having a good foot for a lifetime.
There is always a chance things won't be 100% forever, but so far from what we know, Ponseti feet do so well that we should expect that for most feet treated with the Method.
Unfortunately, there are still doctors who modify the method and damage feet. While others may still be learning and may someday be more skilled. In most studies looking at why things go wrong, the reasons outlined for failure of feet to remain corrected are for bracing non-compliance, and the previous doctor's improper techniques.
If you are looking for a doctor for your child, make sure to check the PIA Trained Doctor Listing listing here, and also the Red Light Green Light Parental Review Doctor Listing. Also, check out the support groups online and ask.
Some parents never see the surgeon who does their baby's tenotomy. Many surgeons aren't actually interested in doing clubfoot treatment. If your surgeon leaves casting to others in their practice, this is a Red Flag.
It is the way the trade works that most surgeons prefer to do surgery, and tenotomy is the only part that they do. When the surgeon is absent most of the time, it is a sign that the physician is not very interested in the child's treatment. This is a red flag that should not be ignored.
Some are interested in non-surgical treatments and participate, but the surgeon is made to be the kind of person who excels at cutting. This is not to disparage surgeons, we absolutely need people like this to fix things that need surgical intervention. Not every doctor is able to perform surgery, and we love them when we need them.
We also love any surgeon who is dedicated to the Ponseti Method and who is an active participant in the clubfoot correction process.
Clubfoot has historically been treated with surgery (once surgical methods were developed - (see Treatment of idiopathic clubfoot: an historical review. - Dobbs MB, Morcuende JA, Gurnett CA, Ponseti IV. Iowa Orthop J. 2000;20:59-64). It is only recently that correction without surgery using the Ponseti Method became mainstream. It is not something that just any doctor knows how to do. They must be trained specifically in the Ponseti Method, which is not just "wrenching the foot into position".
Failure Rates
The failure rate of Ponseti Method is associated with the feet that require surgery down the line, after all casting and bracing efforts have been exhausted.
Not all doctors can achieve this low of a failure rate, and some have a very high failure rate. High relapse rates are always pointed out as contributing to or the main result of bracing non-compliance in studies. Bracing is the most important thing we can do to help prevent relapse.
It is important to help all parents be compliant with bracing by helping them understand how to brace properly and how to prevent blisters and sores. This is the main reason for bracing non-compliance, and also baby night waking. We work to help parents solve bracing issues. For help with bracing, see the Bracing Techniques page, or if you need additional troubleshooting please contact Kori via Facebook Messenger.
Gradual reduction in hours can also help reduce the risk of relapse in the first year.
Relapsing
Some feet will relapse no matter what you do even with strict bracing (about 3%). However this kind of relapse is usually treated with a much more minor surgery than has been typical called the Anterior Tibialis Tendon Transfer. It often fully resolves any reoccurring pulling of the tendons that is unable to be overcome with casting and bracing by transferring the tendon to a different location in the foot. This surgery is usually only done after the age of 5 or 6, after growth spurts are finished and all casting and bracing options have been exhausted and the foot has been fully corrected (The function of the tendon transfer is not to provide correction; rather, it is to maintain correction that has been previously obtained). If your doctor wants to do this surgery earlier than the age of 5 or 6, a second opinion might be an option just to be sure of this course of treatment.
Some feet will need more extensive help and bracing. While most feet will do well, some do have issues and need additional help over the years. We believe this to be less than we currently see in adult reports of disability and pain. We will know more as time goes on and Ponseti feet actually grow older in the world. At the time of this writing only 10 or so years ago did the Method become close to mainstream. Understanding how Ponseti feet really do is something for the future. But since we have over a century of data on surgically treated feet, we're doing very well and have high hopes.
Non-Idiopathic or Syndromic Associated Clubfoot
Idiopathic clubfoot means that there are no other conditions present that are associated with clubfoot. There are no conditions known to be associated with clubfoot, but there are conditions that are associated with clubfoot. Meaning, the underlying condition is associated with clubfoot, and clubfoot is not known to be an underlying condition. For non-idiopathic or syndromic cases, treatment can take longer and be more difficult to complete. The syndromic/non-idiopathic clubfoot is sometimes more difficult to correct and remain corrected. It can also be more difficult to brace. It is also associated with higher relapse rates than idiopathic clubfoot. For more good information on syndromic conditions, see the Non-Idiopathic Studies page. When viewing studies about clubfoot, note that there are none that include non-idiopathic or syndromic clubfoot unless specified. The statistics and general prognosis for clubfoot does not include syndromic or non-idiopathic clubfoot.
Some doctors are still unable to correct clubfoot like other doctors are able to, and some doctors still don't believe the method works better than surgery. When a clubfoot is deemed "not able to be corrected without surgery", it is not the fault of the child, the foot, or the parent. Any doctor that is unable to get a proper correction of a clubfoot with casting alone (and Achilles Tenotomy) is suspect, and this is the perfect reason to get a second opinion.
Your doctor may or may not be trained to properly correct clubfoot without surgery. Many doctors now are doing non-surgical corrections without the proper training. Many deviate from the Ponseti Method in the form of changing the casting material, or the process of manipulating the foot/bones into position, or by changing the bracing protocols and bracing schedules. All of these changes are considered modifications of the method, and are usually a significant part of any failed clubfoot correction.
There actually are no feet that can't be corrected with the Ponseti Method that I have ever heard of. I have heard of plenty of Dr's who can't correct some clubfeet, but none that couldn't be corrected by someone (else). Some feet will relapse, but nearly every foot can be corrected and braced if the practitioner is skilled in the Ponseti Method.
When the Ponseti Method is followed to a "T", the same results as Dr. Ponseti are achievable. When Dr's are unable to achieve Dr Ponseti's success rates, this only reflects on the Dr's skill level. It does not reflect on the Ponseti Method.
Your first appointment with the doctor or physical therapist (outside of US usually) will be your first casting. They will almost always do the first cast at this initial appointment. Prepare for this to occur unless they have told you otherwise.
At each casting appointment, expect to get a little messy with plaster so make sure to take extra diapers and some hand towels that you can use under the new fresh plaster in the carseat so it doesn't get plaster all over the place.
Make sure to take pictures of the cast immediately after it is complete, paying special attention to the toes. Also, use a pen and mark where the cast edge is at the toes so you'll know if it slips right away. Remember to take pictures of the feet between casts so you can refer back if needed.
After the cast is applied the plaster will still feel wet, and it may also feel warm. That is normal, as the plater hardens it gives off heat (exothermal), and then it will feel cold and wet, yet it is not wet. You can use some of daddy's old tube socks to keep the casts from rubbing against each other or you can use baby legwarmers.
This documentary video was released in June 2021. Delightfully done, it shows the casting process and manipulation prior to wrapping under the outside layers. Plaster casting does not equate to fiberglass.
The Ponseti Method is really all about plaster casts. Drs keep trying to make it work with the "soft casts" that aren't as messy, but then they fail and slip and cause complex clubfoot over and over and over. So no, we don't accept fiberglass casts. Even if they do work sometimes, sometimes the Posterior Medial Release also worked. Or any of the other surgeries that "worked".
Blobby fiberglass casts do not do the same as specifically molded plaster casts. NoSurgery4Clubfoot does not endorse or recommend fiberglass casts.
