Toe to Groin Cast

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Ponseti Method Checklist
Many physicians claim to be proficient in the Ponseti Method, but they are not. It is not because they are “bad” doctors; it is because the Ponseti Method, although simple, is very precise and requires great attention to detail. Deviations from the true Ponseti Method often result in less than satisfactory corrections. Also, there are casting methods that predate the Ponseti Method, and many doctors may not understand the difference. Below are the basics of the Ponseti Method. If your physician is deviating from the protocol without a good reason (such as a problem with the skin, swelling, etc), please look for another provider or contact us.


The Ponseti casts are long leg casts. They should be over the knee (from toe to groin) and well molded onto the foot. Casts should be removed within the hour before or during the appointment when a new cast is put on to guard against relapse. Plaster casts are the best material for making Ponseti casts. Some doctors will use soft fiber, that is okay, but it is harder to get the well-molded casts using soft fiber, and there is scientific evidence that the results are not as good.

For newborns, only about 5-6 casts should be required to achieve correction (95% of the cases). If the doctor has to use more than eight casts, their techniques in applying the method are probably not well perfected. Each time a new cast is used, the outward rotation of the foot should change by about 10-15 degrees. The last cast should be set to about 70 degrees of abduction (external rotation).

            From left to right, these casts show the increase in outward rotation as prescribed by Dr. Ponseti.

Most children treated with the Ponseti Method will need a heel cord tenotomy (clipping of the tendon). This is the only invasive part of treatment, though it is much less invasive than traditional surgical correction. It is typically done in conjunction with the application of the final cast (almost never before). The reason for this procedure is that the heel cord is resistant to stretching. The tenotomy used is called a percutaneous tenotomy, and is different than an open incision, z-lengthening tenotomy or heel cord lengthening procedure. This procedure will most likely be done under local anesthesia and takes about 10 minutes to perform. The physician will use a very thin knife and cut the heel cord. No stitches are necessary to close the puncture wound after this process. The last cast, put on after the tenotomy, will be left on for two and a half to three weeks while the tendon heals.

The brace should be used the same day the last cast is taken off. Do not wait a few days to get the brace as it will result in an early relapse. For more information on the brace, read our bracing tips.