"When parents are faced with this disaster of seeing a baby born with clubfeet, they get to be very depressed.When they go to the doctor and are told that their baby must have surgery, they are sad. But when they can see that this deformity is nothing, that is a very easy thing to correct and the child is normal, they have hope." Dr Ignacio Ponseti

What is clubfoot?

Clubfoot is a congenital deformity of the foot that occurs in about 150,000-200,000 babies each year worldwide.  Clubfoot results from the abnormal development of the muscles, tendons, and bones in the foot while the fetus is forming during pregnancy.  While researchers have been unable to pinppoint the exact cause of clubfoot, both genetic and environmental factors are thought to play a role.  Clubfoot is about twice as common in boys and occurs in both feet about 50% of the time.  Clubfoot in an otherwise normal child can be corrected using the Ponseti method of manipulation and plaster cast applications, with minimal or no surgery.  Treatment should begin in the first week or two of life in order to take advantage of the elasticity of the tissues that form the ligaments and tendons in the foot.

Clubfoot in Developing Countries 

80% of clubfoot cases occur in developing countries and most of these children are either left untreated or receive substandard care.  Neglected clubfoot is one of the most frequent causes of physical disability worldwide.  The Ponseti method is uniquely suited for use in these countries because there is no surgery required and the technique can be taught to therapists, orthopaedic assistants, and other health care providers.   This treatment is economical and easy on the infant, and when implemented correctly, will significantly increase the quality of life among children with clubfoot.  

Does surgery "cure" clubfoot?
Extensive surgery does not "cure" clubfoot. It improves the appearance of the foot but diminishes the strength of the muscles in the foot and leg and causes stiffness in the second and third decade of life (if not earlier). This limits the motions of the foot joints, and the foot becomes often painful at midlife. Extensive surgery does not prevent the recurrence of the deformity in a number of cases. To our knowledge no followup studies of operated patients older than 16 years of age have been published to date. Therefore, orthopaedic surgeons are ignorant of the results of their surgeries.

Foot and ankle surgeons, however, who treat adult patients have noticed that those surgically treated for congenital clubfoot in infancy have weak, stiff and often very painful feet.

How long has clubfoot been treated in this manner?
Clubfott has been treated with manipulations, bandages, braces, and plaster casts for centuries. The practice of heel-cord tenotomy was started in the middle of the 19th century; extensive ligament release surgery has become the fashion in the past 50 years.

When should a baby with clubfoot begin the Ponseti Method?
When a baby is born with clubfeet, a provider (orthopaedic surgeon, podiatrist, physiotherapist, nurse) with expertise in the manipulation and plaster-cast method devised by Dr. Ponseti, should be sought to start correcting the deformity soon after birth, (7-10 days).

How often do the manipulations need to take place to correct clubfoot in otherwise normal children?
Most clubfeet in otherwise normal children can be corrected with manipulations every 5 to 7 days followed by plaster-cast applications. If the deformity is not corrected in 5 to 7 plaster-cast changes, the treatment is most likely faulty. Exceptions to the above are complex clubfeet.

What is metatarsus varus or metatarsus adductus?
A foot deformity called metatarsus varus or metatarsus adductus is often confused with the clubfoot deformity. The metatarsus adductus is a mild turning in of the foot which often corrects by itself. The heel is never in equinus (unyielding plantar flexion). In more severe cases it can be easily corrected with two to three plaster-cast applications. Some doctors believe they have corrected clubfeet when they have corrected metatarsus adductus.

What is the manipulative treatment of clubfoot deformity based on?
The manipulative treatment of clubfoot deformity is based on the inherent properties of the connective tissue, cartilage, and bone, which respond to the proper mechanical stimuli created by the gradual reduction of the deformity. The ligaments, joint capsules, and tendons are stretched under gentle manipulations. A plaster cast is applied after each manipulation to retain the degree of correction and soften the ligaments. The displaced bones are thus gradually brought into the correct alignment with their joint surfaces progressively remodeled yet maintaining congruency. After two months of manipulation and casting the foot appears slightly overcorrected After a few weeks in splints however, the foot looks normal.

Proper foot manipulations require a thorough understanding of the anatomy and kinematics of the normal foot and of the deviations of the tarsal bones in the clubfoot. Poorly conducted manipulations will further complicate the clubfoot deformity. The non-operative treatment will succeed better if it is started a few days or weeks after birth and if the orthopaedist understands the nature of the deformity and possesses manipulative skill and expertise in plaster-cast applications.

What does a foot look like in an adult born with unilateral clubfoot deformities that was treated with the Ponseti Method?
In all the patients with unilateral clubfoot, the normal foot was slightly longer (mean 1.3 cm) and wider (mean 0.4 cm) than the clubfoot. The limb lengths, on the other hand, were the same, but the circumference of the leg on the normal side was greater (mean 2.3 cm).

Where can I find more information about the Ponseti Method?
The Ponseti method, which more and more doctors are becoming acquainted with, is described in detail in the book by Dr Ponseti Congenital clubfoot. Fundamentals of Treatment (Oxford University Press), 1996. The above mentioned book (also known as the Green Ponseti Book) is provided by Dr Jose Morcuende on behalf of the Ponseti International Association free of charge at www.ponseti.info/pia (electronic format). You can read online or download and print. Chapter 7 is the one covering treatment in-depth.

The printed hardcover copy is available for 75$+shipping costs through the Dept. of Orthopaedic Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242.

Another informative publication is "Clubfoot: Ponseti Management" (also known as the Red Ponseti Book) produced by Global-HELP Publications. This is a shorter version of the above manual and it has translations in multiple languages. Web site: www.global-help.org

What is the incidence of clubfeet in children where one or both parents are also affected?
When one parent is affected with clubfoot, there is a three to four percent chance that the offspring will also be affected. However, when both parents are affected, the offspring have a 15% chance of developing clubfoot.