DESIGN

The design of foot abduction brace is not complicated. Each brace consists of the same components, independently from the place where it was made. However, these components should meet some conditions, because the correctness of the treatment depends on them at this stage. And if the brace does not meet these requirements, after some time, specific problems and regress of treatment can be seen.

The FAB consists of two shoes/ boots connected by a bar.

Boots which are used in FAB:

• have a straight form: it means that boots are not profiled inside: the right boot is good to the left foot and the left one is good to the right one;
• have the open toes: they provides not only ventilation but also allows toes to move freely;
• have a high heel counter: it supports the Achilles tendon and calf;
• they can be laced and strengthened with a leather (or synthetic) strap in the place where the foot flexes up and down. An additional strap keeps the foot in a good position in the boot. These are Markell shoes or similar ortotic products used around the world;
• they can also have three leather straps instead of lacing: sandal form. And these are MITCHELL (PONSETI) SANDALS;
• in the back part of the boot they have holes (or a hole) cut out so that it is possible to see the position of the heel inside;
• they can be attached to the bar with screws (in the Denis Browne bar) or the “quick clip” system (MITCHELL and Dobbs bar).

The bar connects two boots together. That is the simplest way to describe it. However, it is not just an ordinary piece of lightweight metal. It must allow the feet to be positioned in external rotation and maintain dorsiflexion. Positioning the feet in external rotation is the first condition. This means that the feet are turned outward to a greater or lesser degree. A proper brace allows for smooth adjustment of this parameter.

• in the Denis Browne brace the boot is the most often attached to the bar with the screw and it is the boot which has a metal plate on the sole with drilled holes, where it attachs and tightens the bar with a screw
• in the Mitchell and Dobbs bar the ends of the bar have drilled holes, which are hidden under a black circle (in the Mitchell bar) or a black and green circle (in the Dobbs bar) and the boot is attached to the bar with “quick clip” system, i.e. quick-connector . As a standard, the holes are drilled every 10° so the external rotation is set at 30°, 40°, 50°, 60° and not e.g. 34°, 45°, 53° etc.

TWO WIDTHS

For the brace to effectively maintain the correction, it must be properly adjusted. In many publications, the term “to the shoulder width”  often appears. It seems necessary to clarify this concept, as there is significant confusion, leading to misunderstandings of the issue.

Experience from doctors treating clubfoot with the Ponseti method shows that the principles of proper brace adjustment are not widely known, even though they should be—especially among medical personnel dealing with congenital clubfoot treatment.

The primary factor is the width of the brace itself, followed by setting the brace width to match the child’s shoulder width. Let’s take a closer look at these two aspects.

The width of the brace is the distance between the central screws in the black “discs.” In the Mitchell brace, this will be the black disc (similarly in the Dobbs brace). In the Denis Browne brace, it is usually a metal disc attached to the sole of the shoe, to which the brace is fastened with a screw. Following this logic, the width of the brace is measured from one central screw to the other. The graphics below illustrate this.

When asking parents what the “arm width” measurement means for them, the most common statement is that it is the distance from the end of the arm to the end of the arm. Yes that is true. The problem arises when we consider the correct medical terms.

• Arm to is the part of the upper limb located between the shoulder girdle (connected by the shoulder joint) and the forearm (which ends with the elbow joint).
• Shoulder is in other words a shoulder girdle, so it is a combination of the scapula, a collarbone (clavicle) and the joints accompanying them both on the right and left side.

The correct setting of brace width is widely discussed worldwide, as there is no single universal recommendation. In many publications, one can find information stating that the width of the brace should correspond to the width of the shoulders. It is also common to encounter numerous illustrations (often created by parents) attempting to show a proper fit. This variety of information and concepts inevitably leads to confusion.

As a Foundation, we adopt one approach: the brace width should equal the child’s shoulder width, measured from the front. This way, the natural curvature of the back is not included in the measurement, which would otherwise add unnecessary extra centimeters to the brace width.

In the study conducted by Anil Agarwal, “Is the same brace fit for all? The length of abduction bar in Steenbeek foot abduction brace for Indian children – a pilot study”, one of the most commonly used derotation braces — the Michiel Steenbeek brace — was analyzed. It turned out that the bar of the brace is much too wide and does not correspond to the child’s shoulder width. Instead, it has more of the width of the arms, meaning it is wider. It was also shown that “the ankle dorsiflexion decreased following an increase in bar width”. In other words, ankle dorsiflexion decreased when the bar width was increased. The same conclusions can be drawn from the research work of Andrew J. DiMeo: “A biomodeling investigation of bracing on clubfoot children treated by the method of Ponseti”.

If you think about it carefully, the brace width should correspond to the width of the shoulders. Unfortunately, a great deal of confusion arises from the many different approaches used in various centers treating clubfoot — not only in Poland, but also worldwide.

As a Foundation, we have adopted one clear guideline: the brace width should equal the child’s shoulder width, measured from the front, as this does not take into account the curvature of the back.

WHAT IS AFFECTED BY THE BAR WIDTH?

COMFORT

The width of the bar primarily affects the comfort of the child’s life. Too wide bar affects into its tolerance and hence a real treatment effect: it will be good or none. If we don’t like something and we don’t feel comfortable with it, we don’t want to use it. We try our best to avoid this by inventing a series of excuses, until at some point we give up using it. Everyone can predict the effect of such kind of treatment. Perhaps the following examples will help you to better understand this issue:

• Imagine that you have a malocclusion that causes not only health problems (e.g. inflammation of the temporomandibular joint or headaches), but also your teeth are crooked and it makes you smile reluctantly. You need to wear an orthodontic braces to achieve a specified health effect, but also a visual one. What do you think: would an orthodontic braces bought on AliExpress be a good solution for you? If the braces were not adjusted to your bite and its anomalies, being too big, too loose and badly profiled, what treatment effects would you get by using it? Would the inflammation go away or get worse? Would your head stop aching? Would such a braces be worn by you willingly? Probably not. You would notice a great difference if after a month of wearing such braces, you would start using the correct orthodontic braces.
• Imagine you have vision problems. You see that … you can’t see correctly. Do you buy glasses at the poor market or do you do firstly the research, and then you order the appropriate glasses to be made in an appropriate optical shop, where after they are made, they are also adjusted to you (axis alignment, temples bending, nose pads bending)? Improperly fitted glasses cause that you still cannot see or see out of focus and that you may have a headache from unsuitable lenses or pressure the frames.
• Imagine you are skiing but the skis are not well suited to your height. Yes, skiing is possible, but it is definitely not comfortable. If the skis are too short, the risk of losing control on the slope is high, because they are unstable, very maneuverable, they are unable to support the skier and vibrate quite strongly. On the other hand, skis that are too long are clunky, hard to maneuver and spring strongly. In both cases, skiing with this kind of skis require putting more force than skiing with fitted skis. Our joints feel it after a whole day of “fighting” with the equipment, when they start to ache while resting. It is easy then for injuries and fractures to happen, e.g. overload fractures, which will effectively eliminate us from the slope to…the hospital.

CORRECTION

When the bar is wider, the heel in the boot does not fit well to the boot insert and “hangs” – the heel goes up and this is an occurrence which is not good. When the heel hangs in the air, the Achilles tendon becomes shorter. Each change in the position of the joints in relation to each other is compensated elsewhere in our body.

CHANGES AND CONCLUSIONS

When our Foundation began to popularize the set of the bar to the width of the shoulders, we noticed many benefits that confirmed our belief that this is the right way.

• children tolerate the bar better (the increase in tolerance of this equipment increased from 40% to 87%)
• dorsiflexion increases and remains at an average level of about 20°
• the foot fits better in the boot – the “holes” in Mitchell boot are filled – the heel is good in the insole and does not hang over it
• the condition of the foot is not getting worse
• physical activity is not limited – children became more active and, for example, rolling over from the back to the tummy became easier (because the width of the bar does not block them) and it happened at a similar time as for their healthy peers (and often even faster)
• hips and knees are not overloaded with excessive width
• in more difficult periods of life, e.g. growth and developmental spurts, teething or feverishness, children tolerate the bracing time more gently than with a wider bar
• the number of skin complications, such as pressure sores or wounds has also decreased – they occur less frequently
• due to the elimination of poor equipment and due to the fact that the bars are tolerated better and used longer according to a specific scheme (bracing protocol) – the number of unnecessary operations and surgical interventions has decreased definitely and significantly. And that is very good news!

The direction which we chose, we tested firstly on our own children. They were the most perfect settings and observations “testers”.

EXTERNAL ROTATION

After correctly adjusting the bar width, the next parameter to be set is the external rotation of the feet. And as in the case of ignorance of setting the width correctly, the occurrence is exactly the same here.

Generally, this parameter should be set only by a doctor. Taking into account the correctness of the previously applied plaster casts, the condition of the foot after removing the last cast and the degree of correction which was obtained, he should set the degree of external rotation. However, the occurrence of “automation” very often takes place here, so how as in the book, publications, scripts it is written that the clubfoot is to be set at 60-70°, it is set this way, without taking into account many factors that have already been mentioned. It’s a mistake.

If the doctor really knows the Ponseti method in its extent, he knows well that the degree of external rotation of the feet is set exactly like in the last plaster cast. It means that if the last plaster cast (before FAB) was in the so-called hypercorrection (abduction up to about 60-70° in 10-15° dorsiflexion at the same time) it is true – the abduction can be set to 60°, as stated by most scientific sources. These parameters are only used when the treatment is perfectly. If the last plaster cast did not have much abduction, the bar is set up in the same way as the plaster cast.

Example:
If the last plaster cast (the one after tenotomy – if it was done) had only 20° of abduction, when the child starts to use the brace, the boot abduction should also be 20°. And it should be increased gradually so that all soft structures inside the foot have time to stretch slowly and evenly. Abduction should finally reach 60° after a few / several weeks.

If the last cast had 40° of abduction, the boot abduction in the brace should also be 40 °. And it should be increased gradually so that all soft structures inside the foot have time to stretch slowly and evenly. Abduction should finally reach 60° after a few / several weeks.

Yes, we are talking about “standard” clubfeet, so those that most children have. ATYPICAL AND COMPLEX FEET have their own rights when it comes to setting the correct external rotation. And the doctor needs to know that.

60° OR 70°?

CAN THE DEGREE OF FEET AEXTERNAL ROTATION CHANGE DURING THE TREATMENT?

Yes. It can be changed many times as necessary. The most common reasons for changes are:

• sudden discomfort in usage of the brace by children around 2 years old – it is caused by the increasing tension of the periosteum due to the growth spurt (the periosteum is very nerved) – this is often manifested by the pain in the legs, grabbing the knees or feet, nervousness. Excessive external rotation of the foot (and thus also the shin bones) causes the periosteum to stretch. Often, changing the derotation by 10° less (yes, so little) reduces this problem. Of course, this is not a long-term change
• „tibial torsion” – torsion of the tibia, what is related to the natural biomechanics of the lower limb: the greater the external rotation is, the worse it is getting, causing discomfort. Tibial torsion should be checked by a doctor in an MRI (Magnetic Resonance Imaging) or CT (Computer Tomograph) examination, sometimes with the help of an X-ray examination (in specific X-rays views)
• excessive heel valgus which can have many reasons (e.g. articular-ligament laxity). Then the external rotation is reduced to 30°–40°
• overcorrected foot does not require abduction at 60°: it requires much less
• positional clubfoot does not require a huge derotation – 30° is enough
• atypical and complex clubfeet – usually starts between 20°–40° and is gradually increased every few weeks until reaching 60°

YEARS AND HOURS

When Dr. Ponseti published the results of his first studies on the effectiveness of the method in 1963, it turned out that 56% of patients experienced a relapse. At that time, a strong correlation was observed between relapse and not using the foot abduction brace. Back then, the brace was applied only until 21.5 months of age — which is quite short. Dr. Ponseti’s recommendation was to use it until the child was 3 to 5 years old.

Doctors around the world who treat with the Ponseti method agree that the longer the brace is used (in terms of years), the lower the risk of relapse. Time frames repeated in many studies suggest brace use until 4–5 years of age. Some physicians are also working on standardizing the duration of brace wear depending on the specific type of foot, in order to better define how long the brace should be used in individual cases.

Just as important as the length of bracing measured in years, is the number of hours per day the brace is worn. The daily duration of brace use is by no means insignificant.

The time a child should wear the abduction brace must be individually tailored to the patient, taking into account age, relapse frequency related to that age, completion of correction, foot condition, and overall predispositions.

Example:
The number of hours in the brace will be longer for a newborn who has been corrected within the first 4 weeks, compared to an older child who has already achieved correction and is walking.

Nevertheless, even with this individualized adjustment, there are general frameworks followed by doctors using the Ponseti method worldwide.

For this reason, we rely on the protocol proposed by Dr. José Morcuende, which is based on a gradual reduction of daily bracing hours. We have also introduced a small modification supported by scientific studies: in the final stages, the brace is worn for 10–12 hours per day.

The bracing protocol proposed by Dr. Morcuende strikes a careful balance between maintaining correction (to prevent relapse) and supporting the child’s motor development. We observe its tangible benefits not only in our own children, but also in those within our parent community.

However, this does not mean that Morcuende’s protocol is the only one. We are aware of another protocol that is also widely and successfully used.

In short, the bracing protocol defines how many hours per day a child should spend in the brace, in relation to the total duration of use measured in months, and how this time is gradually reduced. Of course, the protocol may be adjusted by a competent physician who fully understands the Ponseti method.

The protocol is worked out to keep the clubfoot in a correction through the brace and at the same time not to limit the child natural activity. You might say there are two “protocols”. They take into account the age of the child at the time of starting the  usage of a FAB.

THE AGE OF A CHILD UP TO 8-9 MONTHS

Most corrections are achieved around 2-3 months of child age. It means that around this time they begin their journey with the foot abduction brace. So they use the protocol for children up to 8-9 months of age. Sometimes it happens (and you need to be fully aware of this) that a relapse may occur and the re-treatment will be needed. If the baby achievs correction till 9 months of age, he continues to follow the protocol for babies up to 8-9 months. It is quite logical: most of the time a small child spends passively, what means that the brace can be safely used a little bit longer. When the activity appears and when it is dominant: the hours of bracing are reduced.

THE AGE OF A CHILD ABOVE 9 MONTHS

If your child starts the treatment or repeats it for any reason at the age of 8 months or more when he starts bracing, he will use a different protocol. It is related to the relatively well-developed activity of the child. Often children around 9 months old start to stand, some try to walk. Nature can not be stopped: children will cope with almost any obstacle or limitation, finding their own way for them. However, having this activity in mind, you need to find a balanced way to keep the correction of the foot.

THE ADVANTAGES OF THE PROTOCOL

• good maintenance of correction, reducing the risk of relapse;
• slowly reducing the hours of using the brace, taking into account the increasing activity of the child;
• low risk of rejection and intolerance of the brace due to the fast hourly jump: 23/24 hours -> 8 hours … 5 hours … 11 hours …

IMPORTANT
The foot abduction brace brace should be worn for at least 10 hours per day. If your child naps during the day, the brace should be applied during every nap. Naps are just as important as nighttime sleep. Why? Children fall into deep sleep quickly. During deep sleep, the entire body relaxes—muscles, tendons, and ligaments become inactive because they are no longer controlled by the brain. Every instance of foot relaxation during sleep requires the brace, even if the nap lasts only 10 minutes.

Consistency is key. Developing a routine will help you, as a parent, maintain proper brace use. It’s also crucial for your child, providing clear daily reference points—especially in the evening. Evening routines are essential because they prepare your child for nighttime sleep—the longest and most consistent period of brace wear. This nighttime routine should remain stable, so even as daytime brace hours are reduced over time, the evening routine remains unchanged. When a child is used to wearing the brace at bedtime, it simply becomes a natural part of their daily schedule.

If your child has 4 hours of brace-free time per day, split it into defined periods. For example in the morning – some free time after waking up and in the evening – a  break before bath and bedtime. However, always adjust the brace-free time based on your child’s activity level. If they are inactive, put the brace back on.

PSYCHOLOGICAL ASPECTS OF USING THE BRACE

Using the FAB is not only a physical matter but also a psychological one – both for the child and the parents. Understanding these aspects and having the right approach can significantly impact the effectiveness of the treatment and the comfort of the whole family.

Very often, parents share with us concerns such as “the brace limits my child” or “they won’t be able to sleep in it” or even “my child is suffering because of the brace.” Sometimes, these concerns come from physiotherapists, rehabilitation specialists, or pediatricians. Parents are also frequently confronted by their own families, who say things like, “Don’t make the child suffer,” or “Why are you putting this on them? Their feet look fine.”

We understand all these concerns, and at the same time, we want to assure you, Parent, that your deep awareness, thorough understanding of the use of this orthopedic device, and, most importantly, your attitude are the foundation of your child’s successful treatment. We can guarantee that you are not alone on this journey—before you, we have walked this path as practitioners but also as keen observers. And we assure you that if the brace is appropriate and your attitude toward it remains optimistic, this phase of treatment goes much more smoothly, even when occasional challenges arise.

The child gets used to the brace through routine. If it has been used regularly during sleep from an early age, it becomes a natural part of daily life. It is important for parents to perceive the brace as something normal and necessary rather than as an obstacle or punishment.

Some children may initially protest, especially as they become more mobile and independent. Frustration, crying, or temporary discomfort may occur, but parents’ consistency in using the brace helps the child adapt. The key is to introduce a stable evening routine, associating it with sleep and making the brace an inseparable part of that process.

Parents play a huge role in the treatment process. If their attitude is positive and confident, the child will accept the need to wear the brace more easily. Negative comments should be avoided, and the brace should be treated as something obvious. Some parents may feel tired, frustrated, or guilty, but understanding that consistency in using the brace minimizes the risk of relapse helps maintain motivation.

Practical tips to make using the brace easier:

• Establishing a positive bedtime ritual, such as reading books or listening to calming music
• Praising the child for cooperating when putting on the brace
• Allowing the child to have brace-free time at appropriate times during the day
• Avoiding treating the brace as a problem – it is a natural part of the treatment process
• Seeking support from other parents in similar situations, for example, in support groups

The brace is not a limitation – it is a tool that helps the child walk healthily and without pain in the future. Parents’ approach and consistency play a key role in the success of the treatment.

NOT EVERY BRACE

As clearly stated above, a FAB must meet two conditions to fulfill its function of maintaining the correction of clubfoot. If any of these conditions are not met in the brace’s design, it is not a reliable piece of equipment. A lack of basic knowledge about the proper construction of a brace leads to cases where children experience a rapid RELAPSE after using such devices. The first symptoms of this can appear as early as one month after starting use.

There are many low-quality braces on the market that are not suitable for treating this specific condition. Internationally there is a vast array of orthopedic equipment that is not only ineffective but even harmful when it comes to clubfoot treatment.

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