Your child is perfect, we only have to straighten his little feet.
SOMETHING IMPORTANT...
First and foremost, it is crucial to fully understand that the Ponseti method is an entire philosophy of treating congenital clubfoot. It is not just a treatment technique but a comprehensive approach to the patient—from diagnosis through treatment, the use of a foot abduction brace, and the management of relapses. Using a metaphor, we can confidently say that the Ponseti method is not a menu from which one can pick individual elements. It is a perfectly composed dish that provides everything necessary for proper function.
Mere knowledge of the treatment is not enough. A deep understanding is essential. Only this will lead to success in the form of healthy and functional feet.
The Ponseti method is not just some random manipulations before applying a cast
- it is precise and biomechanically accurate correction of the foot.
The Ponseti method is not just any casting
- it is a highly precise process of casting following specific principles.
The Ponseti method is not just any surgery
- it is a percutaneous Achilles tendon tenotomy.
The Ponseti method is not just any orthopedic equipment
- it is a specifically designed foot abduction brace.
GOOD TO KNOW BEFORE THE TREATMENT
With the vast amount of information coming at you from all directions, it is essential to organize it and discard anything that is not true. This brings clarity and helps you plan the treatment properly, starting with thorough preparation. This is important because it brings peace of mind - you can consciously choose the right doctor and treatment center, and if any potential mistakes arise, you will be able to react quickly.
The goal of treatment is to reduce or eliminate all components of the congenital deformity so that the patient has normal-looking feet that are functional, pain-free, flexible, and have a full range of motion.
„We like to allow time to bond with the mother and to become accustomed to something of a routine”, said Dr. Ponseti, which is why treatment does not need to begin immediately after birth. The well-being of both the mother and the child is key - bonding, feeling secure, and establishing a sense of safety are crucial, as parents play an important role during the casting process. Moreover, understanding the condition itself, the treatment approach, and finding a skilled doctor familiar with the Ponseti method are all significant factors. A lack of urgency can actually be beneficial, allowing you to prepare consciously for treatment. Sometimes, treatment must be postponed due to complications such as an extended hospital stay or urgent medical interventions necessary to protect the health and life of both the mother and child. Experienced doctors specializing in the Ponseti method can still successfully correct the foot even if treatment is delayed for various reasons. However, do not postpone treatment for too long! Visit our blog to learn more about WHEN TO START CLUBFOOT TREATMENT?
Advanced imaging tests such as X-rays or MRI scans of the foot are not necessary! The exception applies to children with additional conditions or syndromes that require such tests due to their primary illness, where clubfoot is a secondary outcome—such as in spina bifida, arthrogryposis, or Down syndrome. In these cases, advanced imaging may be useful in treatment planning.
If the child does not have additional health issues, a standard orthopedic visit is usually sufficient. Through a physical examination, the doctor can assess the position of individual bones, determine the severity of the deformity, and, considering its key components, decide on the course of treatment—including the estimated number of casts needed for correction and whether a percutaneous Achilles tendon tenotomy will be required.
3 STAGES
The Ponseti method consists of 3 stages. Understanding each stage is essential to actively and consciously participate in the process.
This is important because, at every stage, numerous modifications can be introduced—many of which go far beyond the standard Ponseti method. Correcting previously applied deviations can be difficult, time-consuming, and even costly.
STAGE 1.
CASTING
STAGE 2.
TENOTOMY
STAGE 3.
FOOT ABDUCTION BRACE
1. CASTING
WHO APPLIES THE PLASTER CASTS?
Casts are applied only by a qualified and skilled orthopedic paediatric doctor who is highly knowledgeable about the Ponseti method, assisted by a trained casting technician. No one else should perform this procedure. You also play an active role in this stage: holding your child to minimize movement but, most importantly, distracting, calming, and reassuring them to provide a sense of security.
DOES THE CHILD FEEL PAIN DURING CASTING?
The casting phase should be gradual, slow, and very gentle - this is the fundamental principle of Dr. Ignacio Ponseti’s method. Therefore, both the pre-casting manipulations and the casting itself should not be painful! Additionally, since all manipulations and casting are performed in complete accordance with the foot’s biomechanics, following its natural movement, the child does not experience pain.
However, the child may become irritated by the handling of their feet - whether from gentle stretching, being held still during casting, or the initial warmth of the cast as it sets and gradually cools. They may also be unsettled by the presence of unfamiliar people and the unfamiliar clinical environment compared to the comfort of home.
MANIPULATIONS BEFORE APPLICATION OF THE PLASTER CAST
Before applying the cast, the doctor - usually seated (less commonly standing) in front of the child lying down - performs a series of gentle manipulations (redressions). These manipulations involve stretching the internal structures of the foot delicately and in alignment with the joint surfaces, always following the foot’s biomechanics. After each movement, the limb returns to its starting position, allowing for a brief pause to relax the muscles, ligaments, and tendons. This movement is then repeated, with slight variations each time, progressively guiding the foot outward and upward as much as possible within safe limits. After several redression movements, the foot is prepared for casting, ensuring that the achieved correction is maintained.
* manipulations of the clubfoot: Visual Science Media. All rights reserved.
HOW DOES CASTING WORK?
First, the doctor performs gentle manipulations (redressions) to stretch the contracted soft tissues. Then, the casting technician or assistant places a special cotton sleeve (tubular/ stockinette) and/or wraps the child’s leg with a thin layer of under-cast padding.
Next, the wet plaster cast (also in roll form) is applied, starting from the toes. During this process, the doctor holds the foot in the corrected position. Once the cast material is wrapped around the leg, the doctor carefully molds the damp plaster, especially around the talus bone and ankle joint, ensuring proper stabilization as the cast begins to harden. During casting, the child can be gently fed or entertained to provide a sense of security and comfort.
WHAT ARE THE CHARACTERISTICS OF A WELL-APPLIED CAST?
First and foremost, the cast used in the Ponseti method is a standard white plaster cast made from calcium sulfate, commonly known as plaster of Paris - not synthetic materials. This is important because traditional plaster allows for excellent molding and shaping, which directly impacts the quality of the correction. The cast is applied to the entire leg, from the toes up to the groin (a long cast). The knee must be bent at a 90° angle (or 110-120° in the case of ATYPICAL AND COMPLEX CLUBFOOT).
This long cast with a bent knee ensures that the foot remains properly positioned, preventing the talus bone from rotating back into its pathological position. At the same time, the soft tissues - ligaments, tendons, and other structures—are gradually and evenly stretched. During this correction, the joint surfaces reshape to align with the new, proper positioning. Additionally, with the leg positioned this way, the cast remains securely in place and does not slip off.
A well-applied cast is perfectly molded, especially around the ankle joint, heel, and foot. Furthermore, each successive cast should be applied in a slightly different position, progressively guiding the foot toward a natural, corrected alignment.
KEY FEATURES OF A WELL-FITTED CAST
- Toe Space & Positioning: There should be enough space inside the cast for the toes. They must be fully visible, evenly spread out on the plaster platform, and not compressed. Toes should also not protrude from the cast, as this can lead to complications such as contractures.
- Groin Area: The cast should be slightly wider near the groin. The edges must be well-protected to prevent skin irritation and reduce crumbling. This is why using a cotton stockinette before casting is beneficial—it can be folded over the cast for extra comfort.
- Knee & Heel Reinforcement: More plaster is applied around the knee and heel, especially for children who start crawling. This provides durability and prevents the cast from breaking down too quickly.
- Optional Outer Layer: Sometimes, a synthetic cast material (such as Soft Cast or Scotch Cast) is wrapped over the standard plaster. This prevents crumbling, cracking, or excessive wear, particularly in active children who crawl, try to stand, or begin walking.
- Proper Thickness & Shape: The cast should not be too thick, heavy, or misshapen. An overly bulky or irregular cast indicates poor technique, suggesting that the doctor or casting technician may not be fully experienced with the Ponseti method.
Want to learn more? Read our blog article on CAST SHAPE for further details.
HYGIENE DURING CASTING
During the application of the cast, it is necessary to protect the delicate areas of the child's body (most commonly the genitals) with a piece of fabric (a cotton diaper works well). During casting, the diaper is removed as it makes applying the cast more difficult. After the cast is applied, the child should be cleaned as soon as possible with a cotton pad (or a damp cotton diaper) to remove any plaster residue. Drying plaster forms a crust and irritates the child's delicate skin. The toes and the spaces between them must be cleaned. The best way to do this is with cotton swabs moistened with warm water. This gently removes any remaining plaster and dirt from hard-to-reach areas. Learn more from our articles about BATHING a child in a cast and TOES HYGIENE in a cast.
The toes inside the cast must all be visible and evenly positioned (they must not be squeezed, bent, or tucked under). The doctor should also check circulation and the color of the toes once the cast has hardened slightly (if you press on the toes, they should turn white and then return to their pink color).
HOW OFTEN IS THE CAST CHANGED?
To maintain the correction achieved through manipulation, the foot remains in the cast for 5-7 days (most commonly a week). During this time, the ligaments and tendons soften, stretch, and stabilize in their new position. After a week, the cast is removed, and the foot is once again subjected to gentle manipulations, gradually bringing it closer to the appearance of a healthy foot.
The weekly change of casts is repeated until the foot reaches proper correction and a partially normal appearance - fully reducing forefoot adduction, heel varus, supination, and cavus.
HOW MANY CASTS SHOULD BE STANDARDLY APPLIED TO ACHIEVE CORRECTION?
This can be achieved by applying 5-7 casts*. According to Dr. Ponseti, even very rigid feet require no more than 8 to 10 casts.
Once the foot achieves proper correction, the final and crucial element to be corrected will be the equinus of the calcaneus. The doctor will then make the decision to perform a percutaneous Achilles tendon tenotomy.
* Using a larger number of casts is not recommended: this often leads to so-called secondary deformities. It also increases the risk of abnormalities in the formation of bone and cartilage cells. Importantly, too few casts are also detrimental, as an insufficient number of casts leads to partial correction. It is often an indication to take a closer look at the issue of "rapid correction," where the doctor attempts to quickly fix the foot by radically manipulating it and using the fewest possible casts, while in reality, the foot requires more due to its rigidity. The consequences of such an approach are harmful.
You invite the foot to come back in the normal position. Already, the foot knows what this position is. It was in that position for the first half of pregnancy. The foot was normal until then.
2. TENOTOMY
OF CHILDREN NEED A TENOTOMY
DO ALL CHILDREN NEED TENOTOMY?
No, not all children need it. The exceptions are usually the cases of light deformity which is very correctable and does not require many plaster casts. Usually one or two plaster casts are enough to fully correct all components of the deformity, including even the equinus. However, as many as 90-95% of children need tenotomy.
Percutaneous Achilles tendon tenotomy is a relatively simple surgical intervention, needed by as many as 90-95% children with clubfeet. Tenotomy is performed because, after a series of castings, the heel remains in strong plantar flexion due to the shortening and high tension of the Achilles tendon. Unlike the ligaments in the tarsal area, which are stretchable, the Achilles tendon is composed of non-stretchable, thick, tightly packed collagen bundles with few cells. This means that only a surgical incision can effectively "stretch" it. Cutting the Achilles tendon (tenotomy) corrects the equinus position of the calcaneus.
It is usually performed under local anesthesia on an outpatient ward, which means that the child does not have to stay in the hospital overnight. In facilities with anesthetic support, general anesthesia (light sedation) is more commonly used, allowing the procedure to be carried out more calmly and precisely.
The procedure takes less than 5 minutes, and the incision on the skin is no larger than 3-5 mm, usually not requiring stitches. After the procedure, the final and very important casting is applied.
THANKS TO ACHILLES TENDON TENOTOMY,
THE CLUBFOOT ACHIEVS FULL DORSIFLEXION (10-15°),
THE CALCANEUS GOES BACK TO ITS PLACE (DOWNWARDS)
AND THE FOOT ACQUIRES NORMAL LOOK
AND FULL FUNCTIONALITY.
HOW IS THE PROCEDURE PERFORMED?
During the procedure, the child lies on their back. The assistant holds the child's leg bent at a 90° angle at the knee. The doctor, holding the foot in the maximum dorsiflexion that can be achieved and using a very thin scalpel (a cataract surgery scalpel), makes an incision approximately 1.5-2 cm above the calcaneus. Inserting the scalpel slightly deeper, the doctor cuts the Achilles tendon transversely from the medial to the lateral side of the foot (this direction is intentional to avoid the neurovascular bundle). The length of the incision on the skin is no more than 3-5 mm and usually does not require stitches. Optionally, a small suture or a "strip" (a closure tape) may be applied to bring the wound edges together. During the tendon cut, a characteristic snapping sound can be heard, similar to the breaking of a highly stretched rubber band. After the procedure, a small dressing is applied to the incision site, and a long cast is placed on the foot with the knee bent at a 90° angle (or 110-120° if the foot is ATYPICAL AND/OR COMPLEX).
The difference in casting before and after tenotomy is very significant. Immediately after the tenotomy, the doctor applies the final cast. This cast is extremely important and must be applied perfectly. It must also meet specific conditions, meaning it should be in so-called hypercorrection.
FOR HOW LONG IS THE PLASTER CAST PUT ON THE LEG AFTER TENOTOMY?
As a standard, the plaster cast remains on the leg for three weeks; but older children, who are already more active – start to crawl, sit, stand – stay in the plaster cast for four weeks. Some doctors also make a plaster cast change after tenotomy, usually dividing the above period to 1 week + 2 weeks or 2 weeks + 2 weeks. Such action is recommended only when it is necessary to have a look at the foot during the healing of the tendon, to correct the position of the foot by changing abduction or dorsiflexion.
When the leg is put in the plaster cast after tenotomy, tissue forms between the two ends of the cut Achilles tendon to reattach them. The tendon regenerates into proper length. For this reason, the plaster cast must be applied in hypercorrection and then left without interference.
3. FOOT ABDUCTION BRACE
Despite the complete correction of the clubfoot deformity, the congenital predispositions that may have caused this condition can remain active for some time. The risk of recurrence decreases with age. To prevent relapse, the child begins wearing a foot abduction brace immediately after the last cast is removed.
The FAB (foot abduction brace) brace is a crucial element of the Ponseti method for treating congenital clubfoot. It is used to maintain the correction previously achieved with casts, meaning that a foot that is not fully corrected is not suitable for the brace! The brace does not treat the foot; it only keeps it in the correct position, preventing recurrence.
Since the topic of the FAB is extensive and requires a detailed explanation, it has been covered in a separate article containing a wealth of important information.
FOOT ABDUCTION BRACE
WHAT IS FAB? HOW TO USE IT?
What to do?
The foot abduction brace for clubfoot is a real opportunity to improve quality of life!
This solution supports the Ponseti method, provides security, and helps take steps—literally!—toward a better future. After all, who hasn’t heard the story of Cinderella, whose life changed with just one pair of shoes?
Modern treatments can restore full mobility and the joy of movement. Visit our website to learn more about the FAB and see how it can help your child.
Take the first step toward health and comfort - with us, it is possible!
SIMPLE, BUT NOT EASY...
The basic principles of the Ponseti method are simple. This simplicity allows for proper application of the method. Despite the advances in medicine, which are welcome, sometimes it is necessary to hold back and return to the sources with no modifications which result in wrong treatment.
The method itself is simple, so very many doctors fall into the trap of taking it lightly, thinking that they can do it well, that “this is not difficult at all”. However, the number of badly treated children is very high worldwide. Why?
Many unnecessary modifications are introduced to this method, which cause the original method to seem easy and trivial to many specialists. This false impression results in poor effects of treatment, sometimes even contrary to what was planned. Many doctors say that they use the Ponseti method, whereas actually this is their own method or the method that was used before the Ponseti method – a bit similar to it in the first stage of treatment. The correctness of the Ponseti method usage depends on very subtle differences and nuances, which affect the whole treatment of the child. If you take them into account during the treatment, you can see that the Ponseti method is not so simple, even though it seems to be.
(...) following the published Ponseti technique and protocol to the smallest detail greatly improves the chance of achieving the outstanding results published by many other groups.
THE PONSETI METHOD IS THE "GOLD STANDARD" FOR TREATING CONGENITAL CLUBFOOT,
WHICH IS NOT COMMON IN MEDICINE. THERE ARE NOT MANY "GOLDEN METHODS."
THE AMERICAN ACADEMY OF PEDIATRICS AND THE WORLD HEALTH ORGANIZATION HAVE APPROVED THIS METHOD AS THE BEST FOR TREATING THIS DEFORMITY.
- Ponseti I.V.: „Congenital Clubfoot. Fundamentals of treatment.” (2nd edition)
- Ponseti I.V., Smoley E.N.: „The Classic: Congenital Club Foot: The Results of Treatment.”
- Ponseti I.V.: „To Parents of Children Born with Clubfeet.”
- Ponseti I.V., Campos J.: „The Classic: Observations on Pathogenesis and Treatment of Congenital Clubfoot.”
- Radler C.: „The Ponseti method for the treatment of congenital club foot: review of the current literature and treatment recommendations.”
- Ullah S. et al.: „Management of Congenital Talipes Equino Varus (CTEV) by Ponseti Casting Technique in Neonates: Our Experience.”
- Morcuende J.A. et al.: „Radical Reduction in the Rate of Extensive Corrective Surgery for Clubfoot Using the Ponseti Method.”
- Colburn M.: „Evaluation of the treatment of idiopathic clubfoot by using the Ponseti method”
- Herzenberg J.E. et al.: „Ponseti versus traditional methods of casting for idiopathic clubfoot.”
- Jowett C.R. et al.: „Management of congenital talipes equinovarus using the Ponseti method: a systematic review.”
- Jerome T.J.: „Aberrant Tendo-Achilles Tendon in Club Foot: A case report.”
- Scher D.M. et al.: „Predicting the need for tenotomy in the Ponseti method for correction of clubfeet.”
- Barker S.L.: „Correlation of clinical and ultrasonographic findings after Achilles tenotomy in idiopathic club foot.”
- MacNeille R. et al.: „A mini-open technique for Achilles tenotomy in infants with clubfoot.”
- Bor N. et al.: „Sedation protocols for Ponseti clubfoot Achilles tenotomy”
- Dar R.A. et al.: „Percutaneous Tendo Achilles Tenotomy in the management of Equinus Deformity in conservatively treated CTEV.”
- Lebel E. et al.: „Achilles tenotomy as an office procedure: safety and efficacy as part of the Ponseti serial casting protocol for clubfoot.”
- Parada S.A. et al.: „Safety of percutaneous tendoachilles tenotomy performed under general anesthesia on infants with idiopathic clubfoot.”
- Alves C.: „Ponseti Method: Does Age at the Beginning of Treatment Make a Difference?”
- Liu Y.B.: „Timing for Ponseti clubfoot management: does the age matter? 90 children (131 feet) with a mean follow-up of 5 years.”
- „Report of the 1st European consensus meeting on Ponseti clubfoot treatment.”
- Ullah M.S. et al.: „Management of Congenital Talipes Equino Varus (CTEV) by Ponseti Casting Technique in Neonates: Our Experience.”
- Morcuende J.A. at al.: „Effect of Cast Removal Timing in the Coreection of Idipoathic Clubfoot by the Ponseti Method”
- Laurent R.: „Interet de la kinesitherapie complementaire au sein de la methode de Ponseti dans le traitement du pied bot varus equin congenital.”
- Wilcox C.: „A Healing Touch.”
- Dr Ignacio V. Ponseti
- Manipulations of the foot: Visual Science Media | © 2009-2018 | All rights reserved.
- Tenotomy: Dobbs M.B. et al.: „Early Results of a New Method of Treatment for Idiopathic Congenital Vertical Talus: Surgical Technique.”
- Dr José Morcuende
- Other: Own/Goodwill People