Therefore, when we understand the pathogenesis of the clubfoot, the causes of the relapse will become clear.
TERMS
Relapse is one of those realities that instinctively sends chills down the spines of all parents of children with congenital clubfoot. They imagine a series of worst-case scenarios regarding both the condition and its treatment. However, when asked to define what recurrence actually is, they often struggle to articulate their thoughts and concerns.
It’s no surprise—even doctors find it difficult to provide a clear definition of relapse/ recurrence. For some physicians and clinicians, it means a complete return of the foot to its primary CLUBFOOT POSITION, while for others, recurrence is the reappearance of even a single component of the deformity. As we can see, the concept is far from straightforward, resembling an unfinished puzzle or scattered building blocks—seemingly disconnected pieces.
Dr. Ignacio Ponseti and Dr. José Morcuende defined recurrence as the return of two key elements of the deformity: equinus (excessive plantarflexion) and varus (inward heel position).
UNEVENLY
Different elements of the deformity can recur unevenly, meaning at varying degrees and in different parts of the foot.
Recurrences affecting the anterior and midfoot occur much less frequently than those affecting the hindfoot, but the latter are more significant and harder to correct—they require more knowledge, experience, involvement, and patience.
Recurrence of forefoot adduction (metatarsus adductus) to less than 20° has been noted by Ponseti in less than a quarter of the treated cases. Correction of forefoot adduction is usually permanent, but if recurrence occurs, it is easily corrected with 2-3 plaster casts. Ponseti also observed a persistent recurrence of forefoot adduction in only two cases, but these had been previously treated with capsulotomy of the Lisfranc joint, which resulted in stiffness and pain in adulthood.
Recurrence of cavus (high arch) is typically mild and responds well to manipulations and casting, provided the pressure during correction is directed upward—towards the first metatarsal bone. Percutaneous plantar fasciotomy is rarely necessary—only in about 6% of cases. Transfer of the long toe extensor muscle to the head of the first metatarsal may be performed if there is a need to correct persistent plantarflexion of the first metatarsal.
CAUSES
In children with clubfoot, the CHANGES IN THE FOOT are so significant that, regardless of the treatment method, there is a strong tendency for relapse. This is primarily due to the nature of the deformity, which is multi-planar. However, recurrence can often be influenced by various factors, and this happens quite frequently, but more on that later in the article.
Following Dr. Ponseti's words: "When we understand the pathogenesis of clubfoot, the causes of recurrence become clear"—the causes are partially understood. The statement that recurrence occurs because the foot was not properly corrected is partially true. However, when we assume that the treatment was carried out correctly by a qualified physician, and the parents diligently followed the recommendations for the use of the foot abduction brace, recurrence can still happen.
In clubfoot, the soft tissues have a "deforming power", meaning that there are pathologies within them that remain active for a long time, and they "pull" the foot into the wrong position. The tendons, ligaments, and muscles on the medial side of the foot are shorter and stronger compared to those on the lateral side. There is a slight reduction in muscle size and an excess of collagen synthesis, leading to fibrosis in the medial and posterior ligaments of the foot, the deep fascia, the Achilles tendon, and the posterior tibial muscle.
Fibrosis also affects the gastrocnemius muscle and other ligaments and tendons in the foot. These changes contribute to severe equinus position (plantarflexion), displacement of the navicular bone, varus of the heel, and adduction, which make up the COMPONENTS OF THE DEFORMITY.
RISK GROUPS
Does the risk of recurrence affect all children with congenital clubfoot? Yes, the risk of recurrence applies to all children with clubfoot!
Recurrence tendencies become active in the second trimester of pregnancy when the defect develops and remain most active until around the age of 4-5 years. This is primarily related to the increase in collagen levels in the tendons and ligaments of normal mammals and likely in humans as well. Additionally, the growth rate of the foot increases after the first year of life.
It is incorrect to assume that children whose feet have been classified as "difficult," "resistant to treatment," or have a higher degree of deformity (based on the Dimeglio or Pirani score) will necessarily experience a recurrence, while those with milder deformities will not. The severity of the deformity at birth is not a reliable predictor of the likelihood of recurrence in the future. However, it is true that certain risk groups can be identified in which the risk of recurrence is higher or lower than normal.
LOW-RISK GROUP
- children with very loose ligaments (large amount of collagen)
- children with a milder degree of deformity
- no recurrence occurs in children with POSITIONAL CLUBFOOT
- children over 5 years of age
- children using the brace according to the protocol till they are 4-5 years of age
- children growing at a steady rate without sudden growth spurts
HIGH-RISK GROUP
- premature babies
- children with hard, stiff clubfeet and thin calves
- children with higher degree of deformity
- ATYPICAL OR COMPLEX CLUBFOOT, as well as those with a neurological or syndromic condition
- children who have undergone foot surgery, regardless of age
- children up to 2 years of age
- children using the brace inconsistent with the protocol for less than 4 years
- intensive growth periods in children with less physical activity at the same time
SIGNS OF THE RELAPSE
Initially, a relapsing foot is flexible and elastic. However, it gradually loses dorsiflexion, which over time leads to the heel bone shifting into a varus position. At this stage, dynamic deformities begin to appear – for example, while running, walking, or standing, the child starts to load the lateral side of the foot, while the heel remains lifted off the ground.
If these changes are not detected in time, they can progress into static deformities that become fixed, causing the foot to stiffen and lose correction even further. Most relapses develop gradually and may be difficult to recognize at an early stage, since visible changes often appear only once the child begins to stand and walk independently.
IS THIS A RELAPSE?
When children learn to stand and walk independently, they begin putting weight on their feet, often twisting them in all directions. Parents are often highly sensitive to this and may see every "strange" foot position as a sign of recurrence. However, this is not necessarily the case—and in the vast majority of situations, it isn’t. It’s important to check whether the foot remains flexible—whether it can still move in all directions and return to a normal position. If so, there is no reason to panic. Most likely, your child is simply learning to balance and shift weight onto their legs, which are still weak and "learning" their functions.
IF YOU HAVE ANY DOUBTS ABOUT YOUR CHILD’S FEET AND THEIR FUNCTIONS
– CONTACT AN EXPERIENCED PONSETI DOCTOR!
CRUCIAL ELEMENT
Almost all recurrences occur when a child is at the bracing stage, meaning they are already wearing a foot abduction brace.
THE FOOT ABDUCTION BRACE is only to maintain the correction resulting from previous treatments — casting and tenotomy. Any modifications to its design, wearing schedule, or method of use often lead to a rapid recurrence of the deformity.
WATCH OUT!
TREATMENT BY PONSETI METHOD IS VERY FAST.
IT TAKES 4-6 WEEKS TO FULLY CORRECT THE FEET,
THEY BEGIN TO LOOK NORMAL AND ARE FULLY FUNCTIONAL.
THIS IS HOWEVER A TRAP, BOTH FOR PARENTS AND DOCTORS!
DESPITE QUICK AND NOTICEABLE TREATMENT EFFECTS
AND AN ILLUSION THAT FEET
ARE NORMAL, HEALTHY AND LOOK CORRECT,
CHILDREN STILL NEED TO “FIGHT” FOR MAINTAINING THE CORRECTION.
THE MAIN CAUSE OF A RELAPSE IS
NOT USING OR WRONG USAGE OF THE FOOT ABDUCTION BRACE.
THIS IS THE KEY TO SUCCESSFUL TREATMENT.
BRACE SHOULD BE WORN AT LEAST UNTIL THE AGE OF FIVE.
YOUR PARENTAL GUIDANCE IS FUNDAMENTAL AT THIS PHASE OF TREATMENT
AND IT DEPENDS ON YOU WHETHER YOUR CHILD WILL HAVE
FULLY FUNCTIONAL AND FLEXIBLE FEET!
WHY IS THE BRACE NECESSARY?
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.
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IF A RELAPSE HAPPENS…
During the first 20 years of treatment by Dr. Ponseti, recurrences occurred in about half of his patients between the ages of 10 months and 5 years (averaging around 2.5 years). He observed that recurrence typically appeared between 2 to 4 months after parents decided they could stop using the brace because the feet "looked fine," mistakenly believing that the foot correction was stable enough to discontinue further maintenance treatment.
As his method evolved, with small modifications and the growing influence of the internet, Ponseti noticed that:
I have further overcorrected the deformity in the last plaster cast, to be certain that the calcaneus is fully abducted and its anterior joint surface is well under the head of the talus. Secondly, there has been greater awareness on the part of the parents regarding the importance of maintaining the night splints after correction for three to four years.
The treatment approach depends on the child's age, the type of recurrence, and its severity. The treatment for an 8-month-old will differ from that for a 3-year-old or a 6-year-old. However, regardless of age, the first step should always be re-casting, rather than resorting to invasive surgery without first attempting to correct the feet using simple yet effective methods.
The initial focus is on correcting excessive foot cavus, forefoot adduction, and heel varus, following the standard PONSETI METHOD protocol. The equinus (heel position) should only be corrected after the other deformities have been properly addressed. Otherwise, this could lead to additional complications such as rocker-bottom foot (previously known as a "bean-shaped" foot), worsening of foot cavus, overcorrection at the Chopart joint, incomplete correction of the foot deformity.
CASTING
The first part of relapse treatment method is re-casting. It gives good results without using invasive methods.
In general, the correction can be regained in four to six weeks by manipulations and casts.
Depending on child’s age and the severity of relapse the cast may be long-leg cast (from toes to groin, with the knee bent at an angle of 70-90°) or short cast (under knee). The casts are changed weekly or every two weeks. The cast should be abducted significantly and at maximum dorsiflexion in the ankle joint.
You can read about the features of a good cast on TREATMENT BY PONSETI METHOD.
LONG-LEG CAST
it is most commonly used when the foot has lost its correction and needs to be realigned to free the heel bone from its improper position. This type of cast prevents the rotation of the ankle and talus bone. Since the foot must be held in abduction under the talus, this bone cannot rotate, ensuring proper alignment.
SHORT CAST
it is most commonly used when the foot requires a slight correction of the subtalar joint, a mild increase in dorsiflexion, or to soften the foot before anterior tibial tendon transfer (ATTT) surgery.
TENOTOMY
When dorsiflexion is less than 5-10°, a repeat percutaneous Achilles tendon tenotomy may be necessary. However, this procedure has age limitations.
Dr. Ponseti believed it was best performed before the child turns one year old, though opinions on this vary. Some doctors perform the procedure on much older children. For children older than 2.5 years, an alternative percutaneous tenotomy may be preferred, avoiding open surgery on the back of the foot. One such procedure is the Hoke tenotomy, which involves a percutaneous, triple hemisection of the Achilles tendon.
Compared to other techniques (such as the Z-tenotomy called Z-cut), the Hoke tenotomy offers better results in older children because it minimizes scarring at the lengthening site, the tendon is less prone to injury and a posterior capsulotomy is rarely needed.
FAB
As previously mentioned, the foot abduction brace (FAB) should be used both after initial treatment and after any recurrence treatment. Its role is to maintain foot correction, and discontinuing its use significantly increases the risk of recurrence—leading to a cycle of relapses, prolonged treatment, higher costs, and additional stress.
If a child reaches an age where wearing the brace becomes extremely intolerable or there is a high risk of non-compliance, an ADM ORTHOSIS (Abduction Dorsiflexion Mechanism) may be considered as an alternative. However, the parameters of the ADM must be determined by a doctor, as selecting the appropriate spring force is essential for effective treatment.
RECOMMENDED SURGERIES
When there is a strong muscle imbalance caused by excessive tension of the tendons and ligaments on the medial side of the foot, it often results in foot supination and heel varus. This can cause the child to walk on the lateral edge of the foot, rotating it inward. The first surgical option approved within the Ponseti method—also described by Dr. Ponseti himself—is the Anterior Tibialis Tendon Transfer (ATTT). In this procedure, the tendon of the anterior tibial muscle is transferred to the third cuneiform bone, helping to restore balance and prevent further deformity.
The anterior tibial tendon should be transferred in a way that preserves its ability to invert the foot. An improper transfer may completely eliminate the foot's ability to supinate, negatively affecting gait mechanics. Therefore, the tendon should not be transferred to the fifth metatarsal or entirely to the cuboid bone, as this could cause excessive outward rolling of the foot, leading to severe pronation and valgus deformity of the heel.
After ATTT surgery, the foot remains flexible and functional almost immediately after the postoperative casts are removed. Children typically regain full mobility quickly without requiring rehabilitation. Additionally, there are no large scars on the foot, which is important not only for aesthetics but also for preventing recurrences. Scar tissue is inflexible and could pull the foot back into an incorrect position, increasing the risk of deformity.
The only marks left by ATTT surgery are three small incisions through which the procedure is performed. Because it is done without fully opening the foot to expose all internal structures, some refer to it as “orthopedic laparoscopy.”
small incisions after ATTT in clubfoot
huge incisions after posteromedial release in clubfoot
STOP! THIS IS NOT THE RIGHT PATH!
Is Surgical Treatment with Invasive Procedures Necessary for Clubfoot? In the vast majority of cases—absolutely not! Invasive surgeries should never be the first choice for treating clubfoot or recurrence. However, despite Ponseti's method being the gold standard, we are witnessing a troubling trend—a widespread return to highly invasive surgical techniques.
When we say "invasive", we refer to procedures such as:
- posteromedial release (PMR)
- posterior release (PR)
- total clubfoot release (Cincinnati or Turco approach)
- open Achilles tendon lengthening (e.g., Z-tenotomy or "mini-open" technique)
- lateral or medial release
- dorsal release
- McKay, Turco, and Goldner methods
- Dwyer or Evans osteotomy
These are NOT proper treatments for congenital clubfoot and should not be routinely performed.
CLUBFOOT RELAPSE TREATMENT SHOULD NEVER START
WITH AN INVASIVE SURGERY!
Indeed, the use of these invasive procedures can lead to severe anatomical and functional damage, resulting in actual disability. The consequences of the aforementioned surgeries include, but are not limited to:
- pain in the feet
- stiffness of the feet
- reduced mobility of the foot
- frequent bone and soft tissue infections
- scarring
- avascular necrosis (bone death)
- bone damage
- vascular and ischemic complications
- loss of sensation in the operated areas
- secondary joint and bone deformities
This is why invasive surgeries should never be the first choice in treating clubfoot. The Ponseti Method is safer, more effective, and offers better long-term results.
The reasons why some doctors still resort to invasive surgeries despite the Ponseti method being the gold standard are complex and influenced by multiple factors:
- lack of proper knowledge or understanding of the Ponseti method, and the inability to apply it effectively
- limited manual skills when it comes to casting and performing the Ponseti technique
- skepticism about the high success rate of the Ponseti method, leading some to underestimate its effectiveness
- fnancial incentives: Invasive surgeries tend to be much more financially profitable compared to the relatively inexpensive Ponseti method
- ambition: Some doctors may feel that they need to use the surgical techniques they've spent years learning, and abandoning them in favor of non-surgical treatments feels like a blow to their professional pride ("I didn't train for years just to not perform surgeries")
- time considerations: The Ponseti method requires weekly follow-ups with a skilled team, which can be less attractive compared to a single surgery—though multiple follow-up surgeries can often lead to more complications and longer-term costs
Unfortunately, these factors may lead to suboptimal choices, which harm patients in the long term. The Ponseti method remains the most effective, safe, and less invasive option for treating clubfoot, with proven long-term success.
You are absolutely right. Invasive surgeries should never be the first solution when treating recurrence in children with congenital clubfoot. Non-invasive methods like recasting and other simple yet effective procedures should always be the first choice. These methods can often avoid the need for invasive surgery altogether. Unfortunately, many doctors still opt for surgery first because it's easier and gives immediate results in terms of appearance. However, this is a false sense of improvement, as invasive surgeries carry hidden risks: the need for repeated procedures. Every major intervention in the foot’s structures can weaken its functionality and cause long-term damage. Often, adults who were treated surgically without the Ponseti method complain of pain, stiffness, and difficulty in daily activities. The Ponseti method, with its focus on gradual correction and non-invasive treatment, offers better long-term outcomes, helping children achieve functional feet with much less risk of complications later in life.
STATISTICS
It’s absolutely true that statistical data on recurrences in children with clubfoot cannot be neatly packaged into one single range. The variation in these data can sometimes be significant. However, there is a key takeaway that unites all these statistics: recurrence is directly linked to the use of the Foot Abduction Brace. This is the crucial factor affecting whether the deformity returns.
According to research, 78% of recurrences are associated with non-compliance with the BRACING PROTOCOL whereas only 6% of recurrences happen in cases where the brace was used as prescribed. A common reason parents stop using the brace is the false belief that the foot is already healthy. Contributing factors include parental education, social status, and awareness of the severity of the condition and the critical role the brace plays in maintaining correction.
You are absolutely right—there is a significant discrepancy in the effectiveness of the Ponseti method depending on the medical center and the level of understanding and adherence to the protocol. Studies show that EFFECTIVENESS rates of the Ponseti method can be as low as 26.2% in some centers. In stark contrast, dedicated centers that specialize in treating clubfoot report success rates for initial treatment ranging from 98% to 100%. This huge gap is alarming and underscores that the method may not always be applied consistently by all medical professionals.
This highlights the critical importance of ensuring that medical staff fully understands and correctly applies the Ponseti method. There is a greater focus on continuous training and adherence to the protocols. Parental awareness and education are enhanced, especially regarding the importance of brace usage in preventing relapse. By improving understanding of the method and its application, we can significantly reduce recurrences and improve long-term outcomes for children with clubfoot. It's crucial to continue educating both healthcare providers and parents to ensure the best possible results.
Statistics presented below , elaborated by Dr. José Morcuende from Ponseti International Association, show how important it is to wear a brace as a method of relapse prevention:
-
90% of children had a relapse in the first year of life when they stopped using the brace
-
70-80% of children had a relapse in the second year of life when they stopped using the brace
-
30-40% of children had a relapse in the third year of life when they stopped using the brace
-
10-15% of children had a relapse in the fourth year of life when they stopped using the brace
-
6% of children had a relapse after the age of 4 when they stopped using the brace.
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- The image of scars after a posteromedial release surgery: Cure Organisation
- Others: own