When Should Clubfoot Treatment Begin?

The answer to this question seems to be quite obvious: immediately! Such information can be found in many articles on the Internet, they are repeated by neonatal wards doctors, neonatologists, paediatricians, orthopedists, physiotherapists. Also it can be found in many old studies. However, the truth about starting treatment can be somewhat different… and surprising.

Parents most often ask: “When should we start treatment?”
And just as often, they receive the wrong answer — that treatment must begin right after birth, immediately, without delay. It usually comes as a relief when parents hear that treatment does not have to start right away. There is no medical necessity to begin treatment immediately after birth — and in fact, rushing may negatively influence long-term outcomes of foot development.

We explored this topic, looked at the research, talked to trained and competent doctors dealing with the treatment of congenital clubfoot – there are no medical reasons to start the treatment immediately after birth, the more so as the speed at which treatment is started has an impact on the long-term prognosis of the development and condition of the treated feet.

HURRY? HURRY?

Many early authors studying clubfoot wrote that treatment began right after birth.
Even Dr. Ignacio Ponseti, in his book “Congenital Clubfoot: Fundamentals of Treatment”, described how in Iowa, treatment would begin “shortly after birth“, so that by two or three months of age, children were already wearing the abduction brace.

He explained that newborn connective tissues have “favorable viscoelastic properties” making early correction easier. But with time and further research, including laboratory studies, it became clear that starting treatment immediately after birth offers no significant advantage compared to beginning a few weeks later.
Long-term results were not better in those treated immediately.

SCIENTIFIC DISCUSSION

Research by Noam Bor (2009) – “Ponseti Treatment for Idiopathic Clubfoot: Minimum 5-year Followup.” showed that “age at the time of presentation doesn’t affect the final outcome of the treatment”, and therefore – starting it quickly will not contribute to better results. Dr. Crisitna Alves reached similar conclusions – “Ponseti method: Does age at the beginning of treatment make a difference? showing that it doesn’t matter whether the treatment starts immediately after birth or after the child is 6 months old – the treatment effects are comparable. Dr. Matthew Dobbs reached similar conclusions –“Factors predictive of outcome after use of the Ponseti method for the treatment of idiopathic clubfeet.”

In a study by Lewis E. Zions (2015)- “Does Clubfoot Treatment Need to Begin As Soon As Possible?“  cites authors that starting treatment soon after birth had more benefits, but admits that only Dr. Vincent Mosca has suggested that “treatment should begin as early as feasible” but added that “there was no evidence that a delay of several days influences the rate of success.”    

The conclusion of the Zionts study was: “We found no significant influence of the age at the start of treatment on the number of casts, the duration of the cast phase of treatment, the need for heel cord tenotomy, skin problems attributable to the cast or brace, brace compliance issues, or early relapse.”

In the research by Serkan Itlar (2010) – “Treatment of Clubfoot with the Ponseti Method: Should We Begin Casting in the Newborn Period or Later?”  clearly states: “In the current study, infants whose cast treatment began after the first postnatal month achieved better clinical outcomes than those whose cast treatment began before the first month.” They also concluded that treatment using the Ponseti method should begin in infants older than 1 month of age, or whose foot was equal or more than 8 cm in length.

We can also read about the length of a child’s foot at the start of treatment in the study by Y.Hemo (2019) – “The significance of foot length at the initiation of the Ponseti method: a prospective study”, we read: “The small foot size may represent a less mature newborn with a lesser developed foot. Our data show that a smaller foot needs more casts changes to achieve correction. In our study, feet that were 8 cm long or more benefited from less casts and shorter treatment periods.” Interesting research was also carried out by Chinese scientists led by Dr. Yu-Bin Liu – “Timing for Ponseti clubfoot management: does the age matter? 90 children (131 feet) with a mean follow-up of 5 years.”, who examined a group of 90 children. This group was divided into three subgroups and it turned out that:

• treatment initiation time from 28 days of age to 3 months of age was associated with fewer required castings and a lower recurrence rate.
• early treatment (before 28 days of age) required more casts and had a higher recurrence rate.

Treatment for clubfoot should start not later than within the first months of life – it is described in “Report from the first consensus meeting on the treatment of clubfoot using the Ponseti method.”  As you can easily see: there is no rush and no need. Nevertheless, doctors say that to start treatment as a child already has a month is most optimal. It’s such a balanced time. Start treatment in the first period of life has many practical reasons:

• the foot to be treated is slightly larger, which makes it easier to precisely determine the position of individual bones in relation to each other, and therefore the correction is more accurate
• the risk of the plaster cast slipping down decreases
• the child before Achilles tendon tenotomy is slightly larger and more mature multi-systemically – general anesthesia used during the procedure (if it is performed under general anesthesia) is associated with a lower risk of complications and complications
• the smallest size of the Mitchell bar will be adequate to the width of the child’s shoulders

WHAT ABOUT PREMATURE BABIES?

There is no need to start casting in the neonatal intensive care unit (NICU).
The consensus clearly states:

“In preterm infants, treatment should be postponed for several weeks to allow the foot to grow.”

Ideally, treatment begins around the equivalent of a full-term age (≈40 weeks gestation), with a small additional delay if needed due to the baby’s condition.

A MESSAGE TO SPECIALISTS

The best thing you can do for a mother and her baby after birth is… to give them time.
Guide them toward reliable sources of knowledge, where parents can find accurate and up-to-date information about the condition and its treatment. This will allow them to compare their expectations with the real experiences of other parents.

As mentioned earlier, there is absolutely no need to start treatment immediately in the hospital.
It is also not appropriate to pressure or rush parents — give them the freedom to choose the treatment path, the specialist, and the options that feel right for them.
Do not frighten them with unrealistic consequences that have no scientific or factual basis.

PARENT, YOU DON’T HAVE TO!

Parent!
You really have time before starting treatment — use it wisely. Treatment cannot be undone, especially if it’s not done correctly, and mistakes can have long-term consequences that often don’t show up right away but appear at different stages of the process. Take this time to prepare properly. You need it to learn about and understand the condition, and to familiarize yourself with the treatment itself.

In the hospital (after birth), everything often feels rushed and pressured — the medical staff insist, the doctor demands, and you may be frightened with warnings about disability or legal consequences if you don’t start immediately, making you feel as if you’re harming your child.

But remember — you don’t have to agree to everything right away.
You have the right to pause, to ask questions, and to make informed decisions for your baby.

GIVE YOURSELF TIME

Births vary: some are quick and easy, others long and exhausting. Reality is very dynamic. The condition of the mother and baby after delivery often differs from expectations—especially with a first child. Sometimes circumstances are surprising, and the mother’s (and family’s) condition doesn’t allow you to start treatment quickly. Fatigue, stress, a sudden hormonal dip (days 3–5 postpartum), difficulties with care and feeding… the list goes on.

Parent, rest first—then start building solid knowledge. “On-the-run” learning is never good and won’t bring the results you want. The comparison may be a bit extreme, but… people spend months choosing where to live, checking many parameters and calculating mortgage rates, while the decision about a child’s treatment is sometimes made in 10 minutes—without seeking reliable information or learning from other parents’ experiences.

• look for quality information, sort through sources — a reliable resource is https://ponseti.eu
• join to local clubfoot parent group
• learn as much as possible about the condition
• understand the treatment and its nuances
• plan where you will treat your child; think through the logistics of weekly trips for cast changes
• give yourself time to figure out childcare for siblings (if you have other children) while you travel with the baby
• learn to say “NO” when someone gives you inappropriate advice or tells you to do something immediately
• be able to push back—explain calmly, logically, and clearly what you want and what you don’t
• ask questions and don’t accept superficial answers
• find the right physician; don’t choose just because “friends said so” or because someone has 5 stars on a review site—choose well, because poor treatment can’t be undone, and its consequences aren’t visible right away but can hit hard later on.

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POSITIVE BOUNDS

Dr. Ignacio Ponseti said: “Give time for the bond with the mother to form.” Ponseti knew very well that this bond takes time—and that it plays a crucial role in the treatment process. The mother (and parents in general) are the key to successful treatment. They provide safety and comfort for the baby. For that to happen, the mother needs time to get to know her child—to learn to distinguish between different types of crying and different needs. Of course, we learn these things throughout parenthood, but the first stage is the most formative. And it doesn’t matter how many children you have—each one is unique, and every time you have to learn anew. If you give yourself time to get to know your baby, it will be easier to respond appropriately and recognize whether the child is crying because they’re hungry or in pain.

If your baby with clubfoot has an older sibling, the bond between them is important for two reasons:

• The older child plays a key role in accepting the younger sibling’s difference. It’s good to show and explain the condition in a positive way—this teaches empathy and helps them see children with disabilities (or “differences”) in a kind and understanding light, without rejection or fear.
• During the period when you’ll be more focused on the baby and their treatment, the older sibling will handle the situation better if they understand that their brother or sister has a different foot and needs extra help from mom and dad. Involve the older child in the treatment as much as possible. Praise them for helping—let them color the cast or hand over a toy.

Your extended family should also be educated about the condition and the treatment process to help eliminate negative attitudes. Encourage them to be supportive. Speak clearly about your needs and set boundaries when someone close to you insists on doing things differently—for example, suggesting that you remove the brace or claiming that “therapy alone will fix it.”

CONSCIOUSLY

You have plenty of time. Don’t make decisions in a rush, and don’t choose a doctor just because they’re “the closest.” Very often, “local treatment” eventually turns into “global treatment” — meaning you may later need to seek help far away to correct what was done improperly.

Remember: some mistakes can never be fully repaired, or doing so can be time-consuming, costly, and uncertain. Also keep in mind that errors are not always immediately visible — they may surface at different stages of your child’s development and treatment. By the time they become apparent, it may no longer be possible to fix them.

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