Congenital clubfoot, or congenital talipes equinovarus (CTEV), is one of the most common congenital musculoskeletal deformities affecting newborns. It is characterised by four related components: forefoot cavus, forefoot adduction, hindfoot varus and ankle equinus. The deformity may occur in one or both feet and can be associated with neurological, syndromic or chromosomal conditions, although idiopathic clubfoot is the most common form. Without effective treatment, the child may develop a rigid, painful and poorly functioning foot that makes plantigrade walking difficult. The Ponseti method has become the standard conservative treatment because it corrects the deformity through gentle manipulation, serial casting, limited surgical intervention and prolonged bracing.
The method was developed by Ignacio Ponseti in the mid-twentieth century. Earlier treatment strategies often relied on extensive surgical releases, which could produce a plantigrade foot but were associated with stiffness, weakness, scarring and degenerative changes later in life. Ponseti’s approach was based on an understanding of the three-dimensional anatomy of clubfoot and the plasticity of infant tissues. Rather than forcing the foot into correction, the method gradually realigns the tarsal bones while stretching contracted ligaments, joint capsules and tendons. Systematic reviews have consistently reported high initial correction rates, particularly in idiopathic clubfoot treated during infancy. A review of children younger than two years found that all included studies reported the Ponseti method to be effective, although relapse remained common when bracing was not followed.
Principles of correction
The essential principle is that the components of clubfoot must be corrected in a specific sequence. The cavus is corrected first, followed by adduction and varus, with equinus addressed last. This sequence is sometimes summarised as “CAVE”: cavus, adductus, varus and equinus. The clinician first palpates the head of the talus, which serves as the point of counter-pressure and the fulcrum for correction. The forefoot is gently supinated to elevate the first metatarsal and reduce the cavus deformity. The foot is then abducted beneath the talus while pressure is maintained over the lateral talar head.
A critical feature of the technique is that the calcaneus must be allowed to move with the rest of the foot. Pressure should not be applied directly to the calcaneus because this can prevent its normal derotation beneath the talus. Similarly, the foot should not be pronated during manipulation. Incorrect force application may create a “rocker-bottom” or midfoot-break deformity, in which the midfoot becomes dorsiflexed while the hindfoot remains in equinus and varus. These technical details explain why appropriate training and clinical experience are important for achieving reliable results.
Serial manipulation and casting
Treatment should ideally begin soon after birth, often during the first few weeks of life, when the infant’s connective tissues are particularly adaptable. At each appointment, the foot is gently manipulated for approximately one minute before a cast is applied. The cast generally extends from the toes to the upper thigh, with the knee flexed. Above-knee casting is necessary because a short-leg cast cannot adequately maintain the required abduction and is more likely to slip.
The first cast maintains correction of the cavus by positioning the forefoot in supination. In subsequent casts, progressive abduction is applied while the talar head is stabilised. Casts are usually changed every five to seven days, allowing the soft tissues to stretch gradually and the bones to remodel in the improved position. Most infants require approximately four to seven casts, although the number varies according to the initial severity, rigidity and complexity of the deformity. The foot is not forced into dorsiflexion prematurely, because equinus should be corrected only after the subtalar component of the deformity has been adequately addressed.
Clinical scoring systems, particularly the Pirani score, may be used to document severity and monitor correction. Examination remains central, however, because the position of the talar head, heel and midfoot must be assessed by palpation. Radiographs are not routinely necessary in typical idiopathic cases, although imaging may be useful in complex or atypical deformities.
Achilles tenotomy
After the cavus, adduction and varus have been corrected, residual equinus is commonly caused by a shortened Achilles tendon and posterior capsular structures. In most cases, a percutaneous Achilles tenotomy is required to achieve adequate ankle dorsiflexion. Published reports indicate that approximately 60% to more than 90% of patients may require this procedure, depending on the severity of the deformity and the criteria used to define correction.
The tenotomy is a small procedure, often performed under local anaesthesia or appropriate sedation, and is followed immediately by the final cast. It should not be performed before the hindfoot and subtalar alignment have been corrected. Premature release of the Achilles tendon may leave persistent hindfoot varus and can contribute to a false appearance of correction through midfoot dorsiflexion. The final cast is generally maintained for approximately three weeks, allowing the tendon to heal at its corrected length.
Although the procedure is usually safe, complications can include bleeding, infection, incomplete tenotomy and, rarely, injury to nearby neurovascular structures. Careful anatomical localisation and appropriate procedural expertise are therefore essential.
Bracing and relapse prevention
The bracing phase is as important as the casting phase. Once the foot has been corrected, it has a strong tendency to relapse, particularly during the first several years of life. A foot-abduction orthosis, commonly consisting of shoes attached to a bar, maintains the feet in external rotation and prevents the corrected position from being lost. The usual protocol involves wearing the brace for approximately 23 hours per day for the first three months, followed by use during sleep and naps until the child is around four or five years old.
The brace does not correct an unreduced clubfoot; rather, it preserves a successful correction. Consequently, it must be applied only after the foot has been adequately corrected and the ankle has sufficient dorsiflexion. Correct shoe fitting is essential. The heel must remain seated in the shoe, the straps must be secure without impairing circulation, and the skin should be checked regularly for pressure areas or blisters.
Relapse is the principal limitation of the Ponseti method. It may present as recurrent forefoot adduction, dynamic supination, hindfoot varus or equinus. Non-adherence to bracing is one of the strongest recognised risk factors. Families may find the orthosis difficult to use, particularly when the infant initially resists having both legs connected by a bar. Clear education, practical demonstrations, early review and a supportive clinician–family relationship can substantially improve adherence.
Outcomes and limitations
The major advantage of the Ponseti method is that it usually produces a flexible, plantigrade and functional foot while avoiding extensive corrective surgery. Long-term follow-up has shown that treated individuals can achieve activity levels and pain outcomes comparable with those of people without clubfoot. The method also reduces healthcare burden by replacing prolonged hospitalisation and major surgery with outpatient casting and, when necessary, a brief tenotomy.
Nevertheless, the method is not equally predictable in every patient. Complex, neglected, recurrent, neurological and syndromic clubfeet may require more casts, repeated tenotomies or additional procedures. Relapses may often be managed initially with repeat manipulation and casting. Older children with persistent dynamic supination may eventually require tibialis anterior tendon transfer, while resistant deformities may still require more extensive surgery. These possibilities do not represent failure of the method but reflect the biological and anatomical variability of clubfoot.
The Ponseti method is a highly effective, minimally invasive treatment for idiopathic clubfoot. Its success depends on more than serial casting alone: accurate manipulation, correct cast moulding, timely Achilles tenotomy, appropriate bracing and long-term surveillance are all essential. When these components are delivered consistently, most children can develop a plantigrade, pain-free and functional foot capable of normal footwear and participation in physical activity. The method therefore represents an important example of how detailed anatomical understanding and family-centred conservative care can transform the management of a disabling paediatric deformity.