Treatment of clubfoot

Clubfoot (pes equinovarus) is one of the most common congenital deformities of the musculoskeletal system in children. In a normally developing pregnancy, the foot is initially formed completely normally, and it is only in the second trimester that its growth is disrupted. As a result, the heel rises upward, the longitudinal arch is excessively hollowed out, the forefoot "escapes" inward, and the child—when it begins to stand—leans mainly on the outer edge of the foot and toes. That is why it is so important to properly plan the treatment of clubfoot, starting from the first months of life.

The name "clubfoot" is a literal translation of the Latin pes equinovarus. "Equinus" refers to a horse-like stance, i.e., walking "on tiptoes" with the heel high above the ground. "Varus" means bowleggedness—the heel and rear part of the foot pointing inward. A foot with this deformity also resembles the end of a golf club, hence the popular English name clubfoot.

From this article you will learn:

• Characteristics – acronym CAVE
• What causes clubfoot?
• Diagnostics – what does an orthopedist evaluate?
• What does clubfoot treatment involve?
• The Ponseti method – a philosophy, not just a technique
• Stage 1. Plastering – the foundation of treatment
• Stage 2. Achilles tendon tenotomy
• Stage 3. Derotation splint – securing the results
• When is surgical treatment of clubfoot necessary?
• What does surgical treatment of clubfoot involve?
• Rehabilitation and orthotic supplies
• Why should you treat clubfoot at the Paley European Institute?
• Treatment of congenital clubfoot – trust a specialist with extensive experience
• Summary – which treatment path to choose?

Characteristics – acronym CAVE

Before starting treatment for congenital clubfoot, the doctor confirms the presence of all typical components of the deformity, described by the acronym CAVE:

• C – cavus – excessive hollow of the longitudinal arch of the foot; it looks as if it were "broken" in the middle.
• A – adductus – adduction, i.e., turning the forefoot inward.
• V – varus – heel varus, causing the foot to rest on its outer edge, with the sole partially "facing" upwards.
• E – equinus – a horse-like position of the heel resulting from shortening of the Achilles tendon; the heel "hangs" above the ground and the child stands as if constantly on tiptoes.

Another typical feature is a noticeably slimmer calf on the side of the affected foot. This is due to atrophy and fibrosis of some muscles, especially the triceps surae and the posterior tibial muscle.

What causes clubfoot?

The cause of the defect is not fully understood. It is assumed that clubfoot develops as a result of a combination of family predisposition, developmental abnormalities, and environmental factors. In some children, the deformity is isolated, while in others it coexists with other health problems, especially those such as genetic defects.

From the point of view of planning treatment for clubfoot, it is important to divide it into:

• idiopathic clubfoot – the only defect, without other coexisting diseases,
• syndromic foot – associated with specific congenital malformation syndromes, including Pierre-Robin sequence, diastrophic dysplasia, and arthrogryposis,
• neurogenic foot – occurring in the course of neurological disorders, e.g., cerebral palsy or spina bifida,
• teratogenic factor – resulting from the effects of harmful factors during pregnancy, such as certain medications, drugs, nicotine, alcohol, or toxins.

A distinction is also made between postural clubfoot, in which the range of motion remains normal, and structural clubfoot, or "true clubfoot," with permanent changes in the bones, ligaments, and muscles. It is in the latter group that the treatment of congenital clubfoot requires the most experience.

Diagnostics – what does an orthopedist evaluate?

The diagnosis can usually be made within the first 24 hours of a newborn's life. The appearance of the foot is so characteristic that complex imaging tests are usually not necessary. During the visit, the doctor will:

• assesses the range of motion in the foot and ankle joints,
• checks the stiffness of the deformation and the possibility of passive correction,
• compares the appearance and circumference of the calves,
• assesses the severity of the defect using clinical scales (e.g., Dimeglio, Pirani).

Advanced tests, such as X-rays or magnetic resonance imaging, are mainly reserved for children with complex deformities accompanying other systemic diseases. For other patients, a thorough orthopedic examination is sufficient to plan treatment for clubfoot.

What does clubfoot treatment involve?

The main goal is to achieve a foot that looks healthy and functions like a healthy foot – it is flexible, painless, with a full range of motion, allowing for normal physical activity. In practice, the treatment of clubfoot is a multi-stage and long-term process, and the approach must be tailored to the type of defect, its stiffness, and the child's response to therapy.

At the Paley European Institute, treatment is based on the Ponseti method, recognized worldwide as the gold standard for the treatment of congenital clubfoot. We treat surgery as a supplement, reserved for special situations when conservative methods do not produce the desired results.

The Ponseti method – a philosophy, not just a technique

Dr. Ignacio Ponseti emphasized that his method is not a simple "step-by-step" instruction, but a whole philosophy of patient management – from diagnosis, through plaster cast correction and Achilles tendon tenotomy, to relapse prevention using a derotation splint. Well-conducted treatment of congenital clubfoot using the Ponseti method:

• is gentle and compatible with the physiology of the joint,
• should not be painful for the child,
• uses the ability of tissues to gradually stretch and remodel,
• requires very good knowledge of the method by the physician and the physiotherapy team.

Treatment does not have to begin in the first hours after birth. A few days to bond with the baby and stabilize the situation after birth is actually beneficial. It is important for parents to have time to familiarize themselves with the principles of clubfoot treatment and to consciously choose a center they trust. However, it is not worth postponing therapy for many weeks, because over time the deformity becomes more and more rigid.

Stage 1. Plastering – the foundation of treatment

The first phase of the Ponseti method involves gradual correction of the foot position using a series of plaster casts. This is a key element on which the success of the entire treatment of congenital clubfoot depends.

What does plastering look like in practice?

1. The doctor performs gentle, repeated adjustments – movements that stretch the contracted tissues, always in accordance with the natural joint surfaces.
2. The plaster technician applies a long plaster cast from the toes to the groin, with the knee bent at an angle of approximately 90° (in atypical and complex feet, this angle may be greater).
3. The cast is carefully molded, especially around the ankle joint and heel, to maintain the achieved correction.

The dressing remains on the leg for 5–7 days. It is then removed, the foot is gently corrected again, and another cast is applied—this time in a different position, closer to the correct alignment. The cycle is repeated until all components of the deformity, except for the heel, have been corrected.

Full correction is usually achieved after 5–7 casts, rarely more than 8–10. Too few casts may indicate overly aggressive, "rapid" correction, while too many increase the risk of secondary deformities. That is why the experience of the center plays such an important role in the treatment of clubfoot.

Stage 2. Achilles tendon tenotomy

In approximately 90–95% of children, despite very good correction in the first stage, the heel remains clubbed. The reason for this is an Achilles tendon that is too short and not flexible enough. In such cases, the next step in the treatment of congenital clubfoot is percutaneous Achilles tendon tenotomy – a minor but extremely important procedure.

• The procedure takes a few minutes.
• It is performed under local anesthesia or short general anesthesia.
• Through a few-millimeter incision, the doctor cuts the Achilles tendon, which immediately allows the foot to be positioned in the correct dorsiflexion.
• Immediately after the procedure, the final, long cast is applied in a so-called hypercorrection – the foot is slightly "overcorrected" so that the regenerating tendon reaches the correct length.

The cast after tenotomy usually remains on the leg for three weeks (sometimes four in older, more active children). This is the stage at which the treatment of clubfoot determines whether the foot will be flexible, stable, and pain-free in the future.

Stage 3. Derotation splint – securing the results

After the last cast is removed, the feet usually look very good, sometimes even "overcorrected." However, the predisposition to recurrence of the defect persists for several years. Therefore, the third mandatory element of treatment for congenital clubfoot is wearing a derotation splint.

Derotation splint:

• does not actively correct deformities, but maintains the correction achieved earlier,
• connects both feet in the correct position, preventing them from returning to a distorted position,
• is tailored individually to the child.

As a standard practice, the splint is worn around the clock during the first few months, and then mainly at night, up to the age of 4–5. Research and experience show that premature discontinuation of this stage is the most common cause of recurrence of the defect, which in extreme cases requires more extensive surgical treatment of clubfoot.

When is surgical treatment of clubfoot necessary?

In most cases, proper treatment of clubfoot using the Ponseti method allows extensive surgical procedures to be avoided. However, there are situations in which surgical treatment of clubfoot becomes necessary. This mainly applies to:

• neurogenic and syndromic forms, e.g., in the course of cerebral palsy, spina bifida, or arthrogryposis,
• very rigid, unusual deformities that respond poorly to plaster casting,
• recurrence of the defect after premature removal of the derotation splint,
• secondary deformities following improper treatment, including incorrect plaster casting.

It is estimated that in approximately one-third of children, despite initially good correction, clubfoot and bowlegs may redevelop if therapy is not carried out consistently. In such situations, well-planned surgical treatment of clubfoot allows for the restoration of the best possible foot function and reduces the risk of pain in adulthood.

What does surgical treatment of clubfoot involve?

The scope of the procedure is always determined on an individual basis, following a detailed clinical and radiological analysis. Surgical treatment of clubfoot may include, among others:

• Achilles tendon lengthening,
• lengthening or transfer of the posterior tibial muscle and other tendons,
• soft tissue plasticity around the ankle joint,
• corrective osteotomies of the tarsal and metatarsal bones,
• in severe, recurrent cases – more extensive multi-level reconstructions.

The aim of the procedure is to correct the deformity as fully as possible while maintaining maximum joint mobility and correct limb alignment. At the Paley European Institute, surgical treatment of clubfoot is planned by an experienced team of pediatric orthopedic surgeons specializing in foot reconstruction.

Rehabilitation and orthotic supplies

Regardless of whether conservative or surgical treatment of clubfoot prevails, appropriate rehabilitation and individually selected orthotic supplies play a huge role.

• Neurophysiological physiotherapy (e.g., using the Vojta method) helps to properly shape muscle tone, movement patterns, and body posture.
• Dynamic taping (kinesiotaping) can support the work of selected muscle groups and gently influence the position of the foot.
• Custom insoles, orthotics, and orthopedic footwear stabilize the foot after the main stage of clubfoot treatment is complete, helping to maintain the achieved results.

Close cooperation between orthopedists, physical therapists, and orthotic technicians is particularly important for patients who have undergone surgery, where surgical treatment of clubfoot requires precisely planned rehabilitation afterwards.

Why should you treat clubfoot at the Paley European Institute?

At the Paley European Institute, we offer both comprehensive treatment of congenital clubfoot using the Ponseti method and advanced surgical treatment of clubfoot, including in cases of recurrence and complications resulting from previous incorrect treatment.

We provide our patients with:

• a team of experienced pediatric orthopedic surgeons specializing in limb reconstruction and lengthening,
• physical therapists who work with children after treatment for congenital clubfoot on a daily basis,
• individual orthotic supplies,
• long-term care – from the newborn's first visit through to adolescence.

If your child has been diagnosed with this condition or if previous treatment for clubfoot has not produced the desired results, please contact us. We will help you plan further treatment—from detailed diagnostics, through treatment of congenital clubfoot using the Ponseti method, to possible surgical treatment of clubfoot—so that in the future, the foot will be as functional, flexible, and pain-free as possible.

Treatment of congenital clubfoot – trust a specialist with extensive experience

Treatment of congenital clubfoot at our institute is supervised by Dr. Jacek Kąpiński, an experienced pediatric orthopedist and renowned expert in the treatment of foot deformities. For many years, Dr. Kąpiński has specialized in the treatment of clubfoot using the Ponseti method, considered the gold standard of treatment worldwide.

He gained his unique experience during an internship at the Department of Orthopedics and Rehabilitation at the University of Iowa Health Care under the supervision of Prof. Jose Morcuende, one of the most prominent authorities in this field, thanks to which he obtained a recommendation from Ponseti International. He regularly participates in international courses and training sessions, constantly improving his qualifications. At our institute, patients receive comprehensive, empathetic care based on knowledge, experience, and an individual approach to each child and their family.

Summary – which treatment path to choose?

For most children, the basis is early, well-planned treatment of clubfoot using the Ponseti method. It is this technique that most often allows extensive surgery to be avoided and gives the chance of a fully functional, pain-free foot in adulthood. When clubfoot treatment is carried out consistently, following all stages of the method, the results are very good and advanced surgery is not necessary.

However, despite the efforts of specialists, treatment of congenital clubfoot does not always result in complete correction, especially in severe neurogenic and syndromic cases. In such cases, properly planned surgical treatment of clubfoot becomes crucial, allowing for the correction of the most stubborn deformities, followed by continued therapy based on rehabilitation and orthotic treatment. Sometimes, surgical treatment is also necessary in children who have previously undergone incorrect therapy.

At the Paley European Institute, we decide on a case-by-case basis whether conservative treatment of clubfoot will be sufficient or whether a phased surgical approach is necessary. Regardless of the chosen path, our goal remains to provide safe, effective help to the youngest patients and support to their parents. Together, we plan both the treatment of congenital clubfoot in infancy and subsequent surgeries, if they prove necessary at later stages of development.