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Ponseti method

The Ponseti method is a conservative, non-surgical treatment protocol developed for correcting congenital idiopathic clubfoot (talipes equinovarus), a common birth deformity characterized by the foot's inward and downward pointing position, through serial manipulation, casting, and post-correction bracing to realign the foot's bones and soft tissues into a functional position.^[1]^[2] Introduced by orthopedic surgeon Ignacio V. Ponseti in the 1940s and first detailed in a seminal 1963 publication, the method emphasizes gentle correction of the deformity's components—cavus, adduction, varus, and equinus—while preserving joint mobility and avoiding invasive surgery.^[3]^[4] The treatment begins in the first few weeks of life, when the foot's ligaments and capsules are most pliable, starting with weekly sessions of manipulation to stretch the tight structures followed by the application of a long-leg plaster cast held in progressive abduction and dorsiflexion, typically requiring 5 to 7 casts over 6 to 8 weeks.^[1]^[2] In approximately 80% to 90% of cases, a percutaneous Achilles tenotomy—a minor outpatient procedure to lengthen the tendon—is performed under local anesthesia to fully correct the equinus deformity before the final cast.^[4] Post-casting, maintenance involves a foot abduction orthosis (FAO), such as a bar-connected brace with shoes, worn nearly full-time for the first 3 months and then at night and during naps until the child reaches age 4 or 5, to prevent relapse.^[1]^[2] As the global gold standard for clubfoot management, the Ponseti method achieves initial correction in 90% to 98% of cases and long-term excellent or good outcomes in 74% to 78% of patients when bracing protocols are strictly followed, significantly reducing the need for extensive surgical interventions from over 70% in the 1990s to under 15% today.^[4] Non-compliance with bracing is the primary risk factor for recurrence, which can often be addressed with repeat casting or, in persistent cases, procedures like tibialis anterior tendon transfer.^[1]^[4] Applicable to most idiopathic cases and adaptable for certain complex or syndromic clubfeet with modifications, the method enables treated children to wear ordinary shoes, engage in physical activities, and avoid lifelong complications like pain or arthritis.^[2]^[4]

Background and Overview

History and Development

The Ponseti method originated in the 1940s at the University of Iowa, where orthopedic surgeon Ignacio V. Ponseti developed a nonoperative approach to treating idiopathic congenital clubfoot. Ponseti, who joined the University of Iowa as a resident in 1941 and the faculty in 1944, began refining the technique around 1948 after observing poor long-term outcomes in surgically treated patients, including rigid, weak, and painful feet. His development was informed by anatomical dissections of stillborn infants, which provided insights into hindfoot structures such as the talus and calcaneus, and by clinical observations suggesting that clubfoot deformities could correct gradually without aggressive surgery, allowing for natural improvement in flexibility.^[5] Ponseti's initial results were published in 1963 in the Journal of Bone and Joint Surgery, detailing outcomes for 94 clubfeet in 67 patients treated primarily with serial plaster casting over an average of 9.5 weeks, often combined with subcutaneous Achilles tenotomy and Denis Browne splints for maintenance. The paper emphasized conservative management through gentle manipulation and casting to realign the foot's components—addressing cavus, adduction, varus, and equinus deformities—over extensive surgical release, achieving good results in 71% of cases and highlighting the risks of surgery-induced stiffness.^[6]^[7] Despite these findings, the method saw limited adoption until the 1990s, when renewed interest sparked by Ponseti's 1996 book Congenital Clubfoot: Fundamentals of Treatment and advocacy from his successor, Jose Morcuende, led to clinical trials validating its efficacy. Morcuende, who trained under Ponseti and began treating patients at the University of Iowa in the late 1990s, conducted key studies demonstrating the technique's success; for instance, a 2004 study of 157 patients (256 clubfeet) showed correction without extensive surgery in 98% of cases, prompting widespread orthopedic adoption. This revival was further propelled by parent-led awareness via the internet, increasing patient referrals and establishing the Ponseti method as the preferred conservative treatment globally.^[8]^[9] Global dissemination accelerated in the early 2000s through training programs and initiatives like the Ponseti International Association, founded in 2006 to promote the method worldwide, and the Global Clubfoot Initiative, established in 2009 as a consortium of over 35 organizations focused on low-resource settings. By the 2010s, the World Health Organization had endorsed the Ponseti method as the standard of care for idiopathic clubfoot, recognizing its cost-effectiveness, minimal invasiveness, and high success rates in preventing disability, particularly in developing countries.^[10]^[11]

Pathophysiology of Clubfoot

Congenital talipes equinovarus (CTEV), commonly known as clubfoot, is a structural deformity characterized by inversion and adduction of the forefoot, varus deformity of the hindfoot, and equinus positioning of the ankle, resulting in the foot pointing downward and inward.^[12] This condition affects approximately 1 in 1,000 live births worldwide, is approximately twice as common in males as in females, and is bilateral in about 50% of cases.^[13] The key anatomical deformities in CTEV are often summarized by the acronym CAVE: cavus, referring to a high medial arch due to plantar flexion of the forefoot; adductus, an inward deviation of the forefoot; varus, an inward tilting of the hindfoot; and equinus, a fixed plantar flexion of the ankle and subtalar joint.^[13] These deformities arise from abnormal positioning and development during fetal growth, leading to a rigid, resistant structure if untreated.^[14] The etiology of idiopathic CTEV, which accounts for approximately 80% of cases, is multifactorial, involving both genetic and environmental influences.^[15] Genetic factors include mutations in genes such as PITX1, a transcription factor critical for hindlimb development, which have been identified in rare familial cases and underscore the role of disrupted limb patterning pathways.^[16] Environmental contributors, such as oligohydramnios during critical gestational periods, can restrict fetal movement and promote abnormal foot positioning in utero.^[17] Biomechanically, the deformities in idiopathic CTEV primarily stem from soft tissue contractures rather than inherent bony malformations, particularly involving the tibialis posterior tendon, Achilles tendon, and posterior ankle joint capsule, which create a fixed equinus and hindfoot varus.^[18] These contractures, including those in the posterior talocalcaneal interosseous ligament and flexor hallucis longus, lead to imbalance and rigidity but are amenable to correction in early infancy due to the plasticity of immature connective tissues.^[13]

Indications and Patient Selection

Suitable Cases

The Ponseti method is primarily indicated for idiopathic congenital talipes equinovarus (CTEV), also known as clubfoot, in infants, encompassing both unilateral and bilateral presentations. This conservative approach achieves high initial correction rates of 90-98% in idiopathic cases when applied appropriately.^[4] Optimal patient selection targets infants under 6 months of age, with the most favorable outcomes occurring when treatment initiates within the first 1-3 weeks of life. Early intervention, particularly between 28 days and 3 months, correlates with fewer serial casts required (mean of 3.7 versus 4.5 or more in neonates under 28 days), reduced relapse rates (as low as 11% in this window), and superior final functional scores on scales like the International Clubfoot Study Group (ICFSG) rating. Delaying beyond 3 months still permits effective correction but may necessitate additional interventions due to increased foot rigidity.^[17]^[19] The technique demonstrates efficacy across varying degrees of deformity severity, from mild to severe, as quantified by established clinical scoring systems. The Pirani score, which assesses hindfoot, midfoot, and overall contracture on a 0-6 scale, reliably predicts treatment needs and monitors correction progress in Ponseti casting. Similarly, the Dimeglio classification, evaluating equinus, varus, derotation, and adduction on a 0-20 scale, guides severity grading and has shown strong correlation with the number of casts required, particularly in moderate to severe cases where scores exceed 10. These tools enable standardized assessment without relying on radiographic imaging for initial suitability.^[20]^[21]^[22] Although designed for isolated idiopathic CTEV, the Ponseti method is adaptable to select mild syndromic cases, such as those linked to arthrogryposis multiplex congenita or spina bifida, absent severe muscle rigidity or joint contractures. In arthrogrypotic clubfeet, it serves as an effective first-line option for achieving plantigrade feet, though patients often require more casts (up to twice as many) and experience higher relapse rates (around 50%) compared to idiopathic counterparts, potentially necessitating adjunctive procedures. For spina bifida-associated clubfoot, the method can be applied with tailored modifications to account for concurrent medical conditions.^[23]^[24]^[25] Prior to initiating treatment, diagnostic evaluation must confirm isolated CTEV through a comprehensive clinical examination at birth, excluding comorbidities like neural tube defects. Prenatal ultrasonography, feasible from 20 weeks gestation, aids in early detection with high sensitivity for fixed deformities, while postnatal ultrasound or MRI is recommended if neurologic involvement (e.g., myelomeningocele) or syndromic features are suspected to ensure suitability and rule out neurogenic etiologies.^[17]^[26]

Contraindications and Limitations

The Ponseti method has absolute contraindications in cases of atypical clubfoot associated with certain severe neuromuscular disorders, such as cerebral palsy or myopathies like Duchenne muscular dystrophy, where the underlying neurological deficits lead to rigid deformities that resist standard manipulation and casting.^[23] Similarly, central nervous system disorders like cerebral palsy or myopathies such as Duchenne muscular dystrophy preclude its use due to the inability to achieve correction without extensive surgical intervention.^[23] Relative contraindications include older children over 2 years of age presenting with rigid deformities. The method remains effective for initial correction in these cases, though increased tissue stiffness may require more casts or minor adjunctive procedures.^[27] Teratologic clubfoot, such as that caused by amniotic band syndrome, represents another relative contraindication, where the method may achieve partial correction but carries a substantially higher risk of recurrence and suboptimal outcomes compared to idiopathic cases.^[28] Key limitations of the Ponseti method arise in neglected cases presenting after 12 months of age, where delayed treatment results in stiffer tissues that may require more casts, though success rates remain high and extensive surgical augmentation is uncommon.^[27] In syndromic forms of clubfoot, the recurrence risk is notably elevated, reaching up to 39% in some cohorts, attributed to underlying genetic or systemic factors that impair long-term stability post-correction.^[29] Additionally, in high-resource settings with complex anatomical presentations, surgical options may be preferred over the method due to its conservative nature and potential for prolonged bracing.^[30] Referral to an orthopedic specialist is indicated if initial casting shows no meaningful progress after 6 to 8 weeks, signaling a resistant or atypical deformity that may demand alternative interventions.^[31]

Treatment Procedure

Initial Assessment and Casting

The initial assessment of idiopathic clubfoot using the Ponseti method begins with a clinical evaluation to quantify the severity of the deformity and determine the foot's flexibility. The Pirani scoring system is employed, which assesses six clinical signs—three in the midfoot (medial crease, lateral border curvature, and talar head coverage) and three in the hindfoot (posterior crease, heel emptiness, and equinus rigidity)—each scored from 0 (normal) to 1 (most abnormal), yielding a total score ranging from 0 to 6.^[32] Higher initial scores, often around 5-6 in untreated cases, indicate greater severity and may predict the need for more casts.^[33] Gentle manipulation without force is performed to assess rigidity, palpating key structures like the talar head and calcaneus to evaluate correctability while avoiding any aggressive stretching that could cause harm.^[4] The serial casting phase follows immediately, typically starting within the first two weeks of life for optimal outcomes, and involves weekly applications of long-leg plaster casts to gradually correct the deformities in a sequential manner. The protocol generally requires 5 to 7 casts over 4 to 8 weeks, with each cast changed after 5 to 7 days to allow progressive stretching of tight ligaments and tendons.^[4] Above-knee casts are used, extending from toes to groin, to prevent slippage and maintain the correction, particularly by immobilizing the knee.^[3] Correction begins with the cavus deformity, addressed by elevating the first ray and supinating the forefoot to flatten the arch, followed by sequential targeting of adduction and varus through lateral rotation of the foot, and finally equinus by dorsiflexion once the other components are partially corrected.^[4] During manipulation, counter-pressure is applied with the thumb on the lateral head of the talus to stabilize it, while the forefoot is gently abducted without touching the calcaneus or forcing the correction; the position is held briefly—typically 30 to 60 seconds, repeated 2 to 3 times—before molding and applying the well-padded plaster cast with the knee in 90 degrees of flexion.^[34] This sequence aligns with the pathomechanical order of the clubfoot deformities, ensuring balanced correction without over-stretching any component.^[3] Near-full correction is achieved when the foot can be dorsiflexed to at least 15 degrees with the knee extended and the navicular is aligned over the talar head, as monitored by repeat Pirani scoring.^[32]

Achilles Tenotomy

Achilles tenotomy is a minimally invasive procedure integral to the Ponseti method for correcting idiopathic congenital clubfoot, specifically targeting the persistent equinus deformity after initial serial casting. It involves a percutaneous release of the Achilles tendon to achieve adequate dorsiflexion, enabling full correction without extensive surgery. This step is necessary because the Achilles tendon, composed of dense collagen, resists lengthening through manipulation and casting alone, unlike more pliable joint capsules and ligaments.^[4] The procedure is indicated when residual equinus remains following correction of cavus, adduction, and hindfoot varus, typically assessed by the inability to dorsiflex the foot to at least 15 degrees with the knee extended. In such cases, the hindfoot fails to reach neutral or slight dorsiflexion despite external rotation of the foot to 60 degrees or more. Tenotomy is required in 79–90% of idiopathic clubfoot cases treated with the Ponseti method to ensure complete deformity resolution.^[4]^[35] Performed as an outpatient procedure under local anesthesia, such as 0.5–1 ml of lidocaine injected medially just above the tendon's calcaneal insertion, the tenotomy entails a small percutaneous incision or puncture using a #15 scalpel blade or needle. The surgeon palpates the tendon and advances the instrument to achieve a complete release, often confirmed by a palpable "pop" and an immediate increase in dorsiflexion of 10–20 degrees. No sutures are needed, and the procedure minimizes risks to neurovascular structures when executed medially. It is typically conducted after 4–7 weekly casts, once the subtalar joint is aligned, and is followed by a final above-knee cast for 3 weeks to allow tendon healing in the lengthened position.^[4]^[35]^[36] The rationale for Achilles tenotomy lies in its ability to prevent equinus recurrence by addressing the tendon's mechanical resistance, thereby promoting long-term foot alignment without the complications of open surgery, such as scarring or stiffness. Studies following Ponseti's protocol report successful initial correction in over 90% of cases when tenotomy is incorporated, with the tendon regenerating sufficiently within 3 weeks to support subsequent bracing. Rare complications, including minor bleeding (2%) or over-release, underscore the procedure's safety profile when performed by trained providers.^[4]^[37]

Post-Correction Bracing

After the deformity has been fully corrected through serial casting and tenotomy, the post-correction bracing phase begins to maintain the foot's position and prevent relapse during periods of rapid growth.^[38] This maintenance is crucial as the child's ligaments and bones continue to develop, requiring sustained external rotation and dorsiflexion to hold the correction.^[39] The standard protocol involves the use of a foot abduction orthosis (FAO), typically initiated immediately following the removal of the final cast, and continued for several years.^[4] The bracing schedule is structured in phases to gradually reduce wear time while ensuring retention of correction. Initially, the orthosis is worn for 23 hours per day—allowing only one hour for bathing and stretching—for the first three months.^[38] Following this, usage decreases to 15 hours per day, primarily during naps and nighttime, and continues until the child reaches approximately four years of age.^[39] This regimen balances the need for consistent positioning with the practicalities of daily life, with the total bracing duration often spanning two to five years depending on individual growth patterns.^[2] The FAO device consists of a rigid aluminum or plastic bar, approximately shoulder-width in length, connecting two specially designed shoes or sandals at each end.^[4] The shoes are fixed to maintain the corrected foot in 70 degrees of external rotation (abduction) and 10 to 15 degrees of dorsiflexion, even for unilateral cases where the unaffected foot is also braced to promote symmetry.^[40] This positioning stretches the medial and posterior structures while avoiding excessive force, and the device is adjustable for growth through shoe size changes every few months.^[41] Compliance with the bracing protocol is a key determinant of successful long-term outcomes, heavily influenced by family involvement and education.^[42] Comprehensive parental training on brace application, skin care, and troubleshooting common issues—such as mild redness that resolves quickly—is provided to foster adherence and reduce dropout rates.^[43] For families facing challenges with the standard FAO, alternatives like the Mitchell Ponseti brace, which features softer, more flexible components for improved comfort, may be recommended to enhance wear time without compromising efficacy.^[44] Monitoring during the bracing phase involves regular clinical assessments to evaluate foot position, brace fit, and deformity status.^[38] Monthly visits in the initial months use tools like the Pirani score—a six-component clinical scale assessing hindfoot and midfoot alignment—to confirm maintenance of correction and detect any early signs of deviation.^[45] Adjustments for growth, such as bar length or shoe size, are made as needed, with follow-up frequency tapering to every four to six months thereafter until skeletal maturity.^[39]

Efficacy and Outcomes

Success Rates and Evidence

The Ponseti method achieves initial correction rates of 90% to 100% in idiopathic clubfoot cases without the need for major surgery, as demonstrated across multiple U.S. treatment centers.^[17] Relapse rates following initial correction typically range from 3.2% to 34.2%, with meta-analyses indicating low relapse of approximately 10% to 20% in compliant patients.^[46]^[47] Seminal evidence includes Ponseti's 1996 long-term follow-up study at the University of Iowa, which reported excellent functional outcomes in adults treated decades earlier, with nearly normal foot function and minimal residual deformity in the majority.^[17] A 2004 analysis of Iowa cases further confirmed the method's efficacy, showing a radical reduction in extensive corrective surgeries to under 10%.^[9] Global data in low-resource settings report success rates varying from approximately 60% to 90% when delivered by Ponseti-trained providers, supporting its scalability in resource-limited environments.^[48] Outcome measures such as the Laaveg-Ponseti score, which assesses pain, function, and gait, yield excellent or good results (≥80 points) in 76% of treated idiopathic cases at mid-term follow-up.^[49] The method is also highly cost-effective, costing less than one-tenth the price of surgical alternatives in low-income settings, representing approximately 90% savings per patient.^[50]^[51] Recent evidence from 2023 studies on telemedicine adaptations for post-correction follow-up post-COVID-19 shows maintained compliance rates of 77% to 85%, comparable to face-to-face visits, with no missed recurrences and improved brace adherence in some cohorts.^[52]^[53]

Long-Term Follow-Up

Long-term follow-up of patients treated with the Ponseti method emphasizes the durability of correction, the need for ongoing monitoring, and adaptations as the child grows into adulthood. Relapses, defined as recurrence of deformity components such as equinus or varus, occur in approximately 20-30% of cases by age 5, often managed through repeat serial casting and bracing adjustments.^[54]^[55] Continuous clinical monitoring is recommended until skeletal maturity, typically around age 14-16 years, to detect and address any residual or recurrent deformities early, preventing the need for more invasive interventions.^[56] In adulthood, outcomes remain favorable, with studies demonstrating that about 80% of patients achieve excellent or good functional results, characterized by pain-free status and normal gait patterns comparable to unaffected individuals.^[57] Minimal arthritis is observed, affecting only around 3% of joints moderately or severely, underscoring the method's role in preserving joint health over decades. These findings are supported by a comparative analysis of adults treated as children, where the Ponseti group exhibited superior ankle motion and power generation during gait compared to those who underwent surgical release.^[57] Growth-related considerations include periodic adjustments to footwear and activity restrictions to accommodate any residual differences in foot shape or size, enabling participation in sports and daily activities. In bilateral cases, a slight leg length discrepancy of approximately 1 cm may arise due to varying severity of initial deformity or treatment response, though prevalence of clinically significant discrepancies is low at about 14% overall.^[58] Quality of life assessments reveal high satisfaction rates exceeding 90% among patients and families, attributed to functional mobility, avoidance of major surgical scars, and reduced psychological burden from non-invasive treatment.^[17] Patient surveys highlight improved self-esteem and social integration, with the method's emphasis on early correction contributing to lifelong benefits without the stigma of visible surgical marks.^[17] As of 2025, recent long-term studies continue to affirm typical functional outcomes despite residual deformity in some cases.^[59]

Complications and Management

Common Risks

The Ponseti method, while highly effective for correcting idiopathic clubfoot, carries several common risks primarily related to the serial casting, percutaneous Achilles tenotomy, and post-correction bracing phases. During the casting stage, skin irritation and cast sores are frequent minor complications, occurring in approximately 2% to 5% of cases due to pressure from the casts or inadequate padding. These issues often manifest as erythema, superficial abrasions, or dermatitis and typically resolve with temporary casting interruptions or adjustments, though severe cases can lead to pressure sores or maceration if not addressed promptly. Improper casting technique, such as excessive pressure or below-knee application, can also result in iatrogenic deformities like rocker-bottom foot, where overcorrection of the midfoot creates an abnormal convexity. Additionally, skipping the Achilles tenotomy when equinus deformity persists after serial casting leads to incomplete correction and ongoing hindfoot equinus, increasing the risk of residual deformity or early relapse. Bracing with the foot abduction orthosis (FAO) introduces risks tied to patient tolerance and adherence. Non-compliance with the prescribed bracing regimen—often due to discomfort in the hips or knees from the orthosis's rigid positioning—is a leading factor in treatment failure, with studies showing non-compliance rates of 36% to 49% and associated relapse odds 10 to 20 times higher than in compliant cases. This discomfort can manifest as pressure sores or joint irritation, particularly in the early months when bracing is worn nearly full-time, contributing to up to 30% of overall failures through inconsistent use. Relapse following initial correction is common, affecting 20% to 40% of patients, with dynamic recurrences—characterized by re-tightening of the Achilles tendon and imbalance in surrounding muscles—most prevalent between ages 2 and 7 due to growth-related changes and ongoing neuromuscular factors. Although less frequent, risks from the Achilles tenotomy include infection at the percutaneous site, occurring in fewer than 1% of procedures, alongside rare instances of bleeding or neurovascular injury if the technique is imprecise. These complications are generally mild and manageable but underscore the need for sterile conditions during the office-based intervention. Overall, while the method's risks are predominantly minor and reversible, they highlight the importance of precise execution to minimize recurrence and secondary issues.

Prevention and Treatment Strategies

Prevention of complications in the Ponseti method emphasizes rigorous training for healthcare providers in proper casting techniques to ensure gentle manipulation and accurate application, minimizing risks such as cast slippage or deformity persistence.^[31] Standardized programs, including the Africa Clubfoot Training initiative and advanced modules from MiracleFeet, deliver curricula on casting, tenotomy, and error recognition, particularly tailored for low-resource settings to enhance treatment accuracy and reduce procedural errors.^[60]^[61] Family education plays a pivotal role in preventing relapse through optimal brace hygiene and compliance. Strategies include dedicated nurse-led weekly phone support during the initial bracing phase to troubleshoot issues and reinforce adherence, alongside resources such as instructional videos and apps that guide parents on cleaning, fitting, and monitoring the orthosis.^[62]^[63] These interventions have demonstrated improved compliance rates, with dynamic orthoses achieving up to 81% adherence compared to 47% with standard braces.^[62] Treatment of relapse involves repeating serial above-knee casting, typically requiring 2 to 5 weekly applications over 2 to 5 weeks to address recurrent deformities, followed by extended bracing to maintain correction.^[64] If equinus deformity persists after casting, a salvage percutaneous Achilles tenotomy is performed, often under local anesthesia, to facilitate full correction without major surgery.^[65]^[66] Management of complications focuses on targeted interventions to address specific issues. For skin irritation from casting, use of non-woven cotton undercast padding combined with a one-inch moleskin strip at the proximal edge prevents abrasions and allows easy family replacement if soiled.^[67] Orthosis-related discomfort is mitigated through adjustments such as verifying brace length against shoulder width, ensuring heel seating with sequential strap tightening, and setting appropriate abduction angles (60-70 degrees for the affected foot) to optimize fit and reduce fussing.^[68] In syndromic cases, multidisciplinary care involving pediatricians, neurologists, geneticists, and orthopedic specialists coordinates the Ponseti protocol, often requiring more casts (average 6.5) and adjunctive ankle-foot orthoses to manage associated conditions like psychomotor delays.^[69] Global efforts, such as MiracleFeet's task-sharing model training physiotherapists and casting technicians alongside surgeons, promote standardized Ponseti implementation in resource-limited areas, fostering sustainable networks to minimize complications through ongoing supervision and supply chain support.^[61]

Comparisons and Alternatives

Versus Surgical Methods

Traditional surgical methods for correcting idiopathic clubfoot, such as the posteromedial soft-tissue release procedure exemplified by the McKay technique, are typically reserved for severe or rigid deformities that do not respond adequately to conservative treatments. These approaches involve extensive incisions to release contracted soft tissues around the posterior and medial aspects of the foot, aiming to achieve correction through direct manipulation of tendons, ligaments, and joint capsules. Postoperatively, patients require immobilization in a cast for 6 to 12 weeks to allow healing, often followed by prolonged bracing and physical therapy, with initial hospital stays ranging from 1 to 3 days.^[70]^[1]^[71] The Ponseti method offers several advantages over these surgical interventions, primarily due to its non-invasive nature, which avoids scarring, minimizes joint stiffness, and preserves muscle strength more effectively in the long term. Unlike surgery, which can lead to complications such as overcorrection, wound infections, or neurovascular injury, the Ponseti approach relies on serial casting and minimal percutaneous procedures, resulting in better functional outcomes like improved gait and range of motion. Additionally, the Ponseti method is substantially more cost-effective, with Ponseti treatment averaging around [$500](/page/500) globally in supported programs compared to $10,000-30,000 for surgical correction in high-resource settings like the US, making it particularly beneficial in resource-limited environments.^[72]^[73]^[74]^[75]^[76] Surgery may be preferred or combined with the Ponseti method in cases of treatment failure, particularly when relapse occurs after the child is older than 2 years, or in atypical clubfoot presentations with complex deformities such as short medial crease or rigid equinus. In such scenarios, approximately 5% to 10% of cases require surgical intervention to address residual contractures, often involving limited releases rather than extensive procedures. Combined approaches, such as adjunctive tibialis anterior tendon transfers, are used in about 15% to 40% of relapsed Ponseti cases to enhance stability without full soft-tissue release.^[77]^[78]^[13]^[79]^[30] Evidence from comparative studies supports the superiority of the Ponseti method, with a 2017 randomized trial demonstrating better long-term morphology, function, and radiographic outcomes compared to surgical release, including lower rates of stiffness and higher patient satisfaction. A 2024 prospective long-term (18-year) follow-up study confirmed superior outcomes with the Ponseti method, including better function, ankle dorsiflexion, lower pain, and quality of life, with relapse in about 17% of Ponseti cases; broader studies report relapse rates of 20% to 30% for Ponseti versus reoperation rates up to 65% in some surgical series. These findings underscore the Ponseti method's role as the preferred initial treatment, reducing the need for major surgery by an average of 85% across institutions.^[80]^[74]^[81]^[82]

Versus Other Non-Surgical Approaches

The French functional method, also known as the French physiotherapy approach, involves daily gentle manipulations performed by trained physiotherapists or parents to stretch contracted tissues, stimulate weakened muscles, and maintain reductions through taping or redressive splints, with minimal emphasis on percutaneous Achilles tenotomy.^[83] In contrast to the Ponseti method's structured serial casting and post-correction bracing protocol, the French method prioritizes ongoing functional exercises and immobilization without rigid sequencing, which can demand greater parental involvement and frequent clinic visits.^[13] Some studies indicate relapse rates of 20% to 29% with the French method compared to lower rates (e.g., 8%) with Ponseti, often necessitating subsequent surgical interventions in relapsed cases.^[84] The Kite method, or hybrid casting approach, employs serial manipulations and below-knee casts to address clubfoot deformities sequentially—starting with cavus correction followed by adduction, varus, and equinus—without the precise counter-rotation and long-leg casting emphasized in Ponseti.^[85] This less standardized technique, historically used in some regions, risks complications like rocker-bottom deformity due to its focus on isolated component correction rather than simultaneous cavus and adduction management.^[86] Meta-analyses show Ponseti achieving higher initial correction rates (relative risk 1.23) and lower relapse (relative risk 0.50) than Kite, along with fewer required casts (mean difference -3.0).^[86] The Ponseti method demonstrates superiority over these alternatives through its evidence-based, protocol-driven approach, including Achilles tenotomy and standardized abduction bracing, which global comparative studies support with approximately 10-15% better correction rates and reduced long-term recurrence.^[84] For instance, a 2022 prospective study reported 90% correction and 8% recurrence with Ponseti versus 75% correction and 20% recurrence with French physiotherapy.^[84] Similarly, Ponseti's structured sequencing yields more predictable outcomes than Kite's variable application, minimizing overcorrection risks.^[86] Alternatives like the French or Kite methods may be employed in resource-limited settings where access to specialized casting materials or tenotomy procedures is unavailable, or for mild deformities where hybrid approaches suffice without full Ponseti bracing.^[87] In such cases, these methods offer accessible physiotherapy options but generally require closer monitoring to address higher relapse potential.^[88]

References

[1]
Clubfoot - Diagnosis and treatment - Mayo Clinic
Oct 19, 2024 · Stretching and casting, called the Ponseti method. · Moves your baby's foot into an improved position and then places it in a cast to hold it ...
[2]
The Ponseti Method for Clubfoot Correction - HSS
Mar 29, 2023 · The Ponseti method is a systematic series of casting and orthotic bracing treatments that permanently and nonsurgically corrects clubfoot in young children.
[3]
The Classic: Congenital Club Foot: The Results of Treatment - PMC
This Classic article is a reprint of the original work by Ignacio V. Ponseti and Eugene N. Smoley, Congenital Club Foot: The Results of Treatment.
[4]
The Ponseti method for the treatment of congenital club foot - NIH
The Ponseti method is not only a detailed method of manipulation and casting but also of preventing and treating relapse.
[5]
The life and legacy of Ignacio Ponseti - PMC - NIH
Based upon his improved understanding of clubfoot anatomy, he developed his nonoperative approach to clubfoot, which he began to utilize in 1948. In 1963, ...
[6]
Congenital Club Foot: The Results of Treatment - JBJS
Congenital Club Foot: The Results of Treatment ... PONSETI, IGNACIO V.; SMOLEY, EUGENE N. ... The Journal of Bone & Joint Surgery 45(2):p 261-344, March 1963.
[7]
congenital club foot: the results of treatment. 1963 - PubMed
This Classic article is a reprint of the original work by Ignacio V. Ponseti and Eugene N. Smoley, Congenital Club Foot: The Results of Treatment.
[8]
Best feet forward - Stories | The University of Iowa
Mar 12, 2019 · Ponseti published his first clubfoot paper in 1963 demonstrating that his early patients had flexible and pain-free feet. Later studies found ...Missing: original | Show results with:original
[9]
Radical Reduction in the Rate of Extensive Corrective Surgery for ...
Feb 1, 2004 · DISCUSSION. This study demonstrates that with the use of the Ponseti method, >95% of patients' idiopathic clubfoot can be corrected without the ...
[10]
The Ponseti Method: Steps and Technique for Clubfoot Treatment
This method provides full mobility in 95% of cases. It requires a series of casts to gently manipulate the feet, a simple outpatient procedure to release the ...
[11]
MiracleFeet on X: "What is @GlobalClubfoot? The Global Clubfoot ...
Mar 18, 2024 · The Global Clubfoot Initiative, founded in 2009, is a consortium of 35+ organizations working to increase access to clubfoot treatment.
[12]
Clubfoot - StatPearls - NCBI Bookshelf
Clubfoot is a congenital deformity of the foot, otherwise known as congenital talipes equinovarus. It is one of the most common congenital malformations.
[13]
Clubfoot (congenital talipes equinovarus) - Pediatrics - Orthobullets
Jan 10, 2024 · Etiology. Pathophysiology. muscle contractures contribute to the characteristic deformity that includes (CAVE). Cavus (tight intrinsics, FHL ...
[14]
Clubfoot (Talipes): Practice Essentials, Anatomy, Pathophysiology
May 15, 2023 · The true etiology of congenital clubfoot is unknown. Most infants who have clubfoot have no identifiable genetic, syndromal, or extrinsic cause.
[15]
Clubfoot | Select 5-Minute Pediatrics Topics - Unbound Medicine
ETIOLOGY · Most cases (80%) are idiopathic (multifactorial with genetic and environmental influences). · Remaining cases likely associated with associated ...
[16]
Update on Clubfoot: Etiology and Treatment - PMC - NIH
The importance of genes involved in early limb development was recently shown by the identification of a rare mutation in the transcription factor PITX1 in a ...Missing: percentage | Show results with:percentage
[17]
Diagnosis and Treatment of Idiopathic Congenital Clubfoot | Pediatrics
Jan 31, 2022 · Dr Ponseti first published his results in 1963. Of the 93 feet treated, 71% had a good result, 28% had a slight residual deformity, and only 1 ...
[18]
Clubfoot: Etiology and treatment - PMC - NIH
The posterior contractures include the tendo Achilles, tibiotalar capsule, talocalcaneal capsule, posterior talofibular ligament and calcaneofibular ligament.
[19]
Timing for Ponseti clubfoot management: does the age matter? 90 ...
Oct 18, 2018 · Age between 28 days and 3 months at start of treatment method was associated with fewer casts required, lower relapse rate, and lower final ICFSG score.
[20]
The role of the Pirani scoring system in the management of club foot ...
Aug 1, 2006 · The Pirani scoring system is reliable, quick, and easy to use, and provides a good forecast about the likely treatment for an individual foot.Missing: suitable | Show results with:suitable
[21]
The Correlation of Pirani and Dimeglio Scoring Systems for Ponseti ...
Nov 6, 2017 · In conclusion, our research confirmed that when the deformity of the clubfoot was mild and very severe, the initial Pirani or Dimeglio scoring ...Missing: suitable | Show results with:suitable
[22]
Can clubfoot scoring systems predict the number of casts and future ...
Apr 5, 2021 · Patients with severe and very severe idiopathic clubfoot undergoing Ponseti treatment were entered. Their initial Pirani and Dimeglio scores, ...Missing: suitable | Show results with:suitable
[23]
The effectiveness of the Ponseti method for treating clubfoot ... - NIH
The Ponseti method is an effective first-line treatment for arthrogrypotic clubfeet to achieve functional plantigrade feet. Children will often require more ...Missing: suitability | Show results with:suitability
[24]
Correction of Arthrogrypotic Clubfoot With a Modified Ponseti ... - NIH
Recently, the Ponseti method has been used to treat clubfeet associated with distal arthrogryposis syndromes. Boehm et al. [5] used the technique successfully ...Missing: suitability | Show results with:suitability
[25]
Diagnosing Clubfoot in Children - NYU Langone Health
Clubfoot is almost always diagnosed during a prenatal ultrasound—a technique that uses high-frequency sound waves to create images of babies in the womb.
[26]
[PDF] Clinical-Guidelines-for-the-Management-of-Clubfoot-Deformity ...
Nov 1, 2015 · Over-correction in valgus is a contraindication for the Ponseti Method. (A post-surgical valgus foot is one in which the entire foot is ...
[27]
Ponseti Method: Does Age at the Beginning of Treatment Make a ...
The Ponseti method is reportedly effective for treating clubfoot in children up to 9 years of age. However, whether age at the beginning of treatment influences ...
[28]
The Ponseti Method for the Treatment of Clubfeet Associated With ...
Clubfeet associated with ABS have higher rates of recurrence, a greater need for later surgery, and worse clinical outcomes than idiopathic clubfeet.
[29]
EVALUATION OF PONSETI METHOD IN SYNDROMIC CLUBFOOT ...
Jun 14, 2024 · Recurrence occurred in 35 (39%) children, with 18 (20%) needing surgical intervention. Conclusion: Ponseti casting is effective in correcting ...
[30]
Atypical Club Foot | Pediatric Orthopaedic Society of North ... - POSNA
Complications: Atypical clubfeet do not correct with the standard Ponseti method. Frequent cast slipping may cause foot edema, bruising, and skin breakdown.
[31]
Ponseti method - Physiopedia
The Ponseti Method is a conservative and manipulative method that is utilised worldwide to correct clubfoot or Congenital Talpes Equino Varus (CTEV)
[32]
Use of the Pirani score in monitoring progression of correction and ...
Jun 19, 2017 · The Pirani scoring system takes into consideration six different components of clubfoot deformity: posterior crease (PC), emptiness of the heel ...
[33]
Treatment of Idiopathic Clubfoot by Ponseti Technique of ...
Every clubfoot taken up for the study was graded according to the Pirani Severity score for hind foot, mid foot and total score & and also goniometric ...
[34]
[PDF] Treatment Of Congenital Clubfoot Using The Ponseti Method
b) “Older child” (= already walked at treatment start):. - Hold the correction for 1-2 minutes, then release and repeat 3-4 times. It will take 5-10 minutes per ...
[35]
Achilles Tenotomy - Physiopedia
In infants the tendon heals sufficiently in 3 weeks. Remember: In most cases after the Ponsetti Method, tenotomy is still needed.
[36]
Ponseti Method for Clubfoot in Children | NYU Langone Health
A minimally invasive treatment approach in which casts and braces are used to gradually correct the position of your baby's foot or feet.Weekly Casting · Percutaneous Achilles... · Dynamic Foot Braces<|separator|>
[37]
Clubfoot | Pediatric Orthopaedic Society of North America (POSNA)
Ponseti Method. The Ponseti method is based on gradual correction of the deformity with serial weekly long leg casting. The deformities are corrected in ...Missing: scale | Show results with:scale
[38]
The Ponseti Method for Clubfoot: What to Expect - Stanford Medicine ...
The Ponseti method is a nonsurgical treatment for clubfoot that uses casts and braces to help your child's foot function normally.
[39]
The Ponseti Method: Bracing Phase | Nemours KidsHealth
The bracing phase will last 2 to 5 years. A child will wear the brace all the time (except during baths) for about 3 months, and then only during naps and at ...Missing: contraindications limitations
[40]
Foot abduction brace in the Ponseti method for idiopathic clubfoot ...
The Ponseti method has shown to be effective in treating idiopathic clubfoot deformity. Application of a foot abduction brace is crucial to long term ...
[41]
Ponseti Sandals and Abduction Bar - Gillette Children's
This fixed position maintains a stretch on the feet, maintaining correction of both the Achilles tendon and ankle flexibility, and the tight structures on the ...
[42]
Exploring Bracing Adherence in Ponseti Treatment of Clubfoot - PMC
Jul 19, 2023 · Adhering to bracing for a minimum of two years was associated with improved outcomes, as non-adherent patients experienced 2.6 times the odds of deformity ...
[43]
Full article: Factors associated with adherence to bracing in Ponseti ...
Aug 7, 2024 · This systematic scoping review aimed to identify and synthesize factors associated with brace adherence and non-adherence in the Ponseti method.
[44]
[PDF] Current Concepts on Bracing in the Ponseti Method
The use of the abduction brace is essential to prevent relapse in patients treated with the Ponseti method. The type and brand of the brace are not important ...
[45]
Significance Of Pirani Score at Bracing-Implications for Recognizing ...
The Pirani scoring system works by assessing six clinical signs of contracture, which may score 0 (no deformity), 0.5 (moderate deformity) or 1(severe deformity) ...Missing: post- | Show results with:post-
[46]
The Efficacy of the Ponseti Method in the Management of Clubfoot
Jan 18, 2024 · The Ponseti method has a high success rate in the treatment of idiopathic clubfoot, and hence it is an excellent conservative method of treatment.
[47]
Prevalence and factors associated with relapse clubfoot treated by ...
The Ponseti method retains a rate of relapse between 10% and 20% (5,6). Relapse clubfoot is the recurrence of any of its above-mentioned four components after ...Introduction · Methods · Results · Discussion
[48]
The Ponseti Method for Clubfoot Treatment in Low and Middle ...
Aug 6, 2025 · The success rate of the Ponseti method was 82% for idiopathic ... Ponseti method, particularly in low-resource settings. View. Show ...Missing: 2020s | Show results with:2020s<|separator|>
[49]
Ponseti method compared with soft-tissue release for the ... - NIH
Jul 18, 2013 · CONCLUSION: The Ponseti method should be considered the initial treatment of idiopathic clubfeet, and open surgery should be reserved for ...Figure 3 · Functional Outcome · Radiographic Outcome
[50]
[PDF] Cost-effectiveness of club-foot treatment in low-income ... - Givewell
May 26, 2016 · In this study, we aimed to calculate the average cost-effectiveness ratio of the Ponseti method for correcting club foot in sub-Saharan Africa.
[51]
Cost-effectiveness of club-foot treatment in low-income and middle ...
May 26, 2016 · The average treatment cost using the Ponseti method is US$167. The cost-effectiveness ratio is US$22.46 per disability-adjusted life year ...
[52]
Do live-stream telemedicine follow-up appointments for a Ponseti ...
This initial study shows encouraging results for equivalence with the usual F2F assessment of a single TM appointment for confirmation of compliance, detection ...
[53]
Do live-stream telemedicine follow-up appointments for a Ponseti ...
Apr 17, 2023 · The use of TM for routine follow-up of Ponseti-treated clubfoot patients can be as clinically effective as F2F assessment, and has potential ...
[54]
Factors associated with the relapse in Ponseti treated congenital ...
Jan 26, 2022 · The average follow–up period was 7.27 ± 1.29 years (from 5 to 10 years). The rate of relapse was 21.6% (32 cases) at the end of the follow-up.<|control11|><|separator|>
[55]
Long-term outcomes of the Ponseti method for treatment of clubfoot
Aug 20, 2021 · Long-term follow-up of infants with primary idiopathic clubfeet treated by the Ponseti method revealed relatively high relapse and additional surgery rates.
[56]
Narrative Review of the objective analysis of long-term outcome of ...
This article summarizes the experience from Dallas treating idiopathic clubfeet using the Ponseti technique, and is based on previously published studies.
[57]
Long-term Results of Comprehensive Clubfoot Release Versus the ...
Nov 19, 2013 · Our study showed that the biomechanical function and long-term outcomes of young adults treated with the Ponseti method more closely compare ...
[58]
Prevalence and Risk Factors for Leg Length Discrepancy in ...
Apr 1, 2025 · Conclusion: This study reported a prevalence of LLD in 14.4% of children with idiopathic clubfoot treated with Ponseti casting. LLD prevalence ...
[59]
Leg Length Discrepancy in Unilateral Congenital Clubfoot Following ...
Three patients who underwent extensive posterior, medial and lateral release were noted to have an average discrepancy in foot height of 2.1 centimeters.Missing: bilateral | Show results with:bilateral<|control11|><|separator|>
[60]
Africa Clubfoot Training Program Empowers Ponseti Providers
Apr 26, 2018 · The Africa Clubfoot Training (ACT) project began in 2015 as a way to provide streamlined, standardized training in the Ponseti method of clubfoot treatment.
[61]
Training at MiracleFeet
The Ponseti method is well-suited to scaling in low-resource settings because it requires only basic treatment supplies and is relatively straightforward to ...
[62]
Improved bracing compliance in children with clubfeet using a ... - NIH
Non-compliance with foot abduction bracing in children with clubfeet treated with the Ponseti method is the leading risk factor for deformity recurrence.
[63]
Clubfoot treatment with Ponseti method relies on teamwork, family ...
Jan 31, 2022 · Phase 1 is a specific casting technique that should be started soon after the baby leaves the newborn nursery around 1-3 weeks of age. The casts ...Missing: original paper
[64]
Repeating Ponseti method for treating relapsed idiopathic ...
Mar 15, 2025 · Repeating of Ponseti technique is very effective in management of relapsed deformities of idiopathic CTEV in children less than two years of age ...
[65]
Management of Clubfoot Relapses With the Ponseti Method - PubMed
Manipulation and cast treatment alone (55%) and cast treatment with tenotomy (23%) were reported as the 2 most common initial treatment approaches for a ...
[66]
MRI recovery of the Achilles tendon after percutaneous tenotomy in ...
Apr 13, 2021 · Clubfoot has a strong tendency to relapse in which case the Ponseti method can be applied again and Achilles tenotomy is performed for a second ...
[67]
Pearls to Address Challenges in Initial Casting Treatment for ...
In order to prevent slippage in complex clubfeet, Ponseti et al. emphasize casting with hyperflexion of the metatarsals and >110 degrees of knee flexion [40].
[68]
Bracing Tips | Ponseti International Association
Relapses and Bracing for Children Treated with the Ponseti Method Approved by Dr. Jose A Morcuende, President and CEO of the Ponseti International ...
[69]
Syndromic clubfoot beyond arthrogryposis and myelomeningocele
The Ponseti method effectiveness has been demonstrated in arthrogryposis and myelomeningocele clubfoot. There are few clinical studies demonstrating the ...Missing: suitability | Show results with:suitability
[70]
Clubfoot (Talipes) Treatment & Management - Medscape Reference
May 15, 2023 · Mobilize and expose the tendons of the tibialis posterior, FDL, FHL, Achilles tendon, and posterior NV bundle.
[71]
[McKay operation in the correction of rigid clubfoot] - PubMed
It was considered that the favorable time for operation was when the child being 6 to 18 months old. ... MeSH terms. Child; Child, Preschool; Clubfoot / ...
[72]
Ponseti Method
Surgery in the clubfoot is invariably followed by scarring, stiffness and muscle weakness which becomes more severe and disabling after adolescence. The ...Missing: complications | Show results with:complications
[73]
Ponseti method is superior to surgical treatment in clubfoot
Aug 10, 2025 · Ponseti group had more favorable long-term outcomes according to the FRS (p = 0.005), higher ICFSG, scores for morphology (p = 0.021), function ...
[74]
The Ponseti Method vs. Surgical Treatment for Idiopathic Clubfoot
Nov 26, 2024 · The data indicate that the Ponseti method results in better outcomes in terms of mobility, walking capabilities, and overall quality of life.
[75]
MiracleFeet: Providing Clubfoot Treatment to Children
Treatment costs only $500 on average and provides hope and opportunity for children and their families. Few investments have this level of impact on a child's ...Missing: surgery | Show results with:surgery
[76]
Comparison of hospital costs and duration of treatment with two ...
Aug 7, 2025 · The cost of treating clubfoot varies by country and can range from $170 to $30,000 [22]. As the total number of plaster casts increases, the ...
[77]
What Proportion of Patients Need Extensive Surgery After Failure of ...
Correction was achieved and maintained in 90% (65 of 72) of the feet; 10% (seven of 72) of the treated feet did not improve and needed subsequent surgery.
[78]
Treatment of relapsed, residual and neglected clubfoot - NIH
However, even Ponseti himself routinely used surgery for certain patients: at least 90% of feet need percutaneous tenotomy, and 15% to 40% may require tibialis ...
[79]
Long-term outcomes of atypical clubfoot treated with the Ponseti ...
Aug 7, 2025 · Results Relapses requiring re-operation occurred in 51 children (83 feet) that amounted to 48.1 % of the total atypical clubfoot cases treated ...
[80]
Ponseti method is superior to surgical treatment in clubfoot
These results suggest that the Ponseti method provides superior long-term outcomes for idiopathic clubfoot deformity.Missing: free | Show results with:free
[81]
Comparison of Ponseti Versus Surgical Treatment in Congenital ...
The relapse rate for Ponseti versus surgery was 18.2% versus 0% for grade 2, 36.2% versus 20.4% for grade 3, and 35.3% versus 65.4% for grade 4, respectively.<|control11|><|separator|>
[82]
Comparison of different conservative treatments for idiopathic clubfoot
This meta-analysis suggests that the application of Ponseti's method appears to yield a lower likelihood of the need for major clubfoot surgery. Although we ...
[83]
Clubfoot Treatment: Ponseti and French Functional Methods ... - NIH
The purpose of our review is to summarize the previously reported TSRH experience of nonoperative clubfoot treatment using both the Ponseti method and the ...
[84]
[PDF] comparative study of ponseti method versus french functional ...
The Ponseti method showed a significantly lower recurrence rate (8%) compared to the French method ... Clubfoot recurrence rates between different treatment ...<|control11|><|separator|>
[85]
the Ponseti method and the French functional (physiotherapy) method
The initial correction rates were 94.4% for the Ponseti method and 95% for the French functional method. Relapses occurred in 37% of the feet that had initially ...
[86]
Comparison of Ponseti and Kite's method of treatment for idiopathic ...
... Ponseti method of manipulation and casting was superior in reduction and correction of clubfoot deformity as compared to the Kite method of manipulation and ...
[87]
Kite Versus Ponseti Method in the Treatment of Idiopathic ...
Jun 24, 2024 · Kite and Ponseti methods are two popular manipulating methods for correcting the deformity of idiopathic congenital clubfoot.
[88]
Management of Clubfoot - Physiopedia
A Comparison of Two Nonoperative Methods of Idiopathic Clubfoot Correction: The Ponseti Method and the French Functional (Physiotherapy) Method. J Bone ...<|control11|><|separator|>
[89]
The functional method: experience from the Robert Debré Hospital
Clubfoot treatment: Ponseti and French functional methods are equally effective. Clin Orthop Relat Res 2009;467:1278-82. [Crossref] [PubMed]; Canavese F ...Introduction · Methods · Results · Discussion