Treatment Strategies

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The recommended treatment for clubfoot for many years was a surgery to release the posterior medial tendon. Unfortunately, relapses were common and were treated with further surgery similar to the initial surgery. In the 1940s, Dr. Ignacio Ponseti made some astute observations when performing the postural medial release. He noticed that the ligaments of the tarsus (bones between the tibia and fibula of the lower leg and the metatarsals of the toes) had to be severed to loosen them in order to move the foot into the proper position. In performing relapse surgeries, Dr. Ponseti observed that extensive scar tissue existed in the very ligaments that needed to be loosened. Furthermore, the posterior tibial tendon and toe flexor tendons (which were released in the initial corrective surgery) were often adhered and immobilized in the massive scar tissue from the first surgery. After a few years of repeatedly observing the same scenario, he was certain that a better option could be developed. In the years to follow, Dr. Ponseti developed his alternative technique which was first published in March, 1963, in the Journal of Bone and Joint Surgery. Unfortunately, the article was almost completely disregarded by the orthopedic community. His method did not receive acceptance until he published a long-term follow-up study in 1995 and a book in 1996.

At the Paley Institute, we treat clubfoot using the Ponseti Method at our Clubfoot Clinic in our Rehabilitation Department.

The Ponseti Method

The Ponseti Method of clubfoot correction consists of manipulation of the foot by abducting the foot (toward the outside of the body) in supination (foot rolled outward) while applying counter pressure over the side of the head of the talus (ankle bone) to prevent rotation of the talus in the ankle. All components of clubfoot deformity are corrected simultaneously, except for the ankle equinus (limited ability to pull the foot upwards).

Manipulation is performed for approximately one minute followed by application of a well-molded, long-leg plaster cast. The manipulation and casting is performed by two Paley Institute physical therapists who have been specially trained in the Ponseti Method. Casts are worn for five to seven days and are removed in the Physical Therapy Department minutes before the next manipulation and cast is applied. Most cases of clubfoot are reduced in 5 to 7 casts. For more information on casting, please see Cast Care Instructions.

Approximately 80 percent of clubfoot infants require an Achilles tendon tenotomy to complete correction. The Achilles tenotomy corrects the equinus of the ankle.

Achilles Tenotomy

A tenotomy is a minor surgical procedure that involves cutting the tendon of a shortened or deformed tendon in order to restore normal length. In the case of clubfoot, the tendon to be cut is the Achilles tendon located at the back of the heel. It is also known as the heel cord.

Achilles tenotomy is indicated to correct the equinus of the ankle and will allow the patient to pull their foot upwards. The tenotomy is performed after all the other components have been corrected via Ponseti casting. The foot should be able to fully abduct (move toward the outside of the body) to 60 degrees prior to the tenotomy. The tenotomy will allow the ankle to dorsiflex (bend upwards) 15 to 20 degrees following the final casting.

The tenotomy is a minor outpatient procedure that we perform under local anesthetic in the office. A numbing cream is applied to the patient’s heels one hour prior to the procedure, with an occlusive bandage covering the cream to keep it in position. At this time, x-rays are taken of the patient. Most parents prefer to wait in the waiting room during the actual procedure. Your baby will be well-cared for and prepared by the Paley Institute staff. Once the skin is numb one hour after application of the cream, the surgeon will inject numbing medication around the Achilles tendon in preparation for the tenotomy. He will then perform the tenotomy with an incision of approximately 1/4 inch which will be closed with a single stitch afterwards. If both feet are undergoing tenotomy, the surgeon will continue to the other foot.

After the tenotomy is complete, the physical therapists will apply the final long-leg plaster cast. They will now be able to dorsiflex (bring upwards) the foot by 15 to 20 degrees for full correction. Our staff will bring you into the room to be with your child while the casts are applied. The casts will remain for three weeks to allow full healing.


The final stage of clubfoot correction is the bracing phase. Prior to application of the last cast, the patient is measured for boots and bar for bracing. Following removal of the last cast, the family is instructed on donning and doffing the boots and bar.

The goal of the boots and bar is to maintain the correction (60 to 70 degrees of abduction and 10 to 15 degrees of dorsiflexion). The brace will be worn 23 hours per day for three months after the last cast is removed. After three months and no sign of relapse, the boots and bar are worn during resting and relaxing for 15 to 17 hours per day until the child reaches three to five years of age. Follow up at the Paley Institute is recommended every three months during the first two years of bracing, every six months after the second year of bracing, and yearly once out of the brace.

For more information, see Boots & Bar FAQs.

Anterior Tibial Tendon Transfer

Once correction has been achieved through manipulation and serial casting, maintenance of correction requires bracing full-time and gradually fades to sleeping or resting only until age 4 or 5. Approximately 20 percent of the children who have achieved full correction with the Ponseti Method will require the anterior tibial tendon transfer to correct relapsing congenital clubfeet.

In relapsing clubfeet, the dorsiflexion/eversion activity of the tibialis anterior muscle is suppressed and the muscle functions as an invertor of the mid and forefoot. In order to permanently correct this, a relatively minor procedure is performed under general anesthesia to transfer the tibialis anterior tendon laterally to the third cuneiform underneath the extensor retinaculum. This procedure restores the normal function of the muscle to perform dorsiflexion/eversion preventing further relapses in most cases. This treatment converts the tibialis anterior muscle from an inversion force to an eversion force of the mid and forefoot thus correcting dynamic supination of the foot during gait. The goal is to correct the deformity before it becomes fixed. The anterior tibial transfer procedure will require a 23-hour hospital admission followed by 6 week cast post-operatively. Many studies have demonstrated excellent results with long-term maintenance of correction of the relapsed clubfoot after the anterior tibial tendon transfer procedure.

In order for the procedure to be successful, your child must demonstrate radiographically ossified cuneiform bones in the foot. The ideal age for the procedure is after age four. An analysis of your child’s walking pattern will help determine if he or she is a good candidate.