Overview
Almost all orthopaedists agree that idiopathic clubfoot (talipes equinocavovarus) should first be treated nonoperatively, and that earlier treatment is more successful because the newborn foot is viscoelastic. Neonatal surgical release tends to produce a scarred, stiff foot. Ponseti's method of weekly manipulation and casting relaxes collagen and remodels joint surfaces without fibrosis; when begun within the first month of life, posteromedial and lateral release is avoided in more than 95% of cases. It is still worth attempting in older infants (7 to 10 months) to reduce the extent of later surgery. (Tachdjian)
Pathoanatomy (Tachdjian)
The talus is dysmorphic: small, poorly seated body, a short neck deviated medially and plantarward with a markedly decreased neck-body angle (normal 150 to 160 degrees), and absent, fused or misshapen anterior and middle subtalar facets. The navicular is subluxated medially on the talar head, and the calcaneus is internally rotated and inverted beneath the talus (medial spin of the calcaneopedal block). Ponseti emphasized the cavus component, which governs the order of nonoperative correction.
Assessment (Tachdjian)
Identify syndromic or nonidiopathic clubfeet (arthrogryposis, diastrophic dysplasia, Möbius or Freeman-Sheldon syndromes, spina bifida, fetal alcohol syndrome). They resist correction and recur; surgery should be expected despite reports of Ponseti success.
Grade severity before treatment for prognosis and monitoring. The authors favor the Dimeglio score: equinus, heel varus, rotation of the calcaneopedal block and forefoot adductus are each scored 4 to 1 by reducibility, plus 1 point each for posterior crease, medial crease, cavus and poor muscle condition (grades I benign to IV very severe). The initial score predicts outcome at 2 years.
Hip dysplasia occurs in under 1% of idiopathic clubfeet, so routine hip radiographs are probably not warranted.
Ponseti Casting Technique (Tachdjian)
The acronym CAVE (cavus, adductus, varus, equinus) gives the order of correction.
Schedule. Manipulate for 1 to 3 minutes and apply a well-molded long-leg plaster cast (toes to upper thigh, knee at 90 degrees) every 5 to 7 days. Five or six casts correct most feet. Cast during feeding to relax the infant. Use thin cotton padding, no benzoin and no fiberglass (poor molding); avoid pressure over the heel and malleoli and leave a plaster platform under the toes.
Cavus first. Supinate the forefoot and elevate the first metatarsal relative to the hindfoot (never pronate it). Cavus is almost always corrected in the first cast.
Adductus and varus together. Abduct the foot, kept in slight supination, under the talus while the thumb applies counterpressure on the lateral talar head. This gradually displaces the navicular, cuboid and calcaneus laterally.
Keep the forefoot in slight supination to preserve cavus correction and metatarsal collinearity.
Do not touch or constrain the heel and do not dorsiflex prematurely: abduction in equinus lets the calcaneus abduct and evert under the talus.
Place counterpressure on the talar head, not on the calcaneocuboid joint, which would block hindfoot correction.
Gradually reduce supination with each cast while increasing abduction.
Equinus last. Correct it once the hindfoot is neutral to slightly valgus and the foot is abducted about 70 degrees relative to the leg. Dorsiflex with pressure under the whole sole, not the metatarsal heads, to avoid rocker-bottom deformity.
Percutaneous Achilles Tenotomy (Tachdjian)
Needed in at least 85% of patients and safe up to 1 year without overlengthening or weakness. It can be done in clinic under topical anesthetic cream applied for 30 minutes, or in the operating room in older, stronger infants.
After sterile preparation, an assistant holds the foot in mild to moderate dorsiflexion (excess tension makes the tendon hard to palpate).
Enter along the medial border of the tendon 0.5 to 1 cm proximal to its insertion (the calcaneus sits high in the fat pad).
Pass the blade medial to and under the tendon, and press the tendon onto the blade with the opposite index finger. Avoid excessive lateral motion (lesser saphenous vein and sural nerve).
A palpable pop and 15 to 20 degrees of additional dorsiflexion confirm complete transection. No sutures are needed.
Apply a long-leg cast in maximal dorsiflexion with 70 degrees of abduction for 3 weeks (up to 4 weeks after 6 months of age).
Foot Abduction Orthosis (Tachdjian)
After the last cast, fit straight-last open-toe shoes on a bar at shoulder width, with the affected foot in 70 degrees of external rotation and 5 to 10 degrees of dorsiflexion (normal foot at 40 degrees in unilateral cases).
Wear full time for at least 3 to 4 months, then at naps and night for 2 to 4 years. Flexible bars may improve compliance.
Examine the feet several times a day during the first week; heel counter and tongue liners improve fit. Noncompliance is the main cause of recurrence, and without the brace recurrence is inevitable.
Results and Recurrence (Tachdjian)
About 95% achieve satisfactory initial correction. Partial recurrence occurs in about one third of feet within 2 to 3 years, usually from poor brace compliance or late treatment; at 5 years, 32% to 35% need some surgery.
Early relapse can be salvaged by repeat casting in about one third. The remainder need selective surgery, usually not before 18 months: repeat heel cord lengthening, posterior ankle release or plantar fascia release; extensive posteromedial-lateral release is rarely necessary.
Dynamic supination after 2 to 3 years from tibialis anterior overpull: after brief repeat casting, transfer the tibialis anterior to the third (lateral) cuneiform, leaving it under the extensor retinaculum to avoid bowstringing, with Achilles Z-lengthening if equinus has recurred.
Gait studies show near-normal sagittal ankle motion in many children but reduced total arc, plantarflexion and push-off strength compared with normal feet.
Pitfalls (Tachdjian)
Pronating the forefoot to correct cavus, applying counterpressure at the calcaneocuboid joint, or dorsiflexing before hindfoot varus is corrected can produce a rocker-bottom deformity or incomplete correction.
Abduction less than about 70 degrees in the final cast and brace favors recurrence.
Additional Detail from Campbell
Epidemiology (Campbell)
Incidence is about 1 per 1000 live births. Most cases are sporadic, though autosomal dominant families with incomplete penetrance exist. About 50% are bilateral, and severity and treatment response correlate closely between the two feet. Associated factors include parental smoking, maternal obesity, family history, amniocentesis and some SSRIs. Studies show no correlation with DDH, so clinical hip screening is sufficient. Clubfoot often coexists with internal tibial torsion.
Pirani score (Campbell)
Six examination signs, each scored 0 (normal), 0.5 (moderate) or 1 (severe), for a maximum of 6. Midfoot: curved lateral border, medial crease, lateral head of talus coverage. Hindfoot: posterior crease, rigid equinus, empty heel. Both Pirani and Dimeglio scores have good interobserver reliability after a learning phase, correlate with radiographs and help document prognosis and recurrence.
Practical points (Campbell's Concepts)
Success rates above 90% are reported in children 2 years and younger, even after failed previous nonoperative treatment, and the method is reproducible in developing nations. Recurrence after Ponseti casting is reported at 10% to 30%, and is higher in syndromic clubfeet; nonoperative treatment remains first-line even in older or syndromic children.
Start ideally within the first 4 weeks of life. Accelerated (twice-weekly) casting and fiberglass casts give comparable results. Trained nonsurgeon providers can perform casting.
Apply each cast in two stages, below the knee first and then above the knee once set. Long-leg casts maintain the external rotation force under the talus and prevent slippage.
Derotate the forefoot about the talus, not the calcaneocuboid joint, and do not manipulate the heel directly. Maintain forefoot supination to avoid premature calcaneal eversion.
For percutaneous tenotomy, a rounded Beaver eye blade helps avoid injury to the peroneal artery and lesser saphenous vein.
Final cast: about 70 degrees of abduction and 15 degrees of dorsiflexion for 3 weeks.
Brace: shoes on a bar at 70 degrees of external rotation and 15 degrees of dorsiflexion, about 1 inch wider than shoulder width; 23 hours a day for 3 months, then during sleep for 3 to 4 years. Bilateral braces are superior to unilateral ones, and bracing to age 4 may be better than stopping at 3. Monitored wear declines over time, so frequent follow-up is essential.
Recurrence algorithm (Campbell)
Repeat Ponseti casting for recurrence. Dynamic supination between 3 and 8 years is treated with tibialis anterior tendon transfer. Rigid recurrence may need à la carte releases; persistent recurrence may require talectomy, fusion, osteotomies (such as medial cuneiform opening and cuboid closing wedges for residual forefoot adduction), Ilizarov correction or guided growth.
References
Herring JA, ed. Disorders of the foot. In: Tachdjian's Pediatric Orthopaedics. Philadelphia: Elsevier. Chapter 19, Congenital clubfoot.
Kelly DM. Congenital anomalies of the lower extremity. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 31, Congenital clubfoot.