Clubfoot.Clubfoot is a complex deformity of one or both feet that is present at birth. This condition affects one in 1,000 newborns.  

In the past, surgery was used to make the foot straight. Today most patients are started in casting shortly after birth.

Some children are born with clubfeet due to nerve or muscle problems. For most children, the cause is unknown (idiopathic) although the nerves and muscles in the involved leg(s) may still be somewhat abnormal.

Most clubfeet have no known cause and respond well to casting. Other types of clubfeet, called complex clubfoot, are harder to correct.  Sometimes clubfeet are linked with conditions such as spina bifida, arthrogryposis (arth-ro-grip-OH-sis) or other genetic abnormalities. These feet are harder to correct and the clubfoot is more likely to recur.

The only way to determine the severity of clubfoot is to see how easily it is corrected.  Some feet look “severe,” but correct easily; others look like they should be easy to correct but are not.  

When a clubfoot is seen on the 20-week ultrasound, there is an 80 percent to 90 percent chance that your child will be born with a clubfoot.  Around 50 percent of children who were found to have a clubfoot on the 20-week ultrasound will have other issues found at birth; most often heart, neurologic and/or genitor-urinary, or a syndrome that causes clubfoot.

Roughly one in 1,000 children is born with clubfoot.  If a close relative (like a parent or sibling) has a clubfoot, the rate increases to about one in 100.

What do we do after our child is born?

  • Have the doctor perform a full exam on your child. 
  • The most important thing is to treat your baby like any other child – feed, bathe and play with them. 
  • If breastfeeding, once your child is breastfeeding well, start giving them a bottle once a day in preparation for casting. 
  • Contact our clinic after you go home to schedule your first appointment.

We use casting to correct the feet.  Before casting begins, your child should be healthy and gaining weight.  Breastfeeding should be well established.  Typically, we start casting when your child is around 2 to 3 weeks old.  If this needs to be delayed because of other issues, don’t worry. Most children have good results no matter when casting is started.

Timeframe for casting:

Step 1: Long leg casts are applied when your child is around 2 weeks old.

Step 2: These casts are changed every week for four to 10 weeks.

Step 3: The heel cord is cut and a final cast is placed for three to four more weeks.

Step 4: After this last cast is removed, your child is fitted for a foot-abduction-brace, which is worn full time for at least three months. 

How is the casting performed?

First, the foot is gently stretched and a cast is applied to hold the foot in the stretched position.  More plaster is added to the upper leg to make the cast a long leg cast that goes from the toes to the upper thigh.  This helps keep the cast in place. 

Every week, the cast is removed, the foot is stretched, and a new cast is applied.  For older children, the casts are usually changed every two weeks.

Casting is not easy in infants and small children.  Ideally, children should be relaxed and calm.  Feeding them with a bottle helps, so breastfed infants should be given a bottle on a daily basis once breastfeeding is established.  Not feeding children right before leaving home also makes it more likely they will be hungry and take a bottle during casting.

Your child may appear uncomfortable during the procedure, but the casting itself is not painful.  Children may be unhappy since they are not able to move their legs, and the longer your child is in the casts, the more sensitive their feet become.  You will notice that they will actually become calmer once the lower portion of the cast is put on.

For older children, bring along some toys (make sure they have something they can play with while lying on their back). Giving them something to eat and drink while you are waiting may also keep them from getting fussy before we start casting.

Follow-Up after Casting

Your child will be seen every one to two months during this time. 

If the foot / feet remain fully corrected, your child will continue with a brace, primarily at night, until they are at least 4 years old.  Over this time, you will see the doctor every three to six months. 

  • Wearing the bar and shoes as instructed is essential to reduce the chance that the clubfoot will recur.  If the clubfoot recurs, we will try to correct it with casting.
  • Many children require some surgery to obtain the best correction, but repeated or more severe recurrences often require bigger surgeries.

Potential Problems with Casting

Casting is a gentle and safe method of correction, but casts that are too tight or that become loose can cause problems. 

  • Call the clinic and talk with the orthopaedic resident on-call if your child:
    • Is fussy for more than 36 hours after the cast is placed.  It may be too tight or too loose.
  • Go to the closest Emergency Room to have the cast removed for any of the following. Be sure to tell whoever removes the cast that it is thin and there is very little padding.  You do not want your child to be cut or nicked when the casts are removed. 
    • Toes on cast foot become white or purple. This means the cast is too tight.
    • Toes that sink back into the cast and you are unable to see them. Sores might develop. 

Call our clinic first thing in the morning to schedule a time to replace the cast. 

  • If you have concerns about your child’s cast, go the Emergency Room to have the cast removed – it is always easier to put on a new cast than fix a more serious problem.

Cast Care and Daily Concerns

  • Check the circulation in the foot every hour for the first 12 hours after new cast application. After that, check it four times a day – morning, noon, dinner and bedtime. To check the circulation:
    • Pinch the toes and watch the return flow of blood.  The toe will turn white and then quickly return to pink if the blood flow is good to the foot. 
    • Compare this with the other foot if it seems delayed to you.
    • If toes are dark and cold, or are very white, the cast may be too tight.  If this occurs, have the cast checked at the Orthopaedic Cast Clinic or by the local doctor or emergency room immediately.  Call our clinic to talk to the orthopaedic nurse or the orthopaedic resident on-call to find out what to do.
  • Make sure you can always see the toes on the casted foot.   If you cannot see the toes, it may mean the cast has slipped and correct reduction is not being maintained. 
    • Call the Orthopaedic Clinic immediately so we can change the cast.
  • Keep the cast clean and dry.  You can wipe the cast with a slightly dampened cloth if it becomes soiled. 
  • Place the cast on a soft surface for the first 24 hours − it takes this long for the cast to completely dry.  This prevents pressure on the heel, which could cause a sore.
  • Change diapers often to prevent cast soiling.  Apply the diaper above the top of the cast to prevent urine from getting inside the cast.  Disposable diapers with elasticized legs works the best, but cloth diapers work fine if watched closely and changed as soon as they become wet.

In 95 percent of cases, a small procedure where the Achilles tendon or heel cord on your baby is cut is needed to make sure the foot is fully corrected.  The tendon always grows back and this procedure does not appear to affect your child’s long-term function in any way.  Most children have this procedure done in clinic, but some children may need to go to the operating room to have it done.

What does cutting the heel cord involve?

The skin is numbed with the same type of medicine your dentist uses. A small cut is made to the heel cord.   After this procedure, we will apply another cast for three weeks to allow healing of the tendon. 

The first night after the procedure you may notice some blood on the cast; this is not a sign of problems and is normally expected.  The only risk to this procedure is infection, which is quite rare.  However, if your child develops a high fever and has a smelly cast, you should call the office immediately.

After the final cast has been removed, your child will receive a foot-abduction-brace (bar and shoes).  They will need to wear the brace full time (at least 23 hours per day) for at least three months.  You can remove the brace to bathe your child and during any stretching exercises prescribed by the doctor.

  • Your child’s feet may be very sensitive since they have had casts for most of their whole life.  For the first week, the bar and shoes should be removed at every diaper change to look for sores and to massage the feet.  If any red spots are seen that do not go away after five minutes, the shoes need to be adjusted by an orthotist within a day or two.

After at least three months of full-time bar and shoe wear, the time in the brace is gradually decreased to 16 hours per day.  Some children may need to continue full-time wear longer, depending on the type of clubfoot the child has or how it is doing while in the bar and shoes.  Part-time wear (16 hours per day) continues until 4 years of age.  If your child has complex clubfeet, longer full-time wear and part-time wear are necessary.  As your child grows, we will modify the braces and shoes to fit.

Clubfeet will recur if the bar and shoes are not worn as prescribed and may require major reconstructive surgery.

Recurrence of part of the clubfoot deformity is possible until 5 years old, although it may rarely occur up to age 8.  We recommend that you use your braces as prescribed and attend your clinic appointments at least until kindergarten.

Call your doctor or the clinic nurse if you notice any of the following:

  • Any drainage on the cast
  • Any foul-smelling odors coming from inside the cast
  • The skin at the edges of the cast becomes very red, sore, or irritated.  A mild amount of irritation may be present and we suggest placing cotton around the margins of the cast to pad the irritating areas.
  • Fever over 100.4° F (38° C) or higher without an explainable reason, such as virus or a cold
  • If your child remains irritable without any explainable reason 36 hours after cast application
  • If, after the heel cord is cut, the spot of blood gets bigger than 1 inch or stays red more than 24 hours
  • Check your child’s toes for any sores if they are in bar and shoes.

More than 95 percent of children with clubfoot will be corrected with initial casting.  However, even when the foot is fully corrected with casting and the heel cord procedure, 20 percent of children may require additional, smaller surgeries for best correction.  These surgeries are typically performed around 3 years old.

Recently a long-term follow-up study (25 to 42 years) of patients from Iowa treated with this technique was reported.  In this study there were no differences in adults treated for their clubfoot with casting as a child when compared with a group of normal people without clubfoot.

Less than one in 20 children will not respond to this technique and will require reconstructive foot surgery at about 1 year of age.  This surgery is also highly successful and is the best option for feet that do not respond to the technique of Ponseti.

> Watch a video: Ponseti Method for Clubfoot

With early expert treatment, most children with even severe clubfoot can grow up to wear regular shoes, take part in sports and lead full, active lives.  However, the affected foot is generally ½ to 1½ shoe sizes smaller than the unaffected one, and the calf is slightly thinner.  The differences are minimal and have no impact on function.

Last Updated 11/2015