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Division of Orthopaedics

Clubfoot Program

What is Clubfoot?

Clubfoot is a condition that causes the lower leg, ankle and foot to be turned inward and pointed down. The deformity occurs during early development of the fetus and is present at birth. It affects 1-2 children for every 1000 live births. Clubfoot can run in families. The cause is multifactorial, including genetic, though the responsible gene(s) has not yet been found. Other names for idiopathic clubfoot include congenital clubfoot and Talipes Equinovarus.

The deformity can occur in one or both feet and is twice as common in boys as it is in girls. Because the muscles, tendons and bones have been growing in an abnormal position, the foot is often quite rigid and requires several stages of treatment.

The standard of care treatment globally, and our practice in the SickKids Clubfoot Clinic, is the Ponseti Method of casting, a minor surgical procedure and bracing. Ideally, treatment should begin in the weeks soon after birth, after you and your baby are comfortably settled at home. 

Broadly, there are three stages:

1) Weekly Ponseti stretching and casting of the foot and leg
2) A minor surgical procedure to the Achilles tendon
3) Bracing to hold the corrected position

Visit our Clubfoot Clinic page for more information about location, registration, appointments and more. 

Stages of treatment

Stage 1: Casting

The first part of treatment involves a specific series of gentle stretching and casting of the affected foot/feet to gradually correct the alignment. This is often referred to as manipulation and casting. The treatment is performed by a physical therapist or orthopaedic surgeon trained in the Ponseti Method.

Casting ideally starts within 4 weeks of birth and repeated every 1-2 weeks, for an average of
4-7 weeks. The number of casts can depend on the stiffness of the foot, age of the infant or child, and skin condition and response to casting.

The stretching and casts do not hurt the baby as they are done gently. Each infant will respond differently to the casting, but as the babies get used to their casts they may be a little fussy for 1-2 days after casting.

View our parent information sheet for Cast Care.

Stage 2: Achilles Tendon Tenotomy (Release)

The casting corrects the foot alignment, but in the majority of infants the Achilles tendon (where the calf muscle attaches to the heel) is too strong and prevents full upward motion of ankle. As the Achilles tendon is very tight, it is recommended to surgically release/cut it, rather than continuing to put force on the foot with casting. Over 90% of babies will require this.

The procedure is done by the orthopaedic surgeon in the clinic under local anaesthetic. It involves a very small incision at the back of the ankle, and does not require stitches. Babies are very comfortable after the procedure and do not need pain medicine. After the tendon is released, the foot will be casted in the fully corrected position for 3 weeks. Infants over 6 months of age typically require the procedure in the operating room under general anaesthetic.

Stage 3: Bracing

When the infant’s foot is fully corrected, he or she will need to wear a brace to maintain its good position. The bracing phase is essential for preventing the deformity from returning and success is dependent on the parents developing a good routine for brace wear!

The brace is called Boots and Bar (B&B). Learn more about maintenance using a B&B brace, on AboutKidsHealth.ca.  It includes 2 boots attached to a bar that holds the feet shoulder-width apart and turned outward, away from the body. This position is natural and comfortable for the baby and prevents the previously tight muscles from pulling the foot back in a downward and inward position. There are several versions of this brace available on the market and your physical therapist and surgeon will discuss the options available to you and approximate costs.

Your child will need to wear these 23 hours at a time for the first 3 months. If the foot shape remains well corrected, brace wear is then decreased to nighttime only aiming for 12-15 hours. The casting, tenotomy, and full-time bracing stages are typically completed within 6 months. The child will continue to wear the brace at nighttime only until 4-5 years of age. Bracing is necessary for all patients and is essential to prevent relapse of the deformity. Most children will not require any special footwear or bracing for daily function.

The majority of infants with idiopathic clubfoot will experience normal developmental milestones during and following treatment. The average child with idiopathic clubfoot walks by 18 months of age. This is within the normal time frame for all healthy children.

Response to Treatment

The Ponseti Method is considered the most effective treatment of idiopathic clubfoot. As each clubfoot is unique, so will be its response to each phase of treatment. Some clubfeet are more flexible yet others are more rigid, requiring more casts than initially predicted or possibly recasting during later phases of treatment. A small percentage of children may require surgery at some stage in the child’s treatment if the foot is not correcting well with casting.

Attending all appointments and commitment to keeping casts and braces on as prescribed are important to achieve and maintain correction of the foot deformity.

Regardless of the severity of the clubfoot, the goal and result of treatment is to achieve a functional and painless foot with good alignment. The affected clubfoot is typically a little smaller than the normal foot and the calf muscle may develop slightly smaller. The affected leg may also be slightly shorter and may toe-in slightly. If both feet are involved, they are usually symmetric. None of these differences will cause pain or affect the child’s growth or function. Your child should be able to walk and run normally and to participate in most physical activities.

Our Clinic and Team

Our clinic team consists of surgeons, physiotherapists and orthopaedic technologists, as well as our front line staff.  Dr. Ryan Katchky is in clinic Tuesday, Dr. Andrew Howard on Wednesday, and Dr. Maryse Bouchard on Thursday. The clinic's physiotherapists are Barb Harvey and Stacy Robitaille.

Read more about the Clubfoot Clinic at SickKids, and learn more about appointments, our clinic hours, phone numbers and location.