Your child has been diagnosed as having Congenital Talipes Equinovarus (CTEV) foot deformity, also known as Club Foot. This affects 1 in every 1000 babies born and twice as many boys as girls. It may affect one foot (unilateral) or both feet (bilateral). This condition develops early on in the baby’s development, and can often be seen on the 20 week
gestation anomaly scan.
Congenital - present at birth
Talipes - refers to the foot and ankle
Equino - foot points downwards
Varus - heel turns inwards
This is a treatable condition and we offer the Ponseti method of correction at RNOH.
We still don’t understand exactly why clubfoot happens. There is evidence of a genetic inheritance but this is not always the case. In clubfoot, the foot points down and inwards due to tightness of the
Achilles tendon, weakness of muscles on the outside of the lower leg and some abnormality of bone shape.
The Ponseti treatment can realign the abnormal bony anatomy of the foot and lengthen the tight structures. However, the calf muscle will remain smaller and tighter and affected feet will be slightly smaller than
unaffected feet. The club foot cannot be ‘cured’, but the position of the foot is corrected to produce normal appearance and normal levels of function.
This is a technique of gentle manipulation and plaster casting to straighten the foot. It was developed by Professor Ponseti in the USA and has been successfully used for over 45 years.
Each week the foot is manipulated by a doctor or specially trained physiotherapist. A plaster cast is then applied from your baby’s toes to their groin to hold the foot in a new position.
The cast is changed weekly and your baby’s foot is corrected a little more each time. After 4-6 weeks of casting your baby may need an Achilles tendon tenotomy. This is a surgical procedure to release the
tight Achilles tendon. A cast is then applied while the tendon heals.
After this casting phase, your baby should have a corrected foot position. However, there is an almost 100 % chance that with no further management the foot will return or relapse back to it’s original position.
Therefore your child will be fitted with a foot abduction brace (FAB) which is worn for 23 hours a day for 3 months and then at night times and nap times for 5 years.
We expect the Ponseti method of treatment to result in pain free, normally functioning feet.
RNOH offers comprehensive assessment and treatment for children with Congenital Talipes Equino Varus (CTEV) foot position, or Clubfoot deformity. We use the Ponseti method of correction as the primary treatment of choice, and follow Professor Ponseti’s treatment protocol.
We do recognise that every child is an individual and can tailor our management to suit the child. The service at the RNOH has been well established since 2004 under the management of Miss Sally Tennant,
Consultant Orthopaedic Surgeon. The team has expanded to include a Consultant Paediatric Physiotherapist, specialised in CTEV management, and a specialist Ponseti practitioner running a weekly casting clinic. We are a busy service with excellent results in Ponseti management.
Ante-natal counselling is offered following diagnosis at the 20 week gestation foetal anomaly scan, and treatment is usually started 2 to 3 weeks following delivery.
Plaster casts are applied on a weekly basis to manipulate and correct the foot position. It usually takes about one hour to remove and apply the plasters each week. Plaster of Paris casts are used which provide an excellent moulded fit around your baby’s foot. We ensure a good foot position is maintained by extending the plaster above the knee, with the knee bent to 90 degrees. This is a comfortable position for your baby to rest in. The toes are exposed and clearly visible.
The casting process is gentle and should not hurt your baby. Some babies are very calm while others do not like being handled. All babies are different!
We encourage you to feed your baby while casting is being done. We can accommodate both breast and bottle feeding. This helps as the baby is more relaxed.
Once the first cast has been applied you are not able to bath your baby at home. You will need to lay them on a towel and clean them with a washcloth or wipes. On the morning of clinic you will be able to bath
your baby and let the casts soak in the bath for 20-30 minutes. This makes the casts soft enough to be removed with a knife and scissors at the hospital.
• Babies lose a lot of heat through their skin so may feel warmer than
normal with casts on
• Toes may feel cold as they are not moving as much but must pink up
when pressure is applied and then released
• The toe position in the cast must be monitored and if the cast slips
you must contact us as soon as possible for cast removal.
You are not able to check your baby’s weight accurately while in plaster cast. You will be able to weigh your baby in the clinic between casts andmrecord their weight in the red book.
Following the casting stage, your specialist will decide whether your baby needs to have an Achilles tendon tenotomy, a surgical release of the tight tendon at the back of the heel.
It is usually the case that a tenotomy is required to complete the foot correction. The procedure is carried out under a local anaesthetic in the Ponseti clinic. The surgeon will make a small cut in your baby’s heelcord to release their foot into a more natural position. A plaster cast will then be applied. Two to three weeks of casting is required, while the tendon heals in a lengthened position. Often the cast will need to be changed at two weeks and replaced if the baby is growing fast.
Some bleeding through the cast is normal. Bleeding up to the size of a 20 pence piece is acceptable, more than this should be checked by the hospital.
After your baby’s feet have been corrected in terms of position, they will be ready for the bracing phase of treatment. A foot abduction brace (FAB) is fitted with Mitchell Ponseti boots. The boots are fitted separately.
They are soft and comfortable and are made in standard sizes. A bar is slotted in to the base of the boots and turns the feet outwards. This provides a gentle stretch to maintain a corrected foot position as your
baby grows. Your baby will wear socks with the boots to avoid excessive sweating and make the boots more comfortable.
The FAB is worn initially for 23 hours a day for 3 months. You should remove the boots and bar for one hour every day. In this time you can bath your baby and enjoy playing with them without the brace. After 3 months, the baby will need to wear the FAB for 14 hours every day. Ideally this will be timed with sleeping and worn for 12 hours overnight and 2 hours during a day time nap.
This fits in well with your child’s development. For the first 5 months they will be in cast or boots and bar, after this time they will be free for normal developmental play during awake time. We do not expect any
delay in normal developmental milestones and will be expecting your child to walk independently between 9 and 18 months of age.
It is important to stay positive about the boots and be consistent in application of them. They are an extremely important part of your child’s treatment and without them the old club foot position will return
(relapse). A regular bedtime routine is helpful and ideally the boots and bar should be fitted when the child is awake and aware of what is happening.
The FAB will need to be worn at night times until your child is 5 years old. After this time, the chance of relapse is very low.
Sometimes a child will benefit from additional intervention to improve their foot position and function. This will always be more likely if the boots and bar are not consistently worn.
Serial casting
• Your child may benefit from casting if they have a relapse or tightness
associated with growth.
Repeat Achilles Tendon Tenotomy
• Occasionally a repeat tenotomy is required. This is always performed
under a general anaesthetic, followed by 3 weeks of plaster cast.
Tibialis Anterior Tendon Transfer Operation
• This operation can help to correct a dyamic, intoeing presentation in
older children, over 4 years of age. It involves re-siting the Tibialis Anterior muscle tendon in the foot. Often pre operative casting is required to optimise the foot position and then 6 weeks of casting will be needed after the surgery.
As part of our Ponseti service you can expect:
• To be seen for antenatal counselling by one of our team
• To be offered an appointment for your baby within 2 weeks of referral
• To be seen for an initial outpatient appointment for assessment, examination and discussion on treatment
• To be booked into the plaster cast clinic for treatment on a Friday morning
• To attend for weekly appointments during the casting phase
• To attend for 3-4 monthly outpatient review appointments once established in the Foot Abduction Brace, and provided with new boots as required, until the age of 5 years
• To be reviewed for annual follow up until your child has stopped growing.
Miss Sally Tennant, Consultant Orthopaedic Surgeon
Christine Douglas, Consultant Paediatric Physiotherapist
Cicily James, Specialist Ponseti Practitioner
Contact details
rnoh.
Secretary to Miss Tennant - Tel: 020 8909 5758 or Email: rnoh.
Plaster room: Tel: 020 8909 5467
24-51 © RNOH
Date of publication: July 2024
Date of next review: July 2028
Author: Christine Douglas, Consultant Paediatric Physiotherapist
Page last updated: 16 January 2026