Treatment for Clubfoot
Clubfoot treatment follows the Ponseti Method, a mainly non-surgical treatment involving weekly massage and plaster cast application to gradually improve the position of the foot. This is usually followed, in a number of cases, by a minor procedure known as a tenotomy and fitting of a foot abduction brace to maintain the correction. Studies show that the treatment of clubfoot by the Ponseti Method is very effective if the protocol is followed closely. However, sometimes clubfoot can reoccur; when this happens, it is known as a relapse.
When there has been a relapse, it may be necessary for some of the treatment to be repeated, for example, your child may need to have their foot manipulated again and put in a cast.
Relapses are estimated to occur in 1 or 2 out of every 10 cases. Continuing with the boots and bar reduces the incidence of a relapse to 15-20%. Non-compliance with foot abduction bracing has seen a significant increase of a relapse by up to 60%; there is also evidence of a higher relapse rate with children with syndromic feet (non-idiopathic feet).
In some cases, ensuring that your child continues to wear the boots and bar may be enough to improve their clubfoot significantly. However, in other cases where there has been a relapse, surgery may be required.
Signs and Diagnosis of Relapsed Clubfoot
One of the first signs of a relapse is the loss of dorsiflexion (the movement of lifting the foot upwards). The foot should be flexible enough to draw the toes towards the shins and back again to a range of 20° (see image below).
This happens because of tightness in the Achilles tendon (the large tendon at the back of the heel) and can result in walking on the toes or the inability to her the heels flat on the floor when standing. It may become difficult to get the feet down fully into the boots and bar.
The heel may also start to roll inwards slightly and the front of the foot may appear to lift more on the inside than the outside as the child is walking, so that the weight is taken on the outside border of the foot.
Untreated relapsing feet may gradually become rigid. It is possible that a Pirani Score will be used to reclassify feet suspected of relapse, but there is no definitive classification to assess relapse.
Learn more in our webinar about relapse of clubfoot:
Treatment for Relapsed Clubfoot
Treatment for relapsing clubfoot will depend on the severity of the relapse. If the relapse is related to problems keeping boots and bars for the recommended time, simply addressing the problem, and following the treatment protocol closely may be enough to correct the feet. For more severe relapses, it is possible that a clinician may need to manipulate the feet and reapply a plaster cast to maintain the correction. This will be followed by a repeat of the boots and bars stage of treatment.
In some cases, surgery to the foot may be required, followed by a plaster cast and again a repeat of boots and bars.
In some cases, a tibialis anterior transfer is required. This is a way of moving one of the tendons on the foot to make it more balanced. The tibialis anterior tendon attaches on the inside of the front of the foot, near the toes. A total tendon transfer will result in the foot being pulled straight. The wounds are stitched and will leave minimal scarring. Stitches are usually dissolvable, but a strong, removable stitch may be used to secure the tendon into its new position. A plaster cast will be worn for approximately 6 weeks following the surgery.
It is important, if you think there is a relapse, to keep the foot in a brace throughout. In the meantime, stretching is really important. If you are able to do effective stretches, especially calf stretches, keep doing so: hopefully, you have been shown how to do these by a physiotherapist as well as simple exercises. Exercises to practice may include hopping, walking on heels, balancing on one leg and how to use resistance bands (which help the muscles on the outside of the foot). You will want to keep all the muscle groups strong particularly around your foot keeping it as supple and mobile as possible. Work on strengthening the core and leg muscles and keeping a general fitness is recommended but in a low impact way. Cycling, swimming, yoga, when possible, are all low impact activities the whole family can enjoy together and there are some great online resources for children and families readily available.
Sources of support
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