Treatment of Equinovarus Feet (Clubfoot)
The Ponseti method is the gold standard first-line treatment for congenital clubfoot, consisting of serial manipulation, casting, and often Achilles tenotomy, followed by bracing to maintain correction. 1, 2, 3
Initial Assessment and Classification
- Evaluate the severity of the deformity using a standardized classification system
- Assess for:
- Four components of deformity: forefoot adductus, midfoot cavus, hindfoot varus, and ankle equinus
- Rigidity versus flexibility of the deformity
- Age of the patient (newborn, infant, child, or adult)
- Whether the condition is congenital or acquired (post-stroke, neurological)
Treatment Algorithm for Congenital Clubfoot
1. Conservative Management (First-Line)
Ponseti Method
- Begin treatment as soon as possible after birth
- Weekly gentle manipulation and serial casting (5-7 casts typically)
- Percutaneous Achilles tenotomy in 80-90% of cases to correct residual equinus
- Followed by foot abduction brace (23 hours/day for 3 months, then nighttime for 3-4 years)
French Functional Method (Alternative)
- Daily manipulation by specialized physiotherapists
- Immobilization with adhesive bandages and pads
- May be combined with Ponseti techniques in some cases
2. Management of Recurrence
- Most recurrences are due to non-compliance with bracing protocol 3
- For mild recurrence: repeat casting
- For persistent deformity: consider tibialis anterior tendon transfer
- Avoid extensive surgical release if possible due to long-term complications
3. Surgical Management (Reserved for Resistant Cases)
- Consider only after failure of proper conservative management
- Options include:
- Soft tissue releases
- Tendon transfers
- Osteotomies for older children with fixed deformities
- Arthrodesis for severe rigid deformities in older patients
Treatment of Acquired Equinovarus (Post-Stroke)
For post-stroke equinovarus deformity:
- Initial management: physical therapy, orthoses, chemodenervation (botulinum toxin)
- Consider surgical correction earlier rather than later if deformity persists after neurological recovery period 4
- Surgical intervention can significantly reduce ongoing physical therapy needs and orthotic use
Footwear and Orthotic Considerations
- Appropriate footwear is essential for all patients with equinovarus feet 5
- Shoes should have:
- Adequate width
- Rounded toe box
- Flexible flat sole with heel support
- Laces or straps to prevent foot slippage
- Seamless internal lining 5
- Custom orthoses may be needed to redistribute pressure and prevent recurrence
Monitoring and Follow-up
- Regular follow-up during active treatment (weekly during casting phase)
- After initial correction: follow-up every 3-4 months during first year
- Then every 6 months until age 4
- Annual check-ups until skeletal maturity
- Monitor for signs of recurrence: increasing adduction, varus, or equinus
Practical Considerations
- Early treatment initiation (ideally within first weeks of life for congenital cases) yields best outcomes
- Family education and compliance with bracing protocol is critical to prevent recurrence
- A renewed interest in Ponseti's techniques has led to a significant reduction in extensive surgical releases 6
- Success rates of 90-95% can be achieved with proper implementation of the Ponseti method 3
Cautions and Pitfalls
- Avoid extensive surgical releases as primary treatment due to poor long-term outcomes
- Non-compliance with bracing is the primary cause of recurrence
- Overly aggressive manipulation can lead to rocker-bottom deformity
- Inadequate correction of all components before bracing will lead to recurrence
- For diabetic patients with equinovarus, special attention to pressure points is essential to prevent ulceration 5
The evidence strongly supports minimally invasive approaches over extensive surgical release, with the Ponseti method showing excellent long-term results when properly implemented.