What are the Treatment Options?

1. Serial Plaster Casting
2. Splints/Braces
3. Non-Surgical Treatment Methods
   • Ponseti Method
   • French Physiotherapy Method
   • Botox - botulinum toxin
4. Surgery

1. SERIAL PLASTER CASTING: All treatment options should begin with casting. Treatment should be started right away. The initial treatment consists of manipulating the foot to get it to the best position possible, and then holding the correction in a cast. The cast is changed regularly (at first on a weekly basis), with manipulation before each casting, to obtain further correction. Casting should be the full-leg cast not just to the knees as was done in Evan's case. 

2. SPLINTS/BRACES: Are used as a follow-up after serial casting, or after casts applied at surgery. 

• Ponseti AFO - more information can be found here 
• Denis Brown (DBB) type where boots or shoes are attached to a bar which can be adjusted gently daily, until eventually the feet are in the correct position, 
• Ankle-foot orthoses (AFO's), which are a light-weight, plastic splint held on by velcro. These can be worn 24 hours a day, or at night only. They can be removed easily for bathing. Shoes that may be used after splints are straight last shoes where the medial border is straight.

3. Non-Surgical Treatment Options:  The Ponseti method is rapidly becoming the universal standard in clubfoot treatment. I encourage parents to use this method even if you have to travel a very long way! We didn't know that any other options existed until many years after Evan's surgeries. How we would have loved to avoid surgery (and the stiffness of scar tissue) if possible and gain a better correction. There are two non-surgical methods of treatment:

• Ponseti non-surgical treatment (Dr. Ignacio Ponseti of Iowa) consists of a weekly series of gentle manipulations followed by placement of casts which extend from the toes to the upper thigh. Five to seven weekly casts are applied. Before applying the last cast, which is worn for three weeks, the heel-cord is cut in the clinic in order to complete the correction of the foot. By the time the cast is removed the heel-cord has healed. Following this two month program of casting, a denis-browne splint is worn full-time for 2-3 months and then is worn only at night for 2-4 years. The splint consists of two high-top open-toed shoes connected to a bar. The shoes maintain the foot or feet in the corrected position. To locate a Doctor qualified in the Ponseti method, check out this listing. Dr. Ponseti: Tel: (319)356-3469 University of Iowa Hospitals and Clinics 200 Hawkins Drive 010255 JPP Iowa City, IA 52242 E-mail: ignacio-ponseti@uiowa.edu
  
• French technique, consists of daily visits with the physical therapist. Gentle, painless stretching of the foot is performed. The foot is then taped to maintain the improved position and is held this way until just before the next day's visit. At night, the taped foot is placed into a continuous passive motion machine at home in order to maximize the amount of stretching. This is tolerated well by the infants. The tape is removed for two hours each day to allow for bathing, airing of the skin, and home exercises. Removable aquaplast splints are also used to reinforce the taped position. The one-hour physical therapy sessions are conducted five days each week for as long as three months (in very stiff feet). Taping is discontinued when the child starts to walk.
  
• Botox has also been used in conjunction with physical therapy and casting/splinting produced significant improvements in foot flexibility and in some cases surgery was not required.  This method involves injecting calf muscles with a purified form of botulinum toxin (a deadly poison if injested).

4. SURGERY: The Last Resort Surgery, called posteromedial release, consists of releasing all the tight tendons and ligaments in the posterior and medial aspects of the foot, and repairing them in the lengthened position. More recently, it has been recognized that some of the lateral ligaments have to be released as well, to allow a complete release. The incision used may vary.

After surgery, the foot needs to be casted followed by the use of splints to hold the correction. The objective of clubfoot treatment is to obtain a plantigrade and flexible foot. "Plantigrade" means the child stands with the sole of the foot on the ground, not on his heels or the outside of his foot. "Flexible" means one can move the foot around freely without pain.

When recurrence occurs, further surgery may be needed. In the younger child, soft tissue releases and lengthening may suffice. In the older child, because of bone changes, surgery involving osteotomy (cutting the bone) may be needed. Following treatment, children with clubfeet will go on to lead normal active lives. They will need to have regular assessment of their feet during childhood and adolescence until they reach maturity, to ensure that there is not a recurrence of the condition. Although their feet will be functional, some children with only one foot affected may require 2 different shoe sizes. It is normal that the calf muscle will be smaller and that there will be some degree of stiffness as scar-tissue builds up following surgery.