International Orthopaedics

, Volume 37, Issue 9, pp 1747–1753 | Cite as

The Ponseti method for the treatment of congenital club foot: review of the current literature and treatment recommendations

  • Christof RadlerEmail author
Review Article


The Ponseti method has become the gold standard of care for the treatment of congenital club foot. Despite numerous articles in MEDLINE reporting results from around the globe there are still crucial details of the Ponseti method which seem to be less commonly known or considered. The Ponseti method is not only a detailed method of manipulation and casting but also of preventing and treating relapse. Recommendations on how to correct complex club foot have resulted in an almost 100 % initial correction rate. The foot abduction brace is crucial for preventing relapse and is still a challenge for families and sometimes doctors alike. Experience and knowledge on how to support the parents, how to set and apply the brace in the best possible way and how to solve problems that can be encountered during the bracing period are essential to ensure compliance. Regular follow-up visits are necessary to be able to detect early signs of recurrence and prevent full relapse by enforcing abduction bracing, recasting or performing tibialis anterior tendon transfer. Recent midterm outcome studies have shown that by following the Ponseti treatment regime in all aspects it is possible to prevent open joint surgery in almost all cases. The body of literature of the last decade has evaluated many steps and aspects of the Ponseti method and gives valuable answers to questions encountered in daily practice. This review of the current literature and recommendations on the different aspects of the Ponseti method aims to promote understanding of the treatment regime and its’ details.


Ponseti treatment Congenital club foot Abduction bracing Tibialis tendon transfer Club foot casting Foot abduction brace Manipulation 


  1. 1.
    Ponseti IV, Smoley EN (1963) Congenital club foot: the results of treatment. J Bone Joint Surg Am 45-A:261–344Google Scholar
  2. 2.
    Ponseti IV, Campos J (1972) Observations on pathogenesis and treatment of congenital club foot. Clin Orthop Relat Res 84:50–60PubMedCrossRefGoogle Scholar
  3. 3.
    Laaveg SJ, Ponseti IV (1980) Long-term results of treatment of congenital club foot. J Bone Joint Surg Am 62(1):23–31PubMedGoogle Scholar
  4. 4.
    Cooper DM, Dietz FR (1995) Treatment of idiopathic club foot: a thirty-year follow-up note. J Bone Joint Surg Am 77-A:1477–1489Google Scholar
  5. 5.
    Morcuende JA, Abbasi D, Dolan LA, Ponseti IV (2005) Results of an accelerated Ponseti protocol for club foot. J Pediatr Orthop 25:623–626PubMedCrossRefGoogle Scholar
  6. 6.
    Morcuende JA, Dolan LA, Dietz FR, Ponseti IV (2004) Radical reduction in the rate of extensive corrective surgery for club foot using the Ponseti method. Pediatrics 113(2):376–380PubMedCrossRefGoogle Scholar
  7. 7.
    Zionts LE, Zhao G, Hitchcock K, Maewal J, Ebramzadeh E (2010) Has the rate of extensive surgery to treat idiopathic club foot declined in the United States? J Bone Joint Surg Am 92(4):882–889PubMedCrossRefGoogle Scholar
  8. 8.
    Zionts LE, Sangiorgio SN, Ebramzadeh E, Morcuende JA (2012) The current management of idiopathic club foot revisited: results of a survey of the POSNA membership. J Pediatr Orthop 32(5):515–520PubMedCrossRefGoogle Scholar
  9. 9.
    Herzenberg JE, Radler C, Bor N (2002) Ponseti versus traditional methods of casting for idiopathic club foot. J Pediatr Orthop 22(4):517–521PubMedGoogle Scholar
  10. 10.
    Chotel F, Parot R, Durand JM, Garnier E, Hodgkinson I, Bérard J (2002) Initial management of congenital varus equinus club foot by Ponseti’s method. Rev Chir Orthop Reparatrice Appar Mot 88(7):710–717PubMedGoogle Scholar
  11. 11.
    Colburn M, Williams M (2003) Evaluation of the treatment of idiopathic club foot by using the Ponseti method. J Foot Ankle Surg 42(5):259–267PubMedCrossRefGoogle Scholar
  12. 12.
    Tindall AJ, Steinlechner CW, Lavy CB, Mannion S, Mkandawire N (2005) Results of manipulation of idiopathic club foot deformity in Malawi by orthopaedic clinical officers using the Ponseti method: a realistic alternative for the developing world? J Pediatr Orthop 25(5):627–629PubMedCrossRefGoogle Scholar
  13. 13.
    Aurell Y, Andriesse H, Johansson A, Jonsson K (2005) Ultrasound assessment of early club foot treatment: a comparison of the Ponseti method and a modified Copenhagen method. J Pediatr Orthop B 14(5):347–357PubMedCrossRefGoogle Scholar
  14. 14.
    Segev E, Keret D, Lokiec F, Yavor A, Wientroub S, Ezra E, Hayek S (2005) Early experience with the Ponseti method for the treatment of congenital idiopathic club foot. Isr Med Assoc J 7(5):307–310PubMedGoogle Scholar
  15. 15.
    Göksan SB, Bursali A, Bilgili F, Sivacioğlu S, Ayanoğlu S (2006) Ponseti technique for the correction of idiopathic club feet presenting up to 1 year of age. A preliminary study in children with untreated or complex deformities. Arch Orthop Trauma Surg 126(1):15–21PubMedCrossRefGoogle Scholar
  16. 16.
    Thacker MM, Scher DM, Sala DA, van Bosse HJ, Feldman DS, Lehman WB (2005) Use of the foot abduction orthosis following Ponseti casts: is it essential? J Pediatr Orthop 25(2):225–228PubMedCrossRefGoogle Scholar
  17. 17.
    Radler C, Suda R, Manner HM, Grill F (2006) Early results of the Ponseti method for the treatment of idiopathic club foot. Z Orthop Ihre Grenzgeb 144(1):80–86PubMedCrossRefGoogle Scholar
  18. 18.
    Gupta A, Singh S, Patel P, Patel J, Varshney MK (2008) Evaluation of the utility of the Ponseti method of correction of club foot deformity in a developing nation. Int Orthop 32(1):75–79PubMedCrossRefGoogle Scholar
  19. 19.
    Pirani S, Naddumba E, Mathias R, Konde-Lule J, Penny JN, Beyeza T, Mbonye B, Amone J, Franceschi F (2009) Towards effective Ponseti club foot care: the Uganda Sustainable club foot Care Project. Clin Orthop Relat Res 467(5):1154–1163PubMedCrossRefGoogle Scholar
  20. 20.
    Jowett CR, Morcuende JA, Ramachandran M (2011) Management of congenital talipes equinovarus using the Ponseti method: a systematic review. J Bone Joint Surg Br 93(9):1160–1164PubMedGoogle Scholar
  21. 21.
    Ponseti IV (1997) Common errors in the treatment of congenital club foot. Int Orthop 21(2):137–141PubMedCrossRefGoogle Scholar
  22. 22.
    Ponseti IV, Zhivkov M, Davis N, Sinclair M, Dobbs MB, Morcuende JA (2006) Treatment of the complex idiopathic club foot. Clin Orthop Relat Res 451:171–176PubMedCrossRefGoogle Scholar
  23. 23.
    Terrazas-Lafargue G, Morcuende JA (2007) Effect of cast removal timing in the correction of idiopathic club foot by the Ponseti method. Iowa Orthop J 27:24–27PubMedGoogle Scholar
  24. 24.
    Harnett P, Freeman R, Harrison WJ, Brown LC, Beckles V (2011) An accelerated Ponseti versus the standard Ponseti method: a prospective randomised controlled trial. J Bone Joint Surg Br 93(3):404–408PubMedGoogle Scholar
  25. 25.
    Pirani S, Zeznik L, Hodges D (2001) Magnetic resonance imaging study of the congenital club foot treated with the Ponseti method. J Pediatr Orthop 21(6):719–726Google Scholar
  26. 26.
    Alves C, Escalda C, Fernandes P, Tavares D, Neves MC (2009) Ponseti method: does age at the beginning of treatment make a difference? Clin Orthop Relat Res 467(5):1271–1277PubMedCrossRefGoogle Scholar
  27. 27.
    Iltar S, Uysal M, Alemdaroğlu KB, Aydoğan NH, Kara T, Atlihan D (2010) Treatment of club foot with the Ponseti method: should we begin casting in the newborn period or later? J Foot Ankle Surg 49(5):426–431PubMedCrossRefGoogle Scholar
  28. 28.
    Böhm S, Sinclair M (2013) Report of the 1st European consensus meeting on Ponseti club foot treatment. J Child Orthop 7(3):251–254CrossRefGoogle Scholar
  29. 29.
    Flynn JM, Donohoe M, Mackenzie WG (1998) An independent assessment of two club foot-classification systems. J Pediatr Orthop 18(3):323–327PubMedGoogle Scholar
  30. 30.
    Shaheen S, Jaiballa H, Pirani S (2012) Interobserver reliability in Pirani club foot severity scoring between a paediatric orthopaedic surgeon and a physiotherapy assistant. J Pediatr Orthop B 21(4):366–368PubMedCrossRefGoogle Scholar
  31. 31.
    Dyer PJ, Davis N (2006) The role of the Pirani scoring system in the management of club foot by the Ponseti method. J Bone Joint Surg Br 88(8):1082–1084PubMedGoogle Scholar
  32. 32.
    Chu A, Labar AS, Sala DA, van Bosse HJ, Lehman WB (2010) club foot classification: correlation with Ponseti cast treatment. J Pediatr Orthop 30(7):695–699PubMedCrossRefGoogle Scholar
  33. 33.
    Zhang W, Richards BS, Faulks ST, Karol LA, Rathjen KA, Browne RH (2012) Initial severity rating of idiopathic club feet is an outcome predictor at age two years. J Pediatr Orthop B 21(1):16–19PubMedCrossRefGoogle Scholar
  34. 34.
    Goriainov V, Judd J, Uglow M (2010) Does the Pirani score predict relapse in club foot? J Child Orthop 4(5):439–444PubMedCrossRefGoogle Scholar
  35. 35.
    Lebel E, Karasik M, Bernstein-Weyel M, Mishukov Y, Peyser A (2012) Achilles tenotomy as an office procedure: safety and efficacy as part of the Ponseti serial casting protocol for club foot. J Pediatr Orthop 32(4):412–415PubMedCrossRefGoogle Scholar
  36. 36.
    Bor N, Katz Y, Vofsi O, Herzenberg JE, Zuckerberg AL (2007) Sedation protocols for Ponseti club foot Achilles tenotomy. J Child Orthop 1(6):333–335PubMedCrossRefGoogle Scholar
  37. 37.
    Iravani M, Chalabi J, Kim R, Ebramzadeh E, Zionts LE (2013) Propofol sedation for infants with idiopathic club foot undergoing percutaneous tendoachilles tenotomy. J Pediatr Orthop 33(1):59–62PubMedCrossRefGoogle Scholar
  38. 38.
    Parada SA, Baird GO, Auffant RA, Tompkins BJ, Caskey PM (2009) Safety of percutaneous tendoachilles tenotomy performed under general anesthesia on infants with idiopathic club foot. J Pediatr Orthop 29(8):916–919PubMedCrossRefGoogle Scholar
  39. 39.
    Radler C, Manner HM, Suda R, Burghardt R, Herzenberg JE, Ganger R, Grill F (2007) Radiographic evaluation of idiopathic club feet undergoing Ponseti treatment. J Bone Joint Surg Am 89(6):1177–1183PubMedCrossRefGoogle Scholar
  40. 40.
    Dobbs MB, Gordon JE, Walton T, Schoenecker PL (2004) Bleeding complications following percutaneous tendoachilles tenotomy in the treatment of club foot deformity. J Pediatr Orthop 24(4):353–357PubMedCrossRefGoogle Scholar
  41. 41.
    Burghardt RD, Herzenberg JE, Ranade A (2008) Pseudoaneurysm after Ponseti percutaneous Achilles tenotomy: a case report. J Pediatr Orthop 28(3):366–369PubMedCrossRefGoogle Scholar
  42. 42.
    Changulani M, Garg NK, Rajagopal TS, Bass A, Nayagam SN, Sampath J, Bruce CE (2006) Treatment of idiopathic club foot using the Ponseti method. Initial experience. J Bone Joint Surg Br 88(10):1385–1387PubMedGoogle Scholar
  43. 43.
    Barker SL, Lavy CB (2006) Correlation of clinical and ultrasonographic findings after Achilles tenotomy in idiopathic club foot. J Bone Joint Surg Br 88(3):377–379PubMedGoogle Scholar
  44. 44.
    Maranho DA, Nogueira-Barbosa MH, Simão MN, Volpon JB (2009) Ultrasonographic evaluation of Achilles tendon repair after percutaneous sectioning for the correction of congenital club foot residual equinus. J Pediatr Orthop 29(7):804–810PubMedCrossRefGoogle Scholar
  45. 45.
    Mangat KS, Kanwar R, Johnson K, Korah G, Prem H (2010) Ultrasonographic phases in gap healing following Ponseti-type Achilles tenotomy. J Bone Joint Surg Am 92(6):1462–1467PubMedCrossRefGoogle Scholar
  46. 46.
    Ippolito E, De Maio F, Mancini F, Bellini D, Orefice A (2009) Leg muscle atrophy in idiopathic congenital club foot: is it primitive or acquired? J Child Orthop 3(3):171–178PubMedCrossRefGoogle Scholar
  47. 47.
    Dobbs MB, Rudzki JR, Purcell DB, Walton T, Porter KR, Gurnett CA (2004) Factors predictive of outcome after use of the Ponseti method for the treatment of idiopathic club feet. J Bone Joint Surg Am 86-A(1):22–27PubMedGoogle Scholar
  48. 48.
    Kessler JI (2008) A new flexible brace used in the Ponseti treatment of talipes equinovarus. J Pediatr Orthop B 17(5):247–250PubMedCrossRefGoogle Scholar
  49. 49.
    Garg S, Porter K (2009) Improved bracing compliance in children with club feet using a dynamic orthosis. J Child Orthop 3(4):271–276PubMedCrossRefGoogle Scholar
  50. 50.
    Zionts LE, Dietz FR (2010) Bracing following correction of idiopathic club foot using the Ponseti method. J Am Acad Orthop Surg 18(8):486–493PubMedGoogle Scholar
  51. 51.
    George HL, Unnikrishnan PN, Garg NK, Sampath J, Bruce CE (2011) Unilateral foot abduction orthosis: is it a substitute for Denis Browne boots following Ponseti technique? J Pediatr Orthop B 20(1):22–25PubMedCrossRefGoogle Scholar
  52. 52.
    Janicki JA, Wright JG, Weir S, Narayanan UG (2011) A comparison of ankle foot orthoses with foot abduction orthoses to prevent recurrence following correction of idiopathic club foot by the Ponseti method. J Bone Joint Surg Br 93(5):700–704PubMedGoogle Scholar
  53. 53.
    Hemo Y, Segev E, Yavor A, Ovadia D, Wientroub S, Hayek S (2011) The influence of brace type on the success rate of the Ponseti treatment protocol for idiopathic club foot. J Child Orthop 5(2):115–119PubMedCrossRefGoogle Scholar
  54. 54.
    Zionts LE, Frost N, Kim R, Ebramzadeh E, Sangiorgio SN (2012) Treatment of idiopathic club foot: experience with the Mitchell-Ponseti brace. J Pediatr Orthop 32(7):706–713PubMedCrossRefGoogle Scholar
  55. 55.
    Dimeo AJ Sr, Lalush DS, Grant E, Morcuende JA (2012) Development of a surrogate biomodel for the investigation of club foot bracing. J Pediatr Orthop 32(7):e47–e52PubMedCrossRefGoogle Scholar
  56. 56.
    Paulsen-Miller M, Dolan LA, Stineman A, Morcuende JA (2011) Understanding the educational needs for parents of children with club foot. Orthop Nurs 30(4):273–278PubMedCrossRefGoogle Scholar
  57. 57.
    Sala DA, Chu A, Lehman WB, van Bosse HJ (2013) Achievement of gross motor milestones in children with idiopathic club foot treated with the Ponseti method. J Pediatr Orthop 33(1):55–58PubMedCrossRefGoogle Scholar
  58. 58.
    Boehm S, Sinclair M (2007) Foot abduction brace in the Ponseti method for idiopathic club foot deformity: torsional deformities and compliance. J Pediatr Orthop 27(6):712–716PubMedCrossRefGoogle Scholar
  59. 59.
    Bor N, Herzenberg JE, Frick SL (2006) Ponseti management of club foot in older infants. Clin Orthop Relat Res 444:224–228PubMedCrossRefGoogle Scholar
  60. 60.
    Lourenço AF, Morcuende JA (2007) Correction of neglected idiopathic club foot by the Ponseti method. J Bone Joint Surg Br 89(3):378–381PubMedGoogle Scholar
  61. 61.
    Spiegel DA, Shrestha OP, Sitoula P, Rajbhandary T, Bijukachhe B, Banskota AK (2009) Ponseti method for untreated idiopathic club feet in Nepalese patients from 1 to 6 years of age. Clin Orthop Relat Res 467(5):1164–1170PubMedCrossRefGoogle Scholar
  62. 62.
    Nogueira MP, Ey Batlle AM, Alves CG (2009) Is it possible to treat recurrent club foot with the Ponseti technique after posteromedial release?: a preliminary study. Clin Orthop Relat Res 467(5):1298–1305PubMedCrossRefGoogle Scholar
  63. 63.
    Boehm S, Limpaphayom N, Alaee F, Sinclair MF, Dobbs MB (2008) Early results of the Ponseti method for the treatment of club foot in distal arthrogryposis. J Bone Joint Surg Am 90(7):1501–1507PubMedCrossRefGoogle Scholar
  64. 64.
    van Bosse HJ, Marangoz S, Lehman WB, Sala DA (2009) Correction of arthrogrypotic club foot with a modified Ponseti technique. Clin Orthop Relat Res 467(5):1283–1293PubMedCrossRefGoogle Scholar
  65. 65.
    Morcuende JA, Dobbs MB, Frick SL (2008) Results of the Ponseti method in patients with club foot associated with arthrogryposis. Iowa Orthop J 28:22–26PubMedGoogle Scholar
  66. 66.
    Gerlach DJ, Gurnett CA, Limpaphayom N, Alaee F, Zhang Z, Porter K, Kirchhofer M, Smyth MD, Dobbs MB (2009) Early results of the Ponseti method for the treatment of club foot associated with myelomeningocele. J Bone Joint Surg Am 91(6):1350–1359PubMedCrossRefGoogle Scholar
  67. 67.
    Moroney PJ, Noël J, Fogarty EE, Kelly PM (2012) A single-center prospective evaluation of the Ponseti method in nonidiopathic congenital talipes equinovarus. J Pediatr Orthop 32(6):636–640PubMedCrossRefGoogle Scholar
  68. 68.
    Bor N, Coplan JA, Herzenberg JE (2009) Ponseti treatment for idiopathic club foot: minimum 5-year followup. Clin Orthop Relat Res 467(5):1263–1270PubMedCrossRefGoogle Scholar
  69. 69.
    Eberhardt O, Peterlein CD, Fernandez FF, Wirth T (2012) Mid-term results of idiopathic club feet treated with the Ponseti method. Z Orthop Unfall 150(2):190–197PubMedCrossRefGoogle Scholar
  70. 70.
    Church C, Coplan JA, Poljak D, Thabet AM, Kowtharapu D, Lennon N, Marchesi S, Henley J, Starr R, Mason D, Belthur MV, Herzenberg JE, Miller F (2012) A comprehensive outcome comparison of surgical and Ponseti club foot treatments with reference to pediatric norms. J Child Orthop 6(1):51–59PubMedCrossRefGoogle Scholar
  71. 71.
    Radler C, Gourdine-Shaw MC, Herzenberg JE (2012) Nerve structures at risk in the plantar side of the foot during anterior tibial tendon transfer: a cadaver study. J Bone Joint Surg Am 94(4):349–355PubMedCrossRefGoogle Scholar
  72. 72.
    Masrouha KZ, Morcuende JA (2012) Relapse after tibialis anterior tendon transfer in idiopathic club foot treated by the Ponseti method. J Pediatr Orthop 32(1):81–84PubMedCrossRefGoogle Scholar
  73. 73.
    McKay SD, Dolan LA, Morcuende JA (2012) Treatment results of late-relapsing idiopathic club foot previously treated with the Ponseti method. J Pediatr Orthop 32(4):406–411PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  1. 1.Paediatric Orthopaedic Unit, Department of Paediatric Orthopaedics and Adult Foot and Ankle SurgeryOrthopaedic Hospital SpeisingViennaAustria

Personalised recommendations