Club Foot (CTEV)

Introduction

Learning that your baby has been born with club foot can be an emotional moment. The foot looks visibly different, and as a parent it is natural to worry about what this means for your child’s future — whether they will walk, run, play, or wear normal shoes. The reassuring news is that club foot is one of the most well-understood congenital conditions in paediatric orthopaedics, and modern treatment is highly effective. The large majority of children treated promptly and correctly go on to walk, run, and take part in sports without significant limitation.

This guide is written for parents whose child has been diagnosed with club foot — either before birth on an ultrasound scan or at birth — and who are now planning treatment. It explains what club foot is, what causes it, how it is treated using the Ponseti method, when surgery may be needed, what bracing involves, and what to expect during the months and years of follow-up. The aim is to help you understand the treatment journey ahead so you can be an informed and confident partner in your child’s care.

What Is Club Foot (CTEV)?

Club foot is a condition present at birth in which a baby’s foot is turned inward and downward. The medical name is congenital talipes equinovarus, commonly shortened to CTEV. Each part of that name describes a feature of the deformity:

• Congenital — present from birth
• Talipes — relating to the ankle and foot
• Equinus — the foot points downward, like a horse’s hoof
• Varus — the heel and sole are turned inward

In a baby with club foot, several things happen together. The front of the foot is twisted inward, the heel is pulled up and turned in, the arch is high, and the Achilles tendon at the back of the heel is tight. The foot is often a little shorter than expected, and the calf muscle on the affected side may look thinner. The condition can affect one foot (unilateral) or both feet (bilateral). Roughly half of all cases are bilateral.

Club foot is one of the more common congenital differences of the limbs. It is more common in boys than girls, and it occurs in babies of all backgrounds. Importantly, it is not painful for the newborn baby — even though the foot looks twisted, it does not hurt the infant. The position becomes a problem later, when a child tries to stand and walk on a foot that is not aligned correctly.

Idiopathic vs Non-idiopathic Club Foot

Doctors usually divide club foot into two broad groups:

• Idiopathic club foot — the most common type. The baby is otherwise healthy and there is no underlying medical condition. “Idiopathic” means the exact cause is not known.
• Non-idiopathic (syndromic) club foot — the club foot is part of a wider condition, such as spina bifida, arthrogryposis, or certain neuromuscular or genetic syndromes. These cases are often stiffer and may need more intensive treatment.

The treatment approach described in this article applies primarily to idiopathic club foot, which makes up the majority of cases. Syndromic club foot follows the same general principles but often requires more casts, a longer course of bracing, and closer specialist follow-up.

Causes and Risk Factors

The exact cause of idiopathic club foot is not fully understood. Research suggests that it results from a combination of genetic and environmental factors that affect how the foot develops in the womb. The muscles, tendons, ligaments, and bones of the foot do not form in their usual alignment, leaving the foot fixed in the inward-and-downward position seen at birth.

Some patterns are recognised:

• Family history — the chance of club foot is higher if a parent or sibling has had it. This points to a genetic component, although no single gene explains all cases.
• Sex — boys are affected roughly twice as often as girls.
• Other congenital conditions — in non-idiopathic cases, the club foot is linked to conditions affecting nerves, muscles, or the spine.
• Uterine factors — very limited space in the uterus may play a role in some cases, although this is debated.

One point is important and worth stating clearly: nothing the mother did or did not do during pregnancy caused this. Club foot is not the result of how the mother slept, what she ate, the work she did, or any choice she made during pregnancy. Parents often feel guilt when their baby is born with a visible difference, and this guilt is misplaced.

Signs of Club Foot

Most parents reading this article will already have seen the signs in their own child, either on a prenatal ultrasound or at the moment of birth. Club foot is usually obvious at first look. The features include:

• The foot is turned inward and downward
• The sole of the foot may face the other leg
• The heel appears small and pulled upward
• There is a deep crease at the arch and sometimes at the back of the heel
• The Achilles tendon feels tight
• The affected foot may be slightly shorter than the other
• The calf muscle may look thinner on the affected side

If club foot is not treated, the child eventually learns to walk on the side or top of the foot rather than the sole. Over years this leads to thick callouses, skin breakdown, pain, joint stiffness, and difficulty wearing shoes. This is why early treatment matters — not because the newborn is in pain, but because correcting the position in infancy prevents a lifetime of disability.

Diagnosis

Club foot is diagnosed clinically, meaning a doctor recognises it from how the foot looks and feels. Laboratory tests are not needed for the diagnosis itself.

Prenatal Diagnosis

Club foot is often picked up on a routine ultrasound during pregnancy, usually around the 20-week anomaly scan. A prenatal diagnosis gives families time to learn about the condition, meet a paediatric orthopaedic specialist, and plan for treatment soon after birth. It is worth knowing that ultrasound is not perfect — a small number of suspected cases turn out to be a normal foot at birth, and occasionally a club foot is not seen until birth.

When club foot is identified on a prenatal scan, doctors usually recommend a more detailed scan to check for any other findings, since this can change whether the case is treated as isolated (idiopathic) or as part of a wider condition.

Diagnosis at Birth

At birth, the paediatrician or neonatologist examines the baby and recognises the typical appearance of the foot. They will also examine the rest of the body, the spine, and the hips, because some conditions associated with club foot can affect more than the foot.

Severity Assessment

Paediatric orthopaedic surgeons often grade the severity of club foot using a scoring system such as the Pirani score. This involves looking at specific features of the foot and giving each a small score. A higher score means a more severe deformity. Scoring helps the team plan how many casts may be needed and track how the foot improves with each cast. You may hear your child’s surgeon mention this score during clinic visits.

Imaging

X-rays are not usually needed in newborns because the bones of the foot are still mostly cartilage and do not show up well. Imaging may be used in older children, in unusual cases, or before a surgical procedure.

Overview of Treatment

Treatment for club foot has changed dramatically over the past several decades. In the past, large open surgeries were common, and many children grew up with stiff, painful feet despite treatment. Today, the standard of care worldwide is the Ponseti method, a non-surgical approach developed by Dr Ignacio Ponseti at the University of Iowa. The Ponseti method uses gentle weekly stretching and casting, often combined with a small office procedure on the Achilles tendon, followed by several years of bracing.

The Ponseti method has transformed outcomes for children with club foot. Major paediatric orthopaedic societies around the world now recommend it as the first-line treatment. Major open surgical correction, which used to be common, is now reserved for the small number of cases that do not respond to Ponseti treatment or for older children diagnosed late.

Treatment usually begins within the first few weeks of life, ideally before the baby is two to three months old. The earlier the treatment begins, the more flexible the foot tissues are, and the easier it is to achieve a good correction.

The Ponseti Method

Phase 1: Manipulation and Casting

In the first phase, the paediatric orthopaedic surgeon gently manipulates the baby’s foot — stretching it in a specific sequence that gradually moves it toward a normal position — and then applies a long plaster cast. The cast goes from the toes up to the top of the thigh, with the knee bent. The long cast is important because it holds the rotation of the foot and lower leg.

The casts are changed every week (sometimes every five to seven days). At each visit, the cast is removed, the foot is manipulated a little further, and a new cast is applied. Most children need around five to seven casts in total, although some need more, particularly in more severe cases.

Babies generally tolerate the casts well. They sleep, feed, and grow normally. Parents are taught how to bathe their baby with the cast in place (usually sponge baths), how to keep the cast clean and dry, and what signs to watch for — such as toes that look pale, blue, or swollen, or a cast that has slipped.

Phase 2: Achilles Tenotomy

In the great majority of club foot cases, the Achilles tendon at the back of the heel remains too tight even after the casting series. A small procedure called a percutaneous Achilles tenotomy is then performed to release the tendon. This is usually done in the clinic or as a short day-care procedure, using local anaesthesia or light sedation depending on the centre and the age of the child.

The surgeon makes a tiny cut at the back of the ankle with a fine blade and divides the tight tendon. The cut is so small that stitches are usually not needed. A final long cast is then applied for about three weeks, during which the tendon heals at its new, longer length. This step sounds alarming to parents when first described, but it is a brief, well-established part of the treatment and recovery is straightforward.

Phase 3: Bracing (Foot Abduction Brace)

Once the casting phase is complete and the foot is in a corrected position, the most important — and often the most challenging — phase begins: bracing. Without bracing, the foot has a strong tendency to return to its original position. Bracing is what keeps the correction.

The brace schedule typically looks like this:

• For about the first three months after casting: the brace is worn 23 hours a day, with one hour off for bathing and skin care.
• After that: the brace is worn during night-time sleep and during daytime naps.
• The night and nap brace is continued until the child is around four to five years old.

This long bracing period is the single most important factor in preventing recurrence. Studies consistently show that the majority of relapses are linked to brace non-use. The brace does not prevent the child from rolling, sitting, crawling, or learning normal motor skills at the usual ages. Children adapt quickly and most accept the brace as a normal part of their bedtime routine.

When Surgery Is Needed

Most children treated with the Ponseti method do not need major surgery. The small Achilles tenotomy described above is part of the standard pathway and is not considered “club foot surgery” in the traditional sense. However, larger surgical procedures are sometimes needed in specific situations:

• Late diagnosis — when treatment begins in an older child whose foot is already stiff.
• Severe or syndromic club foot — cases linked to neuromuscular conditions are often stiffer and less responsive to casting alone.
• Incomplete correction — when casting and tenotomy do not fully correct the deformity.
• Recurrence — when the foot returns to its original position, often related to bracing difficulties.

Types of Surgical Procedures

The specific operation depends on the child’s age and what part of the foot is still out of position. Options include:

• Tibialis anterior tendon transfer — one of the more common procedures in older toddlers and children whose foot keeps turning inward. The tendon that helps lift the foot is moved to a different position to balance the pull on the foot. This is usually done after the age of two to three years.
• Soft tissue releases — for stiffer feet, the surgeon may lengthen tight tendons and release tight joint capsules. This is used less often today than in earlier decades because Ponseti treatment has reduced the need for it.
• Bony procedures — in older children with long-standing or untreated club foot, procedures on the bones of the foot may be needed to realign the foot. These are uncommon in children treated early.

Larger surgeries are performed under general anaesthesia. The foot is held in the corrected position with a cast for several weeks afterwards. Physiotherapy may be used during recovery to help the child regain movement and strength.

What to Expect During Treatment

For parents, the practical reality of club foot treatment is a series of weekly clinic visits during the casting phase, followed by a long period of brace use at home with regular follow-up.

During Casting

You can expect:

• Weekly clinic visits for around five to eight weeks
• A long leg cast from toes to upper thigh, changed at each visit
• A baby who continues to feed, sleep, grow, and meet developmental milestones normally
• Sponge bathing while the cast is on
• Loose clothing that accommodates the cast

Things to watch for and report to the team include toes that look very pale, blue, or unusually swollen; a cast that slips down the leg; a strong smell coming from inside the cast; or persistent crying that is not explained by hunger or tiredness.

Around the Tenotomy

The tenotomy procedure itself is brief. Afterwards, your baby wears the final cast for about three weeks. Most babies are back to normal feeding and sleeping within hours. A small dressing covers the tiny incision, which usually heals without any stitches.

During Bracing

The transition from cast to brace is often the hardest part for families. Babies who were comfortable in casts sometimes resist the brace at first. With consistency, most settle into it within a few days to a couple of weeks. Tips that families find helpful include:

• Putting the brace on at the same times every day so it becomes routine
• Using thin cotton socks under the brace to protect the skin
• Checking for redness or pressure marks each time the brace comes off
• Avoiding lotions or powders inside the brace
• Holding and playing with your child while they are wearing the brace so it does not become associated only with sleep

Once the child is older and the brace is worn only at night, the routine usually becomes easy and the child often does not remember a time without it.

Recovery and Long-term Outlook

“Recovery” for club foot is best understood as the years-long maintenance phase rather than a few weeks after a procedure. Day-to-day life during this time is generally normal:

• Babies meet motor milestones on time. They roll, sit, crawl, stand, and walk at the usual ages, although first independent walking may be slightly delayed by a few weeks.
• Children play, run, climb, and take part in sports as they grow.
• The treated foot may always look slightly different from a normal foot — sometimes a little smaller, with a slightly thinner calf — but function is usually excellent.
• Shoe fitting is usually straightforward, although in unilateral cases the two feet may be slightly different sizes.

Long-term studies of children treated with the Ponseti method show that the great majority grow into adults with feet that work well for daily life and sport. Some adults notice their feet tire more easily after long periods of standing, but pain and disability are uncommon when treatment has been completed properly.

Risks, Complications, and Recurrence

Like any medical treatment, club foot treatment has risks. With the Ponseti method these are generally small.

During Casting

• Skin irritation or pressure sores under the cast (uncommon when casts are applied carefully)
• Cast slippage
• Temporary swelling of the toes

After the Tenotomy

• Bleeding from the small incision (rare and usually minor)
• Infection (rare)
• Incomplete release, occasionally needing repeat

After Larger Surgery

• Wound healing problems
• Infection
• Stiffness
• Overcorrection or undercorrection
• Need for further procedures later

Recurrence

The most common long-term issue is recurrence — the foot beginning to turn inward again. Recurrence is most often linked to difficulty maintaining the bracing schedule, particularly in the first few years. Other causes include syndromic forms of club foot and severe initial deformity. When recurrence is caught early, it can usually be managed with another round of casting and sometimes a tendon transfer. This is one of the main reasons regular follow-up visits continue for several years.

Follow-up and Long-term Monitoring

After the active phases of treatment, the paediatric orthopaedic team continues to see your child periodically. The schedule typically includes more frequent visits during the early years (when bracing is most intense and recurrence is most likely) and less frequent visits as the child grows. Follow-up usually continues until the child has finished growing.

At each visit the surgeon will check:

• The position and flexibility of the foot
• How the child is walking
• Shoe wear patterns
• Whether the brace still fits (in the bracing years)
• Overall growth and motor development

Parents play a central role between visits by sticking with the bracing schedule, watching for any subtle changes in foot position, and bringing up concerns early. Catching a small recurrence early is far simpler to manage than waiting until the foot has fully relapsed.

Supporting Your Child

Beyond the medical care, families often want to know how to support their child emotionally and practically through years of treatment.

• Normalise the brace. Younger children take their cue from parents. If the brace is treated as a normal part of life, the child generally accepts it that way.
• Explain in age-appropriate language as the child grows. By preschool age, children can understand simple explanations of why they wear the brace at night.
• Encourage normal activity. Children with treated club foot should not be held back from running, climbing, swimming, cycling, or sports.
• Stay in touch with the team. Quick questions answered early often prevent bigger problems later.
• Connect with other families. Many parents find it helpful to speak with other families whose children have been through Ponseti treatment.

Frequently Asked Questions

Will my child be able to walk normally?

Most children treated promptly with the Ponseti method walk, run, and play normally. The treated foot may look slightly different in shape or size, and the calf may be a little thinner, but day-to-day function is generally excellent.

At what age should treatment start?

Ideally treatment starts within the first few weeks of life. The tissues of a newborn baby’s foot are very flexible, which makes the casting phase faster and more effective. Older babies and even older children can still be treated, but the process may take longer.

How long is the casting phase?

Most children need around five to seven weekly casts, sometimes more. The total active casting phase is usually about five to eight weeks, followed by the three-week cast after the tenotomy.

Is the Achilles tenotomy painful?

The procedure is brief and is done with local anaesthesia or light sedation. Most babies are back to feeding and sleeping normally within hours. The incision is tiny and usually heals without stitches.

Why is the brace worn for so many years?

The brace prevents the foot from returning to its original position while the child is still growing. Studies have consistently shown that stopping the brace early is the most common cause of relapse. The full bracing course of three to four years (or longer if advised) is the single most important factor in long-term success.

Can club foot come back after treatment?

Yes, recurrence is possible, especially during the first few years after correction. The most common reason is difficulty keeping up with the brace. Early recurrence can often be treated with another round of casting and sometimes a small tendon transfer procedure, so attending follow-up visits matters.

Will both feet be the same size?

In children with club foot on one side only, the treated foot is often slightly smaller than the other foot, and the calf may be slightly thinner. These differences are usually small and do not affect function.

Can my child play sports?

Yes. Children treated for club foot can take part in sports, including running, football, swimming, dance, cycling, and most other activities. Encouraging an active lifestyle is generally helpful for the legs and feet.

Is club foot a sign of something else wrong with my baby?

In the majority of cases, club foot is isolated — meaning the rest of the baby is healthy. In a smaller number of cases it can be part of a wider condition, which is why the paediatric team examines the whole baby carefully at birth, including the hips and spine.

Could anything I did during pregnancy have caused this?

No. Idiopathic club foot is not caused by anything a parent did or did not do during pregnancy. It results from how the foot developed in the womb, with genetic and other biological factors that are not under any parent’s control.

Conclusion

Club foot (CTEV) is a congenital condition that, with timely and well-managed treatment, has an excellent outlook. The Ponseti method — weekly casts, a small Achilles tenotomy in most cases, and several years of brace use — has become the standard worldwide because it gives most children a foot that looks and works well, without the need for major surgery. Larger surgical procedures are reserved for the smaller number of cases that need them.

The treatment journey is not short. It asks for patience during the casting weeks and steady commitment during the years of bracing. But for the parents reading this with a newly diagnosed baby, the underlying message is hopeful: club foot is one of the success stories of modern paediatric orthopaedics, and your child has every reason to grow up walking, running, and playing on a foot that does what feet are meant to do.