Illustration of a child's foot healing with supportive hands and educational icons.

Clubfoot Challenges: How to Improve Adherence and Outcomes

Elliot Brynn in Health & Wellness December 2025 • 5 min read.

"Unraveling the factors behind brace non-adherence in children with idiopathic clubfoot and practical steps for parents and practitioners to improve treatment success."

Idiopathic clubfoot management in the United States underwent a significant transformation in the early 2000s, driven by compelling evidence supporting the Ponseti method of casting. This approach highlighted reproducibility and success, shifting the treatment landscape from invasive surgical releases to non-operative casting, sometimes combined with tendon transfer at a later stage.

Initially, both patients and practitioners welcomed this shift, moving away from surgical interventions. However, it became evident that long-term success with the Ponseti method requires patience and consistent effort. Recurrence rates have been reported to be notably high, ranging from 30% to 40% within the first two to three years post-treatment. While these recurrences appear milder compared to those following surgical releases, the existing literature on recurrence treatment after the Ponseti method remains limited and not fully understood.

Currently, the most reliable predictor of recurrence following successful initial treatment of idiopathic clubfoot using the Ponseti method is adherence to a strict brace schedule. Once the feet are corrected, children with idiopathic clubfoot must wear a foot abduction orthosis for at least 10 to 12 hours per day. Given that recurrence can occur during periods of rapid growth, current recommendations are gradually extending the duration for which bracing is prescribed. Initially, centers recommended bracing for the first two years; now, many advise continuing for four to five years.

Why is Brace Adherence So Challenging?

Illustration of a child's foot healing with supportive hands and educational icons.

Adhering to a long and sometimes challenging bracing schedule can be frustrating for parents, especially when other options seem limited. Unfortunately, practitioners often lack adequate resources to manage cases of poor adherence effectively. Several barriers contribute to this issue, including socioeconomic challenges, cultural factors, and disparities in access to orthotic services. To address these challenges, institutional changes such as developing educational programs and streamlining care within Ponseti clubfoot programs have shown promise in improving parental cooperation.

One innovative tool designed to improve adherence is a sensor embedded in the brace shoes that objectively measures wear time. This sensor provides feedback to parents who consistently use the orthosis as prescribed. However, it can also negatively reinforce those already aware of their non-compliance. While most interventions target parents, few investigate neurodevelopmental differences in children with idiopathic clubfoot.

Socioeconomic Factors: Financial constraints can limit access to proper orthotics and regular follow-up appointments.
Cultural Beliefs: Varied cultural practices and beliefs may influence perceptions and adherence to medical recommendations.
Access to Care: Geographical barriers and limited availability of specialized clinics can hinder consistent treatment.
Lack of Education: Insufficient understanding of the importance of bracing and potential consequences of non-adherence.
Parental Support: The level of family and social support available to assist with daily bracing routines.

A recent study by Lööf et al. sheds light on these differences, building on prior research that revealed motor skill variations in children with idiopathic clubfoot beyond musculoskeletal factors. Using the parent-report Five to Fifteen questionnaire, the study identified 26 items that differentiated children with idiopathic clubfoot from a control group. These items highlighted difficulties in areas such as writing, attention, memory, and peer interaction. Examining older patients (average age 9 years, 5 months) provides insight into the non-musculoskeletal challenges faced by younger patients with idiopathic clubfoot.

Improving Adherence: A Collaborative Approach

This insight can help practitioners develop greater empathy and build trust with patients and parents who struggle with brace adherence. Further studies may expand on these findings, identifying specific areas where earlier interventions can be beneficial. The work by Lööf et al. represents a significant and valuable contribution to the long-term success of the Ponseti method in treating idiopathic clubfoot. By addressing both physical and neurodevelopmental challenges, healthcare providers can optimize outcomes and improve the quality of life for children with clubfoot.

About this Article -

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Everything You Need To Know

What is the Ponseti method, and why is it considered a significant advancement in treating idiopathic clubfoot?

The Ponseti method is a non-operative casting technique used to treat idiopathic clubfoot, gaining prominence in the early 2000s due to its reproducibility and success rates. It shifted the treatment approach from invasive surgical releases to a series of casts, sometimes followed by a tendon transfer at a later stage. The method is considered an advancement because it's less invasive than surgery and initially showed great promise. However, long-term success hinges on consistent brace adherence to maintain the correction achieved through casting.

What are the main challenges in ensuring long-term success with the Ponseti method for idiopathic clubfoot, and why is brace adherence so critical?

The primary challenge with the Ponseti method is maintaining long-term correction, which requires consistent adherence to a strict bracing schedule. Recurrence rates range from 30% to 40% within the first two to three years post-treatment if bracing isn't followed. Brace adherence is critical because it's the most reliable predictor of preventing recurrence. After the initial correction, children must wear a foot abduction orthosis for at least 10 to 12 hours a day, with recommendations extending the duration over time, sometimes up to four to five years, to mitigate recurrence during rapid growth periods.

What are some of the socioeconomic and cultural factors that contribute to the challenge of brace non-adherence in children treated for idiopathic clubfoot?

Several factors contribute to brace non-adherence. Socioeconomic challenges, such as financial constraints, can limit access to proper orthotics and regular follow-up appointments. Cultural beliefs and practices may also influence perceptions and adherence to medical recommendations. Access to care, particularly geographical barriers and limited availability of specialized clinics, can hinder consistent treatment. Additionally, a lack of parental education about the importance of bracing and insufficient family support for daily bracing routines contribute to the problem.

How can healthcare providers improve brace adherence in children with idiopathic clubfoot, and what role does parental education play in this process?

Improving brace adherence requires a multi-faceted approach, including developing educational programs, streamlining care within Ponseti clubfoot programs, and using innovative tools like sensor-embedded brace shoes to objectively measure wear time. Parental education is critical; parents need a thorough understanding of the importance of bracing and the potential consequences of non-adherence. Healthcare providers should also build trust with families, show empathy for their challenges, and address any socioeconomic or cultural barriers they may face. Addressing the neurodevelopmental aspects can allow healthcare providers to optimize outcomes.

Beyond musculoskeletal factors, what other developmental challenges might children with idiopathic clubfoot face, and how can addressing these improve the outcomes of the Ponseti method?

Research indicates that children with idiopathic clubfoot may face neurodevelopmental challenges, including difficulties in areas such as writing, attention, memory, and peer interaction. These findings suggest that the challenges in brace adherence may not solely be due to physical discomfort or inconvenience. By recognizing and addressing these broader developmental challenges, practitioners can develop greater empathy and tailor interventions to better support these children and their families, leading to improved brace adherence and better overall outcomes with the Ponseti method. Further studies may expand on these findings, identifying specific areas where earlier interventions can be beneficial.