Clubfoot Challenges: How to Improve Adherence and Outcomes
"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.
Factors Behind Persistent or Relapsed Clubfoot
The University of Iowa Ponseti clinical guidelines recommend examining practical and family circumstances when evaluating persistent or relapsed clubfoot. Factors to consider include difficulty obtaining or using braces, family stability and functioning, transportation and housing logistics, and religious or cultural issues.
Ponseti Care and Bracing Challenges
The Ponseti method is described as the gold standard for idiopathic clubfoot, but treatment has challenges, particularly during the bracing phase. A 2026 review highlights that successful care depends on collaboration. Another 2026 source says accelerated protocols aim to shorten treatment without compromising outcomes, but evidence comparing their efficacy and safety with the standard protocol remains inconclusive. A 2024 review describes 4–5 years of bilateral foot-abduction bracing to prevent relapse and notes that adherence is often low and non-adherence is associated with poor outcomes.
Clubfoot Through History
Clubfoot has been represented in historical imagery since ancient times, according to a review tracing its iconographic history. That review identifies Hippocrates as the first to provide written references to clubfoot treatment methods. A separate historical review surveys treatment approaches from antiquity through the end of the period covered in its literature and art review, describing clubfoot treatment as a continuing challenge in pediatric orthopaedics.
Why is Brace Adherence So Challenging?
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.
- 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.
Reviews of Adherence and Nonsurgical Care
A systematic scoping review published in 2024 set out to identify factors associated with adherence and non-adherence to bracing in the Ponseti method, synthesize strategies reported to improve adherence, and provide a clinically meaningful synthesis of available evidence. A separate review examines nonsurgical clubfoot treatment, describing the Ponseti method as widely regarded as the gold standard and reviewing its effectiveness, methodology, and longer-term considerations.
Evidence Gaps in Improving Brace Adherence
The systematic scoping review reports that it identified no studies evaluating strategies to improve brace adherence. Separately, a study measuring foot-abduction-brace wear time with a single 3-axis accelerometer validated its method in a selected group of infants whose parents were known to be highly compliant with brace use and diary reporting. That selected population limits what the study snippet establishes about measurement in less-compliant families.
Relapse Patterns and Brace Wear
A global meta-analysis reported higher relapse rates in studies with at least 36 months of follow-up than in studies with shorter follow-up: 25% versus 18%. A separate study found relapse during monitoring in 8 of 44 patients who completed it; those with relapse averaged 5 hours of brace wear per day, compared with 8 hours among those without relapse, a statistically significant difference (p = 0.045). Another source reports a meta-analysis finding 3.5-times higher odds of recurrence when more than five casts were used, with a 95% confidence interval of 1.6 to 7.8.
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.
Closing the Global Treatment Coverage Gap
The BMJ Global Health overview, “Global clubfoot treatment in 2023: an overview of advances and challenges,” reports that treatment coverage remained approximately 22% across respondent countries. Integration of clubfoot services into national healthcare systems varied widely. The overview also describes strong public-private partnerships in many countries as a foundation for sustainable, long-term treatment programmes.
Adherence as Part of Treatment Success
A 2024 systematic scoping review states that success of the Ponseti method for idiopathic clubfoot depends on both casting technique and the patient’s adherence to the foot-abduction brace protocol. This frames adherence as one component of treatment, alongside the clinical casting process.
Designing a More Mobile Brace
Clubfoot Solutions, a medical equipment manufacturer, sought to improve nonsurgical treatment for children worldwide by rapidly prototyping and iterating a more mobile design for its traditional Iowa Brace. A case study reports that Clubfoot Solutions distributed nearly 100,000 Iowa Braces with Stratasys. These details describe a product-design effort and distribution figure, rather than clinical outcome results.