Ponseti Clubfoot Clinic

The key to Success

If you are following the Ponseti method then once you have corrected the deformity you need to keep it that way.

That is when parents and carers take up the responsibility of diligently wearing the boots and bar.

Your child has now reached the stage in the Ponseti treatment programme to have their boots and bar fitted. This will be done in clinic on the day the after-surgery plaster is removed. Your baby's legs may be swollen and more sensitive than usual when the plaster is removed, but this will settle within a few days. You need to persist and you will win. Contact your physiotherapist if you need support.

Why are the boots and bar important?

As your child grows there is a high risk that the muscles and ligaments will relapse to their original position (research shows 80% relapse without bracing). The boots and bar hold the feet in the position required to prevent this and it only relapses in 7% of children that wear their boots and bar.

Who fits the boots and bar?

Your physiotherapist will fit and set the boots to the correct angles when the plasters have been removed. These settings must not be altered by anyone other than your physiotherapist, orthotist or orthopaedic doctor.

How are the boots fitted?

• Please make sure your child has socks to wear as the boots are leather and may make the skin sore.
• The least flexible foot should be fitted first.
• Make sure the heel is placed at the very back of the boot and should be in contact with the sole of the shoe, and the heel retaining strap done up firmly to secure the position of the heel.
• The laces can then be fastened firmly. The main cause of problems with the boots and bars occurs when they are not done up firmly allowing the child to wiggle their feet, either causing blisters or allowing them to slip out.
• You may find it helpful to mark with a pen where the toes reach on the sole of the boot. If the toes move this means the heel is not securely down at the back of the boot.
• Fit the other boot in the same way.

How long will my child wear the boots and bar?

For the first 12 weeks the boots and bar need to be worn for 23 hours a day. They should only be removed for stretches, bathing and dressing and of course to inspect your child's feet if you are concerned. After the first 12 weeks they need to be worn at sleep times, i.e. overnight and nap times. This should continue until the age of four.

Will my child be comfortable in the boots?

Your child may become upset when they first have their boots fitted. This is because their skin may be more sensitive following the removal of the plasters. Also, it is frustrating to your child to have both feet joined together to the bar. You can help through play by doing exercises that teach your child to bend both knees at the same time. The more time your child spends wearing the boots, the sooner he or she will get used to moving both legs together.

If your child is crying and more distressed than usual, check the boots are not rubbing or blisters are not present. This may indicate the boots have been put on too loosely or the bar needs lengthening. If blisters are present please contact your physiotherapist as soon as possible.

Will my child need any other special equipment?

No. Your child can use their pram, car seat or high chair as before, as long as the strap between the legs is detachable it can be threaded between the bar and legs. If your child is wearing trousers they will need to have poppers or buttons between the legs.

How often will my baby need to be seen?

You will need to be reviewed at two weeks after the first fitting to check the brace. After the first 12 weeks are completed you will need to be checked before wearing the boots for sleep times only. You will then only require checks every 3 months for the first year, every 4 months for the next year, then every 6 months for a year and every year after that at the request of your orthopaedic surgeon.

What will happen if my child is one of the 7% that relapse?

You can expect that we will recommend "Ponseti casting", as your child had initially. Depending on what has relapsed and how stiff it has become, determines how many casts will be required.

If you have caught it early, it may mean 3 to 4 Ponseti casts, or short leg serial casts, that your child can walk in, if it is only for achilles tightness.

Once the foot position is corrected, ideally DF (bending ankle up) = 30 degrees, ER (turning foot out) = 60 degrees, boots and bars are resumed as per previous protocol.

Who can I call if I am having problems?

Please call your physiotherapist if:

• You have difficulty fitting the boots or keeping your child in the brace.
• You are worried your child's skin is developing a sore
• You are having problems keeping your child's heels down at the back of the shoes
• You are concerned about your child's feet

Following all of these instructions is essential to achieve the best results for your child.

Ponseti Programme: Boots and Bar Stage