There are two phases in the Ponseti method. The first phase is called the corrective phase and the second phase is called the maintenance phase. In the first phase, there are two stages. The first stage begins with weekly manipulation and plaster casting and the second stage includes the tenotomy and the three weekly cast.
During the corrective phase, children are given weekly casting for four to six weeks. Week after week new plaster cast is applied and the number of casts could decrease or increase based on the spectrum of clubfoot and the age of the child. When the midfoot score is less than or equal to 0.5 and the hind foot score is less than or equal to one the foot is ready for tenotomy. The cast after tenotomy remains for three weeks. This concludes the second stage in the first phase. So in the first phase, the treatment includes weekly gentle manipulation, plaster casting and tenotomy.
The second phase is called the maintenance phase. In this phase, the foot that is corrected with manipulation and casting is maintained using a foot abduction brace. This bracing phase or maintenance phase has two stages. The first three months constitute the first stage, where the child has to wear the brace for 23 to 24 hours a day. The brace is removed only if it is required during feeding, bathing or changing. The duration of time the child is left without bracing should not be more than an hour.
In the second stage of the maintenance phase, the child has to wear the brace for night and naptime. Why nighttime bracing? Because it is at night when the human bone grows we want to make sure the bone grows in the corrected position. Then why is naptime bracing insisted upon? When children are given bracing both at night and naptime, the children associate wearing of brace with sleep and there is better adherence by the parents to keep the bracing protocol.
When children are given the brace only at night, the child prefers to sleep longer hours during the day (when the foot is left free) and the night sleep gets disrupted. When children are given bracing for the first time, generally the first two days and nights most of the children cry and resist leaving the foot in the bracing position. To avoid such a situation, the child is given the brace both during night and daytime sleep. If the child does not wear the brace according to this protocol, there are definite possibilities for relapse and the corrected foot goes back to the original clubfoot position.
When children are given the brace for the first time they will often resist and cry for the first one or two days but then they get used to it. Parents have to be careful to understand the nature of the crying. Is the child crying because of the first-time brace and annoyance or the child is crying because of some serious problem with the brace? Parents should be careful not to remove the brace carelessly when children cry or ask to remove the brace. Once the brace is removed with crying, there are chance that the child will cry every time and the protocol may get disturbed. However, if there is any discomfort, bruise or blister the parent should consult the doctor and find a solution to the problem and once corrected continue the brace protocol carefully and strictly to avoid recurrence. The parents must understand all four stages (two stages in the first phase and the other two stages during the second phase) in the treatment for clubfoot and follow them without any compromise or change. This protocol has been tested for over fifty years and has proven to be very successful in thousands of children who are now adults leading productive and normal lives. Many of the children treated with the Ponseti method have grown to become very successful sportspersons, athletes, politicians and business leaders.
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