What Is Clubfoot Relapse?
Relapse is the word every clubfoot parent dreads. It means the foot has started to return to its original deformed position — turning inward, pointing downward, or both. It doesn't mean the initial treatment failed, and it doesn't mean starting over from scratch. But it does mean that additional treatment is needed to re-correct and maintain the position.
Relapse occurs in approximately 10-30% of clubfoot (talipes) cases treated with the Ponseti method, depending on the study and how relapse is defined. The most common period for relapse is between 6 months and 4 years of age — the period when the child is growing rapidly and the feet are under the most biomechanical stress. However, relapse can occur at any age until the foot has finished growing (around age 14-16).
The single most important factor in preventing relapse is consistent boots and bar wear. Studies consistently show that the vast majority of relapses occur in children who have reduced or stopped brace wear too early.
Signs of Clubfoot Relapse
Knowing what to look for is your best tool for catching relapse early. Early detection means simpler treatment. Here are the signs, from the most to least obvious:
Physical Signs You Can See
- The foot is turning inward again. When your child stands or walks, you notice the foot pointing inward (in-toeing) more than it used to. In early relapse, this may be subtle — the foot might look fine at rest but turn in when walking.
- Walking on the outside of the foot. Your child seems to bear weight on the outer edge of the foot rather than the full sole. You might notice this as asymmetric shoe wear — the outside of the sole wears down faster.
- Heel not touching the ground. When walking, the heel seems to lift off the ground (equinus). Your child appears to be walking on their toes on the affected side.
- The foot is losing flexibility. During boot-off time, the foot seems stiffer than before. It doesn't move as freely in all directions.
- Deep creases returning. The creases that were present before treatment — on the sole or behind the heel — appear to be deepening again.
- Difficulty getting the boot on. If the foot is starting to turn in, the boot may be harder to fit correctly. The heel may not seat properly, or the foot seems to resist the boot position.
Functional Signs
- Tripping or falling more than usual. An in-turning foot catches on the opposite leg, causing frequent trips.
- Limping. A noticeable asymmetry in the walking pattern that's new or getting worse.
- Reluctance to walk or run. If the foot is becoming uncomfortable, your child might avoid weight-bearing activities they previously enjoyed.
- Asymmetric shoe wear. Check the soles of your child's shoes. If one side is wearing down much faster than the other, this suggests an uneven gait pattern.
What's Normal vs What's Concerning
| Normal | Potentially Concerning |
|---|---|
| Slightly thinner calf on affected side | Foot visibly turning inward at rest |
| Affected foot slightly smaller (up to 1 size) | Walking on outside edge of foot |
| Mild in-toeing in early walkers (common in all children) | In-toeing that's getting worse over time |
| Some stiffness first thing in the morning | Progressive loss of ankle flexibility |
| Occasional tripping (normal for toddlers) | Frequent tripping only on the affected side |
What to Do If You Suspect Relapse
- Don't panic. Relapse is manageable and treatable. It's not a failure, and it's not the end of the world.
- Contact your orthopaedic clinic. Call your NHS orthopaedic team and describe what you've noticed. They'll usually bring your next appointment forward.
- Take photos or video. If the sign is visual (e.g., in-toeing when walking), take a video to show the consultant. Sometimes the foot behaves perfectly at clinic, and having evidence of what you've seen at home is invaluable.
- Continue brace wear. Don't stop the boots and bar while waiting for your appointment. Consistent brace wear is even more important if relapse is suspected.
- Note any changes in brace compliance. Has there been a period of reduced brace wear (illness, holiday, broken bar)? This information helps the team understand the context.
How Is Relapse Treated?
Treatment depends on the severity of the relapse and the age of the child. Options, from least to most invasive:
Re-casting (Repeat Ponseti Casts)
For mild to moderate relapse, especially in younger children (under 2-3 years), a short course of repeat Ponseti casts is often sufficient. Typically 2-4 casts (fewer than the initial treatment), followed by return to boots and bar wear.
Re-tenotomy
If the Achilles tendon has retightened (equinus relapse), a repeat Achilles tenotomy may be performed. This is the same minor procedure as the initial tenotomy and is done under local anaesthetic.
Tibialis Anterior Tendon Transfer (TAT)
For children aged 2.5-5 years with dynamic supination (the foot turns in during walking due to muscle imbalance), a TAT procedure is often recommended. This surgical procedure moves the tibialis anterior tendon from the inner side of the foot to the outer side, rebalancing the muscle pull. It's done under general anaesthetic and is followed by a period in a cast and then bracing.
Soft Tissue Surgery
For more severe relapses that don't respond to casting or TAT, a more extensive soft tissue release may be needed. This involves releasing contracted tendons and ligaments to allow the foot to be repositioned. Recovery is longer, but outcomes are generally good.
Bony Surgery
In rare cases, usually in older children or adolescents with severe relapse, bony procedures (osteotomies, fusions) may be necessary. These are reserved for cases where soft tissue procedures alone are insufficient.
Preventing Relapse
The best treatment for relapse is prevention. Here's what the evidence shows:
- Brace compliance is everything. Wear the boots and bar as prescribed — every night, every nap, until your consultant says to stop. Research shows that non-compliance is the number one risk factor for relapse.
- Don't stop early. Even if the foot looks perfect, the underlying tendency to relapse remains until the growth plates close. The boots and bar maintain the correction while the foot grows.
- Attend all follow-up appointments. Your orthopaedic team monitors for early signs of relapse that you might not notice. Regular appointments (typically every 3-6 months) allow them to intervene early if needed.
- Report concerns early. If you notice anything that worries you — in-toeing, heel lifting, difficulty with boots — contact your clinic. Don't wait for the next scheduled appointment.
- Encourage physical activity. Active feet are healthy feet. Sports and exercise strengthen the muscles that support the corrected position.
Frequently Asked Questions
How common is clubfoot relapse?
Studies report relapse rates of 10-30%, depending on how relapse is defined and the brace compliance of the study population. With excellent brace compliance, relapse rates are at the lower end (10-15%).
When is relapse most likely to occur?
The highest risk period is between 6 months and 4 years of age. After age 5, relapse is less common but can still occur until the growth plates close (around age 14-16). Vigilance is important throughout childhood.
If my child's foot relapses, does it mean the Ponseti method failed?
No. Relapse is a recognised part of clubfoot management, not a treatment failure. The Ponseti method has a built-in protocol for managing relapse (re-casting, re-tenotomy, TAT). Your team will have a clear plan.
Can relapse happen after the boots and bar phase is complete?
Yes, though it's less common. Some relapses occur in older children (5-10 years) even after completing the full bracing protocol. This is why ongoing monitoring until skeletal maturity is recommended.
Is relapse more likely with bilateral clubfoot?
Not necessarily. Relapse risk is more related to the severity of the initial clubfoot, brace compliance, and whether the clubfoot is atypical than whether one or both feet are affected.
My child had a relapse and I feel guilty. Is it my fault?
Relapse can occur even with perfect brace compliance. Some feet are simply more prone to relapsing than others due to the severity of the original deformity. If there have been gaps in brace wear, try not to dwell on guilt — focus on the treatment plan going forward. Your team is not judging you.
Read more in our guide: What Causes Clubfoot in Toddlers? Late Diagnosis and Next Steps.
Further support: Why Does Clubfoot Relapse? Understanding the Causes.
Further support: What Does Clubfoot Relapse Look Like? Warning Signs.