The French Method for Clubfoot: An Alternative to Ponseti?
The French method for clubfoot (also called the French functional or physiotherapy method) is an alternative non-surgical approach to treating congenital talipes equinovarus that relies on daily physiotherapy, taping, and continuous passive motion rather than serial casting. While the Ponseti method dominates clubfoot treatment in the UK and worldwide, the French method has its own evidence base and is still used in parts of France and a handful of specialist centres globally. This article explains what the French method involves, how it compares to Ponseti, and what UK parents should know.
What Is the French Method?
Developed in the 1970s and 1980s by French orthopaedic surgeons and physiotherapists (notably at the Robert Debré Hospital in Paris), the French method treats clubfoot through intensive manual therapy rather than plaster casts. The approach involves three core components:
1. Daily Physiotherapy Sessions
A specially trained physiotherapist manipulates the baby's foot through a structured sequence of stretches, targeting each component of the clubfoot deformity (cavus, adductus, varus, and equinus) in a specific order. These sessions last 30–45 minutes and are performed daily — or even twice daily — for the first 2–3 months.
2. Taping (Strapping)
After each manipulation session, the foot is held in the corrected position using adhesive tape or elastic strapping. The tape maintains the gains achieved during the stretching session until the next appointment. It is replaced daily.
3. Continuous Passive Motion (CPM) Splints
Some centres use a motorised splint that continuously and slowly moves the foot through its corrected range of motion while the baby sleeps. This is more common in French hospitals than in any UK or international setting.
Treatment Timeline
The intensive daily phase lasts approximately 2–3 months. After initial correction is achieved, the frequency reduces to 3 times per week, then weekly, then monthly maintenance sessions. A foot abduction brace (similar to the one used in the Ponseti method) is worn during sleep. Total treatment duration extends over several years, similar to Ponseti bracing.
How Does It Compare to the Ponseti Method?
| Factor | Ponseti Method | French Method |
|---|---|---|
| Primary correction tool | Serial plaster casts | Daily manual physiotherapy + taping |
| Number of hospital visits (initial phase) | 5–8 visits over 5–8 weeks | 60–90 daily visits over 2–3 months |
| Achilles tenotomy rate | 80–90% | 50–60% |
| Long-term bracing | Boots and bar until age 4–5 | Night splint + periodic physiotherapy |
| Requires specialist physio? | No (parent-managed bracing) | Yes (daily trained physiotherapist) |
| Correction rates at 5 years | 90–95% | 85–90% |
| Availability in UK | All NHS trusts | Extremely limited |
What Does the Evidence Say?
The largest comparative study between the two methods was published by Bensahel et al. (2007) in the Journal of Pediatric Orthopaedics B, comparing outcomes of 350 clubfeet treated with the French method against 200 treated with Ponseti. Key findings:
- Initial correction rates were comparable (approximately 90% in both groups).
- The French method group had a lower tenotomy rate (52% vs. 85%) but a higher rate of minor surgical interventions (posterior releases and tendon transfers) later in childhood.
- At 5-year follow-up, functional outcomes (walking, running, sport) were equivalent.
- The French method required significantly more healthcare resources (daily physiotherapy visits vs. weekly casting).
A 2014 Cochrane review examined available randomised controlled trials comparing the two methods and concluded that both produce satisfactory outcomes, but the evidence was insufficient to declare one superior. The review noted that the Ponseti method was more practical for widespread implementation due to lower resource requirements.
A multicentre study by Richards et al. (2008) at Texas Scottish Rite Hospital followed 176 feet treated with either method and found equivalent correction rates at 2 years, but the Ponseti group required fewer total healthcare visits (an average of 12 vs. 68).
Advantages of the French Method
- No casting: The baby never wears a plaster cast, which means no cast-related skin problems, no cast-removal appointments, and no restrictions on bathing.
- Lower tenotomy rate: The intensive stretching programme achieves Achilles lengthening without surgery in approximately half of cases.
- Continuous assessment: Because the physiotherapist sees the baby daily, they can adjust the approach immediately based on how the foot is responding. With Ponseti, corrections are assessed weekly at cast changes.
- Parent involvement: Parents are heavily involved in the daily stretching, which some families prefer to the more passive role during casting.
- Gentler on skin: No cast-related skin issues (dryness, maceration, pressure sores).
Disadvantages of the French Method
- Extremely resource-intensive: Daily 30–45 minute sessions with a specialist physiotherapist for 2–3 months is impractical for most healthcare systems, including the NHS. Travel time, appointment scheduling, and time off work for parents add to the burden.
- Requires specialist training: Very few UK physiotherapists are trained in the French method. The skill set is specific and different from general paediatric physiotherapy.
- Compliance challenges: The method depends on parents attending daily (or near-daily) appointments and applying taping at home. Any interruption (illness, holidays, childcare issues) can compromise the correction.
- Higher surgical rate long-term: While the initial tenotomy rate is lower, some studies show a higher rate of secondary surgical procedures in French method patients, suggesting that the initial correction may not always be as complete.
- Not available in the UK: No NHS trust currently offers the French method as a standard treatment pathway. A small number of private paediatric physiotherapists may incorporate elements of the French method, but full protocol implementation is essentially unavailable in Britain.
Can You Combine the Two Methods?
Some orthopaedic centres worldwide use a hybrid approach — Ponseti casting for initial correction followed by French-method physiotherapy for maintenance. This is sometimes called the "Ponseti-French" or "comprehensive" approach.
In practice, many UK clubfoot physiotherapy programmes already incorporate elements of the French method (daily stretching, taping techniques) as adjuncts to the standard Ponseti pathway. The stretching exercises prescribed for home use between casting sessions and during bracing share principles with the French method's manual therapy component.
Why the Ponseti Method Is Standard in the UK
The NHS adopted the Ponseti method as the standard of care for clubfoot based on several factors:
- Practicality: Weekly or fortnightly cast changes require far fewer healthcare resources than daily physiotherapy sessions.
- Scalability: The Ponseti method can be taught to a wider range of practitioners (surgeons, physiotherapists, orthotists) in a shorter training period.
- Evidence base: While both methods have supporting evidence, the volume of Ponseti-specific research is substantially larger, with more long-term follow-up data available.
- Consistency: The Ponseti method produces reliable, reproducible results across different centres and practitioners. The French method's outcomes are more dependent on the individual physiotherapist's skill and the family's ability to attend daily sessions.
- Global consensus: The World Health Organisation, POSNA (Pediatric Orthopaedic Society of North America), and most international orthopaedic bodies recommend the Ponseti method as first-line treatment.
Should UK Parents Consider the French Method?
For the vast majority of UK families, the Ponseti method is the correct choice. It is available on the NHS, well-supported by evidence, and produces excellent outcomes. The French method is not a realistic alternative within the current UK healthcare system.
However, if your child has had an incomplete response to Ponseti casting, or if you are interested in maximising physiotherapy input alongside standard treatment, discuss this with your orthopaedic team. Incorporating French-method principles (intensive stretching, taping between sessions) into a Ponseti pathway may provide additional benefit in selected cases.
Frequently Asked Questions
Q: Is the French method better than Ponseti?
A: Neither method is definitively better. Both achieve initial correction rates around 90%. The Ponseti method is more practical, requires fewer appointments, and has a larger evidence base. The French method avoids casting and may reduce the need for tenotomy. For UK families, Ponseti is the standard and most accessible option.
Q: Can I get the French method on the NHS?
A: No NHS trust currently offers the full French method protocol. Individual physiotherapists may incorporate some French-method techniques into their practice, but the intensive daily treatment programme is not available within the NHS.
Q: Is the French method used anywhere in the UK privately?
A: A very small number of private paediatric physiotherapists may offer French-method-influenced treatment, but finding a practitioner fully trained in the Bensahel/Robert Debré protocol in the UK is extremely difficult. If you are considering this, ensure the practitioner has specific French method training from a recognised centre.
Q: Does the French method work for severe clubfoot?
A: The French method has been shown to be effective across the severity spectrum, though severe and atypical cases may respond less predictably than to Ponseti casting. Most published outcomes data comes from centres with decades of experience in the technique.
Q: Could the French method be useful after Ponseti treatment?
A: French-method stretching and taping principles can complement Ponseti bracing, particularly for maintaining dorsiflexion and forefoot abduction. Discuss this with your physiotherapist if you are interested in a more intensive home programme.