Recognising what clubfoot relapse looks like early can make the difference between a brief course of repeat casting and more extensive treatment. A relapse occurs when a previously corrected clubfoot begins to return to its original deformed position — and the earlier it's spotted, the simpler it is to address. This guide provides detailed visual descriptions, a practical checklist for parents, and guidance on when to seek urgent review from your child's treating team.
What Exactly Is a Clubfoot Relapse?
A relapse is the recurrence of one or more components of the original clubfoot deformity after successful Ponseti correction. The original deformity has four components, and a relapse may involve any combination:
- Equinus: The foot pointing downward (like standing on tiptoes)
- Varus: The heel turning inward
- Adductus: The forefoot curving inward (C-shaped appearance)
- Cavus: An abnormally high arch in the midfoot
Relapse doesn't always involve all four components returning simultaneously. The most common pattern is a dynamic supination (foot rolling inward during walking) combined with return of the equinus component. This partial relapse is easier to treat than a full recurrence of all elements.
Visual Warning Signs by Age Group
Babies and Infants (Under 1 Year)
During the first year of life, when babies are typically in the full-time brace phase, relapse signs are primarily visible when the brace is removed for bathing or dressing:
- Foot position at rest: When the baby is relaxed or asleep (without the brace), the foot turns inward noticeably. Compare with any "normal" photos taken immediately after the final cast was removed — is the foot reverting?
- Resistance during boot fitting: If the foot is becoming harder to fit into the brace boot, this may indicate increasing stiffness and a return of the deformity.
- Asymmetry with the other foot: In unilateral cases, compare the treated foot with the unaffected side. Any increasing difference in position, flexibility, or shape warrants attention.
- Tight heel cord: Gently flex the baby's ankle upward (dorsiflexion). If this movement is decreasing — the foot can't come up as far as it used to — the Achilles tendon may be tightening, which is a key early relapse sign.
- Sole crease: A deep crease across the sole of the foot (particularly in the midfoot area) can indicate return of the cavus component.
Toddlers (1-3 Years)
As children become mobile, relapse signs become more apparent during movement:
- Toe-walking: If your child consistently walks on their toes on the affected side, this strongly suggests return of the equinus (tight Achilles). Occasional toe-walking is normal in toddlers, but persistent asymmetric toe-walking on the clubfoot side is concerning.
- In-toeing: The treated foot turning inward during walking, while the other foot points forward. Some mild in-toeing is normal in toddlers, but progressive or significant in-toeing on the treated side should be assessed.
- Limping: An uneven gait that favours the unaffected side.
- Foot rolling: The foot rolling onto its outer edge during walking (dynamic supination). This may be subtle — watch your child walk toward you and away from you on a flat surface.
- Shoe wear pattern: Asymmetric wear on the outer edge of the shoe on the treated foot, compared to more central wear on the unaffected side.
Older Children (3-7 Years)
In older children, relapse signs include all of the above plus:
- Pain or tiredness: Complaints about foot or ankle pain, particularly after activity. Young children may not describe this as pain but may become reluctant to walk or ask to be carried more often.
- Declining physical activity: A child who was previously active but starts avoiding running, climbing, or physical play may be experiencing discomfort from a subtly relapsing foot.
- Callus formation: Hard skin developing on the outer border of the foot, indicating abnormal weight-bearing patterns.
- Foot shape changes: Compare current foot shape with photos from previous clinic visits. Progressive changes in arch height, forefoot curve, or heel position are significant.
The Dynamic vs Fixed Relapse
An important distinction for both parents and clinicians is between dynamic and fixed relapse:
Dynamic relapse: The foot appears normal at rest but turns inward during walking or running. This is the most common early relapse pattern and is often caused by muscle imbalance — specifically, overactivity of the tibialis anterior tendon. Dynamic relapse is typically treated with a tibialis anterior tendon transfer (TATT) procedure and has an excellent prognosis.
Fixed relapse: The foot is stiff in a deformed position even at rest. This represents a more established recurrence involving both soft tissue tightening and potentially bone position changes. Fixed relapse usually requires repeat Ponseti casting and may need more extensive surgical correction.
Catching a dynamic relapse before it becomes fixed is the goal of ongoing monitoring.
When to Contact Your Treating Team
Contact your child's orthopaedic team or clubfoot clinic if you notice any of the following:
- The foot is harder to fit into the brace boot than previously
- Ankle dorsiflexion (lifting the foot upward) has decreased
- Consistent toe-walking on the affected side
- The foot visibly turns inward during walking
- Any asymmetry that is new or worsening
- Your child complains of foot pain or refuses to walk
- You can see the deformity returning — trust your instincts as a parent
You do not need to wait for your next scheduled appointment. Most NHS clubfoot clinics have a route for urgent or semi-urgent reviews. Phone the consultant's secretary or the physiotherapy department and explain your concerns. They should be able to arrange a review within 1-2 weeks. For more detail on the NHS clubfoot pathway, see our dedicated guide.
What Doesn't Indicate Relapse
Not every change in the foot is a relapse. The following are generally normal and not causes for alarm:
- Calf size difference: The calf on the treated side is typically smaller than the other leg. This is a permanent feature of clubfoot, not a sign of relapse.
- Foot size difference: The treated foot may be slightly smaller (up to half a shoe size). This is normal and does not indicate ongoing deformity.
- Mild in-toeing: Some degree of in-toeing is normal in toddlers and young children, whether or not they have clubfoot. It usually resolves with maturity.
- Red marks from the brace: Pressure marks on the skin after brace removal are normal, provided they fade within 20-30 minutes. Marks that persist or involve broken skin should be assessed by the orthotist.
- Fussiness when putting the brace on: Some resistance to the brace is normal, particularly during developmental stages. This alone doesn't suggest the foot is relapsing.
Documenting Changes: A Practical Approach
Keeping a visual record of your child's foot is invaluable for detecting subtle changes over time:
- Monthly photos: Photograph the foot from the front, back, sole, and side. Use the same angle and lighting each time for consistency.
- Video of walking: Once your child is mobile, record short clips of them walking from front, back, and side views. This captures dynamic movement patterns that still photos miss.
- Range of motion notes: Gently test ankle dorsiflexion and note how far the foot comes up. If this gradually decreases, it's an early sign worth reporting.
- Clinic comparison: Bring your photos and videos to clinic appointments. They provide objective evidence of change that a single clinic snapshot may not capture.
How Common Is Relapse Really?
Published relapse rates vary, but the most widely cited figures are:
- With good brace compliance: 6-10% relapse rate
- With poor brace compliance: 50-80% relapse rate
- Overall (mixed compliance): 20-40% relapse rate
The relapse risk is highest in the first 3 years of life and decreases progressively after age 4-5. For a deeper analysis, see our article on clubfoot relapse statistics.
The reassuring message is that even when relapse occurs, it is treatable. Most relapses caught early respond to repeat Ponseti casting (2-4 casts), sometimes followed by a repeat tenotomy. More established relapses may require a tendon transfer procedure, which has a high success rate. Extensive reconstructive surgery is rarely needed for relapsed clubfoot in the Ponseti era.
Frequently Asked Questions
Q: Can relapse happen overnight or is it always gradual?
A: Relapse is almost always gradual, developing over weeks to months. It does not happen suddenly from one day to the next. This gradual progression is what makes regular observation and photography so valuable — subtle changes accumulate over time and may not be obvious from day to day but are clear when comparing photos from a month or two apart.
Q: My child's foot looks different in the morning vs evening — is this relapse?
A: Some variation between morning and evening is normal. The foot may look slightly stiffer in the morning after a night in the brace, and more flexible in the evening after a day of movement. This variation does not indicate relapse. Relapse is characterised by a consistent, progressive change in the foot's resting position and range of motion over time.
Q: How can I tell the difference between normal toddler in-toeing and clubfoot relapse?
A: Normal in-toeing (metatarsus adductus or internal tibial torsion) is usually symmetrical — both feet turn in equally. It's flexible, meaning the foot can be easily moved to a straight position. In clubfoot relapse, the in-toeing is asymmetric (worse on the treated side), may be accompanied by tightness in the Achilles tendon, and is progressive rather than stable. If in doubt, seek review from your orthopaedic team.
Q: Should I stop using the brace if I think the foot is relapsing?
A: No — continue brace use unless your treating team advises otherwise. The brace is still providing some corrective force even if the foot is beginning to relapse, and stopping brace use will accelerate the recurrence. The exception is if the brace is causing skin breakdown or injury, in which case contact your orthotist urgently for an adjustment.
Q: Is relapse more common in the left or right foot?
A: Relapse rates are similar for left and right feet. Clubfoot itself is slightly more common on the right side (or bilaterally), but once corrected, neither side has a significantly higher relapse rate than the other. The key factor is brace compliance, not laterality.