When putting on your child's clubfoot (pes equinovarus) orthosis, you may have difficulty positioning the heel, you may not be sure how tight the straps should be, or you may see the foot slipping out of the shoe. Learning this procedure can take time, especially in the first few days.
When applied correctly, the heel should stay in place inside the shoe, the sock and tongue should not be wrinkled, and the straps should secure the foot without causing pain or excessive pressure. If the foot keeps slipping even after you put it on again, or if skin irritation develops, you should ask your orthotist-prosthetist for a fit check.
This guide focuses on the foot abduction orthosis, used after Ponseti treatment, in which two shoes are connected to each other by a bar. The order of putting it on may vary depending on the model of the device; the procedure shown to you at delivery should be taken as the basis.
Starting treatment: from the Ponseti method to orthosis use
Clubfoot (pes equinovarus) is a congenital condition in which the foot is turned inward and downward. The Ponseti method, commonly used in treatment, aims to correct the foot gradually and to maintain the correction achieved.
The process generally includes the following steps:
- Initial assessment: The orthopedic specialist assesses the shape and movement of the foot and the child's general condition.
- Manipulation and casting: The foot is gradually brought into the appropriate position by the trained treatment team, and serial casts are applied. The casts are usually changed weekly.
- Achilles tenotomy: In children for whom it is considered necessary, a minor procedure may be performed to release tension in the Achilles tendon. Casting may then be repeated.
- Abduction orthosis: Special shoes and a bar system are used to maintain the correction achieved with casting.
- Follow-up: At regular check-ups, the development of the foot, the fit of the device and possible signs of relapse are assessed.
The orthosis phase is a continuation of treatment. The daily wearing time and when this time will change are determined by the team following the child. The NHS guide to club foot describes casting, surgical procedures where necessary and the use of shoes with a bar as stages of this whole.
Orthoses are used for different purposes in different diagnoses. For example, orthosis use in cerebral palsy is a topic that addresses these different purposes of use. The settings and wearing schedule of the bar orthosis given for clubfoot, however, should be applied according to the child's own treatment plan.
1. Does the orthosis fit my child's foot?
A fit assessment is not made by looking at the shoe size alone. At delivery, the orthotist-prosthetist checks the shoe size, how the foot is held inside, the position of the heel and the width of the bar together.
The foot going into the shoe is not enough on its own. The heel also needs to stay in the appropriate position, and the foot must not slip inside when the straps are fastened.
At the delivery appointment, try putting on the device yourself. Having the specialist watch you do it can help you identify in advance the points you may struggle with at home.
2. How do I know I have put the orthosis on correctly?
First check your child's skin and sock. There should be no wrinkles in the sock, and no foreign object or folded part inside the shoe.
After completing the order of steps you were taught, go over the following points:
- Is the heel settled into the back and bottom of the shoe?
- Is the tongue lying flat?
- Are the straps fastened without twisting or pinching the skin?
- If the model has a check window, does the heel appear to be in the appropriate position?
- Are the bar connections of the shoes fully locked?
The order in which the straps are fastened and when the bar is attached may vary depending on the model. The family guide of Hull University Teaching Hospitals places particular emphasis on positioning the heel and checking its position after application.
3. Why does the heel ride up, and why does the foot slip out of the shoe?
The heel may not have been fully seated at the start, or the foot may have moved inside the shoe during use. The way the straps are applied and the fit of the device to the foot should be assessed together.
If you notice through the check window that the heel has risen, take the shoe off, check the skin and put it back on as you were shown. Do not force the foot down.
If slipping continues despite putting it on again, the solution is not to tighten the straps more and more. Contact your orthotist-prosthetist and ask for the shoe size, heel positioning and application to be checked. If necessary, the treatment team will also reassess the condition of the foot.
4. How tight should the straps be?
The straps should be tight enough to keep the foot and heel in place; they should not cause pain or excessive pressure. Applying them too loosely can cause the foot to slip, while applying them too tightly can lead to skin problems.
It is useful to note which strap hole was used at delivery. However, because of growth, sock thickness and stretching of the material, the same hole may not always give the same fit.
Each time you put the orthosis on, look not only at the strap hole but also at the position of the heel and the condition of the skin. If you cannot achieve the appropriate tightness, review the application again with your specialist.
5. What kind of socks should I use?
The sock should cover the areas where the device touches the skin and should be the right size for the foot. Oversized socks that bunch up inside the shoe, or prominent seams, can create pressure.
After putting the sock on, smooth it around the heel and toes. Make sure no wrinkles remain. Take into account the sock characteristics recommended by the model's manufacturer or your orthotist-prosthetist.
Rather than deciding on your own to put on several layers of socks to stop the foot slipping, have the fit of the device checked.
6. What should I do if I see redness or strap marks?
When you take the orthosis off, examine the heel, the top of the foot, the area around the ankle and the areas where the straps make contact.
Redness that does not go away, recurring friction, blisters and open wounds should not be regarded as ordinary signs of use. Observe how long it takes for redness to fade and follow the skin-check instructions given by your treatment team. The guide from Leeds Teaching Hospitals states that persistent redness and blistering may require a fit assessment.
If there is a blister or an open wound, do not keep the problem area under pressure; get guidance from your treatment team on the same day about resuming use and skin care. Adding padding on your own can change the pressure inside the device.
7. My child is crying: is it the adjustment period or a fit problem?
In the first few days, having both feet connected by a bar can change the sense of movement the child is used to. However, it is not right to assume that every bout of crying means "they will get used to it."
First check the position of the heel, any wrinkles in the sock, the tongue and the straps, and then the skin. Also review daily needs such as hunger, sleep and diaper changes.
Putting the orthosis on in a calm environment, following the same order as much as possible, can make the process easier. If restlessness continues, or clearly recurs every time you put it on, ask for the device to be assessed. Rather than reducing the wearing time on your own, share the difficulty you are experiencing with the treatment team.
8. How can I tell when the orthosis is starting to get too small?
With growth, putting on a device that used to go on comfortably may become harder. New pressure areas, a change in how the straps fit or being unable to keep the heel in place may require a check.
Especially with open-toe models, deciding that the shoe is too small just by looking at the toes can be misleading. The decision to renew is not made on the basis of the child's age or everyday shoe size alone.
Report newly developing fit problems without waiting for your check-up appointment.
9. Can I change the bar width and shoe angles?
The bar width and shoe angles are set according to the child's treatment plan. Reducing the angles or narrowing the bar because it seems more comfortable can change the intended function of the device.
Do not change any settings yourself other than the daily putting on and taking off procedures you were taught. If you notice loosening or a change in settings, contact your orthotist-prosthetist.
10. Can the shoes be used without the bar?
In the foot abduction orthosis described in this guide, the shoes and the bar work together. Using the shoes on their own does not provide the same function.
Even if only one of the child's feet is affected, the prescribed system may require both shoes to be used together. Do not remove the bar or switch to a different system without discussing it with your treatment team.
11. How do I clean and care for the orthosis?
The cleaning method varies depending on the material of the shoes, straps and bar. Follow the manufacturer's instructions; do not use washing methods not stated to be suitable, or drying with high heat.
During the daily check, look for wear on the straps, damage to the buckles, loose screws and any problems with the locking mechanism.
If the connection does not lock fully or a part is damaged, do not force the device into use. Instead of trying to repair it with tape, glue or a different screw, contact the center that fitted it.
12. What should I bring with me to a check-up?
Bring to the appointment not only the shoe you think has a problem, but both shoes, the bar and the socks you use together.
When describing the problem, the following information is helpful:
- Which foot and which area the problem occurs in.
- Whether it was noticed while putting it on, during movement or during sleep.
- How long the redness lasted.
- Whether there has been difficulty putting it on or slipping in recent days.
- Photos of skin marks, if any.
Putting the device on yourself during the examination and showing the step you struggle with makes it easier to assess the application.
Ask for support when you struggle at home
Putting the orthosis on correctly is a skill that needs to be shown to the family and practiced again when necessary. Do not wait for the problem to grow before asking for help.
Get support from your orthotist-prosthetist on the size of the device, heel positioning, straps and care, and from the orthopedic team following your child on wearing time, treatment progress and suspected relapse. For general information, you can also read our guide to orthotic applications for clubfoot (PEV).
This content is for general informational purposes. The treatment plan given to your child, the device manufacturer's instructions and your follow-up team's recommendations should be taken as the basis.
