Bracing for Clubfoot
Original Editor - Africa Clubfoot Training Team as part of ICRC and GCI Clubfoot Content Development Project
- 1 Introduction
- 2 Brace Features
- 3 Brace Timing
- 4 Bracing Protocols
- 5 Brace Review Protocol
- 6 Brace Compliance
- 7 Resources
- 8 References
Once the foot has been corrected into a normal functional position by manipulation, casting and tenotomy it needs to be braced to keep it corrected and to stop relapse. This is crucial for the future of the child and a lot of children deteriorate at this stage as they fail to wear the brace properly. 
The brace is critical for the success of the treatment programme. No other device will work. If the brace is not worn, relapse is very likely. If bracing is stopped at any point during the treatment the following relapse rates can be expected:
- 1st Year: 90%
- 2nd Year: 70 - 80%
- 3rd Year: 30 - 40%
- 4th Year: 10 - 15%
- 5th Year + : 5%
Essential features of the brace: Foot abduction bar with a distance from one shoe heel to the other equal to the width of the child’s shoulders. The shoes are externally rotated 60-70 degrees on the affected side or sides. (If the brace is not adjustable, the “normal” side can also be set to 60-70 degrees as normal feet externally rotate to 70 degrees easily). If the braces are adjustable, the unaffected or “normal” foot should be set to 40 degrees of external rotation. The shoe is positioned to give approximately 10 degrees of dorsiflexion. The shoe should have a heel cup to prevent the foot from slipping out of the shoe. There should be an ‘inspection hole’ on the medial side at the back of the shoe which is used to check that the heel is down. 
In children under walking age, the brace is worn 23 hours per day for 12 weeks. It is then worn at night and nap time until the child is 4 - 5 years old. Wearing the brace must be started as soon as the last cast is removed to avoid the foot turning back into its previous position. 
Brace Fitting Instructions for Clinicians
Immediately after removal of the final cast post-tenotomy, i.e. on the same day:
- Fit most difficult foot first
- Gently flex the hip and knee and dorsiflex the foot as much as possible
- Hold in position
- Push the foot heel first into the shoe (with the straps undone or laces very loose)
- Check through the inspection hole to make sure the heel is down
- Close the tongue
- Check again and tie laces or tighten the straps (if using a shoe with straps fasten the middle one first)
- Then repeat with the second foot 
Brace Fitting Instructions to Parents
- Check Skin Condition / Circulation regularly
- Use socks for comfort but check they are not creased
- Must be a firm fit to avoid friction with movement
- Constant Use = More Compliant Child
- Check Heel Down
- Advise to look for red marks, blisters, and cold toes
- Wrap knees around mother’s body, rather than feet, when carried on back
- Inform them of their next appointment
- Ask if they have any questions 
Types of Brace
There are many types of brace, some very expensive. The Steenbeek Foot Abduction Brace (SFAB) is cheap, easily made locally, and effective. But there are other braces that are equally effective. Any Foot Abduction Brace that is recommended should have the following features: 
- Shoes attached to bar at 60 - 70˚ abduction on the affected or both sides
- Dorsiflexion 10 - 15˚
- Straight Medial Border
- Heels as far apart as Shoulder Width
- Low Posterior Cut (holds the foot in the shoe, prevents heel slip)
- Well-rounded Heel Counter or Heel Cup
- Inspection Hole - Medial Side
- Large Shoelace Holes (if using laces)
- Open Toe 
Some examples of FABs that are commonly used are:
- Steenbeek Foot Abduction Brace (SFAB) which can be manufactured in any country at low cost
- Mitchell Brace
- Markell Brace
- Miraclefeet Brace
- Iowa Brace
Brace Review Protocol
Most clinics follow a brace check-up timeline similar to this:
- Fit on the day that the Tenotomy Cast is removed
- Review after 1 - 2 weeks
- Review at 4 - 5 weeks. This will be the halfway point of the 23 hours brace wear regime
- Review 6 weeks after this. At this appointment the time in the brace can be reduced to night and nap times
- Continue to review 3-monthly until the child is 2 years old
- Continue to review 6-monthly until the child is 4 - 5 years old at which point you can stop bracing
- If circumstances permit, then continue to review once a year until child reaches skeletal maturity. If this is expensive to parents then do not force it
- It is important for the parents to know that they can come back to clinic after the age of 5 years if they have any concerns 
To be followed each time child seen following initiation of Bracing:
Review History of Clubfoot Treatment
Questions to ask the Parent: 
- What age is the child?
- Developmental Milestones - Are they Crawling, Standing, Walking?
- Any problems or concerns about the brace e.g. Putting it on, Tolerating it?
Look at the Baby in the Brace: 
- Does the brace fit?
- What condition is the brace in?
- Is there an unusual bend in the bar?
- Is the heel down in the boot?
- Tug the Boot - Does the heel slip?
Look at the Baby’s Bare Feet: 
- Are there any sores?
Assess with Pirani Score if the child is not yet walking
Check where the Calcaneum is and does it move when you Dorsiflex / Plantarflex the Ankle?
Range of Motion: 
Watch the Child Stand and Walk (If Age-Appropriate)
Issue new brace if the current one is not fitting or requires replacement
At the end, praise the parent and child, then give the next clinic date
Signs of Relapse / Recurrence
At each brace check-up visit, check for any signs of recurrence of deformity:
- Increase in Pirani Score
- Return of any of the CAVE Signs
- Callus Formation
- Dynamic Supination when Walking 
Suggestions on helping with compliance:
The importance of the brace must be explained to the parents.
Parents have to teach the baby to kick both feet simultaneously by holding the bar while playing with the baby.
Consistent usage will make for a compliant child. Intermittent usage will make for a child that fights the brace.
Make sure the feet have sufficient dorsiflexion at the ankle. If there is not enough dorsiflexion, the feet may pull out of the shoes.
Compliance with the bracing regime can be difficult for parents and sometimes you will be aware that the braces are not being worn as much as recommended. 
Things to check for:
- Check for reasons the patient might not tolerate the Foot Abduction Brace (FAB), such as skin problems or insufficient correction of the foot position – these must be addressed
- Fungal infections are also common and should be treated
- Ask the parents to bring the FAB with them at every visit and check the FAB for signs of wear – you will soon be able to see if the FAB has not been worn and can then work with the parents to try to improve adherence
- If patients stop attending you can be sure they are not wearing the FAB. It is very important to keep a list of patients in the FAB phase, with contact details if possible, and to follow them up if they do not attend for a scheduled visit. 
Parent Advisors / Mentors can help clinic staff to support parents during bracing. Some tasks they can take on include:
- Educating parents on the causes of treatment
- Involving other family members such as fathers
- Educating parents on the full course of treatment from the beginning, with a heavy emphasis on the bracing phase
- Identifying cases of dropout, contacting families to re-engage them with treatment
- Working with parents who have dropped out to prevent this happening again
Remember: Talk to Parents from the Start, especially about Braces! 
- Africa Clubfoot Training Project. Chapter 8 Africa Clubfoot Training Basic & Advanced Clubfoot Treatment Provider Courses - Participant Manual. University of Oxford: Africa Clubfoot Training Project, 2017.