How important is bracing in clubfoot treatment? New study of factors and outcomes in Uganda 

August 07, 2023

Successful clubfoot treatment using the Ponseti Method requires several steps, including identification, casting, tenotomy, and bracing. The final phase, bracing, consists of wearing a foot abduction brace that holds the child’s feet in the proper alignment – similar to the way a dental retainer maintains teeth in their proper position – which needs to be worn at first for 23 hours a day, and after three months only while sleeping. The Ponseti protocol recommends wearing the brace at night until the age of four or five to reduce the risk of relapse.

The Bracing Adherence study in Uganda 

A recent study published in the International Journal of Environmental Research & Public Health compares clubfoot treatment experiences and outcomes for children who were adherent to bracing use and regular follow up versus those who dropped from treatment during the bracing phase. 

This study contributes new learning on the critical role of bracing in patient outcomes in low- and middle-income countries (LMICs), where it can be extremely difficult for marginalized households to adhere to lengthy follow up periods.   

Analysis of data from parent interviews and clinical examination of affected feet, with a focus on functionality, provide a new perspective on results that matter most for parents and children. MiracleFeet is using greater understanding of factors that influenced adherence and outcomes for these Ugandan children to strengthen program interventions and treatment approaches around the world.

Study design and participants

The mixed-method study included reviewing clinical records, examining affected feet with three clinical assessment tools, and administering a caregiver survey with closed- and open-ended questions about clubfoot-related experiences. The study team selected experienced Ponseti providers to conduct the clinical exams and parent advisors to administer the caregiver interviews. Two groups of patients were identified based on whether or not caregivers adhered to the bracing directives given to them by their clubfoot care providers. The study then analyzed data from adherent and non-adherent cases to understand factors influencing adherence and outcomes. 


The study found that wearing a brace for a minimum of two years after completing casting resulted in improved long-term outcomes. Additionally, children who underwent a tenotomy had a higher likelihood of adhering to bracing, while rural-dwelling families were more likely to drop from treatment if they had to travel long distances to the clubfoot clinic. Further research and replication of this study in additional LMICs will increase understanding of the relationship between tenotomy and adherence, as well as the impact of parent or provider education on the importance of following the bracing guidelines.  

Reasons most frequently reported by non-adherent respondents for having dropped from treatment included transportation issues, both inconvenience and cost; family and financial disruptions, sometimes associated with periods of Covid lockdowns; and inadequate understanding of the treatment method and importance of bracing. These findings highlight the importance of treatment programs in LMICs working to address barriers, including reducing travel distance to clinics (by expanding clinic network), reducing waiting times at clinics (by increasing efficiency and capacity), providing ongoing education for caregivers on bracing protocols, and additional support to mitigate transportation barriers and improve education and communication with parents.

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Innovative ways MiracleFeet is addressing barriers 

Studies like this improve understanding of the specific barriers families face in completing care – and knowing is the first step in overcoming these barriers. 

In addition to an ongoing emphasis on the need for tenotomies, some creative tactics MiracleFeet has tried include collaborating with our partners to pilot mobile clinics to bring care to families and providing partners with transportation vans to bring families to and from care facilities. In some countries our programs distribute travel subsidies to parents to offset the cost of transportation to clinic appointments. We’re also exploring expanding telemedicine to reduce the need for travel to appointments and to provide interim support for families during casting and bracing. Everywhere we work we are investing through our partners to expand parent education, community outreach, and global awareness.   

We will apply lessons learned from this study, namely that improving bracing adherence is essential for improving treatment outcomes for clubfoot patients. 

Read the full study here:   

Catherine Elkins
Associate Director of Monitoring, Evaluation, Accountability and Learning (USA)