Achilles tenotomy is a crucial aspect in the nonoperative management of clubfoot as per Ponseti's casting protocol. Achilles tenotomy is routinely carried out percutaneously in a blind manner without any image guidance. This study aimed to determine the role of ultrasound-guided percutaneous Achilles tenotomy (PAT) in improving outcomes in clubfoot management. There are no previous studies that have explored the role of image guidance in PAT. This prospective, single-center randomized control trial included 50 clubfoot cases (74 feet) planned for PAT at a mean age of 30.2 months. A single experienced senior surgeon performed tenotomies. Patients were randomized to two groups, with the tenotomies performed under ultrasound guidance in one group (test group) and PAT carried out without image guidance in the other (control) group. Outcome measures assessed included rate of complications, immediate postoperative FLACC score for pain severity and Pirani score at a minimum follow-up of 12 months. There were no significant differences in the complication rates between the test and control groups regarding bleeding, nerve injury and incomplete tenotomies. The mean pain FLACC score was significantly higher in the control group (PAT without image guidance) (P = 0.03), suggesting that the child would better tolerate the ultrasoundguided procedure. All patients in both groups had a Pirani score of zero and plantigrade feet at final follow up, with no relapses. Ultrasound-guided PAT does not have any added advantage over PAT with clinical examination without image guidance in terms of longterm outcomes. Level of evidence: Therapeutic level II.