Current conservative management and classiﬁcation of club ... Proof prm394.pdf · 2 Congenital talipes equinovarus (CTEV) is a com-3 plex foot deformity in children that affects

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Journal of Pediatric Rehabilitation Medicine: An Interdisciplinary Approach -1 (2016) 1–8 1DOI 10.3233/PRM-160394IOS Press

Review Article

Current conservative management andclassification of club foot: A review

Ganesan Balasankara, Luximon Ameersingb,∗ and Adel Al-JumailyaaDepartment of FEIT, University of Technology Sydney, NSW, AustraliabThe Hong Kong Polytechnic University, Hong Kong, China

Received 17 May 2016

Accepted 27 August 2016

Abstract. Clubfoot, known as congenital talipes equinovarus, is one of the complex paediatric foot deformity with the incidenceof 1 in every 1000 live births. It consists of four complex foot abnormalities such as forefoot adductus, midfoot cavus, andhindfoot varus and ankle equinus. There are a number of surgical techniques (soft tissue releases, arthrodesis) used to correctclubfoot. However currently the conservative management (manipulation, serial casting, and braces) of clubfoot is consideredas the best choice and it is widely accepted among orthopaedists. Clubfoot treated with surgical techniques might suffer variouscomplications such as soft tissues contractures, neurovascular complications, infections, and shortening of the limbs. Althoughconservative method is generally considered as an effective method, it is still challenging to cure clubfoot in advance stages.Also, the classification of the initial severity of clubfoot is essential to evaluate the outcome of the treatment. In this review, theaim is to review the different types of conservative method and the assessment of clubfoot severity.

Keywords: Clubfoot conservative management, clubfoot, Ponseti method, Copenhagen method, French functional or physiother-apist method

1. Introduction1

Congenital talipes equinovarus (CTEV) is a com-2

plex foot deformity in children that affects 150,000–3

200,000 newborn babies every year around the world4

and eighty percentages of clubfoot occurring in de-5

veloping countries [1]. It is characterized by the fol-6

lowing four structural deformities in foot and ankle:7

midfoot cavus, forefoot adductus, hindfoot varus, and8

ankle equinus – CAVE [2] (Fig. 1). The structural9

deformities of clubfoot might be caused by the sub-10

luxation of talocalcaneonavicular joint, dislocation of11

talus bone, abnormalities of peroneus and calf mus-12

cles, and contractures of soft tissues on the medial13

∗Corresponding author: Luximon Ameersing, The Hong KongPolytechnic University, Hong Kong, China. Tel.: +852 27666449;E-mail: [email protected].

side of the foot [3–5]. Children with untreated club- 14

foot, also known as neglected clubfoot, will suffer in 15

their daily life such as difficulties in gait pattern, mo- 16

bility, daily living skills, and social activities. In ad- 17

dition, neglected clubfoot children walk on the dor- 18

sal side of the foot leading to complications such as 19

callus formation, injuries, and infections on the dor- 20

sum of the foot [6]. For many years, there are a num- 21

ber of treatment methods either surgical or conserva- 22

tive procedures that have been proposed and debated to 23

treat clubfoot. However, surgical methods have its own 24

limitations due to post-surgical complications such as 25

soft tissues contractures, neurovascular complications, 26

infections, and shortening of the limbs. Recently, al- 27

most all of the orthopedicians agreed that the con- 28

servative treatment would be the best choice to cor- 29

rect the clubfoot. The goal of all conservative treat- 30

ment methods is to obtain the plantigrade, pain-free 31

1874-5393/16/$35.00 c© 2016 – IOS Press and the authors. All rights reserved


2 G. Balasankar et al. / Current conservative management and classification of club foot: A review

Fig. 1. Clubfoot (Source and approved by [67]).

and functional foot without any mobility problems [7].32

Initially, around 400 BC, Hippocrates discussed about33

the manipulation and casting in a medical literature. In34

this literature, he suggested that management of club-35

foot should be started as early as possible after the36

birth with manipulation method [8]. Subsequently, in37

1782, the first surgical procedure (subcutaneous teno-38

tomy) was developed by Lorenz [9]. Followed by, in39

1930s, Kite developed a gentle progressive manipula-40

tion and followed by plaster casting techniques. Then,41

in 1948, Ponseti developed his own method of manipu-42

lation and casting techniques after several years of ob-43

servation of different conservative and surgical meth-44

ods. It consists of weekly serial manipulations, casting,45

Achilles tendon tenotomy, and using foot abduction or-46

thosis to avoid the recurrences of the clubfoot. Many of47

the researchers reported that Ponseti method achieved48

higher success rate than other conservative methods.49

Also, they reported that success rate of the conserva-50

tive method for clubfoot is higher than surgical pro-51

cedures [10–14]. Based on the literature review, many52

studies explain the use of Ponseti method more than53

other conservative methods. This study is an attempt54

to review the different types of conservative methods55

and its techniques, and the principles of those proce-56

dures for correction of clubfoot deformities. Also, this57

review tried to address the different method of classifi-58

cation and assessment of clubfoot.59

2. Prevalence of clubfoot60

The prevalence rate of clubfoot varies from 0.9 to 761

per 1000 live births in different populations [15–18].62

The highest incidence of clubfoot occurs in the Poly-63

nesian population and lowest incidence in the Chinese64

population [15,19,20]. Most of the studies reported that65

the incidence of clubfoot is higher in male than in fe-66

male (2:1), and this ratio is consistent in all ethnic67

population [2,6,21–25]. Fifty percentage of the cases68

are either bilateral or unilateral clubfoot, and the in- 69

volvement of right foot is higher than unilateral club- 70

foot [24]. 71

2.1. Normal development of children foot 72

A basic knowledge of lower extremity development 73

is essential to understand the infant’s foot. Lower limb 74

buds appear at the 4th weeks of the gestational period, 75

and foot can be noted on the 4.5 weeks. At the 6 weeks, 76

foot looks paddle shaped in an equinus and inverted po- 77

sition. Feet turns into equinus, and hindfoot, forefoot in 78

a adducted position and notches is very clear between 79

the toes during the 8 weeks. During 12th weeks of the 80

prenatal period, the foot rotates into supinated position. 81

All digits are well developed in the period of the 9th82

week, and 1st and 5th metatarsal head drop downward, 83

and form the transverse arch of the foot. In addition, 84

talus and calcaneus together are developing the subta- 85

lar joint. Moreover, tibia and fibula are articulated with 86

the talus during this period. At the period between 13 87

to 16th weeks, lower extremity increases in size, foot 88

equinus level decreases, and foot will be in a perpen- 89

dicular position to the lower leg. Finally, 28th weeks, 90

the foot will achieve the neutral position [26]. 91

2.2. Anatomy and biomechanics of the clubfoot 92

Knowledge of foot anatomy and its biomechanics 93

is helpful to identify and treat the foot deformities 94

well. Biomechanically, clubfoot deformities occur due 95

to abnormalities of the tarsal bones (talus, calcaneus, 96

cuboid, and navicular), ligaments, joints, and atrophy 97

of the calf muscles [27]. In the hindfoot region, due 98

to the misalignment of the navicular, cuboid, calca- 99

neus bone, it leads to medial displacement and inverted 100

position in relation to the talus [28]. In addition to 101

the medial displacement of bones, the hind foot turns 102

into firm position, where the calcaneus and talus are 103

in equines position; especially, head and neck of the 104

talus is turned into severe planter flexion and medially 105

displaced, and calcaneus medially rotated under the 106

talus [29]. In some cases of clubfoot, the talus neck will 107

be absent or shortened [30]. In the case of severe club- 108

foot deformity, the navicular bone will be displaced 109

medially towards the head of the talus and it articulates 110

with the medial side of the head of the talus [31–33]. 111

Also, retraction and atrophy of calf muscles, the calca- 112

neus bone will also be displaced into adducted and in- 113

verted position under the talus [13,34]. In the midfoot 114

region, metatarsal joints are deformed and narrowed 115


G. Balasankar et al. / Current conservative management and classification of club foot: A review 3

Fig. 2. Anatomical dissection of clubfoot (Source and thanks to[62]).

and in the forefoot region, the forefoot turns towards116

to the other side of the foot with a supinated position.117

It is referred as forefoot adduction and supinated po-118

sition of the clubfoot. In relation to the hindfoot, it is119

in a more supinated position than forefoot; it devel-120

ops a cavus deformity at the forefoot with medial and121

posterior skin crease [13]. Based on the literature re-122

view, one of the anatomical dissection studies shows123

that talus and calcaneus are displaced into medially124

and develops varus deformity in the hind foot (Fig. 2).125

Moreover, soft tissue contractures will also develop on126

the posterior, medial side of the ankle and sub-talar127

joint region of the foot, it leads to shortening of the128

medial and posterior tarsal ligaments, and medial dis-129

placement of the tibialis posterior, flexor hallus longus130

and flexor digitorum longus tendon occur. These con-131

tractures of the soft tissue structures limit the motion132

of the sub-talar joint [13,33]. Sometimes, there is a de-133

ficiency or absence of anterior tibial artery and dorsalis134

pedis artery in the clubfoot condition. One of the mag-135

netic angiography studies revealed that diminished size136

of the peronial artery on the affected extremity of the137

leg [35].138

3. Etiology139

The causes of clubfoot are still not clearly known140

and it remains controversial. Previous studies have re-141

ported a number of theories to describe the causes142

of club foot. The causes of clubfoot are vascular, en-143

vironmental, genetic, abnormal position in the utero,144

and anatomical factors [27]. Some of the studies have145

reported observed abnormalities in the intracellular146

structure of the muscles of the clubfoot [36]. Mostly147

clubfoot present as a birth defect (idiopathic congen-148

ital club foot), and around 20% of the clubfoot de-149

formities are associated with other conditions such150

as arthrogryposis, myelodysplasia, Down syndrome,151

Table 1Dimeglio clubfoot classification

Classification Types/FeautuesGrade I Benin: Reducible without any resistanceGrade II Moderate: Reducible with certial degree of

resistanceGrade III Severe: Reducible with certial degree of resistanceGrade IV Very severe: Not reducible

Larsen’s Syndrome, freeman-Sheldon syndrome, and 152

multiple congenital abnormalities [2,24,27,37]. Espe- 153

cially, club foot associated with distal arthrogryposis, 154

meningomyelocele, and is considered a main etiolog- 155

ical factor among the involvement of nervous system 156

disorders [38]. In addition, the causes of clubfoot are 157

also associated with some risk factors such as male 158

gender, smoking during the maternal period, and dia- 159

betes on the maternal stage, maternal age, marital sta- 160

tus, and parity [39]. 161

3.1. Classification of clubfoot 162

Clubfoot can be classified into four types based 163

on the causes and treatment responses: 1) Postural, 164

2) Idiopathic, 3) Neurogenic, 4) Syndromic. Gener- 165

ally, the postural clubfoot can be resolved by stretch- 166

ing and casting. Another type of clubfoot, called id- 167

iopathic clubfoot, is ‘true’ clubfoot and can be clas- 168

sified by various grades of severity. Neurogenic club- 169

foot is usually associated with neurological conditions 170

such as spina bifida. Syndromic clubfoot are rigid type, 171

and are associated with other anomalies [40]. Also, 172

there are numbers of classification available to measure 173

the severity of the clubfoot based on the physcial as- 174

pects of the clubfoot such as Pirani score and Dimeglio 175

scale [41,42]. Dimeglio et al. introduced clubfoot clas- 176

sification in 1995, and it is classified into four types: 177

Grade I–Grade IV [43–46]. In this method, four types 178

of parameters, in a sagittal and horizontal plane, has 179

been used to measure the clubfoot severity: Sagittal 180

plane – 1) evaluation of equinus; 2) evaluation of varus; 181

and horizontal plane – 3) evaluation of derotaion; 4) 182

evaluation of forefoot adduction relative to the hind- 183

foot. The each item of the scale starts from 0–4 points 184

and maximum score is 20 points. It can also be graded 185

as benign, moderate, severe, and very severe (Table 1 186

and Fig. 3). Another method of classification of club- 187

foot severity is, Pirani scoring system, which is com- 188

monly used to assess the severity, and progress of club- 189

foot treatment by Ponseti method. It is a simple scoring 190

system based on the physical appearance of the foot, 191

and it consist of 3 clinical signs in the hindfoot (three 192



Equinus evaluation (Sagittal plane) Varus evaluation (Sagittal plane)

Horizontal plane: Derotation evaluation Horizontal plane: Forefoot relation with hindfoot

Fig. 3. Dimeglio et al. clubfoot classification system (Source andthanks to [63]).

Fig. 4. Pirani Scoring system (Source and approved by [62]).

morphological changes sign: posterior crease, empti-193

ness of the heel, rigid equinus) and 3 clinical signs in194

the midfoot (three morphological changes signs: lat-195

eral curvature of the foot, medial crease, position of196

the head of the talus on the lateral border (Fig. 4). The197

maximum score will be one for each item of the scale198

(0-normal, 0.5-mildly abnormal, 1-severe abnormal),199

and the total score is six [42].200

3.2. Management of clubfoot201

Clubfoot can be corrected by either conservative202

or surgical methods [46]. Historically, in 400 BC,203

the conservative management of clubfoot with ma- 204

nipulation and immobilization techniques was intro- 205

duced by Hippocrates. Based on Hippocrates’s prin- 206

ciples of clubfoot management, there are number of 207

conservative methods (Kite method, French method, 208

Ponseti method – “manipulation, casting, tenotomy, 209

foot abduction brace”, other physical methods such as 210

kinesio-therapy, thermo-therapy, electro-therapy, splin- 211

ting, shoe modification and orthotic devices) devel- 212

oped recently to correct clubfoot [6,47]. In 1930s, at 213

first, Dr. Kite developed a conservative method for 214

treating clubfoot after facing poor results of surgical 215

method [48,49]. In this method, the correction of club- 216

foot deformity components (adductus, varus, and equi- 217

nus) was performed separately with progressive ma- 218

nipulation and serial casting [5,50]. Especially, correc- 219

tion of heel varus was performed by everting the cal- 220

caneus. In this method, when performing the manipu- 221

lation, midfoot was used as fulcrum and pressure was 222

applied on the calcaneo-cuboid joint (mid-tarsal joint 223

area) to abduct the foot. The adducted deformity is 224

corrected by foot abduction with applying pressure on 225

the calcaneo-cuboid joint, and eversion of the hind- 226

foot, which is done by casting or edges, used to cor- 227

rect the varus deformity of the foot. Finally, the equi- 228

nus deformities will be corrected by progressive dor- 229

siflexion of the foot after correction of other compo- 230

nents [33]. In addition, night splint has been used to 231

maintain the foot in dorsiflexion and mild abducted 232

position to avoid the recurrences of the clubfoot. Ini- 233

tially, Kite reported that this method was successful in 234

correcting the clubfoot however other researchers did 235

not achieve the successful correction as mentioned by 236

Dr. Kite [51,52]. In addition, one of the previous stud- 237

ies reported that approximately ninety percentages of 238

the cases required surgical and soft releases in Kite’s 239

method [53,54]. Poor success rate of the Kite meth- 240

ods may be because of inaccurate method of manip- 241

ulation, and below knee or short leg casting. Gener- 242

ally, short leg or below knee casting has disadvantages 243

because it will not provide adequate position to main- 244

tain the corrected clubfoot [6,54]. At the same time, in 245

this method, it will also make some complications due 246

to inaccurate manipulation such as rocker bottom feet, 247

subluxation of the navicular bone, rigidity of ligaments 248

and capsule, torsion of the ankle (lateral side) and talar 249

body [13]. 250

Initially, the conservative management failed due to 251

the poor understanding of functional anatomy of club- 252

foot. However, clubfoot has been treated by conserva- 253

tive methods for more than 40 years. Later, due to the 254



Fig. 5. Stages of casting intervention (Source and thanks to: [42]).

development of advanced surgical procedures, club-255

foot was successfully corrected by “posteromedial re-256

lease” techniques at the age of one year. Then, for257

the past decade, conservative treatment such as Pon-258

seti method achieved high success rate due to the un-259

derstanding of the functional anatomy of the clubfoot260

as compared to the surgical methods [2]. Recently,261

most of the studies stated that Ponseti method is con-262

sidered as more effective method to correct the club-263

foot without further complications such as stiffness and264

pain [55].265

4. Current conservative methods for clubfoot266

4.1. Ponseti method267

Over the past decade, conservative management has268

been wildly used to correct the clubfoot deformity than269

surgical management. Ponseti method is consists of270

weekly gentle manipulation and followed by applica-271

tion of serial long leg casting [56]. In this method,272

casting should be changed every 5 to 7 days (Fig. 5).273

Before the final casting, if there is still equinus de-274

formity persists, Achilles tendon percutaneous teno-275

tomy should be done to correct the equinus deformity276

fully. Approximately ninety percentages of the cases277

requires tenotomy. Then, the foot will be immobilized278

for 21 days with 60◦ abduction and maximum dorsi-279

flexion [42,56,57]. Once the clubfoot is corrected, the280

child needs to wear full-time foot abduction brace for281

twelve weeks (23 hours per day). After 3 months, foot282

abduction brace are used at night and nap time un-283

til the age of four to prevent the relapse of club foot.284

Foot abduction orthosis or brace are used after the285

foot achieves about 60◦–70◦ abduction and 20◦ dor-286

siflexion range of motion. The goal of treatment of287

Ponseti method aims to correct four basic deformities:288

ankle equinus, hindfoot varus, forefoot adductus and289

A B

C D

E

Fig. 6. A–D: Steps of taping techniques. E: Ankle foot orthosis(Source and thanks to: [58] – Picture is adapted and formatted).

cavus. Initially, during the application of the first cast- 290

ing, cavus deformity is corrected by supination of the 291

forefoot with providing pressure in the first metatarsal 292

head of the forefoot. Mostly, the cavus deformity cor- 293

rection will be achieved in the first casting. During the 294

next 3 or 4 casting application, simultaneously adduc- 295

tion and varus, equinus deformity will be corrected by 296

providing counter pressure on the talar head with po- 297

sitioning the foot in the abduction and external rota- 298

tion [42,57]. 299

4.2. French functional or physiotherapist method 300

The principle of French functional conservative 301

method stated that clubfoot deformity occurs due to 302

the contracture of the following foot structures: ten- 303

don of the posterior tibialis muscles and fibrotic tis- 304

sues, weakness of peroneus longus and peroneus previ- 305

ous muscles, and deviation of mid-tarsal joints. There- 306

fore, this method is mainly focused on stretching of 307

medial side of the foot. In this method, treatment tech- 308

niques such as stretching, daily corrective manipula- 309

tions have been used to correct the deformity. The cor- 310

rected foot are maintained by elastic taping and splints 311

until the next day of treatment as shown in Fig. 6 [58]. 312

The total duration of treatment is 1–3 months, and ther- 313

apist sees the patients five days per week. Then, the 314



A. Correction of adducteddeformities

B. Correction of cavus

C. Correction of varus D. Correction of Equinus

Fig. 7. Manipulation of clubfoot by Copenhagen method (Thanksto [47]).

family members need to help the child to do the ex-315

ercise regularly at home. This method has two phases316

of treatment: corrective phase and maintenance phase.317

Corrective phases of the treatments include calf mas-318

sage, forefoot stretch, distraction, derotation, stimula-319

tion of evertors, hindfoot valgus, and dorsiflexion. In320

the maintenance phase, splints are used to maintain the321

correction [58].322

4.3. Copenhagen method323

In 1976, another conservative clubfoot treatment324

technique, Copenhagen method was developed in325

Copenhagen orthopaedic hospital. The following tech-326

nique has been used to treat the clubfoot problems:327

flexion and manipulation, stimulation of muscles of the328

foot, using plaster of cast. These techniques need to329

be practiced daily until the foot become as ‘normal’330

and it might be achieved in 6 weeks period of treat-331

ment [59]. The corrected foot are maintained by ban-332

dage instead of using braces until the child gets to start333

to walk. Also, the corrected clubfoot is inspected pe-334

riodically until the skeletal maturity [47,59]. Accord-335

ing to the modified Copenhagen method, to correct the336

clubfoot adduction, varus, and cavus deformities, the337

following principles of “correction rule” is applied in338

a sequential order: correcting the adducted deformity339

first, then other deformities such as cavus, varus, and340

equinus are performed.341

The adducted deformity is corrected by holding hind342

foot by one hand, and the tibial epiphysis and cuboid343

bone should be between the index finger and thumb344

of the same hand. Subsequently, the forefoot adduc- 345

tion is corrected by distraction movement applied by 346

the thumb of another hand on the first metatarsopha- 347

langeal joint (Fig. 7A). Cavus is corrected by supina- 348

tion of forefoot while performing the dorsiflexion mo- 349

tion at the first metatarsal area of the foot (Fig. 7B). 350

The varus deformity is corrected by holding the heel of 351

the feet (posterior side) by one hand, and pressure pro- 352

vided on the neck of the talus bone to push the inwards 353

while thumb of the same hand used to give pressure on 354

the calcaneal bone towards outside. At the same time, 355

pressure is applied to the metatarsal bones (sole of the 356

foot) by using another hand to obtain the everted posi- 357

tion of the forefoot (Fig. 7C). Equinus deformity cor- 358

rection is achieved by gentle traction of Achilles ten- 359

don by one hand while performing dorsiflexion of the 360

forefoot by another hand (Fig. 7D) [47,60]. Finally, lat- 361

eral side of the muscles (Peroneal muscles and antero- 362

lateral area of the foot) will be stimulated by brush af- 363

ter the manipulation of the foot [47]. Once the clubfoot 364

is corrected, Larsen Active T splint are used to main- 365

tain the foot until 7 to 8 months, after that it is used at 366

night time. At the same time, this method recommends 367

regularly exercises 5 times per day. 368

5. Discussion 369

Although there are a number of conservative method 370

used to treat the clubfoot problems, the outcome varies 371

from one method to another. The purpose of this review 372

was aimed to provide the various method of conserva- 373

tive treatment and classification the of clubfoot sever- 374

ity to predict the outcome of the intervention. Previ- 375

ous studies have reported that clubfoot can be treated 376

by less casting and duration by Ponseti method com- 377

pared to other method to achieve the full correction of 378

the clubfoot with good mobility of the foot [61]. The 379

manipulation and casting techniques were described 380

in both Kite method and Ponseti method, however the 381

success rate varied about ten to eighty percentages 382

in Kite method. Serial casting has been followed as 383

stretching techniques in the both method to achieve 384

normal and functional foot but it differs in their ma- 385

nipulation techniques. Forty two years of experience 386

of Ponseti, he stated that he achieved ninety percent- 387

ages of successful outcomes of clubfoot correction by 388

practicing his own regime method. Ponseti method is 389

mostly used in USA, some part of Europe and devel- 390

oping countries such as India and Bangladesh. Pon- 391

seti method is widely used in the developing and de- 392



veloped counties, with the ninety percentages of suc-393

cessful correction rates, while those who used Kite394

method have stated that fifty percentages of the cases395

required surgical correction and around forty percent-396

ages persisted with residual deformity [33]. In con-397

trast, one of the author reported that they achieved398

successful correction of clubfoot but they performed399

about ninety one percentages of percutaneous teno-400

tomy of the Achilles tendon in their study [12]. An-401

other study, Morcuende et al., stated that they per-402

formed Achilles tenotomy in the eighty six percentages403

of the cases to obtain the stated correction [65]. Other404

method, French functional physiotherapy method is405

also practiced in some centres of America and Europe.406

Few studies have reported that French functional phys-407

ical therapy method is equally effective as the Ponseti408

method. In addition, one of the studies have reported409

that French functional physical therapy and Ponseti410

method achieved about ninety percentages of success-411

ful outcomes in the initial correction of the clubfoot.412

Though, thirty-seven percentage of relapses occurred413

in the Ponseti method and twenty nine percentages414

in the French functional physiotherapy method in the415

follow-up [66]. Very few studies reported and pub-416

lished about Copenhagen method as a conservative417

method for clubfoot correction. Peroneal muscle stim-418

ulation was performed in this method to strengthen the419

hypotonic muscles in addition to the physical manip-420

ulation and physical therapy exercises. In their stud-421

ies, the author has reported that thirty-four percentages422

of feet did not require any surgeries and sixty percent-423

age had posterior release, and two percentage had teno-424

tomy of the Achilles tendon [47]. In conclusion, this425

literature review discussed several conservative meth-426

ods of clubfoot treatment such as Kite method, Ponseti427

method, French physical therapy method, and Copen-428

hagen method. After several decades of debates of sur-429

gical treatment for clubfoot, now-a-days, conservative430

management, especially Ponseti method, has been con-431

sidered as best choice for clubfoot treatment in terms432

of low cost, low technology and effective outcome.433

However, further research is required to reduce the re-434

lapses rate by considering the combination approaches435

of casting, physical therapy, and stimulation of hypo-436

tonic muscles.437

Conflict of interest438

The authors have no conflict of interest to report.439

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