Congenital Talipes Equino Varus

(Club Foot)
What is Congenital Talipes Equino Varus
(CTEV)?
Congenital Talipes Equino Varus (CTEV) for short is commonly
known as clubfoot. This is a condition where a child presents with
either one or both feet pointing downwards and turns inwards. There
are two types of CTEV: postural and structural.

Postural CTEV involves muscle imbalance and / or tightness.

There is usually no bone or joint involvement.

Structural CTEV involves the bone and joints of the foot,

where the child's foot cannot be passively put through a full
range of motion.

Signs and Symptoms

Feet turning inwards

Tightness in calf muscles

For structural: the foot has decreased joint range of movement.

Causes

Postural: packing disorder (first born baby; big baby >4kg at

birth; decrease fluid surrounding the baby)

Structural: The cause is unknown and in some, it can be

genetics.

Complications

Abnormal walking pattern.

Foot pain due to abnormal foot positions.

Treatment Options

Postural: Self resolving. In some cases, physiotherapy

intervention for stretching and stimulation to the feet is
required.

Structural: Serial casting and manipulation with minimal

surgery if neccessary. In severe cases, surgery may be
required. This is followed by maintenance with special boots
and bar till 4 years of age.

Tests and Diagnosis

Orthopaedic assessments

Management of Congenital Talipes Equino Varus (CTEV) by Ponseti Casting Technique in

Neonates: Our Experience
Md Saif Ullah
Affiliation: Department of Pediatric Surgery, Bangladesh Institute of
Child Health (BICH) and Dhaka Shishu (Children) Hospital, Dhaka.
Kazi Md Noor-ul
Affiliation: Department of Pediatric Surgery, Bangladesh Institute of
Ferdous
Child Health (BICH) and Dhaka Shishu (Children) Hospital, Dhaka.
Md Shahjahan
Affiliation: Department of Pediatric Surgery, Bangladesh Institute of
Child Health (BICH) and Dhaka Shishu (Children) Hospital, Dhaka.
Sk Abu Sayed
Affiliation: Department of Pediatric Surgery, Bangladesh Institute of
Child Health (BICH) and Dhaka Shishu (Children) Hospital, Dhaka.
Correspondence: Address for Correspondence: Kazi Md. Noor-ul
Ferdous, Department of Pediatric Surgery - Bangladesh Institute of Child
Health (BICH) and Dhaka Shishu (Children) Hospital, Dhaka
kmnferdous@gmail.com.
Abstract
Objective: The purpose of this study is to evaluate the results of Ponseti
technique in the management of congenital Talipes Equino Varus
(CTEV) in neonatal age group.
Methods: It is a prospective observational study, conducted during the
period of July 2010 to December 2011 at the Department of Pediatric
Surgery in a tertiary hospital. All the neonates with CTEV were treated
with Ponseti casting technique. Neonates with other congenital
deformities, arthrogryposis and myelomeningocele were excluded.
Results: Total 58 CTEV feet of 38 neonates were treated. Twenty six
were males and 12 were females. Thirty seven (63.8%) feet were of rigid
variety and 21(36.2 %) feet were of non-rigid variety. Twenty patients
had bilateral and 18 had unilateral involvement. Mean pre-treatment
Pirani score of study group was 5.57. Mean number of plaster casts
required per CTEV was 3.75 (range: 2-6). Thirty five rigid and 15 nonrigid (total 86.2%) feet required percutaneous tenotomy. Out of 58 feet

56 (96.6%) were managed successfully. Three (5.2%) patients developed

complications like skin excoriation and blister formation. Mean posttreatment Pirani score of the study group was: 0.36 0.43.
Conclusion: The Ponseti technique is an excellent, simple, effective,
minimally invasive, and inexpensive procedure for the treatment CTEV
deformity. Ideally it can be performed as a day case procedure without
general anesthesia even in neonatal period.

Keywords: Neonate, Talipes equino-varus, Ponseti technique.

INTRODUCTION
The congenital talipes equinovarus (CTEV) or clubfoot is one of the most common and complex
congenital deformities. The incidence of idiopathic clubfoot is estimated to be 1 to 2 per 1,000
live births. [1] The deformity has four components: ankle equinus, hindfoot varus, forefoot
adductus, and midfoot cavus. [2] The goal of the treatment is to correct all the components of
clubfoot to obtain painless, plantigrade, pliable and cosmetically and functionally acceptable foot
within the minimum time duration with least interruption of the socioeconomical life of the
parent and child. [2,3]
There is nearly universal agreement that the initial treatment of the clubfoot should be nonoperative regardless of the severity of the deformity. If there is no improvement, then most of the
surgeons prefer postero-medial release (PMR) of the soft tissue. The primary disadvantages of
PMR are high complication and recurrence (13-50%) rate and the difficulty of treating
recurrences. [4] Most of the authors have concluded that extensive surgery is not the right
approach to the management of CTEV. [5] Over the past two decades, more and more success
has been achieved in correcting CTEV without the need for surgery by Ponseti casting technique,
which has become a gold standard worldwide. It includes serial corrective manipulation, a
specific technique of the serial application of plaster cast supported by limited operative
intervention (percutaneous Achilles tenotomy) The method has been reported to have success
rate approaching 90- 96% in short, mid and long-term results. [5-10]
The Ponseti casting technique of club foot management has been shown to be effective,
producing better results and fewer complications than traditional surgical methods. [11] In recent
years, interest has been renewed in the Ponseti casting technique, and many centers now believe
that most clubfeet can be treated by Ponseti casting technique rather than surgery [12]. Ponseti
casting technique is especially important in developing countries, where operative facilities are
not available in the remote areas. The physicians and personnel trained in this technique can
manage the cases effectively with the cast treatment only. [13]
The purpose of this study was to evaluate the result of Ponseti casting technique used over last 2
years in our institute for the treatment of congenital clubfoot in neonates.

MATERIALS AND METHODS

This is a prospective observational study, conducted in a tertiary hospital. The study period was
from July 2010 to December 2011. All the neonates with CTEV presented to the Department of
Pediatric Surgery were treated according to the Ponseti casting technique. Neonates with clubfeet
associated with meningocele, meningomyelocele, arthrogryposis multiplex congenita and other
neuromuscular causes were excluded. A prior approval was taken from the Institutional Review
Board. An informed written consent was taken from all parents. All relevant data were collected
from each participants using predesigned data sheet that included patients demography, physical
examination, management, which included Pirani severity scoring score [11] (for initial
assessment of the severity, and for evaluation of the feet after each component of the treatment
and ultimate final outcome), total number of the casts applied before tenotomy, pre and post
procedure complications like plaster sore, skin excoriation, blister formation, excessive bleeding
following tenotomy or any other complication.
Treatment protocol and follow up:
We followed a protocol according to the Ponseti casting technique (Fig. 1-3).
The treatment included gentle manipulation of the foot and the serial application of above knee
plaster casts at weekly interval without anesthesia, as described by Ponseti [2].
The foot was markedly abducted up to 70 degrees without pronation (combined movements of
abduction, extension and eversion of the foot) in the last cast, which is very important for
complete correction and it prevent early recurrence. If the varus deformity of the heel had been
corrected and residual equinus was observed after the adduction of the foot and, a simple
percutaneous Achilles tenotomy was performed under local anesthesia. After the tenotomy, an
additional above knee cast with knee flexed in 90 degrees was applied and left in place for three
weeks to allow for healing of the tendon. As the tenotomy wound was very minimal (less than
0.5cm), done percutaneously and was not stitched, so no window was made in the cast. After
removal of the cast, a Denis-Browne bar and shoes (D-B splint) was used to prevent relapse of
the deformity. This is best accomplished with the feet in well-fitted, open-toed, medial bar, hightop straight-last shoes attached to Denis-Browne bar. The D-B splint was worn full time (day and
night) or at least 23 hours per day for the first 3 months and then for 12 hours at night and 2 to 4
hours at day for a total of 14 to 16 hours during each 24 hour period. The protocol continues until
the child is 3 to 4 years of age.
The patients were followed up on a weekly basis during the initial stages of treatment. After
applying D-B splint, on a monthly basis for three months and then once every three months till
the patients was three years of age. The parent advised to come for follow up every six months to
one year till 5 years and then after 1-2 years till skeletal maturity is achieved.
Final outcome measurement:
The outcome was measured by Pirani score [11]. This is the main variable of the study which can
detect the degree of correction. It scores 6 clinical signs: 3 for midfoot, 3 for hindfoot. Three

signs of midfoot score (MS) and hindfoot score (HS) grading the amount of deformity between 0
and 3. The Pirani score 0 means normal foot, the Pirani score 3 means moderately abnormal foot,
the Pirani score 6 means severely abnormal foot.
In our study the final outcome was categorized as excellent, good and poor. When Pirani score
became 0, it was graded as excellent, when it became 0.5 to 1, it was graded as good and poor
outcome occurs when the score became more than 1. Excellent and good outcomes obviously
reflected to successful management. Poor outcome reflected treatment failure; these patients
were advised further surgical management.
The collected data was analyzed and presented in tables.
RESULTS
During the study period a total of 70 patients with 109 clubfeet were treated and followed up
diligently. Of these, 38 neonates with 58 CTEV have been reported and analysed in this study.
There were 28 boys and 12 girls with a male female ratio of approximately 2:1.
Of the 58 clubfeet, 37 were rigid and 21 of non-rigid variety. Of the 18 patients having only
unilateral involvement, 11 had right sided affliction and 7 had their left feet involved. Mean pretreatment Pirani score in the study group was 5.57 (SD 0.56). There was no significant
difference between mean Pirani scores for the rigid and the non-rigid verities (5.69 0.47 vs.
5.37 0.69). (Table1).
Mean number of plaster casts required per CTEV was 3.75 0.80. More casts were required for
the rigid feet as compared to non-rigid feet (5.11 6.21 vs. 3.40 0.77 (Fig. 4).
A total of 50 (86.2%) feet (35 rigid and 15 non-rigid) required percutaneous tenotomy. Only 8
(13.79%) feet (2 rigid and 6 non-rigid) were improved by plaster cast alone. Out of 58 feet 56
(96.55%) were managed successfully (Table 2).
Only 3 (5.17%) patients developed complication. One (1.71%) developed skin excoriation and
other 2 (3.4%) developed blister formation.
The Pirani score after completion of overall treatment (with or without tenotomy) was recorded.
Mean post-treatment Pirani score of the study group was 0.36 0.43. As expected, the non-rigid
feet fared better than the rigid feet, with their post-treatment scores of 0.17 0.24 and 0.34
0.45 respectively (Table 3). The average approximate total cost of treatment per patient was also
estimated [Table 4]. Mean follow up period was 1year 11 months (range: 2years 4months to 10
months).
DISCUSSION
CTEV is one of the commonest congenital deformities. It is a complex deformity comprises of
equinus, varus, adductus and cavus, which are difficult to correct. It requires meticulous and
dedicated effort on the part of treating physician and parents for the correction of the deformity

[13]. The goal of treatment is to reduce or eliminate these deformities so that patient has a
functional, pain free, plantigrade foot with good mobility without calluses and does not need to
wear modified shoes [14].
The Ponseti casting technique of correction of CTEV deformity requires serial corrective casts
with long term brace maintenance of the correction The treatment needs to be started as soon as
possible and should be followed under close supervision [2,15]. The Ponseti casting technique
yielded satisfactory anatomical and functional result with simple, effective, minimally invasive,
inexpensive and ideally suited for all countries and cultures [2].
The available literature suggests that the results were better if this method of treatment was
started as early as possible after birth [8, 13]. The factors responsible for clubfoot deformity are
active from the 12th to 20th weeks of fetal life upto 3-5 years of age [16, 17].
More than half of the CTEV patients in our series presented in the neonatal age. This has been
the experience of other authors also [13] and probably relates to the growing awareness of the
entity in the parents nowadays.
Mean pre-treatment Pirani score grouping this series were similar to those reported previously [7,
14, 18]. The mean number of plaster casts required per feet in our series was 3.75, much less as
compared to the other series [13-15]; this is owing to the fact that we have analysed only
neonates in the present study. All the available studies including ours have shown rigid feet
required more casts than non-rigid feet to correct the deformity.
In our study, 86.2% feet (35 rigid and 15 non-rigid) required percutaneous tenotomy. Tenotomy
was needed in 95% of Guptas patients [13] and 91% of Dobbss patients [19]. All the studies
show that tenotomy was required in those patients who initially have severe deformity. Bor et al
quoted, A foot that requires many casts for the initial correction is more likely to require future
additional surgery [7]. As we included only neonates, and started treatment early, our patients
needed tenotomy less frequently. A large number of pediatric orthopedic surgeons think that
success of Ponseti casting technique depends on whether casting begins within hours of birth
[20].
In our study, 96.6% CTEV feet were managed successfully (Table 2). The complication rate was
low. Only one neonate who had rigid feet at presentation required posteromedial release (PMR)
for both feet later. All the parents of the patients with successful repair were satisfied with the
corrected feet of their children. The success rates for this technique in children have been quoted
to range from 78% to 96.7% [5, 7, 9,10].
The most difficult part of the Ponseti casting technique is maintenance of bracing protocol [7].
The parents of our study group reported that initial two or three days were the critical period,
during which patients were restless and tried to remove the splint. After that the patients were
adjusted with splint. We agree with most of the authors that correction of the foot also depends
on the brace protocol [6,7,13,14,17]. Parental compliance can be improved by educating the
parents as to the proper use of bracing and the hazards of improper or insufficient bracing.

Another difficult part of the study was follow-up. Correction of foot by serial cast with or
without tenotomy is only a part of the total management. With the initial correction of the foot,
parents misunderstand that the main and difficult part of the treatment is over and hence they do
not come for follow up. To overcome this problem, we motivated the parents and their family
members. Though none of our patients dropped out from follow up, follow up in one of the
patients was rather irregular; this very patient eventually required further surgical treatment.
Similar to others experience [21], we found this treatment technique to be very cost-effective.
CONCLUSION
It can be concluded that CTEV deformity can be effectively treated by Ponseti casting technique
with excellent results and without significant morbidity. This method is simple, effective,
minimally invasive, and inexpensive and ideally can be performed at outpatient department
without general anaesthesia, even in neonatal period.
Footnotes
Source of Support: Nil
Conflict of Interest: None
Editorial Comment: If pediatric surgery is a specialty of congenital malformations, it then
defies logic as to why most of the pediatric surgeons all over the world do not treat clubfoot
deformities. In fact, it was a pioneer British pediatric surgeon - Sir Denis Browne who
hypothesized that this malformation is due to abnormal position of fetus during gestation. As the
logical extension of this, he was the first to demonstrate the superiority of non-surgical treatment
in 1937. It is only a decade later Ponseti further developed the concept and described his method
of manipulation therapy. The splint designed by Sir Denis Browne to treat clubfoot is still in use
and is once again proved to be effective by Saif Ullah et al. We believe that this article will
revive the interest of younger pediatric surgeons in the management of congenital clubfoot.
Figures

Figure 1: Manipulation and application of cast

Figure 2: Steps of tenotomy

Figure 3: D-B splint

Table 1: Initial Pirani score

Figure 4: Number of plaster cast needed for correction.

Table 2: Final result

Table 3: Pirani score at last follow-up

Table 4: Cost of treatment per patient

References
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of congenital telipes equino-varusJ Pak Orthop Assoc 2011;23:624.
2. Ponseti IV. Clubfoot management. J Pediatr Orthop 2000; 20: 699 700.
3. Colburn M, Williams M. Evaluation of the treatment of idiopathic clubfoot by using
the Ponseti methodJ Foot Ankle Surg 2003;42:25967. [pmid: 14566717]
4. Adegbehingbe OO, Oginni LM, Ogundele OJ, Ariyibi AL, Abiola PO, Ojo OD.
Ponseti clubfoot management: changing surgical trends in Nigeria. Iowa Orthop J
2010; 30: 7 14.
5. Ippolito E, Farsetti P, Caterini R, Tudisco C. Long-term comparative results in patients
with congenital clubfoot treated with two different protocols. J Bone Joint Surg Am
2003; 85: 1286 94.
6. Gksan SB. [Treatment of congenital clubfoot with the Ponseti method].Acta Orthop
Traumatol Turc 2002;36:281287. [pmid: 12510061]
7. Bor N, Coplan JA, Herzenberg JE. Ponseti treatment for idiopathic clubfoot: minimum
5-year follow up.Clin Orthop Relat Res 2009;467:12631270. [doi: 10.1007/s11999008-0683-8] [pmid: 19130158]
8. Cooper D M, Dietz F R. Treatment of idiopathic clubfoot. A thirty-year follow-up
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9. Porecha MM, Parmar DS, Chavda HR. Mid-term results of Ponseti method for the
treatment of congenital idiopathic clubfoot--(a study of 67 clubfeet with mean five
year follow-up).J Orthop Surg Res 2011;6:3. [doi: 10.1186/1749-799X-6-3] [pmid:
21226940]
10. Agarwal RA, Suresh MS, Agarwal R. Treatment of congenital clubfoot with Ponseti
methodIndian J Orthop 2005;39:2447.
11. Dyer P J, Davis N. The role of the Pirani scoring system in the management of club

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Congenital talipes equinovarus (CTEV)

Content list:
1. Search Strategy
2. Definition/Description
3. Clinically Relevant Anatomy
4. Epidemiology /Etiology
5. Characteristics/Clinical Presentation
6. Differential Diagnosis
7. Prognosis
8. Outcome Measures
9. Therapy
10. References

1. Search strategy
Databases searched: Pubmed, Web of Knowledge, Pedro, The Journal of Foot & Ankle Surgery,
The Journal of Bone & Joint Surgery, ScienceDirect.
Keywords searched: ponseti method, congenital talipes equinovarus, clubfoot, foot deformities
and physiotherapy.

2. Definition/Description
Congenital talipes equinovarus, also known as club foot, is a congenital foot deformity present
at birth. It is one of the most common congenital deformities. Incidence varies between ethnic
groups. Incidence in Western countries goes from 1 till 1,50 per 1000 live births and in some
developping countries rises up to 3 per 1000 (ref. C, D en B). Male-to-female ratio is 2,8 - 3 to 1
(ref. A en B).

3. Clinically Relevant Anatomy

The foot consists of 26 bones. Most relevant for this congenital deformity are the talus, calcaneus
and navicular. The calcaneus and navicular are medially rotated in relation to the talus. The foot
is held in adduction and inversion by ligaments and muscles. Muscles that are contracted are
triceps surae, tibialis posterior, flexor digitorum longeus and flexor hallucis longus. Weak
peroneal muscles allow the foot to be inverted. The ligaments of the posterior and medial aspect
of the ankle are thick and taut. (ref. L)

4. Epidemiology/Etiology
According to Pandey and Pandey (ref H) causes of clubfoot have been put forward by various
theories. They include the following possibilities:
I. Neurogenic theory reduced motor unit, which counts in the distribution of the common
peroneal nerve, may be responsible for clinically demonstrable muscle weakness.
II. Myogenic theory suggested by the presence of anomalous muscles, e.g. accessory soleus
muscle and flexor digitorum accessorious longus muscles, wich can produce equinovarus
deformity.
III. Vascular theory diminution of blood flow in the anterior tibial artery and its derivates.
IV. Embyonic theory developmental defect occuring up to 12 weeks of intrauterine life.
V. Chromosonal theory presence of some chromosonal defects in unfertilized germ cells.

VI. Osteogenic theory Due to some unknown cause, temporary arrest of development occurs in
the 7- to 8- week-old embryo, wich can lead to clubfoot or other deformities.
VII. Mechanical block theory due to some mechanical obstruction during the intrauterine
development period, e.g. intrauterine fibrotic bands, less amniotic fluid, disproportionate uterine
cavity, etc, talipes equinovarus can occur.
(ref. H)
Considering the many etiologies, authors agree that talipes equinovarus is a common component
of neurological disorders (ref. F, K).

5. Characteristics/Clinical Presentation
The deformity consists of equinus/plantarflexion at the ankle combined with adduction and
inversion at the subtalar, midtarsal and anterior tarsal joints (ref. K).
Club foot can be discribed as congenital dislocation of the talo-calcaneal-navicular (TCN) joint
(ref. G). Further there is an imbalance between the inverter-plantarflexor muscles and the
everter-dorsiflexor muscles. The calf and peroneal muscles are usually poorly developed (ref. K).

6. Diagnosis
Talipes equinovarus is usually detected at birth. The examination after birth consists of taking the
foot and manipulate it gently to see if it can be brought into normal position. If this examination
is positive the condition is considered to be correctable (ref. J)

7. Prognosis
The prognosis depends mostly on the time the treatment started. When treatment is started within
the first week after birth, the chances of healing without relapse in further life are high.
Persistence in wearing the abduction bar also contributes to a good prognosis (ref. K).

8. Outcome measures
The most common used outcome measure is the scoring system of Pirani. This scoring system
assesses the severity of clubfoot deformity and response to treatment (ref. E). It has a predictive
value concerning the number of casts needed to correct the foot. A high score, 4 or more, predicts
the use of at least 4 casts. A score less than 4 predicts the need of 3 or fewer casts. Each
component is scored as 0 (normal), 0.5 (mildly abnormal) or 1 (severely abnormal) (ref. L)

9. Therapy
The Ponseti method is the most common used and known treatment of talipes equinovarus (ref.
B, D, C, E, I, L). It consists of a series of manipulations/manual stretchings and immobilisation
by plaster casts and abduction bar. The treatment usually starts within one week after birth. The
therapist manipulates the foot (or both feet) gently by stretching the tight anatomical structures,
i.e. the ligaments of the posterior and medial aspect of the ankle, triceps surae, tibialis posterior,
flexor digitorum longeus and flexor hallucis longus. When the foot position has obtained a
degree of correction that shows progress to the initial situation, a plaster cast is applied and held
on for one week. After one week the cast is taken off, the foot is manipulated again and a new
cast is applied to correct the position further. This procedure is repeated until the foot position is
normal.
The manipulations correct first the cavus stance of the foot, then adduction, valgus and at last the
equines stance (ref. E). All components are corrected simultaneously except for the ankle
equinus (ref. L). In severe cases, when plaster casts and manipulation do not obtain the right
correction, tenotomy of the achilles tendon is applied to correct the equines stance or other
surgical interventions are needed.
After removing the final cast, both feet are held in hyperabduction by a foot abduction brace. The
Ponseti bar is to be held on 23 hours a day for three months and afterwards during night till the
age of four. The purpose of this final part is to avoid relapse in later life (ref. A, B, L).
Although the Ponseti method has good results (ref. B, D, F), it is a long and intensive treatment.
In some developing countries people often have to travel far and long to have a treatment. Most
people cant afford or dont have time to travel such a distance several times. Therefor an
accelerated Ponseti method is applied, where patients are treated within 3 weeks (ref. C).
The French technique involves daily manipulation of the foot for 30 minutes followed by
stimulation of the muscles of the foot and lower leg, with the emphasis on the peroneal muscles.
The purpose of muscle stimulation is to maintain the correction obtained by manipulation. After
manipulation and muscle stimulation taping is applied. The treatment has to be applied daily for
two months, followed by three treatments a week for 6 months.
This method gets good results but has decisive disadvantages. The therapy involves too many
hospital visits, depends on the manipulation skills of the physical therapist and is costly (ref. G).

10. References
A: Michael, G.D. (2011). Simultaneous Correction of Congenital Vertical Talus and Talipes
Equinovarus Using Ponseti Method. The Journal of Foot & Ankle Surgery, 50, pp. 494-497.
Level of evidence: 4

B: Boden, R.A., Nuttall, G.H., & Paton, R.W. (2011). A 14-year longitudinal comparison study
of two treatment methods in clubfoot: Ponseti versus traditional. Acta Orhopaedica Belgica,
77(4), pp. 522-528.
Level of evidence: 1b
C: Harnett, P., Freeman, R., Harrison, W.J., Brown, L.C., & Beckles, V. (2011). An accelerated
Ponseti versus the standard Ponseti method. The Journal of Bone & Joint Surgery, 93, pp. 404408.
Level of evidence: 1b
D: Jowett, C.R., Morcuende, J.A., & Ramachandran, M. (2011). Management of congenital
talipes equinovarus using the Ponseti method. The Journal of Bone & Joint Surgery, 93, pp.
1160-1164.
Level of evidence: 1a
E: Docker, C.E.J., Lewthwaite, S., & Kiely, N.T. (2007). Ponseti treatment in the management of
clubfoot deformity a continuing role for paediatric orthopaedic services in secondary care
centres. The Royal College of Surgeons of England, 89, pp. 510-512.
Level of evidence: 2b
F: Gurnett, C.A., Boehm, S., Connolly, A., Reimschisel, T., & Dobbs, M.B. (2008). Impact of
congenital talipes equinovarus etiology on treatment outcomes. Developmental Medicine &
Child Neurology, 50, pp. 498-502.
Level of evidence: 2b
G: Anand, A., & Sala, D.A. (2008). Clubfoot: Etiology and treatment. Indian Journal of
Orthopaedics, 42(1), pp. 22-28.
Level of evidence: 5
H: Pandey, S., & Pandey, A.K. (2003). The classification of clubfoot a practical approach. The
Foot, 13, pp. 61-65.
Level of evidence: 2b
I: Suzann, K.C., Vander Linden, D.W., & Plisano, R.J. (2005). Physical Therapy for Children.
Missouri: Elsevier.
Grade of recommendation: A
J: Goldie, B.S. (1992). Orthopaedic Diagnosis and Management. A guide to the care of
orthopaedic patients. Oxford: Blackwell Scientific Publications.
Grade of recommendation: A

K: Adams, J.C., & Hablen, D.L. (2001). Outline of Orthopaedics. London: Churchill
Livingstone.
Grade of recommendation: A
L: Staheli, L. (2009). Clubfoot: Ponseti Management Third Editon. Seattle: Global Help.
Level of evidence: 1a

Afr Health Sci. 2011 September; 11(3): 444448.

PMCID: PMC3261019
Physiotherapy management of an infant with Bilateral Congenital Talipes Equino
varus
AO Ezeukwu1 and SM Maduagwu2
Author information Copyright and License information
This article has been cited by other articles in PMC.
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Abstract
Background

Clinicians are constantly seeking for the most ideal option in the management of Congenital
Talipes Equino Varus (CTEV), especially among infants.
Objective

This case report presents the outcome of a one year Physiotherapy management of an infant with
Congenital Talipes Equino Varus (CTEV).
Methods

Management commenced 48 hours after birth. During the first three months, passive stretching
and strapping techniques were employed. Subsequently, plaster of Paris cast was applied using
the serial plastering approach. Stretching continued each time the cast was removed for
replacement.
Results

Follow up after one year showed that the child could walk with apparently normal gait and there
was no residual deformity
Conclusion

There is need for more enlightenment on the importance of early referral of CTEV cases for
Physiotherapy care.
Keywords: Physiotherapy, talipes equinovarus, passive stretching, strapping

Go to:
Introduction

Congenital ClubFoot (CCF), otherwise known as Congenital Talipes Equino Varus (CTEV) is
one of the commonest deformities occurring at the region of the ankle, subtaloid and mid-tarsal
joints1. Talipes equino varus is a derivative from Latin: talus (ankle) and pes (foot); equinus
(horse-like), that is, the heel in plantar flexion and varus-inverted and adducted2. Hence the
deformity comprises of three elements visa-viz: Inversion (twisting inward) of the foot,
adduction (inward deviation) of the forefoot relative to the hindfoot and equinus (plantar
flexion)3.
Historically, talipes equino varus was recognized and documented since the time of the ancient
Egyptians2,4. According to Strach5, Smith and Waren in 1924 found that Pharaoh Siptah of the
XIX dynasty was afflicted with clubfoot. Hippocrates introduced talipes equinovarus into the
medical literature in 400 BC5, 6.
The incidence of CCF varies widely with race and sex. World wide, it is estimated at 1 to 2 per
1,000 live births7,8. In the United States the incidence is about 2.29 per 1,000 live births, 1.6 per
1000 live births in Caucasians and 0.57 per 1,000 in Orientals9. All populations show a
consistency of 2: 1 male predominance, with about 50% of cases being bilateral4,6. In unilateral
cases, right side affectation dominates10. A positive family history has been connected to high
incidence6, 11.
According to Strach5, Hippocrates had suggested that the treatment of CTEV should start as soon
as possible after birth with repeated manipulation and fixations by strong bandages which should
be maintained for a long time to achieve over correction. This sage's teaching principles of
treatment are as valid as they were over 2,300 years ago2. Presently management of CTEV is
fraught with controversy hence there is no consensus as to the best treatment for this deformity12.
In Nigeria, most parents/guardians remain unconvinced on why they should allow surgical
procedures for their child. Sometimes they prefer to wait until when the child is old enough
before management can commence. In view of this, this study presents a case report of a 2-day
old baby boy with congenital talipes equinovarus managed conservatively using physical
therapy.
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Case report

A 2-day old baby boy (who weighed 3.2kg at birth) with talipes equinovarus was referred by an
orthopaedic surgeon to the Physiotherapy clinic. The baby was delivered at full term, by
spontaneous vaginal delivery (SVD) in a missionary hospital.

On examination, the baby was found to have bilateral congenital talipes equinovarus(figure 1).
Both feet were noticed to turn inwards with the soles directed medially, giving a bow string
appearance at both ankle regions. The right foot was observed to be more affected than the left.
The characteristics features of CTEV, that is, a three dimensional deformity (inversion, adduction
and equinus) with four components (C.A.V.E) were evident in both feet visa viz:

Figure 1
Infant at presentation (48 hours after birth) with bilateral congenital talipes
equinovarus

C - Cavus (increased longitudinal arch of the feet)

A - Adduction (tarsal bones directed towards the median plane)
V - Varus (inversion and adduction of the calcaneal bones)
E - Equinus (increased plantar flexion of the ankles)
On passive movement, there was relative tightness of the tendoachilles on both ankles (the right
more than the left); the talocrural, the subtaloid and the mid-tarsal joints were stiff. Every other
part of the musculoskeletal system was clinically normal.
Physiotherapy management

The goal of management of the baby consisted of short term and long term goals. The short term
goal was to correct the deformity so that the ankles assume plantigrade position by the time the
baby would be three months old. The long term goal was to maintain the corrected ankle in situ
and follow up the maintained correction until the baby starts walking and if feasible further
follow up to avoid relapse.
Means of management
1. Rhythmic and repeated gentle manipulation 13
2. Strapping14 and plaster of Paris (POP) cast13
3. Education and instructions to the mother and/or parents

Rhythmic and repeated gentle manipulation

The right foot which was more affected was first attended to. Before commencing the procedure,
the right knee was placed at 90 flexion to prevent damage to the lower end of tibial and fibular
epiphyses, and the knee joint. Thereafter the soft tissues of the right foot were passively stretched
as follows: the forefoot was uncurled so that it moved away from the ipsilateral heel (that is
forefoot abduction). This manoeuvre was to correct adduction. Then the foot was turned such
that the sole faced outward (that is eversion), in an attempt to correct the inverted foot. Finally, to
correct the equinus (plantar flexion deformity), the heel was cupped with the right hand from the
front of the foot and an upward pressure was applied to it bringing the forefoot upward. This
brought the ankle into dorsiflexion. Each of the above manipulation lasted for about two minutes
and the entire procedure was repeated four times.
The baby was allowed to rest for about 20 minutes while the mother breast fed him. Then the
same manoeuvre and procedure were performed on the left.
To maintain the feet in the corrected position, strapping was commenced. Materials needed for
the strapping were: a 2.5cm width adhesive zinc oxide plaster, cotton wool, tincture of benzoin
compound (TBC), methylated spirit and a pair of scissors. Before strapping commenced, skin
toileting was religiously observed as follows: the hands were washed with medicated soap and
distilled water, then dried with sterilized towel. Finger nails were always cut and kept clean. One
of the authors stabilized the baby's limb and the other carried out the procedure.
Cotton wool soaked in methylated spirit was used to clean the right lower limb from the lower
1/3 of the thigh to the toes to avoid sepsis. Thereafter tincture of benzoin compound (TBC) was
applied to prevent skin excoriation and improve the adherence of the plaster so that hairs would
not stick to the straps.
Scissors was used to cut the 2.5cm width zinc oxide plaster into four strips of appropriate
lengths. Strapping began by holding the manipulated right foot to over corrected position. The
first strip was applied from the medial border of the midpoint of the right leg down under the
ipsilateral heel then along the lateral border of the leg to the lower 1/3 of the thigh with knee
flexed at 90. This was to correct the heel varus deformity. The second strip was applied over the
dorsum of the mid-foot from lateral to medial then under the sole back to the lateral border of the
mid-foot then along the border of the leg over the lower 1/3 of the thigh with knee still at 90.
This was important to correct the varus and equinus deformities by eversion of the foot and
abduction of the forefoot.
To bring the ankle into dorsiflexed position, the third strip was applied over the dorsum of the
forefoot from lateral to medial, then along the plantar surface of the forefoot to the lateral border
of the leg over the lower 1/3 of the thigh. The last strip was applied circumferentially around the
leg at a point 2cm above the ankle joint. This was to correct the bow string appearance of the

lower 1/3 of the leg, the ankle and the foot, and to increase eversion. The baby rested, then the
left foot underwent the same process (figure 2).

Figure 2
Infant after a strapping

At the end of the procedure the mother was asked to wait for 30 minutes while breastfeeding the
baby. This was to observe for any compromise to circulation. For the first six weeks the baby
was seen thrice a week and strapping applied twice per week. From the period the baby was 7 to
12 weeks, he was being seen two times in a week and the strapping was done once per week. At
three months there was marked improvement, especially on the left foot (figure 3).

Figure 3
Baby at third month

By this period (that is when the baby was three months), the strapping was no more effective
because he was kicking vigorously with the lower limbs. It was then replaced with a full leg
plaster of Paris (POP) with the knees at 90 of flexion. The plaster was changed weekly for the
first eight weeks of application and the knees and feet mobilized on each occasion. Thereafter it
was applied and changed forth-nightly for another eight weeks. The plaster was finally removed
when the baby was exactly seven months. At eight months and three weeks he started standing
with support and good plantigrade position. At the thirteenth month the baby could walk with
good heel strike. The child is now three years without any obvious residual deformity, he is in
nursery school and doing very well.
Education and instructions to the mother

The mother was assured and reassured that with her co-operation, consistency and compliance to
treatment the deformity would be corrected. She was made to understand that the correction
should be gradual and that we would follow up the case beyond when the baby starts walking.
She was taught how to mobilize the feet in the absence of strap. She was instructed anytime a
fresh strapping or plaster was applied to observe at frequent intervals any unusual crying by the

baby, swollen or bluish colouration of the toes and report to the accident and emergency unit of
our hospital. She was also advised to endeavour as much as possible to prevent the strapping or
plaster from being wet or soiled either by water or any other fluid such as urine or faeces.
Precautions taken during the application of the strapping and plaster

Moderate pressure was used to apply the straps and later the plaster, in order to maintain and
preserve circulation;
A layer of cotton wool (the rolled type in layers), enough to cover the malleoli was applied at
medial and lateral malleoli of both ankles to avert pressure sore;
Where the strips of the straps were circumferentially applied, in between spaces were avoided to
prevent window oedema;
The strips of the straps were smoothly applied and no wrinkles were permitted, to prevent skin
excoriation.
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Discussion

The choice of techniques for management of CTEV in infants has historically provoked much
debate. Recently, there is a swing towards conservative management15, 16, possibly because the
results of surgical procedures are unpredictable17. Also there is no consensus on what the
standard or most appropriate conservative method should be18. Various conservative techniques
such as Kite method19, Ponseti technique13 and the French method14 have been tried and have
shown to have varying degrees of success. However, when CTEV proves stubborn to
conservative management, then surgical procedures become the option. Clinical decisions are
usually impeded by a lack of adequate and convincing long-term reviews of treatment based on
prospective assessment and unbiased comparisons of different techniques.
This case report showed the outcome of Physical therapy approach for the management of an
infant who presented with CTEV. Management in this case report involved a combination of
passive stretching and manipulation, strapping technique, Plaster of Paris casting and education
of the guardian. Unlike the Ponseti technique and kite methods the researchers opted to
commence treatment with Zinc oxide strapping similar to the use of adhesive taping technique of
the French method. Although it is usually recommended that serial plaster casting be the first
direction of conservative treatment after manipulation 17, the researchers argued that the use of
zinc oxide strapping could also be as much effective up till the point when the child starts
kicking. The outcome showed that after treatment and at follow up a year later the child showed
no sign of the initial presenting pathology. Until recently, treatment consisted of forcible serial
manipulations under anaesthesias followed by casting. More recently, authors20,21,22 have

advocated the use of serial casting with minimal force (not requiring anesthesia) and have
emphasized its importance and potential for success of non-operative treatment. The case report
presented employed this and shows that there can be remarkable success if serial POP casting is
properly and timely applied. In this case report POP was applied when the application of
adhesive tapping outlived it usefulness. Another major factor for the success of the method is the
early commencement of treatments and subsequent cooperation from the guardian to bring the
child for treatments. Thus, the importance of sufficient and persistent education is essential on
the part of the physiotherapist. It has been reported23 that one of the most common reasons for
failure is that patients are not referred on time and this affects the outcome of the treatments.
Although there is no universally accepted method of assessing outcome in CTEV24 the central
aim of physical therapy is to restore the patient to the maximum functional ability in the use of
the lower limb especially the foot. Early commencement of physical therapy, proper education
and an individualized plan of treatment are essential aspect of this care. This is vital because at
this stage there is an enormous potential for remodeling of the tissues through peripheral
manipulative therapy techniques if appropriately applied. This is also important as most
guardians in Nigeria will not want their wards to undergo surgical procedures at a very early
stage of development even when it is medically advisable.
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Conclusion

This study presents a patient with Congenital Talipes Equino Varus successfully managed by
Physical Therapy approach. This case report indicates that management of Congenital Talipes
Equino Varus if commenced early after birth could help in achieving good recovery and reduce
cost of treatment while ameliorating the psychological burden on both the caregiver and patient's
parents.
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Acknowledgements

The authors wish to thank Ms S Oluwaseun Ogunmakin-Kubeyinje and Mr Vitus Eze for their
assistance.
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