• First correct cavus with forefoot SUPINATED (NOT pronation) by aligning the plantar-flexed 1st MT with the remaining metatarsals (forcible pronation would increase cavus deformity as the 1st MT is plantar-flexed further) • Secondly correct adduction and heel varus by rotating calcaneus and forefoot around talus (head of talus acts as a fulcrum) into forefoot ABDUCTION
• Equinus correction last with tendinoachilles lengthening (TAL)• Perform when foot is 70° abducted and heel is in valgus • Ponseti method uses a complete transverse cut of achilles• Cast in maximal dorsiflexion after TAL
• With Denis-Brown bar in external rotation (70° in clubfoot and 40° in normal foot) • Fit FAO on day of TAL
• 10-20% will need TA transfer with or without repeat TAL for recurrent supination, varus, and/or equinus• Indicated if the patient demonstrates supination of the foot during dorsiflexion (a dynamic intoeing gait)
• Daily corrective manipulations of the clubfoot are performed by an experienced physical therapist and the correction is held with elastic taping and splints until the next day's session.
• Family participation is integral to the success of this treatment program as the family must be able to bring the infant to therapy during the week for 1-3 months
• Each session lasts approximately 30 mins per foot and manipulations are performed in a progressive gentle pattern
• Begin with derotation of the calcaneopedal block and correction of forefoot adduction through massage of the Achilles tendon and gastrocnemius muscle
• Next, medial soft tissues are stretched to allow the navicular to move away from the medial malleolus and its medial position on the head of the talus . Distraction of the forefoot and midfoot helps to loosen the tightened structures, and derotation of the foot facilitates reduction of the talus
• To maintain the gain achieved in passive range of motion, the toe extensors and peroneals are recruited by stimulating (tickling) the lateral border of the foot and leg and the tops of the toes
• Once the talonavicular joint has been reduced, attention is directed toward the correction of varus and equinus. With the valgus maneuver, the calcaneus gradually moves to a neutral and eventually valgus position . The ankle is externally rotated at the same time that the calcaneus is being mobilized into valgus. The knee should be kept at 90° during these maneuvers
• Equinus is corrected with gradual dorsiflexion of the foot. Correction of equinus can be augmented with a percutaneous heel cord tenotomy
• Fewer visits to the therapist are needed as the parents assume the daily treatment exercises and taping
• Periodic follow-up is needed to monitor the range of motion of the foot and the development of the infant and to fabricate new splints
• Once the patient is walking, taping is discontinued and a resting ankle-foot orthosis is used during nighttime and naps until the age of two years.
• Throughout this treatment program, the patient visits the physician every two to three months for evaluation of the foot
Please rate topic.
Average 4.1 of 65 Ratings
Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
A 19-year-old female presents with metatarsalgia and difficulty with wearing closed-toe shoes on her left foot. She is found to have a muscular strength imbalance between the anterior tibialis and peroneus longus on the left side. A clinical image and lateral foot radiograph are shown in Figures A and B, respectively. Which congenital condition most likely contributed to the development of the current foot deformity?
Congenital calcaneonavicular coalition
Congenital vertical talus
Congenital oblique talus
Congenital talipes equinovarus
Select Answer to see Preferred Response
The history, clinical image, and radiograph is consistent with a dorsal bunion and is most likely secondary to a history of congenital clubfoot (talipes equinovarus).
The anterior tibialis muscle is the antagonist of the peroneus longus muscle and its integrity or overactivity is required for the development of a dorsal bunion. An abnomality of its bone insertion or its retraction can be found in congenital clubfoot and partly explains the natural tendency of these feet to develop a dorsal bunion. Dorsal bunions can also occur following surgical clubfoot release secondary to a weak Achilles tendon, excessive power of the flexor hallucis longus muscle, a strong anterior tibial tendon, and weakness of the peroneus longus tendon.
McKay performed a Level 4 review of 17 children with a dorsal bunion. He transferred the tendons of the abductor hallucis, both heads of the flexor hallucis brevis, and the oblique and transverse heads of the adductor hallucis from the base of the proximal phalanx to the neck of the first metatarsal to create a myotendinous ring to correct the dorsal bunion.
Illustration A and B is a clinical image and radiograph following osteotomy and correction of the dorsal bunion. Illustration C is a diagram demonstrating the Mckay tendon transfer procedure for dorsal bunion correction.
J Bone Joint Surg Am. 1983 Sep;65(7):975-80. PMID: 6885876 (Link to Abstract)
McKay, JBJS 1983
Please rate question.
Average 3.0 of 21 Ratings
A 3-week-old infant presents with the unilateral foot deformity displayed in Figure A. All of the following are key concepts for treatment of this deformity with manipulation and serial casting EXCEPT:
Forefoot is supinated and not pronated during correction
Forefoot abduction with lateral pressure on the talus
Percutaneous achilles tenotomy done before final cast application for residual equinus
Weekly cast changes
The last cast is applied with the foot in 30 degrees of abduction
Abduction of the foot is increased incrementally with each manipulation/casting until hypercorrection to 70° of foot abduction is obtained. This foot position is maintained after removal of the final cast and the infant is transitioned to a foot-abduction orthosis. This orthosis consists of a bar with shoes that are attached at 70° of abduction on the affected side and 40° on the normal side. Key features of Ponseti casting include keeping the forefoot supinated, applying lateral pressure to the talar neck only, weekly long leg casts, and percutaneous achilles tenotomy before final cast application to address any residual equinus deformity.
The level IV study by Morcuende et al reports a 98% correction rate in 256 clubfeet in 157 patients. There was a 11% relapse rate, with relapses related to non-compliance with the foot-abduction orthosis.
The article outlines the Ponseti clubfoot manipulation/casting protocol.
Morcuende JA, Dolan LA, Dietz FR, Ponseti IV
Pediatrics. 2004 Feb;113(2):376-80. PMID: 14754952 (Link to Abstract)
Morcuende, PEDS 2004
Average 3.0 of 25 Ratings
A 16-year-old female complains of foot pain with ambulation. She previously underwent clubfoot soft tissue releases at 5 months of age. Each of the following are complications or late deformities associated with clubfoot surgery EXCEPT:
Osteonecrosis of the talus
Rigid pes planus
Tarsal tunnel syndrome
Traditional surgical treatment of clubfoot deformity with wide release (in order to correct the cavus, adduction, varus, equinus) is notable for frequent complications, residual deformity, and secondary surgeries. Tarsal tunnel has not been correlated with previous clubfoot release surgery. Each of the remaining choices are known complications or deformities following clubfoot surgery. Yong et al reviewed 33 cases of deformity following previous clubfoot surgery. Reverse Jones procedure was performed in conjunction with other procedures to fix the first metatarsophalangeal plantarflexion deformity. They reported improvement in pain, activity, footwear, range of motion, callus, and alignment amongst this cohort. Kuo et al reviewed 134 cases of clubfeet who underwent surgical release. 16% went on to have secondary surgery. Late deformities included intoeing gait, overcorrection, rotatory dorsal subluxation of the navicular, vascular insult to the talus with collapse, and dorsal bunion. Patients who underwent surgery prior to 6 months of age had poorer results.
Yong SM, Smith PA, Kuo KN.
J Pediatr Orthop. 2007 Oct-Nov;27(7):814-20. PMID: 17878791 (Link to Abstract)
Yong, JPO 2007
Kuo KN, Smith PA.
Clin Orthop Relat Res. 2009 May;467(5):1326-33. Epub 2008 Dec 17. PMID: 19089522 (Link to Abstract)
Kuo, CORR 2009
Average 2.0 of 33 Ratings
Which of the following photographs is most consistent with pediatric clubfoot deformity?
Figure E shows a clubfoot deformity which is characterized as having hindfoot equinus and varus with concomitant forefoot adduction. The four main components of the clubfoot deformity include cavus, adductus, varus, and equinus (CAVE). The acronym CAVE is also helpful because it delineates the sequence in which the Ponseti method corrects the deformities. Figure A displays a skewfoot(Z deformity or serpentine foot) which is characterized by forefoot adductus, midfoot abduction, and hindfoot valgus. Figure B shows metatarsus adductus which has medial deviation of the forefoot relative to the hind foot, but no associated hindfoot deformity. Figure C shows a calcaneovalgus foot which includes a hindfoot that externally rotates and dorsiflexes to the point that the foot might even be able to touch the anterior tibia. Figure D shows a congenital vertical talus which is characterized by a rigid deformity of the hindfoot that is in equinus and a forefoot that is dorsiflexed resulting in midfoot dislocation (resulting in a rocker bottom deformity).
The review article by Noonan and Richards details the Ponseti, Kite, and French methods for clubfoot management.
Noonan KJ, Richards BS.
J Am Acad Orthop Surg. 2003 Nov-Dec;11(6):392-402. PMID: 14686824 (Link to Abstract)
Noonan, JAAOS 2003
Average 4.0 of 26 Ratings
A 3-year-old boy has been treated in the past with Ponseti casting now presents with dynamic supination during gait. You're planning to perform an anterior tibialis transfer to the lateral cuneiform. All of the following are true EXCEPT:
This transfer is required in 10-20% of children who undergo the Ponseti treatment
Weak peroneals are counteracted by overpull of the anterior tibialis
Grade 4 or 5 strength of the anterior tibialis is needed prior to transfer
Subtalar rigidity supplements the transfer
Dynamic supination includes foot supination during swing phase and landing on the lateral foot border during stance phase
The patient has dynamic supination as a result of overpull of the anterior tibialis in relation to the peroneal tendons. During the Ponseti casting, cavus is corrected by aligning the first ray with the remaining metatarsals.
Next, abduction of the forefoot using the lateral talar head as a fulcrum corrects the forefoot adduction and hindfoot varus deformities. At least Grade 4 strength is needed prior to transfer to ensure that dorsiflexion of the foot will be preserved. Subtalar rigidity is a contraindication to anterior tibial tendon transfer. The referenced book chapter and review article discuss the Ponseti method of clubfoot treatment and its sequelae.
Average 4.0 of 24 Ratings
In patients with clubfeet treated with soft-tissue release, which of the following variables shows the greatest correlation with long-term functional impairment.
Extent of soft-tissue release
Subtalar joint function
Ankle joint function
Peroneal muscle function
Duration of cast treatment
In patients with idiopathic clubfoot, a correlation has been found between the extent of the soft-tissue release and the degree of functional impairment.
Dobbs et al evaluated 45 patients with clubfeet treated with a posterior release and plantar fasciotomy or an extensive combined posterior, medial, and lateral release. The patients were followed for a mean of thirty years post treatment. The authors found a correlation between poor long-term functional outcome and patients treated with extensive soft-tissue release. And while neither group did "well" long term, the authors found that repeated soft-tissue releases resulted in stiff, painful, and arthritic feet and significantly impaired quality of life.
Kuo et al reviewed 134 cases of clubfeet who underwent surgical release. 16% went on to have secondary surgery. Late deformities included intoeing gait, overcorrection, rotatory dorsal subluxation of the navicular, vascular insult to the talus with collapse, and dorsal bunion. Patients who underwent surgery prior to 6 months of age had poorer results.
Dobbs MB, Nunley R, Schoenecker PL
J Bone Joint Surg Am. 2006 May;88(5):986-96. PMID: 16651573 (Link to Abstract)
Dobbs, JBJS 2006
Average 2.0 of 30 Ratings
A 4-year-old boy demonstrates excessive supination occuring during the swing phase of gait following Ponseti casting for an isolated right clubfoot. Which of the following sites identified in Figure A shows the correct destination for the transferred tendon in order to balance the foot and eliminate the supination?
In the surgical treatment of dynamic supination following Ponseti treatment, the accepted sites of insertion for anterior tibial tendon transfer are the lateral cuneiform (more common) and cuboid. The anterior tibial tendon is harvested from its insertion at the medial and under surface of the first cuneiform bone (Point C on Figure A), and the base of the first metatarsal bone. The AAOS COR review book states that either split anterior tibial tendon or whole anterior tibial tendon may be used, but the 2007 OITE question #31 preferred whole tendon transfer over split tendon transfer and whole tendon is the most common choice among surgeons. The dynamic swing phase supination deformity may develop as a result of medial overpull of the anterior tibialis tendon. Incomplete reduction of the navicular onto the talar head results in changing the anterior tibialis muscle from predominately a strong dorsiflexing to a strong supinating force. If uncorrected, this can lead to recurrence of hindfoot varus.
The review article by Ponseti reviews the closed manipulation and casting method he developed along with stating that the presence of vimentin and myofibroblast-like cells in the thick, tight, and shortened medial and posterior tarsal ligaments are probably involved in clubfoot pathogenesis in-utero.
The Level 5 article by Noonan and Richards reviews the Kite method(serial manipulation and casting), Ponseti method (serial manipulation and casting), and French method(requires daily PT and taping) for nonoperative clubfoot management.
The Level 5 article by Cummings et al states that after several decades of operative treatment of clubfoot it was found that the complications of such surgery, including recurrence, overcorrection, stiffness, and pain have led to a renewed interest in nonoperative treatments.
J Pediatr Orthop. 2000 Nov-Dec;20(6):699-700. PMID: 11097239 (Link to Abstract)
Ponseti, JPO 2000
Cummings RJ, Davidson RS, Armstrong PF, Lehman WB.
Instr Course Lect. 2002;51:385-400. PMID: 12064128 (Link to Abstract)
Average 4.0 of 20 Ratings
Which of the following components of the clubfoot deformity should be addressed first when using the Ponseti method?
Cavus should be addressed first when using the Ponseti method to treat clubfoot.
Idiopathic clubfoot is characterized by forefoot adductus, hindfoot varus, ankle and subtalar equinus, and supination of entire foot. The forefoot is pronated relative to hindfoot. Correction of clubfoot requires an organized and sequential methodology. The helpful acronym is CAVE which describes both the clinical position and the general order of deformity correction in the Ponseti method. Cavus is first corrected with forefoot supination via dorsiflexion of the first metatarsal. Some practitioners will add a small degree of abduction to the first cast as well. Metatarsus adductus and hindfoot varus are then simultaneously corrected by abducting the foot and applying counter pressure laterally at the talar head. Meanwhile, foot supination is slowly decreased during each successive casting. Equinus is corrected last and should only be attempted when the hindfoot is in neutral to slight valgus position. This can be done through progressive stretching and casting or by a percutaneous heel cord tenotomy as is done in a large majority of patients.
Noonan et al review the nonoperative management of clubfeet using several techniques. They note that the Ponseti method consists of manipulation and casting of idiopathic clubfeet while the French method consists of physiotherapy, taping, and continuous passive motion.
Illustration A shows a series of casts from the Ponseti method, revealing the progressive changes obtained with each cast.
Average 4.0 of 18 Ratings
A 5-year-old boy has a history of being treated with the Ponseti technique for a unilateral clubfoot. What muscle most commonly causes a dynamic deformity in the swing phase of gait following Ponseti casting?
In clubfoot patients older than 12 to 18 months, a dynamic swing phase supination deformity may develop as a result of medial overpull of the anterior tibialis tendon. Incomplete reduction of the navicular onto the talar head results in changing the anterior tibialis muscle from predominately a strong dorsiflexing to a strong supinating force. If uncorrected, this may lead to dynamic deformity during the swing phase of gait.
The study by Ippolito et al found that at long term followup children treated with Ponseti's manipulation technique and cast immobilization followed by an open heel-cord lengthening had better outcomes than those that underwent Ponseti technique and extensive posteromedial release.
The study by Kuo et al reviewed 71 feet who had residual dynamic clubfoot deformity that underwent either split or complete anterior tibial tendon transfer. Both treatments resulted in increased dorsiflexion and eversion ROM, eversion strength, and correction of forefoot adduction and supination. They concluded there was little clinical signficance between the two surgical approaches.
The article by Ponseti describes his method for the treatment of congenital clubfoot deformity. The cavus deformity is corrected by supination of the fore part of the foot. The varus deformity of the hindfoot is corrected with displacement or lateral rotation of the navicular, together with the cuboid and the anterior aspect of the calcaneus, without pronation of the foot. The foot position is maintained in a toe-to-groin plaster cast with the knee flexed 90 degrees and the foot in maximum external rotation. The equinus is corrected last, by dorsiflexion of the foot with the heel in valgus angulation. A tendo-achilles tenotomy can facilitate correction of equinus. To decrease the risk of recurrence, a Denis Brown splint is utilized full time for several months and then converted to part-time wear.
J Bone Joint Surg Am. 1992 Mar;74(3):448-54. PMID: 1548277 (Link to Abstract)
Ponseti, JBJS 1992
Kuo KN, Hennigan SP, Hastings ME.
J Pediatr Orthop. 2001 Jan-Feb;21(1):35-41. PMID: 11176351 (Link to Abstract)
Kuo, JPO 2001
Ippolito E, Farsetti P, Caterini R, Tudisco C.
J Bone Joint Surg Am. 2003 Jul;85-A(7):1286-94. PMID: 12851354 (Link to Abstract)
Ippolito, JBJS 2003
Residual cavus after surgical correction of a clubfoot deformity with comprehensive clubfoot release and pinning is caused by what technical error?
Inadequate Achilles tendon lengthening
Failure to correct hindfoot valgus
Failure to perform a posteromedial imbrication
Placement of the navicular in a dorsally subluxated position
Failure to perform a lateral column lengthening
Clubfoot, or congenital talipes equinovarus, consists of multiple foot deformities. There is cavus of the foot secondary to a plantarflexed first ray, as well as forefoot adductus, hindfoot varus and equinus. The Ponseti method is tried first, which requires a series of long leg casts to correct the deformity and almost always an Achilles tenotomy at the end of treatment.
Schwend and Drennan provide a thorough description of possible causes as well as work up and treatment of children with cavus foot deformities. They state that cavus has been associated with clubfoot or residual clubfoot deformity in 22% of children and is typically associated with placing the tarsal navicular in a dorsally subluxated position at surgery.
In general, soft tissue releases with tendon lengthening are favored in recalcitrant clubfoot. The complete subtalar release is described in detail by Simons, although ala carte approaches are more common.
1. Would result in persistent equinus
2. The hindfoot is in a varus deformity
3. The posteromedial capsule is released, not imbricated
5. Lengthening of the lateral column in a clubfoot deformity would worsen the metatarsus adductus
Schwend RM, Drennan JC.
J Am Acad Orthop Surg. 2003 May-Jun;11(3):201-11. PMID: 12828450 (Link to Abstract)
Schwend, JAAOS 2003
J Bone Joint Surg Am. 1985 Sep;67(7):1044-55. PMID: 4030824 (Link to Abstract)
Simons, JBJS 1985
A tibialis anterior transfer is appropriate for which of the following patients with clubfoot?
Newborn with forefoot adduction
3-year-old with a foot that supinates when he dorsiflexes
6-month-old residual equinus after casting
5-year-old boy with a fixed hindfoot varus
2-year-old with a foot that pronates when he plantarflexes
Transferring the anterior tibialis - or doing a split transfer - is appropriate for clubfoot patients who are found to have dynamic supination once ambulatory following Ponseti treatment.
Club foot, congenital talipes equinovarus, can be thought of as having four deformities using the following mnemonic:
C = Cavus midfoot
A = Adducted forefoot
V = Varus hindfoot
E = Equinus
The Ponseti method begins with correction of cavus by aligning the first ray with the remaining metatarsals. Subsequent manipulation and casting utilizes lateral pressure on the distal talar head as a fulcrum to correct the forefoot adduction and hindfoot varus. The last step is the correction of equinus which may require tendoachilles release in >90%. Subsequent dynamic forefoot adduction/supination requires transfer of the anterior tibialis laterally in 15-20% of patients. Osteotomies should be considered in rigid deformities.
Laaveg and Ponseti published their long-term results in 1967 showing effectiveness of tibialis anterior tendon transfer to the 3rd cuneiform as helpful for eliminating recurrent cavus deformies and straightening the foot during ambulation.
Dobbs et. al wrote a review with Ponseti of his methods in the Iowa Orthopaedic Journal discussing their treatment of clubfoot. Optimal timing of tibialis anterior transfers is between 2.5-3 years of age, which the muscle becomes a powerful supinator.
1. Forefoot adduction in newborns has many causes, most common of which is metatarsus adductus which usually corrects without intervention
3. The 6-month-old with residual equinus after casting should undergo a tenoachilles lengthening
4. Fixed deformities usually require osteotomies for correction
5. The tibialis anterior is a dorsiflexor and supinator
Laaveg SJ, Ponseti IV.
J Bone Joint Surg Am. 1980 Jan;62(1):23-31. PMID: 7351412 (Link to Abstract)
Laaveg, JBJS 1980
Dobbs MB, Morcuende JA, Gurnett CA, Ponseti IV.
Iowa Orthop J. 2000;20:59-64. PMID: 10934626 (Link to Abstract)
Average 4.0 of 23 Ratings
Figure A shows a lateral radiograph of an 9-month old's dorsiflexed foot. What is the first line treatment for this condition?
Manipulation under anesthesia followed by a single casting
Serial manipulation and casting followed by surgical release and talonavicular reduction with pinning
The radiographs show hindfoot parallelism between the talus and calcaneus which is characteristic of congenital talipes equinovarus, also known as clubfoot. This question emphasizes the importance of the talocalcaneal angle. From a testing perspective, it is important to be able to differentiate clubfoot from congenital vertical talus (CVT) on radiographs. Vertical talus will not show the parallelism between the talus and calcaneus seen with clubfoot and the navicular (which is not ossified in infants) will not be aligned with the talus even on attempts to reduce with plantarflexion. Meary's angle and the talocalcaneal angle are shown for clubfoot and vertical talus in Illustration A and B respectively.
Roye, et al. stated that all radiographs of the foot should simulate weight bearing. The two most commonly used measurements are the lateral and AP talocalcaneal angles, which display parallelism.
Laaveg et al reviewed the long term treatment of congenital clubfoot and found that functional results were satisfactory in both appearance and function in 88.5% of 104 clubfeet.
Roye DP Jr, Roye BD.
J Am Acad Orthop Surg. 2002 Jul-Aug;10(4):239-48. PMID: 15089073 (Link to Abstract)
Roye, JAAOS 2002
Average 4.0 of 49 Ratings
A 6-week-old boy presents with bilateral lower extremity deformities shown in Figure A. All of the following are true regarding the Ponseti technique for correction of this congenital deformity EXCEPT:
Weekly manipulation and application of long leg casts
Achilles tenotomy is indicated for residual equinus before final cast application
Pronation of the foot during initial cast correction
Abduction of the foot with counterpressure at the talus
Correction of adduction deformity prior to equinus
Clubfoot is chrarcterized by hindfoot equinus and varus along with midfoot and forefoot adduction and cavus. A helpful acronym is "CAVE" which describes both the clinical position and the general order of deformity correction. The Ponseti casting technique as described in the articles by both Ponseti and Cummings et al has markedly impacted the way clubfoot patients are treated.
Cavus is first corrected with forefoot supination (NOT pronation) and aligning the plantar-flexed first ray with the remaining metatarsals. An attempt to correct the inversion of the foot by forcible pronation of the forefoot increases the cavus deformity as the first metatarsal is plantar-flexed further. Metatarsus adductus and hindfoot varus are then simultaneously corrected by abducting the foot and applying counter pressure laterally at the talar head. Meanwhile, foot supination is slowly decreased during each successive casting. Equinus is corrected last and should only be attempted when the hindfoot is in neutral to slight valgus position. This can be done through progressive stretching and casting or by a cutaneous heel cord tenotomy as is done in 70 to 75% of patients.
Level 3 evidence from Herzenberg et al showed that with the Ponseti technique, only 1 (3%) of 34 feet required open posteromedial release(PMR). In the control group of traditional casting, 32 (94%) of 34 feet required PMR within the first year of life, despite a longer casting period.
J Bone Joint Surg Am. 2002 Oct;84-A(10):1889-90; author reply 1890-1. PMID: 12377924 (Link to Abstract)
Ponseti, JBJS 2002
Herzenberg JE, Radler C, Bor N
J Pediatr Orthop. 2002 Jul-Aug;22(4):517-21. PMID: 12131451 (Link to Abstract)
Herzenberg, JPO 2002
Average 4.0 of 15 Ratings
PMSTR in Resistant Club Foot:
HPI - neglected clubfoot treatment in childhood
How would you treat this patient