THE 4th JAKARTA PMR SCIENTIFIC FORUM

“SYMPOSIUM”
SUNDAY, 30th JUNE 2019

PMR MANAGEMENT ON CONGENITAL

TALIPES EQUINOVARUS (CTEV)
dr.Nilla Mayasari, M.Kes., Sp.KFR
Physical Medicine and Rehabilitation Departement
Medical Faculty - Hasanuddin University
 CTEV - CLUBFOOT
 The incidence is different among geographic and ethnic
group: 0.64 – 6.8 per 1000 live births
 About 70% occurs in males
 The Right foot is more frequently effected
 Bilateral in about 50% of cases
 Variable with regard to : severity, rigidity and response
treatment
 CLASSIFICATION
A. Typical clubfoot – normal infant
 Positional clubfoot – intrauterine crowding?

B. Atypical clubfoot – associated with other problems

 Rigid or resistant atypical clubfoot
 Syndromic clubfoot – part of a syndrome
 Teratologic clubfoot – eg. Congenital tarsal synchodnrosis
 Neurogenic clubfoot – associated with a neurological disorder
 Acquired clubfoot - eg. Streeter dysplasia
Anatomy - Joints

NOMENCLATURE
 Planus: Flat Foot
 Cavus: Highly Arch foot
 Varus: Heel going
towards the midline
 Valgus: Heel going away
from midline
 Adduction: forefoot
going toward to midline
 Abduction: forefoot
going away from midline
PHYSICAL EXAMINATION
 CLUB FOOT SCORING SYSTEM
 Pirani Scoring System
 Dimeglio score
 GOALS:

a) Classifying the Club foot

b) Assessing Progress
c) Showing signs of reccurences
d) Establishing the Prognosis.
Cont…
PIRANI SCORING SYSTEM
Dimeglio:Based On stiffness
 TREATMENT
 NonSurgery
 The Ponseti method of serial manipulation and holding
casting continues Bracing
 French Method

 SURGICAL RELEASE AND

REALIGMENT
 THE FRENCH METHOD
 Functional PT method
 Consisted of:
 Daily manipulation
 Taping
 Continuous passive motion-third month
 Active therapy exercises
 Most of the correction is obtained within the first 3 mo
 Ends at about age years
 Relaps-inability of families to maintain the correction
initially achieved
 THE PONSETI METHOD
 Conservative treatment of clubfoot is an accepted practice
and has been reported to result in good correction ranging
in 50-90% of cases
 Start soon after birth (7 to 10 days)
 Ponseti method: 6 weeks
 Manipulation
 Casting
 Percutaneous Achilles tenotomy  3 weeks cast
 Bracing
 Outcome: strong, flexible and pain free foot
 BRACING
 Foot Abduction orthosis
(straight last shoes attached to the Denis-Browne bar, with
the footplates set at 70 degrees out-toe, and with the bar bent
to encourage hindfoot valgus and about 15 degrees of ankle
dorsiflexion)

 Full-time basis (23 hours) for 3 months

 Night bracing is continued to age 3-4 years
 Night time use until 4 years old
 Normal foot wear during the day, no splints
  Without them, the deformity will come back
 BRACE ADVICE FOR PARENTS
 Most important stage of treatment!
 Compliant families = 6 % chance relapse
 Noncompliant families = 80% chance relapse

Casting Phase  Clinician does all the

work
 It usually takes a few days for the baby and parents, to get
used to brace
 Often the parents are worried and do not understand the
need for the brace
 It is our duty explain to the parents the great importance of
the brace, we need to support them
THE MECHANISM WHICH THE BRACE
PREVENTS A RELAPSE
 Ponseti and Smoley : recurrence of the deformity occurred
almost immediately following complete correction
 Non-compliance and inappropriate brace wearing
increases the risk of relapse.
 Ponseti hypothesized that the relapses may be related to
retracting fibrosis of the ligaments and musculotendinous
units of the posterior and medial ankle.
 At the end of three weeks of casting, the foot is abducted
to an exaggerated amount and kept in an adequate degree
of dorsal flexion.
 The presence of collagen, vimentin, and myofibroblast-
like cells in the thick, tight, and shortened medial and
posterior tarsal ligaments  important role in the
pathogenesis and relapse of the clubfoot deformity.

 the FAO for stretching the posteromedial soft tissues and

for preventing the relapse of deformity.
 BRACING COSTS
Denis Brown 60usd Plus Boots
Steenbeek 5-10usd Boots atteched
Miraclefeet 10usd Plus boots 10usd, quick
release
Danang 10usd Plus boots 10usd
Mitchell 100usd Plus boots 300usd, quick
release
Dobbs 300usd Plus boots 300usd, quick
release

Usually need two

pairs of boots the
first years in brace
 FOLLOW UP
Check Compliance and detection risk of relapse

 2 week after brace fitted  Full time Brace

 1 month after brace fitted
 3 month after brace fitted  Graduate nights and naps
schedule
 3-6 monthly until 4 years  Check Compliance and
detection of relaps
 4 years until maturity  check every 1 to 2 years

PROBLEM DURING BRACING
 SIGNS OF RELAPS OF DEFORMITY
 Loss of dorsiflexion (equinus developing)
 Loss of abduction
 Inability to wear brace comfortably
 Abnormal supination in gait/lateral weight-bearing on sole
of foot
 RELAPS OR RECURRENT CLUBFOOT
 EARLY 1-2 YEARS
 Almost always due to failure of brace
wear
 Recognised as
 Loss of dorsiflexion, then heel varus
adductus. Cavus rarely recurs.
 Early heel rise or any varus
(walking away)
 Weight bearing lateral ray (walking
towards you)
 Treatment Figure 1: (a) Clinical photograph showing decrease in ankle dorsiflexion to
neutral while stressing the foot (b) Comparative view of the opposite foot
 2 to 3 more cast at 1 to 2 week showing ankle dorsiflexion of 15 degree

intervals
 +/- repeat tendon Achilles tenotomy
 Second recurrence is treated the
same way
 RELAPS OR RECURRENT CLUBFOOT
 LATE 2-5 YEARS
 Recognised as
 Swing phase dynamic
supination
 Passively correctible
 WB last border foot

 Treatment
 If the easily dorsiflexion 10
degrees, and ATT alone is
needed
 If less dorsiflexion is present, a
TAL or rarely a posterior
releases is required in addition.
What should we know in making insole
UC-BL?
 Longitudinal medial and lateral arch (location, width and
height)
 Heel counter
 Locatio of normal and abnormal pressure
 Gait angle rotation (inward or outward)
 ORTHOTIC CHECKOUT
 Its fit, comfort and mechanical alignment
 Appropriate break-in protocols and wearing schedules
 2 hours on day 1, 4 hours on day 2, 6 hours on day 3 and
so forth, until the individuals is able to wear the orthosis
comfortably all day
 A follow up visit-after the orthosis has been worn for at
least 2 week  the patient should feel comfortable with
the orthosis for normal activities of daily living
Take Home Massage
Bracing and foot Orthotic or footwear : rarely as single
intervention in Diminishing effects of Physical impairment
and maximize functional ability

Orthoses and footwear for children: Regularly Follow-up

by Times