Scientific Articles   |    
Gait Analysis of Children Treated for Clubfoot with Physical Therapy or the Ponseti Cast Technique
Ron El-Hawary, MD, MSc1; Lori A. Karol, MD2; Kelly A. Jeans, MS2; B. Stephens Richards, MD2
1 Division of Pediatric Orthopaedics, Isaac Walton Killam Health Centre, 5850 University Avenue, P.O. Box 9700, Halifax, NS B3K-6R8, Canada
2 Department of Orthopaedics (L.A.K. and B.S.R.) and Movement Science Laboratory (K.A.J.), Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219. E-mail address for L.A. Karol: lori.karol@tsrh.org
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).
Investigation performed at the Movement Science Laboratory, Texas Scottish Rite Hospital for Children, Dallas, Texas

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Jul 01;90(7):1508-1516. doi: 10.2106/JBJS.G.00201
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case


Background: Currently, clubfoot is initially treated with nonoperative methods including the Ponseti cast technique and the French functional physical therapy program. Our goal was to evaluate the function of children treated with these techniques.

Methods: We reviewed the cases of 182 patients with idiopathic clubfoot (273 feet) who were initially treated nonoperatively. Seventy-seven patients (119 feet) were excluded because they had either received a combination of nonoperative treatments or had undergone surgery prior to testing. Gait analysis was performed when the children were approximately two years of age. Temporal and kinematic data were classified as abnormal if they were more than one standard deviation from normal.

Results: Gait analysis was performed on 105 patients (fifty-six treated with casts and forty-nine treated with physical therapy) with 154 involved feet (seventy-nine treated with casts and seventy-five treated with physical therapy). These patients were an average of two years and three months of age, and their initial Diméglio scores ranged between 10 and 17. No significant differences in cadence parameters were found between the two groups. The rate of normal kinematic ankle motion in the sagittal plane was higher in the group treated with physical therapy (65% of the feet) than it was in the group treated with the Ponseti cast technique (47%) (p = 0.0317). More children treated with physical therapy walked with knee hyperextension (37% of the feet) (p < 0.0001), an equinus gait (15%) (p = 0.0051), and footdrop (19%) (p = 0.0072); only one patient treated with casts walked with an equinus gait, and only three demonstrated footdrop. In contrast, more of the patients in the cast-treatment group demonstrated excessive stance-phase dorsiflexion (48% of the feet) (p < 0.0001) and a calcaneus gait (10%). More feet in the physical therapy group had an increased internal foot progression angle (44% compared with 24% in the cast-treatment group; p = 0.0144) and increased shank-based foot rotation (73% compared with 57% in the cast-treatment group; p = 0.05).

Conclusions: While the rate of normal kinematic ankle motion in the sagittal plane was 65% in the group treated with physical therapy, the gait abnormalities that were seen in that group were characterized by mild equinus and/or footdrop. The rate of normal kinematic ankle motion in the sagittal plane was 47% in the cast-treatment group, but the most common gait abnormality in this group was mildly increased dorsiflexion in the stance phase. The rates of calcaneus gait and equinus gait were =15% in each nonoperative group. The differences between the physical therapy and cast-treatment groups may, in part, be the result of the percutaneous Achilles tendon lengthening that is performed as part of the Ponseti cast technique but not as part of the physical therapy program.

Level of Evidence: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article
    Sign In to Your Personal ProfileSign In To Access Full Content
    Not a Subscriber?
    Get online access for 30 days for $35
    New to JBJS?
    Sign up for a full subscription to both the print and online editions
    Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.
    Register for a FREE limited account to get full access to all CME activities
    Have a subscription to the print edition?
    Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.
    Forgot your password?
    Enter your username and email address. We'll send you a reminder to the email address on record.

    Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
    by your institution, please contact you librarian or administrator for username and password information. Institutional
    administrators, to reset your institution's master username or password, please contact subs@jbjs.org


    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
    CME Activities Associated with This Article
    Submit a Comment
    Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
    Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

    * = Required Field
    (if multiple authors, separate names by comma)
    Example: John Doe

    Related Content
    The Journal of Bone & Joint Surgery
    JBJS Case Connector
    Topic Collections
    Related Audio and Videos
    PubMed Articles
    Clinical Trials
    Readers of This Also Read...
    JBJS Jobs
    S. Carolina - Department of Orthopaedic Surgery Medical Univerity of South Carlonina
    New York - Icahn School of Medicine at Mount Sinai
    W. Virginia - Charleston Area Medical Center
    District of Columbia (DC) - Children's National Medical Center