Gait analysis of children treated for clubfoot with physical therapy or the Ponseti cast technique.

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 <or=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.

[1]  D. Wenger Congenital Clubfoot: Fundamentals of Treatment , 1997 .

[2]  M E Harrington,et al.  Dynamic foot movement in children treated for congenital talipes equinovarus. , 2003, The Journal of bone and joint surgery. British volume.

[3]  M. Altchek Treatment of idiopathic clubfoot. A thirty-year follow-up note. , 1996, The Journal of bone and joint surgery. American volume.

[4]  G. Yavuzer,et al.  Gait characteristics of patients with bilateral club feet following posteromedial release procedure , 2005, Journal of pediatric orthopedics. Part B.

[5]  L. Staheli,et al.  Measurements on radiographs of the foot in normal infants and children. , 1988, The Journal of bone and joint surgery. American volume.

[6]  J. Paysant,et al.  The effect of inturning of the foot on knee kinematics and kinetics in children with treated idiopathic clubfoot. , 2003, Clinical biomechanics.

[7]  V. Turco Surgical Correction of the Resistant Club Foot , 1971 .

[8]  A. Diméglio,et al.  Classification of Clubfoot , 1995, Journal of pediatric orthopedics. Part B.

[9]  V. Turco Surgical correction of the resistant club foot. One-stage posteromedial release with internal fixation: a preliminary report. , 1971, The Journal of bone and joint surgery. American volume.

[10]  I. Ponseti Clubfoot management. , 2000, Journal of pediatric orthopedics.

[11]  M. York-Moore Paper No. 3 , 1970 .

[12]  L. Karol,et al.  Gait analysis and muscle strength in children with surgically treated clubfeet. , 1997, Journal of pediatric orthopedics.

[13]  L. Karol,et al.  Calcaneus gait following treatment for clubfoot: preliminary results of surgical correction , 2004, Journal of pediatric orthopedics. Part B.

[14]  L. Karol,et al.  Gait Analysis in Children With Severe Clubfeet: Early Results of Physiotherapy Versus Surgical Release , 2005, Journal of pediatric orthopedics.

[15]  J. Aronson,et al.  Deformity and disability from treated clubfoot. , 1990, Journal of pediatric orthopedics.

[16]  E. Simonsen,et al.  Evaluation of the Walking Pattern in Clubfoot Patients Who Received Early Intensive Treatment , 2000, Journal of pediatric orthopedics.

[17]  G. Simons Complete subtalar release in club feet. Part I--A preliminary report. , 1985, The Journal of bone and joint surgery. American volume.

[18]  T. Muneta,et al.  Cause of toe-in gait after posteromedial release for congenital clubfoot. , 1994, Journal of pediatric orthopedics.

[19]  R. Zernicke,et al.  Ankle and First Metatarsophalangeal Joint Dorsiflexion in Children With Clubfoot , 2001, Journal of pediatric orthopedics.

[20]  J. Herzenberg,et al.  Ponseti Versus Traditional Methods of Casting for Idiopathic Clubfoot , 2002, Journal of pediatric orthopedics.

[21]  Lori A Dolan,et al.  Results of an Accelerated Ponseti Protocol for Clubfoot , 2005, Journal of pediatric orthopedics.

[22]  D. McKay New Concept of and Approach to Clubfoot Treatment: Section II—Correction of the Clubfoot , 1983, Journal of pediatric orthopedics.

[23]  K. Noonan,et al.  Nonsurgical Management of Idiopathic Clubfoot , 2003, The Journal of the American Academy of Orthopaedic Surgeons.

[24]  P. Than,et al.  Long-term results of the operative treatment of clubfoot: a representative study. , 1998, Orthopedics.

[25]  D A Yngve Foot-progression angle in clubfeet. , 1990, Journal of pediatric orthopedics.

[26]  A. Diméglio,et al.  Orthopaedic treatment and passive motion machine: consequences for the surgical treatment of clubfoot. , 1996, Journal of pediatric orthopedics. Part B.

[27]  J. Gage An overview of normal walking. , 1990, Instructional course lectures.

[28]  H. Bensahel,et al.  Results of Physical Therapy for Idiopathic Clubfoot: A Long‐Term Follow‐up Study , 1990, Journal of pediatric orthopedics.