c5 cong.Club foot.pdf

By Tesfalem(MPT)Bb
2/14/2022 1
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Outline presentations
Ø Introductions to club foot
Ø Causes
Ø Epidemiology
Ø Club foot assessment
Ø Club foot management
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What is clubfoot?
ØIt is also known as its Latin name,
Congenital Talipes Equinovarus. It is an
easily recognisable deformity due to the
abnormal shape and position of the feet.
ØRigid congenital deformity of the foot
ØCongenital Talipes Equinovarus (CTEV)
.
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Types
A. Based on Eithology
1. Idiopathics
Ø Most common type
Ø No associated with other congenital conditions
2.Postural
Ø the deformity is very flexible and is thought to be due to
intrauterine crowding
Ø The deformity can be corrected easily by the examiner
Ø Not considered as a real club foot
Ø It usually improves by teaching parents some stretching and by
itself with time
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Con…
3. Syndromic
Ø Some congenital conditions are associated with club
foot deformity e.g. arthrogrogryposis ,diastrophic
dwarfism
4.Neuromascular conditions
§ Myelomengiocle
§ Cerebral palsy
ü Equinovarus deformity due to muscle spasticity
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Con…
B. Based on treatment stage
1.Untreated
2.Treated
3.Resistant
4.Recurrent
5.Neglected
6.Complex club foot
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Con…
• Untreated :affected child is under 2 years of age
and had no or very little treatment
• Treated: affected Childs feet have corrected with
ponseti method and they have completed the
casting phase
• Resistant :child has previously untreated clubfoot
and that does not correct with ponseti method this
usually syndromic and surgery may be necessary
• Recurrent :children who show signs of deformity
in previously treated club foot
oUsually treated through casting and surgery
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Con…
• Neglected :child older than two years who had little or no
treatment usually severe soft tissue contracture and bony
deformities
o Ponseti treatment has some success but may requires
surgery
• Complex :club foot treated by other than ponseti
technique
complicated by additional pathology or scaring
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Clubfoot cause(Etiology)
Ø Most often idiopathic
Ø Muscular , neurological disorders
and connective tissue theories have
been proposed
Ø Hereditary influence
Photo credit: CURE International,
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• Average 1-2 cases/1000
• Globally
– 200,000 new cases/year
– 80% in low and middle
income countries
• More common in boys
• 50% of the cases bilateral
• 3 % occurrence in siblings
Incidence
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The components of clubfoot
deformity….CAVE
• Cavus (Midfoot)
• Adductus
(Midfoot)
• Varus (Hindfoot)
• Equinus
(Hindfoot)
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The midfoot - CAVE
• Cavus – 1st ray is plantarflexed in relation to
the hind foot
• High arch foot
• Adductus – the forefoot is adducted in
relation to the hind foot
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The hind foot deformity - CAVE
• Varus – The heel is inverted in relation to the tibia
• Equinus – The entire foot points downward in
relation to the tibia
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Why do we assess?
vTo diagnose
vShows the severity of the Clubfoot
vHelps to monitor treatment progress
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Con….
vHow do we assess club foot?
• Observation for signs
• History taking
• Examination (pirani score)
Ø By making the environment comfortable
Eg. Position the child at mother’s lap
Ø Undress the child
Ø Playing
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Overview of the Ponseti treatment - Basic
Ø Manipulation
Ø Casts after Manipulations
Ø Tenotomy
Ø The Bracing
16
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Overview of the Ponseti treatment - Basic
Manipulation + Cast (5-7 days)- 4 times or more
–(6-7 times max )
Correction of the Cavus, Mid foot Inversion,
and Heel Varus 17

Tenotomy of the Achilles tendon + Cast (3 weeks)
Correction of the Rigid Equinus
18

Bracing
a)full-time = 23 hours (3
months)
b) Sleeping time = 14-16 hours
(2-4 years)
19

Manipulation
Ø The technique of the manipulation is based on the
understanding of the described coupling of movements
Ø To correct the hindfoot we need to manipulate the
mid foot.
Ø The initiator for the correction of the whole foot is
the abduction of the mid foot.
Ø The manipulation can be done on the mother’s lap
and should not cause pain for the child
20

Manipulation technique
1. Stabilize the Talus by placing the thumb over the
head of the Talus .This provides a pivot point around
which the foot is abducted.
2. Manipulate the foot by abducting the foot in
supination with the other hand without any discomfort
to the child.
3. Hold the correction with gentle pressure for a few
seconds, then release, and repeat one or two more
times.
21

CASTS AFTER MANIPULATIONS
Ø The cast is applied after the manipulation and
immobilizes the foot in order to stretch the tight
ligaments.
Ø Always use long leg casts in 90° knee flexion!
Ø Avoid external rotation of the knee!
Ø Always mould well at the heel, Malleoli, and sole of
the foot.
Ø Never cast the foot in a pronated position!
Ø Never hold the heel.
Ø Never attempt to correct the equinus before
achieving the full abduction (aim for 70°).
24

First cast:
Correction of the Cavus:
1. Stabilize the Talus by placing the thumb over the
lateral part of the head of the Talus.
2. Elevate the first metatarsal and achieve a
homogeny supination of the forefoot in line with the
mid foot.
3. Put padding and plaster on by holding this
position and molding well.
– In small babies, correction usually occurs with the
first cast.
– A severe cavus in a stiff foot will need 2 or 3 cast
changes for correction. 25

First cast: Correction of the Cavus
Stabilize the Talus
Elevate the first ray
Holding this position
26

Following casts
Correction of Mid foot Inversion and Heel Varus
v Each cast aim for more abduction of the supinated foot -
70° at the end.
1. Stabilize the Talus by placing the thumb over the lateral
part of the head of the Talus.
2. Hold the supinated foot in abduction while applying the
cast. The correction of the Calcaneus will be achieved
because of coupling.
3. Apply padding and plaster by holding the corrected
position and molding well.
27

Following casts: Correction
of Mid foot Inversion and
Heel Varus
28

A
B
Note the correction of the adductus [A] and heel varus [B] occurs
when the foot is everted and abducted around the head of the talus
29

Removal of casting
• Should be done in the clinic just before the next step
of the treatment
1. Soak the cast in water
2. Remove the cast: above the knee then below
31

TENOTOMY
Ø Percutaneous tenotomy of the achilles
tendon
Ø It corrects the rigid ankle foot equinus./
Ø Equinus when cavus, adductus, and varus
are fully corrected but ankle dorsiflexion
remains less than 10 degrees above neutral.
Ø Make certain that abduction is adequate for
performing the tenotomy.
32

• Cont.
• The Pirani Severity Scoring Method indicates when
sufficient correction has been obtained:
– Mid foot Contracture Score under 1
• Hind foot Contracture Score is about1
• LHT = 0 (70° abduction, older children maybe
less)
• Never perform a tenotomy, if the heel is in varus,
because not enough correction has been achieved.
33

After
Tenotomy
Before
Tenotomy
34

Casting after tenotomy
• A cast will be applied right after the tenotomy had
been done and has to stay on for 3 weeks: 70°
abduction, 10- 15° dorsiflexion.
35

THE BRACING
Ø The bracing is a very important and a
critical part of the treatment
Ø Failure to use the brace in the correct
way and for the required time is the
most common cause of recurrence!
Ø The brace needs to be put on
immediately after the last casts are
removed.
36

Bracing protocol
• Bracing time for small children (who haven't walked before
the treatment is started):
– For first 3 months: full-time (except bathing = 23 hrs a
day)
– For 4 years : sleeping time (night and during day sleeps)
• Bracing time for older children of walking age (about 2-4
years):
– 18 hours a day for 3 months (6 hours out of the brace
during the day time for playing, moving, walking,
bathing, etc.)
– Sleeping time (= 14-16 hours a day) until the age of 5
37

Common Bracing Type
The Abduction Brace (Steenbeek
Type)
• The brace needs to have both
shoes attached to a bar in order to
prevent a recurrence
• Children should not stand or walk
in this brace. The brace is not
designed for this purpose.
• Full-time bracing (for small
children) or 18 hours bracing (for
older children) is only for 3
months.
• After that time, the children must
wear the brace at sleep times.
38
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Bracing Adjustment
• Bilateral clubfoot:
– Both feet in 70° abduction
• Unilateral clubfoot:
– Clubfoot in 70° abduction
– Normal foot in about 45°
abduction.
• Overcorrected clubfoot (e.g.
hypermobile, low muscle tone
child or atypical clubfoot) and
corrected clubfoot that develop
excessive heel valgus and
external tibial torsion:
– Both feet in about
45°abduction 39
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Recurrence
Reasons for recurrences
• Failure to wear the brace
– Failure to wear the brace: more than 80% of
recurrences.
– Proper wearing the brace: only about 6% of
recurrences.
• Muscle imbalance and ligament stiffness
– The Gastrosoleus tendon unit doesn’t grow as fast
as the Tibia which causes (>) :?????
• Failure in the treatment
– Not enough abduction or dorsiflexion have been
achieved.
40
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Prevention of Recurrences
Ø Strict bracing according to the bracing protocol.
Ø Stretching of the Gastrocnemius muscle (daily
exercise done by the parents).
Ø Squatting with heels on the floor: stretches Tibialis
posterior muscle.
41

The Pirani score
• 6 components
– Severity score of 0,
0.5 or 1
• Measure and record
deformity
• Valid and reliable
• Good intra/inter-
observer reliability
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Pirani scoring – Hindfoot contracture score
(HFCS)
Posterior Crease
(PC)
0, 0.5,
1
Empty Heel (EH) 0, 0.5,
1
Rigid Equinus (RE) 0, 0.5,
1
HFCS 0-3
§ Observe, look,
f e e l a n d
measure
§ Score with the
f o o t g e n t l y
corrected
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PC Score
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Rigidity of Equinus
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Midfoot Contracture
Medial Crease
(MC)
0, 0.5,
1
Lateral Head of
Talus (LHT)
0, 0.5,
1
Curvature of
Lateral Border
(CLB)
0, 0.5,
1
MFCS 0-3
• Observe,
look,
feel
• Score
with the
foot
gently
correcte
d
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Lateral head of the Talus
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Infantile torticollis
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Definition
Ø Torticollis literally means “twisted neck or “wryneck”
and is derived from the Latin words “torquere”
(twisted) and “collum” (neck) (Stellwagen 2004, cited
by Burch C. etal).
Ø The generic term “torticollis” is not a specific
diagnosis but a word used to describe the twisted
neck posture. It may be a clinical sign of one of a
variety of underlying pathologies, some benign and
some quite serious
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Classifications of torticollis
torticollis
congenital CMT
CMT
acquired
Skeletal
disorders
Neurological and
physiological
disorders
Spasmodic
occular
CNS lesions and
others
Soft tissue
contracture
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Acquired Cont.
Ø Spasmodic torticolis is an extremely painful chronic
neurological movement disorder causing the neck to
involuntarily turn to the left ,right ,upwards and
downwards
Ø This conditions is also referred to as cervical dystonia
Ø It’s a disease of middle aged and later
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Cont.
Ø Occular- the result of over action of the inferior
oblique muscle which elevates and rotates laterally.
The head is turned to the opposite side in order to
abduct the eye on the same side.
* Only occurs after 18 months of age
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CMT
Ø Congenital muscular Torticollis (CMT)- a postural
deformity detected at birth or shortly after birth ,
primarily resulting from unilateral shortening and
f i b r o s i s o f t h e S t e r n o c l e i d o - m a s t o i d
muscle(SCM).(Karmel-Ross 2006
Ø Unilateral contracture of the Sternocleidomastoid
(SCM)
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Infant with left congenital muscular
Torticollis( CMT)
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Cont.
Ø Over 80% of all infants presenting with a Torticollis
posture will be found to have congenital muscular
Torticollis (CMT). In the remaining 20%, the
Torticollis posture may represent a sign of a more
serious underlying condition.
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Cont.
Ø CMT is the third most frequently occurring
musculoskeletal condition in infants with a reported
incidence of 0.4% to 1.9%.
Ø CMT is often seen in combination with metatarsus
adductus and developmental hip dysplasia
Ø The pathophysiology and etiology of sternocleid-
omastoid impairment in CMT is still unknown
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Etiology
The cause of CMT is unknown, there are several
theories , the most advanced ones are;
v Intrauterine mal positioning of the neck with
resultant local ischemia of died sternocledomastoid.
After breech delivery.
vHemi atlas, rare congenital anomaly of formation of
the first cervical vertebra may cause progressive
torticollis.
vInjury to the neck during delivery
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Cont.
vIntrauterine pressure on the neck due to
positioning in the womb
vTrauma to sternomastoid lead to loss of blood
supply to muscle-------------fibrosis
vHaemorrhage , swelling and degeneration of the
muscle fibres
vAbnormality of blood supply to the fetus----- lead
to scar formation of sternomastoid muscles
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Symptoms
ü The head is tilted to the affected side
ü The chin is turned away from the affected side
ü Face develops asymmetrically
ü Neck mass is usually notice soon after birth but may
not found after several weeks(gradually disappears)
ü Limited ROM of the neck
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Congenital(CMT)...
q CMT is often classified into three clinical
groups:
1. Sternocleido mastoid tumor (SMT), when a definitive mass
or tumor is palpable within the SCM muscle,
2. muscular Torticollis (MT), when contracture of the SCM
muscle is present but no palpable mass is present, and
3. positional Torticollis (POST), when both contracture of the
SCM muscle and a palpable mass are absent. Cheng
etal.2001, Van Vlimmerenetal.2006
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PT assessment and treatment
• History
* birth/delivery
* presence of skull asymmetry at birth
* presence of facial asymmetry at birth
• Current Health
*feeding *positioning
• Torticollis/Plagiocephaly History
*onset *changes in symptoms
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• Visual Function *midline visual focus
*ocular alignment
• Hip Screen *asymmetry
*hip(DDH)
*leg length discrepancy
• Neurological Screen *Predominant Asymmetrical Tonic
Neck Reflex (ATNR)
*Abnormal muscle tone
• Pain Assessment
• Skin Screen
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• Clinical Observations *Resting posture
*Motor development
• Range of Motion *Cervical
*upper and lower
extremity
• Palpation
*SCM
*Trapezius
*Scalenes
• PROM of the neck is performed in all
directions, AROM is tested by using attracting
toy
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Management
Ø When CMT is inadequately managed infants may
develop progressive limitation of cervical movement
along with craniofacial asymmetry, compensatory
scoliosis, delayed achievement of early motor
milestones and functional asymmetry similar to
hemiplegia
Ø physiotherapists are the most frequently using first
line conservative management for infants with CMT
• The majority (>90%) of infants and children
diagnosed with CMT achieve good to excellent
outcome with conservative treatment
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PT TX
Goals:
• Prevent development of contracture
• Stretch tight muscles
• Strength the antagonist muscles including
contralateral sternomastoid and neck muscles
• Prevent delay of normal neck activities
• Encourage normal posture
• Facilitate normal righting reactions
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PT TX
Ø Ice, ultrasound, massage and stretching are all
effective in reducing spasm.
Ø Instructions in posture and resting positions are
helpful in limiting degree of distress and spasm
Ø Passive stretching
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Con….
• Baby position: The baby is placed on a padded table in supine
with affected side away from therapist
• Grasp : one hand fixing the shoulder of the baby allowing the
head to side flexion to perform stretch
• Head gently but firmly stretched into side flexion to the non
affected side ,rotations to affected side for a count of 8(ten
seconds)
Ø Relax slightly for a few seconds
Ø Repeat
Ø Several times ,4 or 5 times daily
Ø Comfortable with breast feeding
• The stretch should be gradually and therapist grasp should be
gentle not harmful
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Active exercises:
Ø After stretching, therapist should encourage the
child to active correction and full ROM of head
and neck muscles
Ø As the head control develop, Facilitate head
righting to improve head side bending and
rotation, facilitate righting by using ball with
baby supine or prone position
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Splinting
Ø Cap and jacket Splint to keep the baby head in full
stretched position , not preferable since long time use
hinders the active correction of neck muscles
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Surgical treatment:
ü Tenotomy of sternomastoid above the
attachment of the clavicle if the contracture
persists treatment
Post operative PT:
ü Immediately after surgery: the child lies without
pillow, sand bag prevent head from returning to
the asymmetrical position, Cap jacket is advised
until the child can maintain head in midline
position;l
Ø Stretching and active correction are started after
36 hours from surgery
Ø Facilitate normal righting reactions
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Home advice
ü Explain to parents not only the purpose of the
treatment but also the practical ways of making
treatment at home
ü The mother should be taught how to stretch the
sternomastoid muscle and how to facilitate the
movements
ü The baby should be encouraged to turn head
away from abnormal posture.
ü The baby should be encouraged to sleep on
one side rather than supine
ü While awake ,place baby so that he/she has turn
his head in the desired direction
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