» Treating Clubfoot: The Ponseti Way or the French Way?
Treating Clubfoot: The Ponseti Way or the French Way?

Physical Therapy in Grapevine for Pediatric

Children born with a foot deformity called clubfoot can be treated without surgery when they are just a few months old. In fact, success is much greater when treatment is applied before the child is three months old. The most successful nonoperative method of treatment has been the Ponseti Method. Now a new method called the French Functional (Physical Therapy) Method is available. In this study, results of the two methods are compared in a group of babies who had similar severity of the deformity.

The clubfoot is unmistakable. The foot is turned under and towards the other foot. The medical terminology for this position is equinus and varus. Equinus means that the toes are pointed down and the ankle flexed forward (like the position of the foot when a ballet dancer is on her toes). Varus means tilted inward. The ankle is in a varus position when you try to put the soles of your feet together. Clubfoot primarily affects three bones: the calcaneus, talus, and navicular. Other bones can be involved as the deformity can affect the growth of the entire foot to some degree.

Uncorrected, this twisted position of the foot can cause other problems. The ligaments between the bones are contracted, or shortened. The joints between the tarsal bones do not move as they should. The bones themselves are deformed. This results in a very tight, stiff foot that cannot be placed flat on the ground for walking. To walk, the child would have to walk on the outside edge of the foot rather than on the sole of the foot. The two treatment methods described in this article can change all of that.

This study was carried out at the Texas Scottish Rite Hospital for Children in Dallas, Texas. A team of two physicians, a nurse, and a Physical Therapist carried out the procedures. The specific steps for each treatment were explained to the parents who then decided which approach to take.

The Ponseti method involves placing the foot in as neutral a position as possible and holding it there with a cast. The bones are manipulated into place one at a time until the full correction has taken place. The cast is removed each week, the foot and ankle position corrected, and a new cast is put on to hold the new position. It takes five to eight of these sessions to get the desired results. The authors provide photos and a complete description of each manipulation performed on the foot. The correction occurs with gradual stretching of the soft tissues while holding the bones in their proper place (or as close to it as possible with each session).

The French Functional Method stretches the soft tissue and bony structures along the inside (medial) edge of the foot. Then the muscles along the outside (lateral) side of the foot are stimulated to contract to help actively correct the foot placement. Exercises, elastic taping, and splinting are part of a daily home program that requires parents to participate. At first, the family must bring the child into the Physical Therapist's clinic daily for hands-on therapy. Gradually, the parents take over the program and visits to the therapist decrease to a more manageable once a week trip.

Again, the authors provided color photos of a child with severe clubfoot who had the French Functional Method. Correct foot positions, stimulation of the muscles, and taping methods are clearly depicted. The therapist also makes each child a special ankle-foot orthosis (AFO) that fits over the tape and holds the foot in the best alignment obtained with the treatment. This brace is worn 22 hours a day until correction is achieved. Once the foot is in normal alignment, then the AFO can be limited to naps and nighttime use until the child is two years old.

There are advantages and disadvantages for each method. The Ponseti method relies less on parents and more on therapists making the corrections and casting the affected feet from week to week. The French Functional Method requires daily dedication on the part of the parents. Either method can be successful. The choice depends on what works best for the family. If they choose one method and it doesn't seem to be working out, they can always crossover or switch to the other method.

The results of this study showed that the correction rate was about 94 to 95 per cent for all the babies no matter how they were treated. Slightly more than one-third of the children in the Ponseti group (37 per cent) had a relapse (the foot drifted back into a clubfoot position) after treatment. Slightly less than one-third of the French Functional group (29 per cent) had a relapse. Relapse required surgical intervention for both groups. Long-term results were slightly better for the Ponseti group (72 per cent considered good for Ponseti compared with 67 per cent good for the French method).

More families selected the Ponseti method over the French Functional approach. This is understandable since the Ponseti method relies on the medical staff rather than the parents for the positive results. With either method, there are times when surgery is needed to release the Achilles tendon. This procedure is called an Achilles tenotomy. The procedure can be done under a local anesthetic on an outpatient basis. Once the tendon is released, the ankle moves more freely into a dorsiflexed position (toes up toward face rather than toes pointed down like a ballerina).

Timing is crucial for the treatment of clubfoot. Treatment too aggressive too early can result in a foot deformity called rocker-bottom. Alignment of the midfoot is such that the bones drop down and instead of forming a nice upward foot arch, the bottom of the foot becomes curved like the bottom of a rocking chair. Failure to stick to the scheduled brace or splint schedule can lead to failure to maintain the foot and ankle correction.

No matter which treatment approach the family prefers, a close working relationship with the medical team is essential. The therapist is the key figure in the ongoing serial treatments. He or she must educate the parents about the importance of treatment and cheer them on when they stick with the program.

It's the therapist's responsibility to assess the results and recommend a change in the treatment plan when the foot position is not as expected. The physician will see the child every two or three months at first and less often after treatment has ended. Long-term follow-up is advised. Further treatment may not be needed but if it is needed, the child can can get the help needed sooner than later when being watched closely.

Reference: Suzanne Steinman, MD, et al. A Comparison of Two Nonoperative Methods of Idiopathic Clubfoot Correction: The Ponseti Method and the French Functional (Physical Therapy) Method. In The Journal of Bone and Joint Surgery. October 2009. Vol. 91. Suppl. 2. (Part 2):299-312, 2009.