Journal of Orthopaedic Surgery 2005:13(3):253-258

Radiographic assessment of congenital talipes

equinovarus: strapping versus forced
dorsiflexion

EHK Yeung, YH Li, ON Ng, W Chow

The Duchess of Kent Children’s Hospital, Sandy Bay, Hong Kong

groups. The mean tibiocalcaneal angle with strapping

ABSTRACT
Purpose. To compare 2 radiographic assessment
methods for congenital talipes equinovarus: strapping
the ankle with tapes versus dorsiflexion with a wooden
block.
Methods. Anteroposterior and lateral radiographs
were taken with the ankle strapped by tapes or
dorsiflexed by a wooden block. Talocalcaneal and
tibiocalcaneal angles were measured and analysed.
Results. 20 radiographic assessments were performed
on 14 patients. From the anteroposterior view, the
mean talocalcaneal angle with strapping was 19.4
degrees (range, 0–34.0; standard deviation [SD], 11.2
degrees). From the lateral view, the mean talocalcaneal
angle with strapping was 22.0 degrees (range, 8.0–38.8;
SD, 8.9 degrees) and with forced dorsiflexion was 21.0
degrees (range, 0–52.7; SD, 11.3 degrees), with a mean
absolute difference of 9.4 degrees between the 2
was 77.9 degrees (range, 43.2–120.0; SD, 18.8 degrees)
and with forced dorsiflexion was 78.2 degrees (range,
29.5–134.0; SD, 24.7 degrees), with a mean absolute
difference of 15.7 degrees between the 2 groups. The
difference between the tibiocalcaneal measurements
in the 2 groups was statistically significant (p=0.026).
Conclusion. Similar results were obtained for
talocalcaneal and tibiocalcaneal angles measured
with strapping and forced dorsiflexion. However, the
strapping method provides better stabilisation while
radiographs are taken.
Key words: clubfoot; equinus deformity; foot deformities;
radiography
INTRODUCTION
Congenital talipes equinovarus (TEV), or congenital

Address correspondence and reprint requests to: Mr Eric HK Yeung, Physiotherapist, The Duchess of Kent Children’s Hospital,
12 Sandy Bay Road, Pokfulam, Hong Kong. E-mail: ericyhk@yahoo.com
254 EHK Yeung et al. Journal of Orthopaedic Surgery

clubfoot, is a common clinical problem. Assessment

typically includes clinical and radiological methods;
unfortunately, there is still no universally accepted
grading system. The Dimeglio 1 and the Pirani 2
classification systems are the more commonly used
clinical grading systems. However, Pirani’s system is
not sensitive: assessors tend to give a diagnosis of
moderate abnormality as there are only 3 levels of
scoring (0 for no, 0.5 for moderate, 1 for severe), and
clinicians tend to resist scoring extremes. For radiolo-
gical assessment, anteroposterior and forced dorsi-
flexion are the most widely used views; however, there
is no standard radiographic method. In the 1970s,
Simons 3,4 took radiographs of TEV patients by
manually holding the child’s foot in the maximum Figure 1 Foot plates are made of plastic and are radiolucent.
correction position, but this position may vary.
We describe a strapping method for immobilising
congenital TEV patients and compare radiographic
measurements of the ankle and foot using strapping
and forced dorsiflexion. (a) (b)

(3)
MATERIALS AND METHODS

We retrospectively reviewed 14 patients (age, <3

months) diagnosed with congenital TEV who
underwent treatment programme of the Duchess of (2)
Kent Children’s Hospital in Hong Kong between
November 1995 and March 2003. All had severe or very (1)
severe structural clubfoot deformities according to the
Dimeglio1 classification. Patients with postural-type
Figure 2 (a) Lateral and (b) anteroposterior views: 3 adhesive
TEV or TEV associated with other congenital
tapes are applied: the first is placed at the site of the Achilles
malformations such as arthrogryposis multiplex tendon insertion to grip the calcaneus (1). The second is placed
congenita and spinal dysraphism were excluded. inferior to the hindfoot to add control of the ankle (2). The last
Patients received manipulation and strapping by is placed inferior to the forefoot (3).
physiotherapist 5 days a week until they under-
went surgery at the age of around 6 months. The
manipulation method was based on the description
by McKay,5–7 and the strapping method was developed
in our centre. After each manipulation session, the (a) (b)
ankle/foot was strapped with a plastic, radiolucent
foot plate (Fig. 1) and tapes. Skin Prep wipe (Smith &
Nephew, Largo [FL], US) was applied to the foot and
leg to reduce allergic reactions and protect the skin.
The foot plate was secured to the sole using non-elastic
tapes after the wipe dried. Three adhesive tapes were
applied: the first was put at the site of the Achilles
tendon insertion to grip the calcaneus, the second was
placed inferior to the hindfoot to control the ankle, and
the last was placed inferior to the forefoot (Fig. 2).
Straps were then put around the foot and knee, and
cotton wool was placed to the thigh to reduce pressure Figure 3 (a) Anteroposterior and (b) lateral views: transverse
and irritability from the tapes. The knee was then tapes were applied anterior to the ankle joint and shin to
flexed maximally. The ankle (with the foot plate) was achieve further anchorage.
Vol. 13 No. 3, December 2005 Radiographic assessment of congenital talipes equinovarus 255

(a) (b)
Figure 4 (a) Lateral radiograph is taken with the strapping in situ. (b) Anteroposterior radiograph is taken with the transverse
and long tapes loosened or removed to prevent the knee and tibia from blocking the X-ray.

(a) (b)
Figure 5 (a) Lateral radiograph of forced dorsiflexion is taken with an assistant holding a wooden block against the sole of the
foot. (b) Anteroposterior radiograph is taken in a standard fashion.

stretched to the best correctable position (Fig. 3). Care
was taken to avoid applying pressure at the forefoot
to prevent the mid-foot from breaking.
Three long tapes were then applied from the
plantar surface, along the lateral side surrounding the
thigh, and back to the plantar surface. The first tape
began at the heel and was used to control the subtalar
joint eversion. The second began slightly towards the
toes and served to control eversion and dorsiflexion.
The third began around mid-foot and served to
provide a maximum amount of dorsiflexion. Finally,
transverse tapes were applied anterior to the ankle
joint and shin to achieve further anchorage (Fig. 3). If
the child was too irritable, the tapes could be loosened
manually by adjusting the transverse and long tapes.
The tapes and foot plate were kept in place overnight
and removed the next morning.
Radiographs were usually taken at 3 months of
age (range, 1–7 months). Lateral radiographs were
taken with the strapping in situ (Fig. 4a), whereas
anteroposterior radiographs were taken with the
transverse and long tapes loosened or removed so
256 EHK Yeung et al.
Table 1
Talocalcaneal angle
Strapping Forced dorsiflexion
(mean, range) (mean, range)
Anteroposterior 19.4Ο (0Ο–34.0Ο).2 NA*
Lateral 22.0Ο (8.0Ο–38.8Ο) 21.0Ο (0Ο–52.7Ο)
* NA not available
that the knee and tibia did not block the X-ray (Fig.
4b). Lateral radiographs of forced dorsiflexion were
taken with an assistant holding a wooden block against
the sole of the foot (Fig. 5a), whereas anteroposterior
radiographs were taken in a standard fashion (Fig. 5b).
Radiographs were measured by a senior ortho-
paedic surgeon. The talocalcaneal angle was the
angle formed by the long axes of talus and calcaneus
in the anteroposterior and lateral radiographs. The
tibiocalcaneal angle was the angle between the long
axes of the tibia and calcaneus in the lateral view.
RESULTS
20 radiographic assessments were performed on 14
patients: 4 had bilateral congenital TEV, 2 had 2 sets
taken at different ages. All patients eventually received
surgical release. In anteroposterior radiographs, only
the talocalcaneal angle using strapping produced
usable measurements (mean, 19.4Ο; range, 0Ο–34.0Ο;
standard deviation [SD], 11.2Ο). The talocalcaneal angle
using forced dorsiflexion and the tibiocalcaneal
angle using either strapping or forced dorsiflexion
were not available because it was very difficult to hold
the block and feet while the radiograph was taken.
Even when the children could be held stationary in
the proper position, the holder’s hands would block
the X-ray. In lateral radiographs, the mean
talocalcaneal angle using strapping was 22.0Ο (range,
8Ο–38.8Ο; SD, 8.9Ο), whereas using forced dorsiflexion
the mean was 21.0Ο (range, 0Ο–52.7Ο; SD, 11.3Ο), with a
mean absolute difference of 9.4Ο between the 2 groups.
The mean tibiocalcaneal angle using strapping was
77.9Ο (range, 43.2Ο–120.0Ο; SD, 18.8Ο), whereas using
forced dorsiflexion the mean was 78.2Ο (range, 29.5Ο–
134.0Ο; SD, 24.7Ο), with a mean absolute difference of
15.7Ο between the 2 groups (Table 1).
Data were analysed using paired t-test of the
Statistical Package for the Social Sciences (Windows
version 10.0; SPSS Inc, Chicago [IL], US). Three paired
data sets were used to compare strapping versus forced
dorsiflexion: talocalcaneal angle in anteroposterior
view, talocalcaneal angle in lateral view, and
Journal of Orthopaedic Surgery
Tibiocalcaneal angle
Strapping Forced dorsiflexion
(mean, range) (mean, range)
NA NA
77.9Ο (43.2Ο–120.0Ο) 78.2Ο (29.5Ο–134.0Ο)
tibiocalcaneal angle in lateral view. There was a
significant difference between strapping and forced
dorsiflexion in tibiocalcaneal angle from the lateral
view (p=0.026) [Table 2].
DISCUSSION
Radiographic assessment for congenital TEV is a
common practice. 3,4,8 In the Nuffield Orthopaedic
Centre in Oxford, UK, congenital TEV patients were
assessed using anteroposterior radiographs with the
foot held in 20Ο equinus after receiving one month of
strapping and manipulation.9
Napiontek10 also used radiographs—both lateral
and anteroposterior views—to assess congenial TEV.
He found a mean tibiocalcaneal angle of 77.9Ο (range,
55Ο–94Ο) among 49 feet. The mean tibiocalcaneal angle
obtained in the present study was 77.9Ο for strapping
and 78.2Ο for forced dorsiflexion. Other clinicians have
used more sophisticated imaging techniques to assess
the deformity of congenital TEV. Cahuzac et al.11
investigated hindfoot deformity using 3-dimensional
magnetic resonance imaging (MRI) and found no
statistically significant medial deviation of the talus.
Although 3-dimensional MRI can give more informa-
tion about the orientations of the subtalar joint, it is
not cost-effective or clinically useful. MRI can provide
a detailed configuration of the clubfoot deformity and
progression of conservative treatment; however,
surgical decision-making does not depend on
diagnostic images but rather on clinical appearance.
In the present study, no significant difference was
found in the talocalcaneal angle between strapping
and forced dorsiflexion on the lateral view. However,
the difference shown on the anteroposterior and
lateral views of tibiocalcaneal angle was statistically
significant (p=0.026) and showed a better correction
of equinus using strapping. The strapping method
provides a standard means of preparing patients for
radiographs and can reliably position the ankle and
foot in maximum dorsiflexion to obtain good
anteroposterior and lateral radiographs. The foot plate
is important in the strapping method. It provides a
Vol. 13 No. 3, December 2005 Radiographic assessment of congenital talipes equinovarus 257

Table 2

Assessment Talocalcaneal angle in Talocalcaneal angle in Tibiocalcaneal angle in

No. anteroposterior view lateral view lateral view
Strapping Forced Strapping Forced Strapping Forced
dorsiflexion* dorsiflexion dorsiflexion
11 10Ο1. NA† 24.0Ο 32.7Ο 178.2Ο 187.5Ο
12 18.0Ο 18.0Ο 13.1Ο 16.2Ο 173.9Ο 169.0Ο
13 18.4Ο NA 21.0Ο 27.0Ο 120.0Ο 127.0Ο
14 24.0Ο NA 18.0Ο 14.0Ο 180.0Ο 184.0Ο
15 27.0Ο NA 14.0Ο 14.0Ο 102.0Ο 190.0Ο
16 32.5Ο 36.0Ο 27.6Ο 23.0Ο 163.6Ο 153.0Ο
17 34.0Ο NA 37.8Ο 17.0Ο 155.4Ο 173.5Ο
18 29.0Ο 12.5Ο 22.3Ο 19.1Ο 169.7Ο 173.7Ο
19 10Ο1. NA 19.8Ο 21.3Ο 180.2Ο 190.0Ο
10 10Ο1. NA 18.0Ο 23.0Ο 187.2Ο 183.0Ο
11 16.0Ο NA 30.0Ο 18.0Ο 193.0Ο 115.0Ο
12 18.0Ο NA 20.0Ο 10Ο1. 196.0Ο 134.0Ο
13 21.0Ο 0Ο 18.0Ο 22.0Ο 180.0Ο 170.0Ο
14 24.0Ο NA 12.0Ο 19.0Ο 172.0Ο 182.0Ο
15 12.0Ο NA 18.0Ο 16.0Ο 188.0Ο 164.0Ο
16 40.0Ο NA 34.0Ο 26.1Ο 143.2Ο 191.3Ο
17 26.9Ο NA 38.8Ο 30.3Ο 146.7Ο 148.7Ο
18 21.6Ο NA 18.9Ο 52.7Ο 188.7Ο 129.5Ο
19 11.1Ο NA 28.5Ο 25.5Ο 180.2Ο 177.2Ο
20 13.0Ο NA 25.1Ο 18.6Ο 101.3Ο 187.9Ο
Mean 19.4Ο NA 22.0Ο 21.0Ο 177.9Ο 178.2Ο
Standard deviation 11.2Ο NA 18.9Ο 11.3Ο 118.8Ο 124.7Ο
Mean absolute difference NA 9.4Ο 15.7Ο
P value of paired t-test 0.388 0.794 0.026

* Only 4 measurements could be taken because the deformities were severe, and the ankles were plantar-flexed even with forced dorsiflexion by
the block
†
NA not available

good grip surface for the tapes to hold the hind foot,
protects the child’s skin from tape irritation, and has a
vertical extension at the medial side to correct the
metatarsal adduction commonly present in congenital
TEV.
CONCLUSION
significantly different from that provided by forced
dorsiflexion. This is probably due to the improved
equinus correction provided by strapping.
Both talocalcaneal and tibiocalcaneal angles
measured with strapping and forced dorsiflexion
give similar results. However, the strapping method
provides a better ankle dorsiflexion angle, and thus is
a better way to objectively assess TEV.

The strapping method is a valuable diagnostic

technique for congenital TEV. It provides rigid ACKNOWLEDGEMENT
positioning during radiography and facilitates
radiographic assessment. The tibiocalcaneal angle The authors wish to thank Mr Aldous Cheng for his
measured from lateral radiographs with strapping is assistance with the statistics.

REFERENCES

1. Dimeglio A, Bensahel H, Souchet P, Mazeau P, Bonnet F. Classification of clubfoot. J Pediatr Orthop B 1995;4:129–36.
2. Pirani S, Outerbridge H, Moran M, Sawatsky B. A method of evaluating the virgin clubfoot with substantial inter-observer
reliability. POSNA, Miami, Florida, 1995.
3. Simons GW. Analytical radiography of club feet. J Bone Joint Surg Br 1977;59:485–9.
258 EHK Yeung et al. Journal of Orthopaedic Surgery

4. Simons GW. Complete subtalar release in club feet. Part II—comparison with less extensive procedures. J Bone Joint Surg
Am 1985;67:1056–65.
5. McKay DW. New concept of and approach to clubfoot treatment: section II—correction of the clubfoot. J Pediatr Orthop
1983;3:10–21.
6. McKay DW. New concept of and approach to clubfoot treatment: section III—evaluation and results. J Pediatr Orthop
1983;3:141–8.
7. McKay DW. New concept of and approach to clubfoot treatment: section I—principles and morbid anatomy. J Pediatr
Orthop 1982;2:347–56.
8. Beatson TR, Pearson JR. A method of assessing correction in club feet. J Bone Joint Surg Br 1966:48:40–50.
9. Tibrewal SB, Benson MK, Howard C, Fuller DJ. The Oxford club-foot programme. J Bone Joint Surg Br 1992;74:528–33.
10. Napiontek M. Clinical and radiographic appearance of congenital talipes equinovarus after successful nonoperative treatment.
J Pediatr Orthop 1996;16:67–72.
11. Cahuzac JP, Baunin C, Luu S, Estivalezes E, Sales de Gauzy J, Hobatho MC. Assessment of hindfoot deformity by three-
dimensional MRI in infant club foot. J Bone Joint Surg Br 1999;81:97–101.