Balance in children with Ponseti correction for congenital talipes equinovarus: preliminary results
Jon Gray, SPT, Jerrica Huber, SPT, and Charlotte Walter, SPT
15 Comments on “Balance in children with Ponseti correction for congenital talipes equinovarus: preliminary results”
There is a significant difference in the dorsiflexion ROM between the CTEV-G and CG with the CTEV-G being limited. Could this limitation be due to the Ponseti serial casting method which limits ROM for a period of time potentially leading to joint stiffness and tight ligaments?
Brittany,
My initial thought on this topic is that the limited DF PROM is a result of the birth defect itself and not the treatment. The extreme amounts of equinus limit DF due to shortened triceps surae and Achilles tendon (https://www.foothealthfacts.org/conditions/equinus). While the Ponseti approach attempts to correct this with a series of casting and an Achilles release and create more proper alignment, it does not completely restore what we would consider to be typical ankle alignment. I believe the persistent lack of DF PROM is due to the initial condition and continued tightness in the Achilles limiting the ability to obtain ankle DF. It is important to recognize we only addressed ROM and not AROM. Often times AROM is greater than PROM (https://www.ncbi.nlm.nih.gov/pubmed/21828385) and (in my opinion) is a greater measure functional status. We did not address AROM, however it would be valuable to investigate this measure in these populations.
Thank you for your question my response simply represents my opinion based upon my understanding and I would be pleased to continue this conversation.
Brittany, thanks for your question! It can be presumed that in children with CTEV, foot ROM is significantly limited at birth causing the defect. We don’t have an exact etiology, but there are many theories for this limited ROM. After working with children who have had the Ponseti correction done, I believe they actually gain some motion compared to their untreated CTEV counterparts. You’re right the Ponseti casting does limit motion for a period of time, but the intention is to stretch the tight ligaments present from CTEV (low-load prolonged stretching). I do believe that individuals with this condition are probably more likely to have joint stiffness and arthritis later in life, but that is another research study!
Jon Gray
November 3, 2017
Brittany,
My initial thought on this topic is that the limited DF PROM is a result of the birth defect itself and not the treatment. The extreme amounts of equinus limit DF due to shortened triceps surae and Achilles tendon (https://www.foothealthfacts.org/conditions/equinus). While the Ponseti approach attempts to correct this with a series of casting and an Achilles release and create more proper alignment, it does not completely restore what we would consider to be typical ankle alignment. I believe the persistent lack of DF PROM is due to the initial condition and continued tightness in the Achilles limiting the ability to obtain ankle DF. It is important to recognize we only addressed ROM and not AROM. Often times AROM is greater than PROM (https://www.ncbi.nlm.nih.gov/pubmed/21828385) and (in my opinion) is a greater measure functional status. We did not address AROM, however it would be valuable to investigate this measure in these populations.
Thank you for your question my response simply represents my opinion based upon my understanding and I would be pleased to continue this conversation.
Jon Gray, SPT
Very interesting stuff. I’m wondering: so my group’s research found that goniometric measurements of ankle PF AROM don’t correlate all that well with a more functional test like a unilateral heel-rise test. Since you were looking at how children function when they received CTEV compare to those who didn’t, do you think your results would’ve changed if you would’ve used an ankle ROM test that was more functional than goniometry? Also, how do you think you’re results would’ve changed if you measured AROM rather than PROM?
While not directly measuring the ankle ROM, both the pediatric reach test and the star excursion balance test are more functional measures that involve ankle mobility (both have found performance to be related to ROM measures). We recognize that these tests also include additional balance strategies, such as the hip strategy, to control balance, and would love the opportunity to continue research to investigate how the CTEV-G may use compensatory measures to address what we are presuming to be limited ROM as gathered by our measurements. I think continued research could look at the heel rise test and knee to wall test to measure AROM or ROM while dependent. Finally, to answer your question, yes I do believe we would have different results if we were measuring AROM. In my experience and according to research (https://www.ncbi.nlm.nih.gov/pubmed/21828385) AROM DF is greater than PROM. A study to investigate this difference in this population between AROM and PROM when compared to peers would also be exciting to conduct, thank you for the continued research ideas!
On behalf of the children who’s quality of life has improved from this study i thank you for your efforts to find the truth! based off of your first hand impression with the children do you feel the CTEV-G children favored any balance system over the other(vestibule, visual, proprioception)?
Thanks for the question Cal. My impression would be that their proprioception might be slightly altered due to changes (congenital and then surgical) within the joint, but that over time their body would learn to adjust. However, our methods did not include measures that would capture that data so I cannot answer with any degree of certainty. Our purpose was more to determine if there was a difference between the two groups as opposed to how the CTEV-G achieved the comparable outcomes. Great idea for future research that we didn’t think of!
First of all, I found this study to be extremely interesting as it explores a specific testing model when working with CTEV-G children so thanks for the work invested into this research. One question that I was simply curious on your sampling is where your sample was derived from specifically? (South Dakota, Midwest, etc.) Do you have any current hypothesis of similar results or differing results being obtained if this study were to include a population over a larger geographical region spanning across the country or around the world and why?
Hi Justine,
The CTEV-G children we tested were recruited through one physician who is based out of Sioux Falls. To my knowledge, all the children are from South Dakota or border areas of Minnesota and Iowa. Since the Ponseti method is a standardized casting protocol, our current hypothesis (and hope) is that any child who received the treatment would have a similar outcome. Part of our purpose was to add to the body of evidence that supports its widespread use. That is also why limited geographical size and single physician recruitment are listed in our limitations.
When looking at your research i saw that your age range is 6.5 to 12 years old and I was wondering do you think if the age range was from 12-15 years olds would there be a difference in balance between the groups? If kids get this casting at an older age will it still help their balance or is it better to do the casting when they are younger?
Thank you for your question Shelby,
It is my understanding that as children develop they have predominantly created their motor patterns and balance strategies by the age of ten. According to Shumway-Cookand Woollacott “a transition from immature to mature balance responses (occurs) between the ages of 4 and 10 years.”1 After that time an increase in balance performance is likely to become linear based upon the child’s individual experiences. We research this age range to investigate the development of mature balance, and track if they are developing as expected compared to peers. I would suspect that comparing results in older age ranges would be very similar to our test population, as older individuals are less likely to continue to develop new skills and are somewhat “working with” the skills that they developed between 4 and 10.
As far as the timing of casting, most children are receive their 1st series of casting on the day they are born. I have seen children who receive additional casting at later ages if a doctor or PT feels that they could benefit from additional casting or have developed additional misalignment. Due to the bio mechanical nature of the body, I would assume that as a child ages, their structure becomes more permanent as bone, tendon, and ligament become stronger. For this reason casting later in life is likely to yield less results or require greater duration to modify bony alignments.
I hope my insight has been valuable to your questions. Please let me know if this answers your question or if you would like additional information.
Thank you
Jon Gray SPT
1. Shumway-Cook A, Woollacott MH. The growth of stability: postural
control from a developmental perspective. J Motor Behav.
1985;17(2):131-147.
A pediatric test that would incorporate aspects of both balance and dorsiflexion would be a great test to use for a study like ours. We did our best to incorporate well-researched and reliable tests that would emphasize any deficits in these areas. While there are several other pediatric balance tests, such as Bruininks–Oseretsky Test of Motor Proficiency (BOTMP) and the Pediatric Balance Scale, are available to test pediatric balance we chose the Star Excursion Balance Test due to its well supported use to identify dynamic balance deficits in individuals with LE conditions (1). While the Star Excursion test doesn’t directly measure DF, it does look at functional/dynamic DF during reach with the LE. As far as strength of the anterior tib/gastroc to concentrically and eccentrically control DF and balance, we could look into EMGs of this muscle during functional activities, but unfortunately our study did not have the financial means to incorporate that.
1) Gribble PA, Hertel J, Plisky P. Using the Star Excursion Balance Test to Assess Dynamic Postural-Control Deficits and Outcomes in Lower Extremity Injury: A Literature and Systematic Review. Journal of Athletic Training. 2012;47(3):339-357.
Great job guys, I think what you have found can help future kids and parents in their decision making! I was just wondering what exactly does the Ponseti Correction method entail? Like how many casts are usually applied and for how long is each one on?
USD PT Research 
There is a significant difference in the dorsiflexion ROM between the CTEV-G and CG with the CTEV-G being limited. Could this limitation be due to the Ponseti serial casting method which limits ROM for a period of time potentially leading to joint stiffness and tight ligaments?
LikeLike
Brittany,
My initial thought on this topic is that the limited DF PROM is a result of the birth defect itself and not the treatment. The extreme amounts of equinus limit DF due to shortened triceps surae and Achilles tendon (https://www.foothealthfacts.org/conditions/equinus). While the Ponseti approach attempts to correct this with a series of casting and an Achilles release and create more proper alignment, it does not completely restore what we would consider to be typical ankle alignment. I believe the persistent lack of DF PROM is due to the initial condition and continued tightness in the Achilles limiting the ability to obtain ankle DF. It is important to recognize we only addressed ROM and not AROM. Often times AROM is greater than PROM (https://www.ncbi.nlm.nih.gov/pubmed/21828385) and (in my opinion) is a greater measure functional status. We did not address AROM, however it would be valuable to investigate this measure in these populations.
Thank you for your question my response simply represents my opinion based upon my understanding and I would be pleased to continue this conversation.
Jon Gray, SPT
LikeLike
Brittany, thanks for your question! It can be presumed that in children with CTEV, foot ROM is significantly limited at birth causing the defect. We don’t have an exact etiology, but there are many theories for this limited ROM. After working with children who have had the Ponseti correction done, I believe they actually gain some motion compared to their untreated CTEV counterparts. You’re right the Ponseti casting does limit motion for a period of time, but the intention is to stretch the tight ligaments present from CTEV (low-load prolonged stretching). I do believe that individuals with this condition are probably more likely to have joint stiffness and arthritis later in life, but that is another research study!
LikeLike
Jon Gray
November 3, 2017
Brittany,
My initial thought on this topic is that the limited DF PROM is a result of the birth defect itself and not the treatment. The extreme amounts of equinus limit DF due to shortened triceps surae and Achilles tendon (https://www.foothealthfacts.org/conditions/equinus). While the Ponseti approach attempts to correct this with a series of casting and an Achilles release and create more proper alignment, it does not completely restore what we would consider to be typical ankle alignment. I believe the persistent lack of DF PROM is due to the initial condition and continued tightness in the Achilles limiting the ability to obtain ankle DF. It is important to recognize we only addressed ROM and not AROM. Often times AROM is greater than PROM (https://www.ncbi.nlm.nih.gov/pubmed/21828385) and (in my opinion) is a greater measure functional status. We did not address AROM, however it would be valuable to investigate this measure in these populations.
Thank you for your question my response simply represents my opinion based upon my understanding and I would be pleased to continue this conversation.
Jon Gray, SPT
LikeLike
Very interesting stuff. I’m wondering: so my group’s research found that goniometric measurements of ankle PF AROM don’t correlate all that well with a more functional test like a unilateral heel-rise test. Since you were looking at how children function when they received CTEV compare to those who didn’t, do you think your results would’ve changed if you would’ve used an ankle ROM test that was more functional than goniometry? Also, how do you think you’re results would’ve changed if you measured AROM rather than PROM?
LikeLike
Lucas,
While not directly measuring the ankle ROM, both the pediatric reach test and the star excursion balance test are more functional measures that involve ankle mobility (both have found performance to be related to ROM measures). We recognize that these tests also include additional balance strategies, such as the hip strategy, to control balance, and would love the opportunity to continue research to investigate how the CTEV-G may use compensatory measures to address what we are presuming to be limited ROM as gathered by our measurements. I think continued research could look at the heel rise test and knee to wall test to measure AROM or ROM while dependent. Finally, to answer your question, yes I do believe we would have different results if we were measuring AROM. In my experience and according to research (https://www.ncbi.nlm.nih.gov/pubmed/21828385) AROM DF is greater than PROM. A study to investigate this difference in this population between AROM and PROM when compared to peers would also be exciting to conduct, thank you for the continued research ideas!
Jon Gray, SPT
LikeLike
On behalf of the children who’s quality of life has improved from this study i thank you for your efforts to find the truth! based off of your first hand impression with the children do you feel the CTEV-G children favored any balance system over the other(vestibule, visual, proprioception)?
LikeLike
Thanks for the question Cal. My impression would be that their proprioception might be slightly altered due to changes (congenital and then surgical) within the joint, but that over time their body would learn to adjust. However, our methods did not include measures that would capture that data so I cannot answer with any degree of certainty. Our purpose was more to determine if there was a difference between the two groups as opposed to how the CTEV-G achieved the comparable outcomes. Great idea for future research that we didn’t think of!
LikeLike
First of all, I found this study to be extremely interesting as it explores a specific testing model when working with CTEV-G children so thanks for the work invested into this research. One question that I was simply curious on your sampling is where your sample was derived from specifically? (South Dakota, Midwest, etc.) Do you have any current hypothesis of similar results or differing results being obtained if this study were to include a population over a larger geographical region spanning across the country or around the world and why?
LikeLike
Hi Justine,
The CTEV-G children we tested were recruited through one physician who is based out of Sioux Falls. To my knowledge, all the children are from South Dakota or border areas of Minnesota and Iowa. Since the Ponseti method is a standardized casting protocol, our current hypothesis (and hope) is that any child who received the treatment would have a similar outcome. Part of our purpose was to add to the body of evidence that supports its widespread use. That is also why limited geographical size and single physician recruitment are listed in our limitations.
LikeLike
When looking at your research i saw that your age range is 6.5 to 12 years old and I was wondering do you think if the age range was from 12-15 years olds would there be a difference in balance between the groups? If kids get this casting at an older age will it still help their balance or is it better to do the casting when they are younger?
LikeLike
Thank you for your question Shelby,
It is my understanding that as children develop they have predominantly created their motor patterns and balance strategies by the age of ten. According to Shumway-Cookand Woollacott “a transition from immature to mature balance responses (occurs) between the ages of 4 and 10 years.”1 After that time an increase in balance performance is likely to become linear based upon the child’s individual experiences. We research this age range to investigate the development of mature balance, and track if they are developing as expected compared to peers. I would suspect that comparing results in older age ranges would be very similar to our test population, as older individuals are less likely to continue to develop new skills and are somewhat “working with” the skills that they developed between 4 and 10.
As far as the timing of casting, most children are receive their 1st series of casting on the day they are born. I have seen children who receive additional casting at later ages if a doctor or PT feels that they could benefit from additional casting or have developed additional misalignment. Due to the bio mechanical nature of the body, I would assume that as a child ages, their structure becomes more permanent as bone, tendon, and ligament become stronger. For this reason casting later in life is likely to yield less results or require greater duration to modify bony alignments.
I hope my insight has been valuable to your questions. Please let me know if this answers your question or if you would like additional information.
Thank you
Jon Gray SPT
1. Shumway-Cook A, Woollacott MH. The growth of stability: postural
control from a developmental perspective. J Motor Behav.
1985;17(2):131-147.
LikeLike
Well done poster! I’m just wondering if there would be a better balance test to use that would test the DF of these patients? Thank you.
LikeLike
A pediatric test that would incorporate aspects of both balance and dorsiflexion would be a great test to use for a study like ours. We did our best to incorporate well-researched and reliable tests that would emphasize any deficits in these areas. While there are several other pediatric balance tests, such as Bruininks–Oseretsky Test of Motor Proficiency (BOTMP) and the Pediatric Balance Scale, are available to test pediatric balance we chose the Star Excursion Balance Test due to its well supported use to identify dynamic balance deficits in individuals with LE conditions (1). While the Star Excursion test doesn’t directly measure DF, it does look at functional/dynamic DF during reach with the LE. As far as strength of the anterior tib/gastroc to concentrically and eccentrically control DF and balance, we could look into EMGs of this muscle during functional activities, but unfortunately our study did not have the financial means to incorporate that.
1) Gribble PA, Hertel J, Plisky P. Using the Star Excursion Balance Test to Assess Dynamic Postural-Control Deficits and Outcomes in Lower Extremity Injury: A Literature and Systematic Review. Journal of Athletic Training. 2012;47(3):339-357.
LikeLike
Great job guys, I think what you have found can help future kids and parents in their decision making! I was just wondering what exactly does the Ponseti Correction method entail? Like how many casts are usually applied and for how long is each one on?
LikeLike