28 Review article

The French functional physical therapy method for the

treatment of congenital clubfoot
Alain Dimeglioa and Federico Canaveseb

The French method, also called the functional physical make surgery easier and less extensive. From the
therapy method, is a combination of physiotherapy, French method to the Ponseti method, the Hybrid method
splinting and surgery à la carte. The French functional or the ‘the third way’, combining the advantages of both
physical therapy method consists of daily manipulations methods, is the future. The primary reason for relapses
of the newborn’s clubfoot by a specialized physical is the inability of families to maintain the correction initially
therapist, stimulation of the muscles around the foot and achieved. The aim of this work is to provide an overview
temporary immobilization of the foot with elastic and of the French functional physical therapy method and to
nonelastic adhesive taping. Physiotherapy is optimized help understand how it has evolved over time. J Pediatr
by early triceps surae lengthening. Sequences of plaster Orthop B 21:28–39 c 2011 Wolters Kluwer Health |
can also be used. If conservative treatment is no longer Lippincott Williams & Wilkins.
effective, surgery should be considered. Mini-invasive Journal of Pediatric Orthopaedics B 2012, 21:28–39
surgery is a complementary procedure to nonoperative
treatment (surgery ‘à la carte’). The French method reduces Keywords: clubfoot, clubfoot surgery, French functional method,
physiotherapy and clubfoot, Ponseti method
but does not eliminate the need for mini-invasive surgical
a
procedures. Equinus is the most difficult deformity to treat; University of Montpellier, Faculty of Medicine and bPediatric Surgery
Department, Estaing University Hospital, Clermont Ferrand, France
posterior release is sometimes necessary in a severe
foot. Very severe feet (stiff–stiff; score, 16–20) are still a Correspondence to Professor Alain Dimeglio, MD, University of Montpellier,
Faculty of Medicine, 2, rue de l’Ecole de Médecine, Montpellier 34000, France
challenge. However, regular manipulations and splinting Tel: + 33 608 332 826; fax: + 33 981 704 790;
improve foot morphology and stiffness, and, ultimately, e-mail: alaindimeglio@wanadoo.fr

Introduction therefore essential to both score clubfoot at birth and to

In clubfoot, orthopaedic treatment is not a new concept. assess the impact of treatment.
Conservative treatment was largely explained by Scarpa
At birth, clubfeet are classified in ascending order of
[1], Delpech [2], Browne [3], Lovell and Hancock [4]
severity, from the mildest to the more severe, with a score
and Kite [5].
on a scale from 0 to 20 as described by Dimeglio et al. [16].
The French functional physical therapy method, as In order to establish a final score, each of the following
described by Masse [6], Bensahel et al. [7,8], Seringe parameters receives a score from 1 to 4: (a) equinus; (b)
and Aita [9] and Dimeglio [10–12], consists of daily varus of the hindfoot; (c) internal rotation of the
manipulation of the newborn’s clubfoot by a skilled calcaneotarsal complex; and (d) adduction of the forefoot
physiotherapist, stimulation of the muscles around the compared with the hindfoot. These parameters must be
foot and temporary immobilization of the foot with elastic assessed in terms of reducibility, without forcing the foot.
and nonelastic adhesive taping to maintain the reduction A small goniometer allows one to measure angulation
achieved by passive manipulation. precisely before and after the reducibility test. To these
four parameters, four pejorative points are added to obtain
The French method aims to avoid surgery as much as a score out of 20: (a) one for the medial (or plantar)
possible and, if needed, attempts to keep it as limited as crease; (b) one for the posterior crease; (c) one for the
possible by performing mini-incisions and by preserving cavus; and (d) one for the infant’s global hypertonia or
ligaments, tendons and sheaths to avoid fibrosis (surgery muscle weakness or short, fat foot (Figs 1–6).
‘à la carte’) [13].
This classification allows surgeons to distinguish and to
The French functional physical method is based, among predict outcomes between four categories of feet: ‘postural’
others, on Salter’s fundamental concept that ‘mobility is (soft–soft; score, 1–5; completely reducible), ‘moderate’
life’ [14,15]. (soft–stiff; score, 6–10; > 50% reducible), ‘severe’ (stiff–
soft; score, 11–14; < 50% reducible) and ‘very severe’ feet
Clubfoot classification (stiff–stiff; score, 16–20; nonreducible) [16]. This classi-
Within the spectrum of all possible talipes equinovarus fication system is simple and reproducible and allows for
conditions, there are different degrees of involvement, reliable comparisons between study populations that use
from the stiffest to the softest foot. Classification is various treatment techniques [17–20].
1060-152X
c 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI: 10.1097/BPB.0b013e32834ee5f8

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 The French functional physical therapy Dimeglio and Canavese 29

Fig. 1 Fig. 2

Derotation Adduction

0°

–20° 20°

1 2 45°

3
90°
0
4
4
0 90°

3
1 2 45°

–20° 20°

0°

Clubfoot classification (derotation). A small goniometer can be used to Clubfoot classification (adduction). A small goniometer can be used to
assess the reducibility. assess the reducibility.

The French functional physical therapy method Fig. 3

The French functional physical therapy method obeys
strict rules. It consists of daily manipulations of the
newborn’s clubfoot by a skilled physical therapist, Varus
stimulation of the muscles around the foot (particularly
the peroneal muscles) and temporary immobilization of
the foot with elastic and nonelastic adhesive taping so
that the reduction achieved by the passive manipulations
is maintained. Manipulations can begin in the delivery
90°
room from the earliest hours, to take advantage of the
reducibility of the foot. The goal is to reduce the 4
deformity quickly but without overhaste, to avoid any 0
deterioration of the foot [7–9]. A thorough understanding
3
of the different deformities of club foot is required to 2 1
45°
perform the manipulative treatment effectively. The
progress of manipulation is guided by the stages of 20° –20°
correction achieved.
0°
At birth, only 35% of the foot is ossified and bones are still
cartilaginous, soft and flexible, whereas fibrous structures
are stiff and resistant. Feet must be corrected gently and Clubfoot classification (varus). A small goniometer can be used to
gradually (Scarpa’s principle [1]); during manipulations, assess the reducibility.
babies must be relaxed.

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 30 Journal of Pediatric Orthopaedics B 2012, Vol 21 No 1

Fig. 4 Fig. 6

Equinus

−20° 0

1
0°
2 Medial crease (1 point).

20° 3
4

45°
calcaneo-pedal complex around the talus are performed.
90°
The reduction should never be forced.
Clubfoot classification (equinus). A small goniometer can be used to As soon as correction in the horizontal plane is complete,
assess the reducibility. the equinus can be addressed by lowering the calcaneus
posteriorly. Plantar face is well maintained to avoid any
breakage in the mid-tarsal joint. This articulation should
not be overmanipulated and its integrity should be
Fig. 5 valued. Moreover, manipulations should not attempt to
correct supination by lowering the first metatarsal bone as
it worsens the cavus [22]. When retraction is no longer
present, manipulation becomes much easier. The func-
tional treatment takes place during the first 3–4 months
of the baby’s life (Figs 7–9).
The functional method is more than a traditional
physiotherapy; it is a philosophy based on movement. It
is a real ‘how to know’, transmitted from one generation
to another, from one school to another. It is a very
demanding method, with strict requirements and rules; it
has been widely described in the literature [6–12].

The Montpellier method

In Montpellier, France, some modifications have been
gradually introduced to the original French functional
physical therapy protocol to improve outcome after
manipulations and taping.
A continuous passive motion machine (PMM) was
introduced to the regimen in 1992. This further mobilizes
the child’s taped foot during the hours of sleep
Posterior crease (1 point). [14,15,23,24]. Once the foot is corrected, maintaining it
in proper alignment is a complex process and the use of
PMM facilitates this stage. The PMM is generally used
for 16–18 h a day and has an inbuilt safety mechanism
Daily manipulations must start in the horizontal plane as that avoids undue pressure to the cartilaginous structures
good horizontal plane correction minimizes residual of the baby’s foot. It is particularly effective during sleep,
equinus (Farabeuf ’s principle [21]). At the same time, with the advantage that it can be used at home and it
forefoot correction (abduction) and derotation of the is easy to use. During weekends, the feet remains

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 The French functional physical therapy Dimeglio and Canavese 31

Fig. 7

Derotation + medial streching

Derotation of the calcaneo block around the talus.

Fig. 8

Forefoot alignment + medial streching

Decoaptation of the tarsal-navicular joint with maintenance of the foot in plantar flexion without forcing the mid tarsal joint. The thumb stabilizes the talus.

Fig. 9

Dorsiflexion + valgisation

Correction of the equinus. Plantar face is well maintained. Counter pressure on the talus.

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 32 Journal of Pediatric Orthopaedics B 2012, Vol 21 No 1

taped and splinted in the stretched position to maintain year old. After this, children wear custom-made splints to
the correction achieved by manipulations and PMM avoid relapse of the equinus (Figs 11–16).
[14,15,23,24] (Fig. 10).
Resin casting is used to maintain the progress achieved by
Since 1997, the lengthening of the tricepts surae as manipulations. It is usually applied on Thursday evening
described by Vulpius [25,26] has been introduced. At 3 or Friday morning and remains in place until Monday
months of age, if a posterior crease persists, or there is morning. The resin is moulded over the bandage, opened
equinus (101 or more) or an empty heel or a lack of laterally to avoid pressure and does not include the knee.
divergence between the talus and the calcaneus on lateral
With resistant feet, a period of casting may be utilized in
foot radiograph, triceps surae lengthening is performed as
the protocol to improve outcome and, most importantly,
described by Vulpius. The aponeurotic tendon of the
if surgery is needed, it is always ‘à la carte’ [13] and
gastrocnemius is exposed and an inverted V-shaped
miniinvasive.
incision is made through it. The ankle is then forced into
slight dorsal flexion and the segments of the tendon
become separated [25,26]. It is a dynamic lengthening.
This procedure is most effective between 3 and 5 months Fig. 11

of age. Manipulation should start immediately after

surgical treatment. Afterwards, manipulation is performed
three times a week and continued until the child is one

Fig. 10

Resin casting is moulded over the bandage and it is opened laterally to

Passive motion machine. avoid hyperpressure. It does not include the knee.

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 The French functional physical therapy Dimeglio and Canavese 33

Fig. 12 Fig. 14

–20°

0°

20°

45°
90°
Lateral foot radiograph in maximum dorsiflexion showing lack of
divergence between the talus and the calcaneum: early triceps surae
lengthening is indicated.
Equinus is the most difficult deformity to treat. Posterior release is
indicated when severe hind foot retraction is present.

Fig. 13
Fig. 15

Indication for early triceps lengthening: persistence of equinus,

posterior crease, empty heel pad.

Antero-posterior and lateral radiographs of the baby’s foot

are taken every 3 to 6 months to assess the divergence
between the talus and the calcaneum and to monitor the
progress of treatment. A lateral foot radiograph in
maximum dorsiflexion is the most informative document.

Mini-invasive surgery and surgery ‘à la carte’

In the French functional physical therapy method, Vulpius lengthening.
surgery is considered as a complementary procedure to

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 34 Journal of Pediatric Orthopaedics B 2012, Vol 21 No 1

Fig. 16 until the child begins to walk. A minimum 101 of

dorsiflexion must be maintained. Any significant lack
of dorsiflexion is an indication for triceps lengthening.
(2) The foot is partially corrected and equinus (10–151)
is still present, a situation usually encountered in a
severe clubfoot (stiff–soft; score, 10–15). In this case,
a Vulpius lengthening should be considered.
(3) The foot is not corrected nor has it significantly
improved after triceps lengthening, a situation encoun-
tered in a very severe foot (stiff–stiff; score, 15–20). For
this, operative treatment is generally required. How-
ever, manipulations are continued and surgery is
deferred to keep the foot as supple as possible and to
reduce the extent to which surgery is required. The
need for extensive surgical release is rare.

Six different principles must be kept in mind when

surgery is planned: (Figs 17–20).

(1) To avoid extensive surgical dissection;

(2) To avoid long skin incision. Clubfoot surgery should
be conducted by multiple mini-skin incisions;
(3) Ligaments, tendons and sheaths must be protected
to avoid fibrosis. The surgeon should treat the
delicate anatomical structures of the child’s foot with
extreme attention, in the same manner as a hand
surgeon would treat the structures in ‘no man’s
land’ [27];
(4) All lengthening procedures must be performed only
at the musculotendinous junction (fractional length-
ening);
(5) After surgery, physical therapy and splinting must be
continued;
(6) In clubfoot, equinus is the most difficult deformity
Fractional lengthening. to treat. Delpech in the early nineteenth century

Fig. 17
nonoperative treatment, which aims to reduce the extent
of surgery in case it is required (surgery ‘à la carte’) [13].
Surgical treatment is only needed when the orthopaedic
treatment is no longer effective and/or when the foot
shows no more improvement. The assessment at the
third month is important, as a choice must be made
between continuing the orthopaedic treatment (phy-
siotherapy, splinting) because it is effective and surgery
can be avoided, or continuing the orthopaedic treatment
in order to maintain what has been achieved, while being
aware that surgery will be necessary.
After completion of functional physical therapy treat-
ment, three possible options should be evaluated at age
3–4 months:

(1) The foot is completely corrected, a situation usually

encountered in a moderate clubfoot (soft–stiff; score, Mini-incision for Vulpius lengthening.
6–10). In this case, manipulations are to be continued

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 The French functional physical therapy Dimeglio and Canavese 35

Fig. 18 Fig. 20

Percutaneous lengthening of the triceps. Separate incision for medial, planter abductor hallucis release.

Fig. 19 (2) Mini-posterior release is indicated when hind foot

retraction is severe, when the lateral foot radiograph
in maximum dorsiflexion shows a lack of talocalcaneal
divergence and when calcaneum is still elevated. It
consists of lengthening of the achilles tendon in
association with a posterior capsular release of the
tibiotalar joint, including both the posteromedial (up
to the flexor hallucis longus tendon) and the poster-
olateral (up to peroneal tendons) corners, and a
limited release of the capsule of the subtalar joint.
The tibialis posterior, the common toe flexor and the
flexor hallucis longus can be lengthened by a
fractional procedure. In selected cases, a Kirschner
wire is inserted through the posterior part of the talus
to reduce the talonavicular joint. Immobilization is
required for about 4–6 weeks.
(3) Mini-posteromedial release is indicated when the
foot is not corrected and has equinus and adduction.
Incision for posterior release. Surgery is conducted by two different incisions,
starting with the posterior release as described above
and followed by a medial incision. It is important that
described clubfoot physiopathology and first reported surgery is kept to a minimum. The medial incision is
that all clubfoot deformities are interrelated. In par- used to release the tibialis posterior tendon at its
ticular, Delpech pointed out that the calcaneus is insertion and reduce the talonavicular joint. The
involved in the equinus, varus and adduction of the de- posterior tibial tendon sheath has to be preserved and
formed foot. In particular, varus is linked to the amount any lengthening in the tendinous part of muscle is to
of residual equinus and, if varus persists, forefoot supi- be avoided. The medial internal ligament or spring
nation and adduction will still be present [2]. ligament and the interosseous ligament between the
talus and the calcaneum should never be sacrificed.
Several surgical options are possible (surgery ‘à la There is no need to dissect the vascular bundle in the
carte’) [13]: tarsal joint. Following nonoperative treatment, most
feet require only minimal surgery and there is rarely a
(1) Achilles tendon lengthening can be performed using need for extensive releases of the midtarsal and the
different techniques. The Vulpius triceps lengthen- calcaneocuboid ligaments. The reduction is main-
ing is our preferred choice. tained by a Kirschner wire and postoperative

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 36 Journal of Pediatric Orthopaedics B 2012, Vol 21 No 1

immobilization is required for 6 weeks. The cast and of very severe feet (score, 16–20) did not require
the Kirschener wire are removed under general extensive surgical procedures.
anaesthesia after 3–4 weeks. This allows the surgeon
to check the skin incisions and the foot shape. A new Moreover, Richards et al. compared the French functional
cast is then applied for the remaining 2–3 weeks of physical therapy protocol with the Ponseti technique.
immobilization. They found that the initial correction rates were equal
(4) Release of the abductor hallucis can be carried out by (95 and 94.4%, respectively) and relapses occurred in 29
a supplementary mini-medial incision [28]. and 34% of the cases, respectively. At the time of the
(5) Anterior tibialis transfer is indicated for active, latest follow-up, the outcomes for the feet treated with
residual foot supination. When a medial release is the Ponseti method were good for 72%, fair for 12% and
performed, the tendon transfer can be carried out poor for 16%. The outcomes for the feet treated with the
through the same incision. French functional method were good for 67%, fair for 17%
(6) Plantar fascia release through a mini-incision. and poor for 16% [15,30].

They concluded that cross-over treatment between the

Results French and the Ponseti method has proven beneficial.
It is very important to differentiate clubfeet according to Early triceps surae lengthening, in the French method,
their degree of severity when assessing the results of may decrease the need for future posterior release.
clubfoot treatment. Benign (soft–soft; score, 1–5), mod- However, both French and Ponseti treatment protocols do
erate (soft–stiff; score, 6–10), severe (stiff–stiff; score, not completely eliminate the need for posteromedial
11–15) and very severe feet (stiff–stiff; score, 16–20) releases. The primary reason is the inability of families to
must be clearly differentiated. The results are not always maintain the correction achieved originally [15,30].
classified by foot severity. Some studies have a short
follow-up and others do not report the number of patients Dimeglio and colleagues by including PMM in the French
lost to follow-up. Therefore, comparisons are difficult to functional physical therapy regimen, found that fewer
establish and the results require a critical assessment. patients needed surgery than previously reported, and for
those who did, less extensive releases were required. In
Bensahel et al. [7], in their report of 338 cases of clubfoot, early 1990s, they reported on a series of 171 clubfeet,
found 48% good, 29% fair and 23% poor results. Extensive demonstrating that 5% of moderate feet (score, 6–10), 51%
surgery was necessary in 52% of their patients and yielded of severe feet (score, 11–15) and 78% of very severe feet
86% good, 10% fair and 4% poor results. Ten years later, (score, 16–20) required surgery (à la carte) [10–12,23,24].
the improvements in the technique of physical therapy
increased the rate of good results up to 77% [8]. In a second series, the same group of authors reported on
a series of 201 feet with at least 10 years of follow-up. At
Seringe and Aita [9], in a series of 269 clubfeet published that time, triceps lengthening was not performed and 3%
in 1990, obtained 48% good results with conservative of moderate feet (soft–stiff; score, 6–10) required a mini-
treatment: 33% were moderate feet (score, 6–10) and posterior release, 48% of severe feet (stiff–soft; score,
43% were severe feet (score, 11–15). However, 70% of 11–15) had posterior and mini-posteromedial releases and
very severe feet required surgery (posterior or poster- 77% of very severe feet (stiff–stiff; score, 16–20) required
omedial release). extensive surgery [10–12,23,24]. The authors observed
Al Khoury et al. recently reported on a series of clubfeet that there was a deterioration in the results between 2
treated with lengthening of the triceps surae performed and 5 years of follow-up.
before the age of 1 year. They concluded that early
In a third series of 204 feet, Dimeglio and colleagues
triceps surae lengthening improved outcome in selected
showed that the combination of functional treatment and
cases [29].
early triceps surae lengthening lowered the rate and/or
The ‘Texas Scottish Rite Hospital’, Dallas, Texas, initiated the extent of surgery. Manipulations and splinting
the French protocol in 1996. Richards and colleagues, in improved the foot morphology and made triceps surae
their first publication with a mean follow-up of 20 months, lengthening more effective. The authors found that
found that 50.7% of feet treated conservatively did not 15% moderate feet (soft–stiff; score, 6–10) required
need surgical treatment, 28.9% required posterior release early triceps surae lengthening alone; 12.6% of severe
and 20.4% required posteromedial release. At that time, feet (stiff–soft; score, 11–15) had posterior release or
early triceps surae lengthening was not performed. posteromedial release and tibialis anterior transfer
[10–12,23,24]; and 70% of very severe form (stiff–stiff;
In a more recent work, Richards and colleagues found score 16–20) had extensive surgical release.
that, following early triceps surae lengthening, results
were improved. They found that 86% of moderate feet Dimeglio et al. concluded that early triceps surae
(score, 6–10), 68% of severe feet (score, 11–15) and 25% lengthening is effective and decreases the rate and the

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 The French functional physical therapy Dimeglio and Canavese 37

extent of surgery [10–12,23,24]. Fair results attained after the two methods in order to combine the advantages of
the use of the functional method may yield a poor result both and apply them in the same strategy. Regardless of
with growth and will need surgery (à la carte) [13]. Very the method, the objective is the same: to reduce the
severe feet (stiff–stiff; score, 16–20) are still a challenge. frequency and extent of surgery and to decrease the risk
The role of physiotherapy is to improve the morphology of relapse.
and the suppleness of the foot and to limit both the
extent of surgery and the risk of relapses. In our Over time, both methods have evolved. The plasters to
experience, the combination of early Vulpius procedure control reduction are now recommended every week
and tibialis posterior lengthening (fractional lengthening) whereas initially they were changed every 3 weeks. In the
is an effective way to improve the effect of physiotherapy French functional physical therapy method, short-term
in this category of feet (Fig. 21a and b; Fig. 22a and cast immobilization and lengthening of the achilles
b; Fig. 23a and b). tendon has been incorporated into the protocol, initiated
by the Montpellier school. A careful manipulation by a
The third way: from the French method to the skilled physical therapist for 30 min before the applica-
Ponseti method tion of a plaster is likely to improve results and to speed
Clubfoot correction can be carried out using different up the reduction of the foot. Following reduction by
techniques, such as functional rehabilitation and manip- plaster, regular physical therapy can reduce the duration
ulations with splints or serial casting, and all techniques in splint and the risk of relapse in the Ponseti method.
aim to achieve a plantigrade, painless and supple foot
The French method is comparable to the Ponseti method
with avoidance of surgery as much as possible.
in aiming to avoid surgery and the associated fibro-
Conservative treatment of clubfoot has established itself sis [5–9,15,19–22,24,25]. The conservative treatment of
as the primary treatment of choice, that is, treatment by the future may probably be half-way between the Ponseti
plaster, the Ponseti method [31] or the French functional method [25,31] and the French functional physical
physical therapy method. therapy method [5–13], and from this, improved results
may be expected.
Rather than comparing them, as competitive treatments,
the time has come to reconcile the differences between
Lessons learned from of our experience
A significant follow-up is necessary to evaluate the effect
of treatment as deteriorations can occur.
Fig. 21
Despite some differences, all conservative treatment
methods share the same basic principles:

(1) The French functional physical therapy method is a

combination of manipulations, splinting and surgery
‘à la carte’. Conservative treatment, surgery ‘à la
carte’ and splinting before and after surgery form a
whole and belong to a programmed action;
(2) Not all clubfeet can be corrected by conservative
treatment alone. Surgical treatment, or surgery ‘à la
carte’, is only needed when the orthopaedic
treatment is no longer effective and/or when the
foot shows no more improvement;
(3) The creation of a unit through which all treatment
and follow-up for a patient with congenital clubfoot
are coordinated shall be given priority. This cen-
tralizes all patients with clubfeet in the region, helps
to inform and motivate the relatives and is of vital
importance in the education of physiotherapists;
(4) Continuity of treatment is mandatory. Any slacken-
ing of treatment may be detrimental;
(5) Families, physiotherapists and splints have the same
impact on the treatment protocol. The primary
reason for relapses is the inability of families to
maintain the correction initially achieved;
(a,b) Very severe feet (stiff–stiff; score 16). (6) After surgery, demobilization may be detrimental;
postoperative physiotherapy is essential;

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 38 Journal of Pediatric Orthopaedics B 2012, Vol 21 No 1

Fig. 22

(a,b) Functional physical therapy method and early triceps surae lengthening. Foot morphology at age 9 years.

Fig. 23

(a,b) Normal radiographs.

(7) The assessment at the third month is important, as a surgery can be avoided or continuing the orthopaedic
choice must be made between continuing the treatment in order to maintain what has been achieved,
orthopaedic treatment because it is effective and while being aware that surgery will be necessary;

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 The French functional physical therapy Dimeglio and Canavese 39

(8) Early triceps surae lengthening improves outcome 10 Dimeglio A. Clubfoot. Montpellier: Sauramps Médical diffusion Vigot.
and decreases the rate of extensive surgery. Very (translated from French); 1985.
11 Dimeglio A, Dimeglio F. Clubfoot. In: Fitzgerald. RH, editor. Orthopaedics.
severe feet (stiff–stiff; score, 16–20) are still a Missouri: Mosby, Inc.; 2002. pp. 1475–1489.
challenge. Daily manipulations, splinting and PMM 12 Diméglio A, Bonnet F. Clubfoot physiotherapy. Encycl Méd Chir
contribute to make surgery less extensive; Kinésithérapie Médecine Physique et Réadaptation 1997; 26-428-B-10:
1–12, (translated from French).
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effect of treatment as deteriorations can be clubfoot: one-stage medioposterior release ‘a la carte’. J Pediatr Orthop
observed around and after 2 years of age. Nothing 1987; 7:145–148.
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can be permanently achieved before skeletal Clements ND, et al. The biological effect of continuous passive motion on
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probably half-way between the Ponseti method joints: the first 18 years of basic research and its clinical application.
and the French functional physical therapy method Clin Orthop 1989; 242:12–25.
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18 Flynn JM, Donohoe M, Mackenzie WG. An independent assessment of two
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