At the turn of the 20th century, treatment for talipes equinovarus consisted of forceful manipulation of the foot under general anesthesia with devices such as the Thomas wrench. The result was destructive pressure on bone and cartilage with stiffness and fibrosis. With more advanced surgery, operations on fascia, tendon, bone and joint became fashionable. The goal of these procedures was to reduce the deformity quickly. Relapses were frequent and many patients had unacceptable rigidity and stiffness. Some were worse off than had they not been treated.
Kite’s technique. Kite studied the anatomy and treatment of talipes equinovarus under Hoke and achieved success with manipulative reduction in the 1920s.57,58 Kite divided the abnormal anatomy into three parts. These were adduction of the forefoot, inversion of the heel and equinus of the ankle. He believed the forefoot was adducted in comparison to the rearfoot and the calcaneus rotated inward under the talus, causing the entire foot to assume an inverted position. The equinus deformity had two components. The forefoot was plantarflexed on the rearfoot, resulting in forefoot equinus. The entire foot was plantarflexed at the ankle, resulting in ankle equinus.
Kite isolated treatment into three sections.57,58 First, he corrected the adduction of the forefoot and subsequently corrected the inversion of the calcaneus. Once he had completely corrected both deformities, he treated the ankle equinus. The first part of the correction occurred by bringing the forefoot out of abduction until the cuboid was in line with the calcaneus and the navicular was anatomically seated on the talar head. Kite accomplished this with lateral cuboid pressure. Once he achieved this, the ankle equinus reduced.57,58
The French technique. The French physiotherapy method developed in the late 1970s and is more popular in Europe.59-61 The theory behind this method is that clubfoot results from a contracted posterior tibial tendon, malpositioned joints and weakness of the peroneal muscle group. It involves daily manipulation by a physiotherapist, splinting with elastic tape, stimulation of muscles by activating tonic cutaneous reflexes to excite the toe extensors and the peroneals, and continuous passive motion while the baby sleeps. It is very labor intensive for both the therapist and family members. This approach is not very popular in the United States although some centers use it.
Correction begins with the rotation of the entire foot around the talus and one augments this with massage of the calf muscles and tendo-Achilles. The first step is to stretch the medial soft tissue to allow the navicular to move away from the medial malleolus and its medial position on the talar head. The second step is to correct forefoot adduction. The third step is to progressively reduce the hindfoot varus. One can only do this after reducing the talonavicular joint. The last step is to correct the equinus deformity.
The technique underwent further modification in the 1990s with the introduction of continuous passive movement.61 Most of the improvement occurs during the first three months of treatment.