Pirani Score and Dimeglio Classification for Clubfoot Assessment

Pirani socre

Pirani score for assessment of clubfoot (CTEV) consists of 6 parameters (3 each in midfoot and hindfoot) which is scored as 0, 0.5 or 1 with a maximum possible score of 6. The parameters can be remembered using the mnemonic: PER TOM

  1. Posterior crease
  2. Empty heel
  3. Rigid equinus
  4. Talar head
  5. Outer (lateral) border curvature
  6. Medial crease
pirani score
ExaminationMidfoot (MFCS)00.51Hindfoot (HFCS)00.51
LookLateral border curvature (reference – pen held against calcaneum)StraightDeviates at metatarsal levelDeviates at calcaneo-cuboid jointPosterior crease (after correction)Several fine creases2-3 moderate creasesSingle deep crease
FeelTalar head (palpate uncorrected and then correct)Completely sinks under navicularMoves partially but doesn’t completely sinkFixedHeel (with index finger in mild correction)Easy to palpate calcaneumPalpable calcaneum felt through later of fleshCalcaneum is deep under layer of tissue and difficult to feel
MoveMedial crease (after correction)Several fine creases2-3 moderate creasesSingle deep creaseEquinus (after correction with knee in extension)Dorsiflexion beyond plantigradeUpto plantigradeBelow plantigrade

Importance of Pirani Score

  1. A higher Pirani Score on presentation may indicate that a higher number of casts will be required.
  2. Relapse is higher with high initial HFCS.
  3. The tenotomy is done when the Midfoot Contracture Score (MFCS) is less than 0.5 but the Hindfoot Contracture Score (HFCS) remains greater than 1. After the tenotomy, the HFCS improves but does not correct completely.

Dimeglio Classification

Based on degrees of reducibility of 4 deformities (Mnemonic: DAVE) –

  1. Derotation of carpopedal block (1-4 points)
  2. Adduction of forefoot (1-4 points)
  3. Varus (1-4 points)
  4. Equinus (1-4 points)

And 1 point each for presence of:

  1. Posterior crease
  2. Medial crease
  3. Cavus
  4. Hypertonia, muscle weakness or chubby foot
Dimeglio classification


IBenign0-5Completely reducible
IIModerate6-10Reducible (>50%), partially resistant
IIISevere11-15Resistant, partially reducible (<50%)
IVVery Severe>15Resistant

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