The Pirani Score

Dr Shafique Pirani, is a committed orthopaedic surgeon who spends a lot of time learning, researching and teaching about clubfoot worldwide. The Pirani score is a common clubfoot assessment language to understand the severity of the deformity and the progress of treatment. It is like sizing in the clothing industry. There are different sizes of shirts and trousers and general terms like ‘I want a big shirt or a small shirt doesn’t make any sense to the seller’. But if someone asks for an XL or XXL or Medium shirt or Large, the seller will understand more clearly what the buyer is asking for. Similarly general statements like ‘I am treating a severe clubfoot in my clinic’, and ‘my child’s clubfoot is very minor’ do not make any sense in the assessment, understanding and treatment of clubfoot.

If a doctor says that, ‘I am treating a child who recorded 6 points in the Pirani score initially and has come down to 2.5 in pirani score after three weekly casts’, does make sense. The Pirani scores and points are universally known at least to doctors who are trained and are familiar with clubfoot treatment and programs. The Pirani score helps senior doctors teach and train junior colleagues in various stages in the treatment of clubfoot. Pirani score helps the Ponseti practitioner successfully use the method and conclude the treatment and long-term follow-up.

Use of Pirani Score.

The Pirani score helps:

• Practitioners understand the severity of the clubfoot deformity.
• Record the progress of the treatment.
• Determine the time for tenotomy. When the hind foot score is more than one (with an empty heel is zero) and the midfoot score is less than one (with the head of the talus and curved lateral border score of zero) it is time for tenotomy.
• Understand if it is time to provide a foot abduction brace. A foot abduction brace is given only when the total Pirani score is zero. That means all the deformities have to be corrected by manipulation, casting and tenotomy before a child is provided with a foot abduction brace. The foot abduction brace cannot correct the deformity and bring the Pirani score to zero. Brace can only maintain the Pirani score achieved by the Ponseti Method.
• To identify recurrence at an early stage.
• Parents understand the importance of brace compliance. Once the parents know that their child should score zero throughout the bracing period they are very careful. They have to be taught that if their child scores any point except zero in Pirani points during bracing, it will result in recast and/or redo tenotomy. The only way to keep the Pirani score zero is by following the bracing protocol strictly.

The Pirani score points

The Pirani score is a common score/number code to help determine the severity of the clubfoot deformity. All Ponseti Providers must know and use the Pirani score to correct the clubfoot deformity. A score is given after evaluating six locations of the foot that have to be corrected during treatment using Ponseti method. Three areas to be evaluated are in the midfoot side and three in the hind foot (behind/back). For each location, the affected posture scores one point.

The less affected position gets 0.5 score points and if the foot is in the normal position the score is zero. If a foot gets 6 points in a Pirani score that means the deformity is very severe. The purpose of the Ponseti treatment cast is to bring the score to zero.

Only when a foot gets a zero in all six areas, is the foot ready for a foot abduction brace.

1 = Very Severe
0.5 = Partially Corrected
0 = Normal