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Pirani score

Free PDF • 6 pages, print-ready • Clinician-reviewed

Maja Popovska Last updated October 27, 2026 Reviewed by Dr. Vanja Kitanova

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The Pirani score is a validated six-component clinical assessment tool used to grade the severity of congenital talipes equinovarus (CTEV) in infants and guide Ponseti treatment decisions at every stage of correction. Developed by Dr. Shafique Pirani, it gives pediatric orthopedic teams an objective, reproducible measure of foot deformity that replaces subjective visual estimation. Each of the six clinical signs is scored 0 (normal), 0.5 (moderate abnormality), or 1 (severe abnormality), producing a total between 0 and 6. This reference guide covers every sign, the interpretation thresholds that drive casting and tenotomy decisions, and how to track scores longitudinally across the full correction course.

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Practice Management Tips

The Pirani score is a six-sign clinical scale that grades clubfoot severity in infants. Totals run from 0 for a normal foot to 6 for the most severe deformity. Developed by Dr. Shafique Pirani, it scores three hindfoot signs and three midfoot signs at 0, 0.5, or 1 each. Ponseti teams use it at every cast change to judge progress, time the Achilles tenotomy, and spot relapse.

It is a widely used severity measure for congenital talipes equinovarus (CTEV). In an interobserver reliability study, agreement was excellent among trained pediatric orthopedic surgeons and good among other surgeons. What follows covers each sign, how to read the subscales, and a sample score trajectory across a full casting course.

Key takeaways

The Pirani score grades six signs across two subscales, hindfoot and midfoot. Each sign scores 0, 0.5, or 1, for a maximum total of 6.

A total score of 0 indicates complete correction. Achilles tenotomy is typically considered once the midfoot subscale reaches 0 and residual hindfoot equinus persists.

The score informs clinical judgment but does not replace it, so tenotomy timing still follows your protocol and the clinical findings.

Reassess both subscales after each Ponseti cast and record them consistently to catch stalled correction or early relapse.

Pabau, the practice management platform we build, lets pediatric teams capture Pirani scores in digital forms and track them across visits without paper records.

Why a standardized score matters in CTEV care

Before the Pirani score, severity grading depended on the clinician’s subjective impression. That variability made it hard to compare outcomes across centers, audit treatment decisions, or hand over care between team members. The score reduces a complex three-dimensional deformity to six observable, palpable signs, each with a clearly defined normal and abnormal state.

Pediatric orthopedic surgeons, physical therapists, and orthotists in a Ponseti program all use the score at each clinical contact. Capturing it in digital clinical forms rather than paper sheets cuts transcription errors. It also puts the longitudinal trend in front of the team at a glance.

The six clinical signs and how each is scored

The six signs are split equally between the hindfoot and midfoot subscales. Each sign scores 0, 0.5, or 1, giving a maximum of 3 per subscale and 6 overall. The table below summarizes what each score value means in practice.

Hindfoot subscale: Three posterior signs

The three hindfoot signs assess what is happening behind the ankle. Posterior crease reflects soft tissue contracture, and rigid equinus reflects how tight the gastrocnemius-soleus complex is. Empty heel indicates calcaneal displacement within the fat pad. All three are assessed with the infant relaxed and the knee extended when judging rigid equinus.

Midfoot subscale: Three anterior signs

The three midfoot signs capture the forefoot and midfoot deformity components. Curved lateral border reflects the supination and adduction of the forefoot. Medial crease indicates the degree of cavus or adduction. Talar head coverage assesses navicular position relative to the talar head, the key landmark for Ponseti correction sequencing.

Pirani score interpretation: Severity ranges and treatment thresholds

Total score interpretation follows a severity gradient, but the subscale breakdown carries equal clinical weight. A foot scoring 3/3 on the hindfoot with only mild midfoot involvement needs a different casting approach from a foot that scores 3/3 on both.

The bands below are an illustrative reading, not part of the validated score. Published studies use different total cutoffs, roughly 3 to 5, when they relate the score to tenotomy.

Tenotomy threshold: Achilles tenotomy is typically considered when the midfoot subscale has reached 0 and residual hindfoot equinus persists. In practice, that means a rigid equinus score of 0.5 or 1. The Ponseti method is the first-line treatment for clubfoot, according to a review of the Ponseti literature. Always verify tenotomy timing against current institutional protocol and individual clinical findings.

How the score guides Ponseti treatment decisions

The Ponseti method is a serial casting protocol that corrects CTEV in a set order: Cavus first, then adduction and supination, then equinus. A study on Pirani score and Ponseti casting found that a higher initial score correlates with more casts. Individual variation is substantial, though, so one score should not be read as a firm cast count.

The score drives decisions at four points in the workflow.

1. Baseline assessment: Score both subscales before the first cast. Document foot laterality, gestational age, and any syndromic associations that may affect correction speed.
2. Post-cast reassessment: Reassess the score at every cast change, typically every five to seven days in infancy. A drop of 0.5 or more per session suggests adequate correction.
3. Tenotomy decision: When the midfoot score reaches 0 and residual equinus persists on the hindfoot subscale, refer for percutaneous Achilles tenotomy. This decision sits with the attending surgeon, and the score informs clinical judgment without replacing it.
4. Bracing and monitoring: After tenotomy and the final cast, move to a foot abduction brace (Denis Browne brace). Keep reassessing the score at follow-up visits to detect early relapse before it becomes a full recurrence.

Teams using measurements tracking tools within their clinical records can plot the subscale trend automatically. Regression then shows between appointments without anyone reviewing a stack of paper sheets.

Tracking scores across Ponseti casting cycles

Few published resources show how a well-correcting foot’s score should move across multiple casts. The downloadable sheet gives each visit its own dated entry, so the trajectory builds as you go. The illustrative table below follows a foot that starts at a total score of 5.5, based on patterns described in the Ponseti literature.

Plotted cast by cast, the pattern is easier to read: the midfoot falls steadily while the hindfoot barely moves until the tenotomy.

Red-flag patterns: A total score that fails to drop by at least 0.5 points after two consecutive casts suggests inadequate correction. Possible causes include casting technique, skin tolerance limiting abduction, or an underlying stiff deformity that may warrant early orthopedic review. Document the stalled trajectory clearly in the patient record, so escalation decisions rest on longitudinal evidence.

Scoring bilateral clubfoot: Special considerations

Bilateral CTEV accounts for roughly 30 to 50 percent of cases. When both feet are affected, score each one independently. Record them as “right foot” and “left foot” within the same assessment sheet.

Asymmetric bilateral presentations are common. One foot may correct quickly while the other lags, needing extra casts on one side only. A single combined score hides that asymmetry, and casting decisions then fall behind the slower foot.

• Score each foot independently at every assessment, even when improvement appears symmetrical.
• Sequence casts by severity when the treating surgeon’s protocol allows: The more severe foot may need its correction sequence adjusted relative to the other side.
• Flag asymmetric relapse early: At bracing follow-up, a rising score on one side is the earliest detectable sign of unilateral relapse. It is far easier to manage when caught at the first visit it appears.

Pediatric orthopedic teams that keep structured patient records with per-limb fields can compare both feet side by side at follow-up. Nobody has to page back through paper bilateral entries to spot a one-sided change.

How to fill in the assessment sheet

The downloadable assessment sheet is built for every Ponseti casting visit. These five steps cover completing and filing it.

1. Record patient and visit details: Note the infant’s date of birth, gestational age at diagnosis, the foot or feet affected, and the visit date. For bilateral cases, record a right and a left score for every sign.
2. Assess and score each of the six signs: Start with the hindfoot signs: Posterior crease, rigid equinus and empty heel. Then score the midfoot signs: Curved lateral border, medial crease and talar head coverage. Assign 0, 0.5, or 1 for each.
3. Calculate and record the subscale totals: Sum the three hindfoot scores and the three midfoot scores separately. Then calculate the total. Never record the combined total without the subscale breakdown.
4. Compare to the previous visit: Note whether each subscale has improved, plateaued, or worsened since the last cast. A stalled subscale score triggers a clinical review of casting technique or sequencing.
5. Document the clinical decision: Record the agreed action: Continue casting, refer for tenotomy assessment, or move to bracing. Date and initial the record. With AI-assisted clinical documentation, structured assessment data can be summarized within the clinical note automatically.

Which clinicians use it

The Pirani score is relevant to any clinician involved in CTEV diagnosis and management.

• Pediatric orthopedic surgeons: Use the score to plan casting sequence, decide tenotomy timing, and document outcome data for audit. Practices on a physical therapy EMR with structured outcome measures can file the scores straight into the long-term patient record.
• Physical therapists and orthotists: Apply the score at cast changes and brace fittings to confirm correction status and advise on brace compliance.
• Neonatology teams: May perform the baseline assessment at birth or in the neonatal unit. It triages severity and sets parental expectations before the Ponseti program begins.
• Pediatric nurses and allied health professionals: Run follow-up visits during the bracing phase, where a rising score is the primary clinical alert for relapse.

Benefits of a standardized assessment sheet

A standardized assessment sheet does more than save time at the appointment. It creates a defensible, auditable record of how clinical decisions were reached.

Consistency across practitioners: When every clinician on the schedule uses the same six-sign rubric, inter-rater variability drops. This matters most in teaching hospitals, where residents and attending surgeons share casting duties.

Outcome benchmarking: Longitudinal score data lets teams compare their correction rates against published benchmarks. It also surfaces outliers that may benefit from technique review and feeds service-level audit cycles.

Parental communication: A completed sheet with a falling score gives parents a progress marker they can see. Parents of infants in serial casting often find that number more reassuring than verbal reassurance alone.

Medicolegal protection: If a relapse occurs or a tenotomy decision is questioned, a complete longitudinal score record shows how each decision was reached. Every step traces back to objective clinical findings.

How Pabau tracks clubfoot correction from first cast to bracing

On paper, every cast change adds another sheet to the file. The trend between visits only appears when someone lines the sheets up and compares them by hand. During bracing, when visits are months apart, a slow rise on one foot is easy to miss.

In Pabau, the assessment sheet becomes a digital form attached to the patient’s record. Each visit’s sign scores, subscale totals and treatment decision are saved against the date, for each foot.

The surgeon, physical therapist and nurse then open the same record and see the same trajectory. A stalled subscale or a one-sided rise shows up at the visit it happens, so you can adjust casting or bring the bracing review forward.

Paperless clinical documentation for pediatric orthopedic teams

Capture Pirani scores, track casting progress, and store consent forms in one place. Pabau replaces paper assessment sheets with structured digital records your whole team can open.

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Conclusion

Score each foot sign by sign at every cast, and record both subscales next to the total. That habit gives your tenotomy timing a documented basis and flags a stalled foot while there is still time to change the casting.

The trade-off is a minute of extra documentation per visit, and it only pays off if every clinician scores the same way. Treat the severity bands as a reading aid and your protocol as the rule.

Book a demo to see how Pabau keeps every Pirani score, cast and brace visit on one patient record your whole team can read.

Continue your research

Checking dorsiflexion as the equinus resolves? Ankle dorsiflexion test explains how to measure and track ankle range of motion between visits.

Assessing foot posture once the child is walking? Foot Posture Index FPI-6 gives you a six-item standing assessment with a free scoring template.

Following development after bracing ends? Pediatric balance scale covers a 14-item balance test with a scoring guide for children.

Building a wider set of outcome scores? Outcome measures template shows how to choose, score and track the measures your team relies on.

Choosing software for a physical therapy team? Physiotherapy practice management software compares the tools musculoskeletal teams use to run records, scheduling and billing.

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