History of the functional method for conservative treatment of clubfoot

In the beginning was the deformity…

As the pioneers of the functional method of conservative treatment of talipes equinovarus, we are pleased to be given this opportunity to describe the beginnings of this method for the historical archives of paediatric orthopaedics.

The Bretonneau University Children’s Hospital (BUCH) in Paris was known as a place where physical therapy had been traditionally used for the benefit of sick or disabled children, especially for those with problems stemming from orthopaedic abnormalities. In 1950s, physical therapy received global recognition for its value as part of the conservative treatment of spinal deformities and of cerebral palsy. As defined by Prof. G. Laurence, Head of the Department of Pediatric Surgery and Orthopaedics, and Dr. P. Masse, the Assistant in Orthopaedics of BUCH, the role of physical therapy in the treatment of foot deformities was focused in the setting of clubfoot and it was aimed towards greater flexibility of the foot in order to lessen the difficulty and extent of surgery. Together with the chief of physical therapy, Dr. Masse stated that the physical therapy aspect was supplementary to surgery, and that its function was limited to preparing the foot to the knife: “….With very rare exceptions, however, we cannot claim that we are able to correct a clubfoot only with orthopaedic treatment, whatever the approach and in spite of the availability of state-of-the art technology” [1].

The BUCH protocol consisted of vigorous stretches in combination with the application of rigid tape for fixing the foot to a Dennys–Browne splint. Due to the forceful pressure induced by the stretches, the manipulations themselves were often harmful. The babies characteristically cried throughout the whole physical therapy session. Moreover, children were obliged to wear orthopaedic shoes for years and had to use rigid shoeing-splints during the night. Practicing sports was severely restricted. This conservative treatment approach was capable of correcting the mild form of clubfoot deformities (grade A), but it could not prevent the need for more extensive surgery in the higher grades. Moreover, there were frequent recurrences, even in idiopathic clubfeet.

This technique was used for years, until H. Bensahel became Head of the Department of Orthopaedics at BUCH. He was adamantly against it and succeeded in convincing the new physical therapy chief and her team of the superiority of an alternative modality, whereupon that approach for the treatment of clubfoot was abandoned altogether. His novel pathophysiologic concept of clubfoot and, more importantly, a new philosophy of its treatment was adopted, and the functional method of conservative treatment was launched. A revolutionary philosophy based on relaxation replaced the stretching one that was associated with infliction of pain and the child’s tears. The newly conceived pathophysiology focused on the origins of the deformity at the level of the Chopart-midtarsal joint [2].

The functional method was developed and implemented during the early 1970s. It is also used at the Robert Debre Children’s University Hospital (Paris) which replaced BUCH. Years of experience have led to the refinement of several technical aspects and to the improvement of its efficiency and effectiveness [3–4]. A yearly training course was organized for physicians and physical therapists, enabling a number of physical therapy teams to acquire skills in the functional method and use it in their own practice. The functional method eventually crossed the boundaries of France and is now being applied worldwide.

This method was reported in the USA at the 1975 Tachdjian Course in Chicago. Subsequent publications in the medical literature contained several works that describe the functional method and its satisfactory long-term follow-up results (i.e., at least to the end of the child’s period of growth) [5-7]. Curiously, at the turning-point of the current century, the functional method was termed the “French Method”, a name that unfortunately caught on and by which it has been called ever since by some individuals. We consider this “unfortunate” since the technique is no more French than are “fried potatoes”, another American expression. An indisputably more appropriate terminology would be the Bensahel Method (as in the Ponseti Technique) or Bensahel’s functional method of conservative treatment of clubfoot.

History should never be rewritten, but it can only be served by getting the facts right.