Assessing Clubfoot Treatment (ACT) Tool

Original Editor - Kim Jackson Top Contributors -

Objective[edit | edit source]

The Assessing Clubfoot Treatment (ACT) score was developed for clubfoot therapists to assess the results of Ponseti treatment in children of walking age, in low resource settings, where access to qualified therapists may be limited. In many of these settings treatment is being offered by non-specialised health workers[1]. It is helpful in predicting the need for referral for further intervention, whether that is a specialist opinion or referral for further manipulation and casting[2]. The use of the ACT score is to accurately inform and predict future management. It answers such questions as:

  1. Does the child need more treatment?
  2. Has the child been successfully treated?
  3. Will the child’s quality of life be improved?

Intended Population[edit | edit source]

An evaluation tool, for clubfoot therapists (non-specialised health workers) in low resource settings, to assess the results of Ponseti treatment of congenital talipes equinovarus (CTEV) in children of walking age.[2]

Method[edit | edit source]

The ACT tool consists of 4 questions; each scored from 0 to 3, giving a total from 0 to 12 where 12 is the ideal result. The 4 questions consist of one physical assessment and three parent reported outcome measures. It takes 5 minutes to administer and has been observed to have excellent inter-observer agreement.[3]

  • The question about the plantigrade position of the foot should be answered first with physical examination of the child in supine, with the knee extended and measurement of passive range of dorsiflexion of the hindfoot.
  • The remaining three questions of the ACT score should be answered by the carers about the child’s pain, ability to wear shoes and satisfaction. The child is then given verbal instructions to complete the functional performance review.

Table 1: ACT questions and score

Score 1.The foot is plantigrade 2.Does your child complain of pain in their affected foot? 3.Can your child wear shoes of your/their choice? 4.How satisfied are you with your child’s foot?
0 Does not reach plantigrade, with additional adduction, cavus or varus Yes and it often limits their activity Never Very dissatisfied
1 Does not reach plantigrade, no additional deformity Yes and it sometimes limits their activity Sometimes Somewhat dissatisfied
2 Plantigrade achieved Yes but it does not limit their activity Usually Somewhat satisfied
3 More than plantigrade i.e. some dorsiflexion No Always Very Satisfied
  • A score of 8 or less indicates that the child needs a referral,
  • A score between 9-10 indicates that the child would benefit from a referral of surgical/medical review
  • A score of 11 or 12 indicated the child had a good outcome.

Reference[edit | edit source]

Smythe T, PhD Thesis - Evidence to improve clubfoot services in Africa with Zimbabwe as a case study London School of Hygiene & Tropical Medicine. DOI:

Evidence[edit | edit source]

T Smythe developed a tool that has good reliability both within and between examiners and is helpful in predicting the need for referral for further intervention (specialist opinion or for further manipulation and casting)[1]. A study by Smythe et al, in 2018, comparing outcome measures after the Ponsetti method had good inter-observer agreement between the two expert physiotherapists. The study found that the ACT score had 79.2% (95%CI: 57.8–92.9%) sensitivity and 100% (95%CI: 92–100%) specificity in predicting the need for referral, with positive and negative predictive values of 100 and 89.8% respectively.[2]

References[edit | edit source]

  1. 1.0 1.1 Smythe T, Wainwright A, Foster A, Lavy C. What is a good result after clubfoot treatment? A Delphi-based consensus on success by regional clubfoot trainers from across Africa. PLoS ONE,2017 12(12): e0190056.
  2. 2.0 2.1 2.2 Smythe T, Gova M, Muzarurwi R, Foster A, Lavy C. A comparison of outcome measures used to report clubfoot treatment with the Ponseti method: results from a cohort in Harare, Zimbabwe. BMC Musculoskeletal Disorders. 2018, 19:450
  3. Smythe, TH; (2018) Evidence to improve clubfoot services in Africa with Zimbabwe as a case study. PhD (research paper style) thesis, London School of Hygiene & Tropical Medicine. DOI: