Original Editor - Africa Clubfoot Training Team as part of ICRC and GCI Clubfoot Content Development Project
The Pirani Score is a simple and reliable system to determine severity and monitor progress in the Assessment and Treatment of Clubfoot . This Scoring System uses the different views of the foot to help visualize the issues in the underling soft tissue and bony anatomy. A foot can be assessed in less than a minute and no technical equipment is required.
Developed by Shaque Pirani, a Canadian Orthopaedic Surgeon, who assisted in the development of Clubfoot Services in Uganda and Malawi, it is an easy to use tool, developed to assess the severity of each of the individual components of Clubfoot. It is used both as a means to assess the severity of the Clubfoot at initial presentation and for ongoing monitoring of the patients’ progress. The Pirani Clubfoot Score documents the severity of the deformity and sequential scores are an excellent way to monitor progress. An increase in the Pirani Score between visits may be an indication that a relapse in the Clubfoot Deformity is occurring.
During Ponseti Management of Clubfoot, the Pirani Score Record shows whether the deformity is correcting normally or whether there is a problem, and the degree of correction of each component of the clubfoot. The Pirani Score is also utilised to assist in determining when to perform the Tenotomy. As highlighted by Dyer et al  and others there is significant positive correlation between the initial Pirani score and number of casts required to correct the clubfoot deformity. A Pirani Scoring 4 or more is likely to require at least four casts, and one scoring less than 4 will require three or fewer. A foot with a hindfoot score of 2.5 or 3 has a 72% chance of requiring a tenotomy, which is done when the midfoot score is less than 0.5.
The Pirani Score System is reliable, quick, and easy to use, and provides a good forecast about the likely treatment for an individual foot but a low score does not exclude the possibility that a tenotomy may be required.
The Pirani Score is intended for use as a means to assess the severity of the clubfoot at initial presentation and for ongoing monitoring of the patients’ progress.
Methods of Use
The Pirani Scoring System is based on 6 well-described Clinical Signs of Contracture characterizing a severe clubfoot:
- If the sign is severely abnormal it scores 1
- If it is partially abnormal it scores 0.5
- If it is normal it scores 0
Scoring the foot at each visit during treatment enables the health care worker treating the child to document how the foot is responding to manipulation and casting.Many degrees of severity and rigidity of Clubfoot are found at birth. Failures in treatment are related more often to faulty technique of manipulation and casting rather than severity of deformity.
The examiner is seated. The infant is on the mother’s lap. A feeding, relaxed infant allows a more precise examination. The measurements are made while the examiner is gently correcting the foot with minimal effort, and no discomfort.
The Pirani Score key features: 
- Six “Signs” are Assessed
- Scored depending on Severity - 0, 0.5, or 1
- 3 Signs in Midfoot
- 3 Signs in Hindfoot
- Total Score (TS) varies from 0 to 6 and is the sum of Midfoot and Hindfoot Contracture Scores:
Mid Foot Contracture Score (MFCS)
Varies between 0 and 3 with 3 signs each scored 0, 0.5, or 1
- Medial Crease (MC)
- Gently correct the foot, e.g. by lifting the foot holding the second toe
- Assess the depth of the crease and the presence of other creases
- The presence of several fine creases is scored 0, two or three moderate creases is scored 0.5, and a single, deep crease where you cannot see the bottom is scored 1. 
- Curved Lateral Border (CLB)
- Make sure the child’s foot is relaxed
- Observe from the plantar aspect, and use a pen held against the lateral edge of the calcaneum
- Assess the point on the lateral border of the foot at which it deviates from a straight line
- If the border of the foot (excluding the phalanges) is straight and without deviation, score 0. If it deviates at the level of the metatarsals, score 0.5. If it deviates at the calcaneo-cuboid joint, score a 1. 
- Lateral Head of Talus (LHT)
- Palpate the head of the talus with the foot uncorrected (it may be easier to find initially if you move the foot into a more deformed position)
- Keeping your finger / thumb on the talus, gently correct the foot
- If the talus completely sinks away under the navicular, score 0. If it moves partially but doesn’t completely sink, score 0.5. If it remains fixed and does not sink, score 1. 
Hindfoot Contracture Score (HFCS)
Varies between 0 and 3
3 signs are each scored 0, 0.5, or 1
- Posterior Crease (PC)
- Gently correct the plantarflexion (equinus)
- Assess the depth of the crease and the presence of other creases
- Empty Heel (EH)
- Hold the foot in mild correction and palpate with a single index finger
- Ascertain how much flesh there is in the heel between your finger and the calcaneum
- If it is easy to palpate the calcaneum, which is not far under the skin, score 0. Score 0.5 for a palpable calcaneum which is just felt through a layer of flesh. If the calcaneum is deep under a layer of tissue and very difficult to feel, score 1. (0 is like touching your own chin, 0.5 like touching the tip of your nose, and 1 like touching the soft part of your palm below the base of your thumb). 
- Rigid Equinus (RE)
- Correct the plantarflexion as much as is comfortable for the child, holding the knee straight
- Assess the degree of dorsiflexion obtained: able to dorsiflex beyond plantigrade = 0, able to reach plantigrade (or 90°) = 0.5, unable to reach plantigrade (or 90°) = 1. 
Pirani Score Record Sheet
The Pirani Score should be recorded at each visit during the correction phase of clubfoot treatment. Most clinics have a paper form to record it. Below is an example of the Global Clubfoot Initiative Pirani Score Form. You will also find two other examples of Clubfoot Assessment Forms including the Global Clubfoot Initiative Pirani Score Form and the CURE Clubfoot Form to record and display the history, physical examination, and treatment in the Resource Section below. 
|Curved Lateral Border
|Lateral Head Talus
|MID FOOT CONTRACTURE SCORE
|HIND FOOT CONTRACTURE SCORE
Pirani Score Graph
Putting the Pirani Score into a Graph:
- If the Midfoot Contracture Score (MFCS), the Hindfoot Contracture Score (HFCS), and the Total Score (TS) are plotted on a simple graph against time, you can follow the improvement of the foot.
Use of Pirani Score to indicate Tenotomy:
- Achilles Tenotomy is the final part of correcting a clubfoot. The Pirani Score can indicate when the foot is ready for a tenotomy. The graph below shows the effects of Ponseti Treatment and Tenotomy on the MFCS, HFCS, and TS. The MFCS drops rapidly with manipulation and casting whereas the HFCS remains high. The tenotomy is done in Week 5 when the MFCS has less than 0.5 but the HFCS remains greater than 1. After the tenotomy, the HFCS improves from 2.5 to 0.5, but does not correct completely.
The Pirani Scoring system has been found to be both valid and reliable, unlike many other Clubfoot Scoring Systems, which are untested.  A higher Pirani Score on presentation may indicate that a higher number of casts will be required, and as such can play a key role as a means for predicting treatment outcomes.  In a child with a high initial Hindfoot Contracture Score (HFCS) the likelihood to experience relapse of deformity during the bracing phase is much higher than in those with lower scores and should have close monitoring with special emphasis put on the importance of the use of Foot Abduction Brace when educating parents/carers.
Mejabi et al  described the Pirani scoring system as a reliable system to determine severity and monitor progress in the treatment of clubfoot. Their study showed significant correlation (p<0.001) between the midfoot score, hindfoot score, Pirani score and the number of casts to achieve correction. Also, there was correlation between the Pirani score and the need for tenotomy (p<0.001) and the progress of treatment can be monitored with the Pirani score (p<0.001).
Shaheen et al  examined the Interobserver reliability in Pirani Scoring between Paediatric Orthopaedic Surgeons and Physiotherapy Assistants who were trained Nurses with further training to work as Physiotherapy Assistants in Clubfoot management. The mean percentage of agreement of both observers for all Pirani Score Components was 83%. They found moderate to substantial interobserver reliability for the Pirani Score and all its subcomponents. Properly trained physiotherapy assistants are efficient in assessing the degree of severity of clubfoot.  Similarly Jillian et al  found the Pirani Score to be a reliable measurement tool by plaster technicians for independent assessment of clubfoot. However, they highlight that prior training and supervision in the early phase is necessary. 
Piarani et al  demonstrated validity of the Piarni Score with excellent inter-observer reliability by evaluating this clinical scoring system by correlating MRI and clinical scores.
Global Clubfoot Initiative Pirani Scoring Sheet
Pirani Score Sheet - From Research on Clubfoot Management by the Ponseti Technique in Saudi Patients
- https://www.researchgate.net/profile/Ayman_Jawadi/publication/40900581/figure/fig1/AS:[email protected]/Figure-1-The-Pirani-score.ppm
CURE Africa Clubfoot Assessment and Treatment Form
- Mejabi JO, Esan O, Adegbehingbe OO, Orimolade EA, Asuquo J, Badmus HD, Anipole AO. The Pirani Scoring System is Effective in Assessing Severity and Monitoring Treatment of Clubfeet in Children , British Journal of Medicine & Medical Research 17(4): 1-9, 2016
- Dyer PJ, Davis N. The role of the Pirani scoring system in the management of club foot by the Ponseti method. Bone & Joint Journal. 2006 Aug 1;88(8):1082-4.
- Africa Clubfoot Training Project. Chapter 4 Africa Clubfoot Training Basic & Advanced Clubfoot Treatment Provider Courses - Participant Manual. University of Oxford: Africa Clubfoot Training Project, 2017.
- Goriainov V, Judd J, Uglow M. Does the Pirani score predict relapse in clubfoot?. Journal of children's orthopaedics. 2010 Aug 29;4(5):439-44.
- Pirani S, Hodges D & Sekeramayi F (2003) A reliable and valid method of assessing the amount of deformity in the congenital clubfoot deformity (The Canadian Orthopaedic Research Society and the Canadian Orthopaedic Association conference proceeding) in The Journal of Bone and Joint Surgery 90 (B) SUPP_1, 53
- Dyer P, Davis N (2006) The role of the Pirani scoring system in the management of clubfoot by the Ponseti method. The Journal of Bone and Joint Surgery 88 (8): 1082-1084
- Goriainov V, Uglow M (2010) The value of initial Pirani score assessment of clubfoot in predicting recurrence. (British Society for Children’s Orthopaedic Surgery conference proceeding) in The Journal of Bone and Joint Surgery 92B, Supp_III, 376.
- Shaheen S, Jaiballa H, Pirani S. Interobserver reliability in Pirani clubfoot severity scoring between a paediatric orthopaedic surgeon and a physiotherapy assistant. Journal of Pediatric Orthopaedics B. 2012 Jul 1;21(4):366-8.
- Jillani SA, Aslam MZ, Chinoy MA, Khan MA, Saleem A, Ahmed SK. A comparison between orthopedic surgeon and allied health worker in Pirani score. J Pak Med Assoc. 2014 Dec;64(12 Suppl 2):S127-30.