## Pirani Scoring System for CTEV **Key Point:** The Pirani scoring system is a clinical tool used to assess the severity of CTEV at presentation and monitor response to treatment. It is based on six clinical signs, NOT imaging. ### Components of Pirani Score The system divides assessment into two domains: #### Hindfoot Domain (3 signs) 1. **Posterior crease depth** — depth and prominence of the crease behind the ankle 2. **Lateral head of talus coverage** — palpable prominence of the lateral talar head 3. **Lateral border of foot** — curvature and rigidity of the lateral border #### Midfoot Domain (3 signs) 1. **Medial crease depth** — depth of the medial longitudinal crease 2. **Medial border of foot** — curvature of the medial border 3. **Lateral border of foot** — (overlaps with hindfoot assessment in some versions) **High-Yield:** Each sign is scored 0 (normal), 0.5 (intermediate), or 1 (severe). Total score ranges from 0 to 6, with higher scores indicating greater severity. ### Scoring Interpretation | Pirani Score | Severity | Clinical Implication | |--------------|----------|----------------------| | 0–1 | Mild | Good prognosis with conservative care | | 1.5–3 | Moderate | Requires intensive treatment | | 3.5–6 | Severe | High risk of relapse; may need surgery | **Clinical Pearl:** Pirani score is **clinical** (bedside), not radiological. It does not require X-rays or imaging, making it practical for resource-limited settings and serial follow-up. **Warning:** ~~Tibial torsion~~ is a separate radiological measurement (not part of Pirani) and is assessed on CT or clinical rotation testing, not as part of the standardized Pirani scoring. 
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