Physiotherapy for CONGENITAL TALIPES EQUINOVARUS

Physiotherapy for CONGENITAL TALIPES EQUINOVARUS

1. Physiotherapy for CONGENITAL TALIPES EQUINOVARUS Dr Sreeraj S R

2. https://www.youtube.com/watch?v=psdsqsdAxc0&ab_channel=NationalGeographic Anatomy of foot https://www.youtube.com/watch?v=ROd1Acma64o&ab_channel=RandaleSechrest

3. Introduction Congenital Club Foot (CCF) OR CTEV Deformities occurring at the region of the ankle, subtaloid and mid-tarsal joints. Three different types: Idiopathic Neurogenic and Syndromic

4. Aetiological theories The ‘mechanical forces’ or ‘positional’ hypothesis due to uterine restriction. The bone/joint hypothesis The connective tissue hypothesis The vascular hypothesis Neurological hypothesis The developmental arrest hypothesis

5. The severity of the deformity depends on the degree of displacement , whereas The resistance to the treatment is determined by the rigidity of the soft tissue structures. Wolf’s law: states that bone in a healthy person or animal will adapt to the loads under which it is placed. Davis law: Intermittent stretch causes collagenous tissues to hypertrophy until the resulting increase in strength reduces elongation in tension to some minimum level (stretch-hypertrophy rule). ‌

6. The underlying deformity of clubfoot can be divided into four components, “CAVE”. C avus : Forefoot plantar flexion A dductus : Talonavicular and tarso metatarsal joint V arus : Primary at sub talar joint but entire tarsus rotated except talus. E quinus : At the ankle joint plantar flexion of the forefoot.

7. Cavus : the foot has a high arch, or a caved appearance. Adductus : the forefoot curves inwards toward the big toe. Varus : . the heel is inverted, or turned in, forcing one to walk on the outside of the foot which is fixed in this position Equinus : the foot is pointed downward, forcing one to walk on tiptoe because the Achilles tendon is tight and pulls the foot downwards.

8. Soft Tissue Posterior contracture: Tendo Achilles, Tibiotalar capsule, talocalcaneal capsule, posterior talofibular ligament, calcaneo fibulas ligament. These structures resist equinus correction. Medial: Most important and most resistant structures Tibialis posterior, deltoid, talonavicular capsule and spring ligament. Subtalar: Talocalcaneal interosseous ligament, bifurcated Y ligament. Plantar : Abductor Hallucis, intrinsic flexors, quadratus plantae, plantar aponeurosis.

9. https://youtu.be/fblU3dD6nwQ?t=18

10. Management of CTEV Aims: To correct the deformity early To correct the deformity fully Hold the correction until growth stops. Non-operative treatment: Manipulation and serial casting Stretching and adhesive strapping (French method) Dennis - Browne splinting Education and instructions to the mother and/or parents

11. The Pirani Score The Pirani Score is a simple and reliable system to determine severity and monitor progress in the Assessment and Treatment of Clubfoot. The Pirani Score is also utilized to assist in determining when to perform the Tenotomy . 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.  https://www.physio-pedia.com/Pirani_Score

12. Stretching and casting ( Ponseti Method) The Ponseti method entails weekly serial manipulation and casting according to a specific protocol followed by heel cord tenotomy when necessary. The components of the clubfoot deformity must be corrected in the sequence C-A-V-E. WATCH https://youtu.be/IVOUKTZaI4w?t=47

13. Stretching and adhesive strapping Before commencing the procedure, the right knee should be in 90 flexion to prevent damage to the lower end of tibial and fibular epiphyses, and the knee joint. Each of the above manipulation is for about two minutes and the entire procedure repeated four times. The soft tissues of the foot is passively stretched to correct adduction, inversion and equinus .

14. Stretching and adhesive strapping To correct adduction The forefoot is uncurled so that it moved away from the ipsilateral heel (that is forefoot abduction). To correct the inverted foot. The foot is turned such that the sole faced outward (that is eversion) To correct the equinus (plantar flexion deformity) The heel is cupped with the right hand from the front of the foot and an upward pressure is applied to it bringing the forefoot upward. This brings the ankle into dorsiflexion.

15. Stretching and adhesive strapping https://www.youtube.com/watch?v=vgp3Id9rX9k&ab_channel=TaralNagda https://www.youtube.com/watch?v=sF9AupChJhs&ab_channel=Nemours

16. To maintain the feet in the corrected position, strapping was commenced. https://youtu.be/R76sG0L9Co8?t=271 Stretching and adhesive strapping

17. Used when long leg cast is removed after 3 weeks of treatment. The bar is fit shoulder-width apart and worn full time for the 1st two months. Dennis - Browne splinting

18. Education to the mother and/or parents Give assurance that the deformity would be corrected with her co operation, consistency and compliance and the progress is gradual. Convey the importance of follow up when the baby starts walking. Teach her how to mobilize the feet in the absence of strap. Observe at frequent intervals for unusual crying by the baby, swollen or bluish coloration of the toes and report the same to hospital. Advised her to prevent the strapping or plaster from being wet or soiled.

19. Further View https://www.youtube.com/watch?v=RzHe92JffIs&ab_channel=hitechlabsrl

20. References Ezeukwu AO, Maduagwu SM. Physiotherapy management of an infant with Bilateral Congenital Talipes Equino varus .  Afr Health Sci. 2011;11(3):444-448. Sahoo J. Club Foot / CTEV [Internet]. [cited 2020 Dec 30]. Available from: http://svnirtar.nic.in/sites/default/files/resourcebook/23._club_foot-Dr_J_Sahoo.pdf Wikipedia Contributors. Wolff’s law [Internet]. Wikipedia. Wikimedia Foundation; 2020 [cited 2020 Dec 30]. Available from: https://en.wikipedia.org/wiki/Wolff%27s_law#cite_note-1 Wikipedia Contributors. Davis’s law [Internet]. Wikipedia. Wikimedia Foundation; 2020 [cited 2020 Dec 30]. Available from: https://en.wikipedia.org/wiki/Davis%27s_law Adewole A, Williams OM, Shoga MO, Kayode MO, Giwa SO. Experience with Ponseti Protocol and Achilles Tenotomy in The Management of Clubfoot at the Lagos State University Teaching Hospital, lagos , Nigeria. J West Afr Coll Surg. 2017;7(2):65-76. Pirani Score [Internet]. Physiopedia . 2011 [cited 2021 Jan 1]. Available from: https://www.physio-pedia.com/Pirani_Score Ponseti IV. Treatment of congenital club foot. J Bone Joint Surg Am. 1992 Mar;74(3):448-54. Ponseti method [Internet]. Physiopedia . 2013 [cited 2021 Jan 1]. Available from: https://tinyurl.com/y87your3 Ezeukwu AO, Maduagwu SM. Physiotherapy management of an infant with Bilateral Congenital Talipes Equino varus. African Health Sciences. 2011;11(3):444–8. Club Foot(Congenital talipes equinovarus) - The Nepali Doctor [Internet]. The Nepali Doctor. 2020 [cited 2021 Jan 2]. Available from: https://thenepalidoctor.com/club-foot/

21. Thank You