Physiotherapy management of deformity

It contain : pes cavus,pes planus,coxa vara

1. PHYSIOTHERAPY MANAGEMENT OF DEFORMITY Bpt 3rd year By Akshat Gautam

2. CONTENT 1. pes cavus 2. pes planus 3.Coxa vara

3. Malformation of any component of body is called deformity. There are two types of deformity a) congenital b) aquired INTRODUCTION

4. It is the deformity characterized by excessive longitudinal arch that results from an equinus position of the forefoot in relation to the hind foot. PES CAVUS

5. People who suffer from this condition will place too much weight and stress on the ball and Heel of the foot while standing or walking. # Delayed onset full rigidity occur before puberty. #8% to 15% of population is suffering #30% cases are idiopathic #70% are neurologic #Also known as claw foot,high arch foot,cavus foot ABOUT THIS

6. EITIOLOGY

7. PATHOANATOMY # Due to weak tibialis anterior and strong peroneus muscle causes the forefoot to undergoes eversion ( pronation or valgus ) to balance tripod position hindfoot undergoes inversion ( supination or varus ) # Extensor hallucis longus , tibialis anterior unable to balance strong peroneus longus,tibialis posterior and tricep surae muscle Which leads to plantar flexion. # Due to weak peroneus brevis and strong tibialis posterior, calcaneus undergoes inversion and adduction means supination of hind foot occur.

8. • In Heel strike • Midfoot unlock • Arch become flexible To absorb shock PATHOMECHANICS • In toe off • mid foot lock • Elevation of arch occur

9. •During gait the first ray strike first before heel strike and interphalangeal joints are flexed while MTP are extended. Note IP joints are flexed due to FDL and MTP joint are extended due to EDL. • Initially the deformity is soft but rigid as the disease progress. Heavy callus and plantar ulcers are common on 1st and 5th metatarsal head due to high plantar pressure and reduced sensation in these area. This can leads to infection and amputation. PATHOMECHANICS

10. 1 . Metatarsalgia 2 . Pain under first metatarsal 3 . Painfull callosites 4 . Keratosis 5. Difficulty in walking 6. Shoes not fit properly 7. Unable to participate in sports,dancing and other activities CLINICAL PRESENTATION

11. physical examination: 1. Assess arch height : measure with 50% of foot length. Over 0.37mm indicate pes cavus 2. Assess arch rigidity: Arch height in standing/ Arch height in sitting 3. Arch drop : Arch height in standing - Arch height in sitting 4. Skin integrity: any lesion or callus under 1st and 5th MTP 5. Enlarged peroneal tubercel on palpation 6. atrophy of TA,PB ASSESSMENT

12. Examination: 1. Range of motion : Ankle dorsiflexion and toe flexion are decrease whereas plantarflexion normal 2. sensory testing : Assess light touch, pain, pressure,temp,proprioception 3. muscle strenth : TP,PL,Calf are tight and stronger than PB,TA,Intrinsic muscle ASSESSMENT

13. 4. Gait analysis: usually pes cavus patient walk with excessive supination 5. Balance assessment: static and dynamic balance 6. fuctional mobility : Time up and go test 7. Neuro motor development : peabody developmentalscale 8. Nerve testing & reflex testing : plantar reflex 9. peek -a-boo sign ASSESSMENT

14. Goal Decrease pain Goal Improve strength of weak muscle Goal Improve ROM Goal Improve gait/balance Goal Return to recreational activity

15. Rehabilitation include : 1. stretching of tight structure : Gastrocnemius, plantar fascia,tibialisposterior, peroneus longus stretching should be provided 2. strengthening of weak muscle : Tibialis anterior, peroneus brevis strengthening must be done 3. Orthotic support: To reduce ulcer formation and callosities lateral border insoles are used to decrease pressure on lateral aspect. It has been suggested that it reduce pain and pressure only in adult population but not effective in growing population. 4. serial casting and night splints : casting along with night splints are more beneficia. It continouslystretch the tight structure and provide foot in neutral position. MANAGEMENT

16. 5. pain relief : TENS along with hydrocolator pack is used in rigid case's while cryo is used in infants and in neurological cases to reduce spasticity. But not more than 5min . 6. Gait and balance : walking with splints and insoles must be encouraged. In case of neurological defict assistive devices can also be used. 7. patient education: position changing and stretching must be done regularly and must avoid high impact sports in case of rigid cavus CONT

17. https://www.ncbi.nlm.nih.gov/books/NBK556016/ https://www.physio-pedia.com/Pes_Cavus https://en.m.wikipedia.org/wiki/Pes_cavus https://now.aapmr.org/pes-cavus/ research paper & orthopedic books REFERENCE

18. Disorder of foot characterized by loss of medial longitudinal arch . Also known as flat foot PES PLANUS

19. 20% to 37% people have pes planus and majority are of flexible. male = female Genetic relationship EPIDEMIOLOGY

20. 1. Weak ligament 2. obesity 3. poor development of foot 4. lack of neuromascular control Etiology Congenital Acquired 1. Dysfunction of tibialis posterior 2. High impact sports 3. Trauma 4. Neuropathy 5. Tarsal coalition 6. Accessory navicular bone

21. Arch present during non weight bearing condition but as the weight loaded arch disappear. Usually seen in children between 8- 10 Yr of age Types Flexible Rigid When the arch is totally absent in non weight bearing and weight bearing condition. Occur due to underlying Pathology

22. • Medial longitudinal arch is made up of : calcaneus, navicular, talus, first three cuneiforms, and first, second, and third metatarsals. PATHOANATOMY • It is supported by : spring ligament, deltoid ligament, posterior tibial tendon, plantar aponeurosis, FHL or FHB

23. • Usually TP and calonavicular ligaments weakness contribute in pes planus. • TP< pL hind foot eversion PATHOANATOMY

24. Physical examination: 1. examine the arch with or without weight bearing 2. check for posterior view of foot to show ' too many toe' sign 3. palpate TP, PF for tenderness and swelling 4. collapse medial longitudinal arch 5. valgus deformityin heel and forefoot abduction ASSESSMENT

25. ASSESSMENT

26. Reduce pain Increase foot flexibility Build normal arch Avoid soft tissue damage Improve foot muscle strength Patient reassurance

27. Management strategy: Infants : Initially casting is done which to maintain the hind foot in varus direction and fore foot adducted and supinated at the same time medial longitudinal arch is shaped by the cast till 2-3month > after 2-3months when cast is removed stretching of calf must be done with ankle rom . > Encourage walking on sand when the child begin to walk PHYSIOTHERAPY

28. PHYSIOTHERAPY Encourage the child to walk over toe and try to pick object with the help of toes. When the child grow more use AFO or supramelolar brace and when they going to school provide them arch support and avoid high impact sports

29. Rest : Initially proper rest must be given in case of both flexible and rigid flat feet to avoid any kind of soft tissue damage. 2. for pain relief: Cryotherapy must be given to heal weak muscle TP and Intrinsic muscle as well as ligament. Ultrasound along with pulsed electrical stimulation also given to reduce pain. PHYSIOTHERAPY

30. 3. To strengthen muscles: TA,TP,FHL,abductor hallucis, plantar interosseous,Intrinsic muscles to prevent valgus and flattening of arch. 4. To stretch : Calf, peroneus brevis to facilitate varus and foot adduction. 5. Toe walking 6. Towel crul 7. Heel drop on stair 8. Toe extension 9. Toe spreading 10. Roll a ball under arch PHYSIOTHERAPY

31. PHYSIOTHERAPY

32. https://www.theseus.fi/handle/10024/807633 https://www.physio-pedia.com/Pes_Planushttps://www.ncbi.nlm.nih.gov/books/NBK430802/ https://radiopaedia.org/articles/pes-planus https://en.m.wikipedia.org/wiki/Flat_feet REFERENCE

33. Coxa vara is a deformity of the hip, whereby the angle between the head and the shaft of the femur is reduced to less than 120 degrees. Types : Congenital Developmental COXA VARA

34. Features Acquired Congenital Eitiology •Proximal femur#, •Faulty maturation of cartilage • compromise vascular supply • sepsis •Secondary to osteoporosis • proximal femoral focal defficency • Fibular Hemimelia • breech presentation • embryonic Maldevelopment Observation ▪ Positive Trendelenburg sign ▪GT is prominent ▪ Restricted abduction, Int rot ▪ genu valgum ▪ ext rot hip

35. Metabolic abnormalities can cause failure, or a delay in, the normal ossification process of the proximal end of the femur 2. Congenital coxa vara is believed to be the result of a primary ossification defect in the inferior femoral neck on which physiologic shearing stresses are applied during weight- bearing.This results in damage of the dystrophic bone and an incapacity to endure repetitive biomechanical forces, resulting in progressive varus deformity PATHOGENESIS

36. physical examination: ● Grater trochanter is prominent and easily Palpable . ● In post operatively examine any incision site for infection,erythema,edema,increase temp ● limb length difference ● in sever cases genu valgum also seen.

37. CONT Examination: 1. Range of motion : Assess active and passive ROM of lower extremity joints bilaterally using goniometer. Note any asymmetry - Hip abduction is limited due to a decreased articulo-trochanteric distance - Internal rotation is limited due to decrease femoral anteversion 2. Muscle strength : Most often, there is significant muscle weakness in the involved hip, particularly the hip abductor

38. 3.Gait Analysis : –Assess gait for symmetry and note any abnormalities or complaints of pain –“Waddling” gait or a pain-free limp is most notable –Positive Trendelenburg sign (can be bilateral) –Assess the need for assistive devices pre- and postoperatively, especially if there are any weight- bearingrestrictions –Use 6-minute walk test (6MWT) for distance 4. Balance: –Assess static and dynamic sitting and standing balance. Note asymmetry or complaints of pain –Use Pediatric Balance Scale (PBS) or Berg Balance Scale (BBS) –Can also use the Balance section of the Peabody Developmental Motor Scales CONT

39. CONT 5. Posture Analysis: –Does the patient sit or stand asymmetrically due to leg-length discrepancy or pain –Increased lumbar lordosis and genu valgum is often present with developmental coxa vara affecting both extremities Special Test : 1. criag Test : patient is in prone with knee flexed 90°, examine rotate the hip so that when grater trochenter is more prominent than measure with goniometer, The degree anteversion , 15° is normal . More than 15° indicate anteversion and less than 15° indicateretroversion .

40. CONT 2. Nelaton line : draw between Asis and ischeal tuberosity. If the head of Femur is lower than this line it indicate coxa vara. 3. Galeazzi sign : patient lie supine with hip 45°flexed and knee 90° flexed and both foot heel at the same level then check the shortening of femur.

41. CONT

42. Goal 1. Decrease postoperative pain,edema and swelling 2.improve ROM 3. improve muscle strength 4.improve balance Physiotherapy Goal 5. Improve walking pattern 6. Increase functional mobility

43. This condition require combination of both physiotherapy or surgical approach to treat. 1. To decrease pain,edema: Use cryotherapy, STM 2. increase hip internal rot and abduction : carefully stretch the hip abductor, internal rotators,adductors,hamstrings and AROM 3. Improve strength: Flexors, extensors, abductors and internal rotators PHYSIOTHERAPY

44. 4. Improve balance and proprioception: single leg stance,parallel bars, obstacles walking 5. Gait Training: walking drill, step up, stair climbing, Treadmill walking 6. Functional movement: lunges,step up, kicking ball 7. pelvic stability : pelvic tilt on swiss ball . PHYSIOTHERAPY

45. https://scholar.google.com/scholar?hl=en&as_sdt=0%2C5&q=physiotherapy+treatment+of+coxa+vara&btnG=#d=gs_qabs&t=1712637525998&u=%23p%3DWnx6r3IXdK0J https://www.orthobullets.com/pediatrics/4041/developmental-coxa-vara https://radiopaedia.org/articles/coxa-vara https://en.m.wikipedia.org/wiki/Coxa_vara Bagga I B, Raghuveer R, Singh S (March 06, 2024) Physical Therapy Interventions: A Case Report of Building Strength, Confidence, and Mobility REFERENCE

46. By Akshat Gautam