Physiotherapy for CONGENITAL TALIPES EQUINOVARUS
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Physiotherapy for CONGENITAL TALIPES EQUINOVARUS
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Physiotherapy for CONGENITAL TALIPES EQUINOVARUS
- 2. Sreeraj S R • https://www.youtube.com/watch?v=psdsqsdAxc0&ab_channel=NationalGeograp hic • Anatomy of foot • https://www.youtube.com/watch?v=ROd1Acma64o&ab_channel=RandaleSechre st
- 3. Sreeraj S R Introduction • Congenital Club Foot (CCF) OR CTEV • Deformities occurring at the region of the ankle, subtaloid and mid-tarsal joints. • Three different types: 1. Idiopathic 2. Neurogenic and 3. Syndromic
- 4. Sreeraj S R 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. Sreeraj S R • 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 adapt to the loads under which it is placed. • Davis law: Intermittent stretch causes collagenous tissues to hypertrophy until the resulting hypertrophy until the resulting increase in strength reduces elongation in tension to some minimum level (stretch-hypertrophy rule). •
- 6. Sreeraj S R • The underlying deformity of clubfoot can be divided into four components, “CAVE”. 1. Cavus: Forefoot plantar flexion 2. Adductus: Talonavicular and tarso metatarsal joint joint 3. Varus: Primary at sub talar joint but entire tarsus rotated except talus. tarsus rotated except talus. 4. Equinus: At the ankle joint plantar flexion of the forefoot. forefoot.
- 7. C a v u s : the foot has a high arch, or a caved appearance. A d d u c t u s : the forefoot curves inwards toward the big toe. V a r u s :. the heel is inverted, or turned in, forcing one to walk on the outside of the foot which is fixed in this position E q u i n u s : the foot is pointed downward, forcing one to walk on tiptoe because the Achilles tendon is tight and pulls the foot downwards.
- 8. Sreeraj S R 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. Sreeraj S R • https://youtu.be/fblU3dD6nwQ?t=18
- 10. Sreeraj S R 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. Sreeraj S R 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.
- 12. Sreeraj S R 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. Sreeraj S R Stretching and adhesive strapping • Before commencing the procedure, the right knee should be in 900 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. Sreeraj S R 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. Sreeraj S R Stretching and adhesive strapping • https://www.youtube.com/watch?v=vgp3Id9rX9k&ab _channel=TaralNagda • https://www.youtube.com/watch?v=sF9AupChJhs&a b_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. Sreeraj S R 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. Sreeraj S R Further View • https://www.youtube.com/watch?v=RzHe92JffIs&ab_ channel=hitechlabsrl
- 20. Sreeraj S R References 1. Ezeukwu AO, Maduagwu SM. Physiotherapy management of an infant with Bilateral Congenital Talipes Equino varus. Afr Health Sci. 2011;11(3):444-448. 2. 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 3. 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 4. Wikipedia Contributors. Davis’s law [Internet]. Wikipedia. Wikimedia Foundation; 2020 [cited 2020 Dec 30]. Available from: https://en.wikipedia.org/wiki/Davis%27s_law 5. 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. 6. Pirani Score [Internet]. Physiopedia. 2011 [cited 2021 Jan 1]. Available from: https://www.physio- pedia.com/Pirani_Score 7. Ponseti IV. Treatment of congenital club foot. J Bone Joint Surg Am. 1992 Mar;74(3):448-54. 8. Ponseti method [Internet]. Physiopedia. 2013 [cited 2021 Jan 1]. Available from: https://tinyurl.com/y87your3 9. Ezeukwu AO, Maduagwu SM. Physiotherapy management of an infant with Bilateral Congenital Talipes Equino varus. African Health Sciences. 2011;11(3):444–8. 10. 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
Editor's Notes
- Idiopathic Clubfoot Also known as talipes equinovarus, idiopathic clubfoot is the most common type of clubfoot and is present at birth. This congenital anomaly is seen in one out of every 1,000 babies, with half of the cases of club foot involving only one foot. There is currently no known cause of idiopathic clubfoot, but baby boys are twice as likely to have clubfoot compared to baby girls. Neurogenic Clubfoot Neurogenic clubfoot is caused by an underlying neurologic condition. For instance, a child born with spina bifida A clubfoot may also develop later in childhood due to cerebral palsy or a spinal cord compression. Syndromic Clubfoot Syndromic clubfoot is found along with a number of other clinical conditions, which relate to an underlying syndrome. Examples of syndromes where a clubfoot can occur include arthrogryposis, constriction band syndrome etc
- The ‘mechanical forces’ or ‘positional’ hypothesis Hoffa (1902) believing that restriction of fetal foot movement by the uterus caused CTEV. Also arguing against the positional hypothesis is the fact that clubfoot can be detected from the second trimester, long before any uterine pressure would be exerted on the developing embryo in most cases. The bone/joint hypothesis The bone/joint hypothesis postulates that positional bony abnormalities underlie the anomaly. Hippocrates wrote: ‘The deformity involves the entire combination of bones which make up the skeleton of the foot. All the changes seen in the soft part are secondary …’ The connective tissue hypothesis This is supported by the association of CTEV with joint laxity (Wynne-Davis, 1964. Affected children have marked plantar fibrosis at surgery. Ippolito & Ponseti (1980) documented the presence of increased fibrous tissue in muscles, fascia, ligaments and tendon sheaths. Atlas et al. (1980) performed a systematic pathological study of 12 fetuses with CTEV. They concluded, ‘muscular, tendinous, fascial & other soft tissue elements are not conspicuously abnormal’. The vascular hypothesis Atlas et al. (1980) documented vascular abnormalities in ‘all deformed feet of 12 foetuses’. At the level of the sinus tarsi there was blocking of one or more branches of the vascular tree of the foot. Individuals with idiopathic congenital talipes equinovarus have muscle wasting of the ipsilateral calf, which may be related to reduced perfusion through the anterior tibial artery in development. Support for a neurological hypothesis Talipes equinovarus is a feature of many neurological syndromes; for example, it is often seen in association with neurological abnormalities that are secondary to spina bifida. Abnormal nerve conduction was reported in 18 of 44 cases of CTEV, with eight of these 18 cases having abnormality at the spinal level (Nadeem et al. 2000). The developmental arrest hypothesis During late normal human limb development (9–38 weeks), chondrification of the foot is completed, ossification commences, joint cavitation and ligament formation is completed, and the distal limb rotates medially (Bareiter, 1995). Böhm (1929) concluded that ‘a severe club-foot resembles an embryonic foot at the beginning of the second month … and the deformity is accompanied by underdevelopment of the bones and muscles. His findings were later replicated by Kawashima & Uhthoff (1990). These studies support the view that clubfoot may arise due to an arrest of the normal medial rotation of the foot in late foetal development. Indeed, it may be that CTEV occurs as a result of aberrant genetic control of this rotation process, or its disruption.
- Wolff's law developed by the German anatomist and surgeon Julius Wolff (1836–1902) in the 19th century. If loading on a particular bone increases, the bone will remodel itself over time to become stronger to resist that sort of loading. The internal architecture of the trabeculae undergoes adaptive changes, followed by secondary changes to the external cortical portion of the bone, perhaps becoming thicker as a result. The inverse is if the loading on a bone decreases, the bone will become less dense and weaker due to the lack of the stimulus required for continued remodeling. This reduction in bone density (osteopenia) is known as stress shielding Davis's law is used in anatomy and physiology to describe how soft tissue models along imposed demands. It is the corollary to Wolff's law It is a physiological principle stating that soft tissue heal according to the manner in which they are mechanically stressed.
- Contributors to Wikimedia projects. bone development disease [Internet]. Wikipedia.org. Wikimedia Foundation, Inc.; 2004 [cited 2020 Dec 31]. Available from: https://en.m.wikipedia.org/wiki/Clubfoot
- https://www.youtube.com/watch?v=fblU3dD6nwQ&ab_channel=TheYoungOrthopod
- All the motion of the foot occurs around the talus Calcaneo pedis block All correction occurs simultaneously by abduction around the talus Correction occurs by allowing normal tarsal bone kinematics