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.

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

11. •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

12. 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

13. 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

14. 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

15. 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

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

17. 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

19. 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

20. 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

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

23. 20% to 37% people have pes planus and majority are of
flexible.
male = female
Genetic relationship
EPIDEMIOLOGY

24. 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

25. 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

26. •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

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

28. 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

29. ASSESSMENT

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

32. 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

33. 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

34. 1. 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

35. 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

36. PHYSIOTHERAPY

37. 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

38. 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

39. 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

41. 1. 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

42. 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.

43. 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

44. 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

46. 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.

47. 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.

48. CONT

49. 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

50. 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

51. 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

53. https://scholar.google.com/scholar?hl=en&as_sdt=0
%2C5&q=physiotherapy+treatment+of+coxa+vara&b
tnG=#d=gs_qabs&t=1712637525998&u=%23p%3D
Wnx6r3IXdK0J
https://www.orthobullets.com/pediatrics/4041/develop
mental-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

54. By Akshat Gautam