It contain all types of deformity physiotherapy management

1. Pt management of deformity
By Akshat Gautam
Bpt 3rd year
Orthopedic physiotherapy

2. What is deformity
• Malformation of any component of body is called deformity
• The malformation may be due to bony deformation or Alternation in
typography of soft tissue
Types of deformity
There are two types of deformity
a) Congenital
b) Acquired

3. Congenital deformity
• These are the deformity that are present by birth
• Some of these deformity present at birth while some develop during
growth
• Deformity may be sever & lifetime
Cause of congenital Deformity
1. Genetic abnormality [eg : diaphysial aclasis, Mongolism ]
2. Environmental factor [ eg : Phocomelia]
3. Combined factor [ eg : Congenital dislocation of hip,clubfoot]

4. Acquired deformity
The acquired deformity is that which Was not present at birth and has
developed after birth
They could be bony disease,joint disease,muscle disease,ligament
disease,
They develop due to postural issue,nerve lesion,occupation
related,pathological

5. Deformity covered
1. Thoracic outlet syndrome
2. Torticollis
3. Congenital talipes equinovarus
4. Pes cavus
5. Pes planus
6. Coxa Vera

6. Thoracic Outlet syndrome
• It is the varied pattern of sing and Symptoms Caused by the
compression of upper Extremity neurovascular bundle at interval
within thoracic outlet space.

7. Physiotherapy management
• Goal of treatment :
1. Calm the nervous system
2. Increase strength & functional stability In the core muscle of
spine,shoulder & trunk
3. improve cardiovascular condition
• Exercise Programme
1. Breathing exercises in supine
2. Seated ball exercise
3. Foam roll exercise & thoracic mobilization

8. Cont,
4. Scapular strengthening
5. Neural mobilization
6. Postural training & core stabilization
7. Aerobic conditioning

9. Breathing exercises
Main aim of Breathing exercises is to calm down the nervous system.
There are 4 types of Breathing exercise
(A) Diaphragmatic Breathing exercises: Patient is in supine lying with
hands rest on abdomen and knee are flexed or the position may be
modified by genral relaxation technique (placing rolled towel below
neck,shoulder,low back knee) To achive relaxation.Main aim of
diaphragmatic Breathing is to Limit activation of sclanea muscle
used in upper chest breathing. Patient is asked to do
• Inhalation through nose while tilting pelvis anteriorly
• Exhalation through mouth by blowing action while tilting pelvis
posteriorly

10. https://youtube.com/shorts/1Fg0SO3pPfk?si=fe9ybYwXZziwB
LTu

11. Cont,
• You can also support the upper extremity By using
cotton tshirt or belt to achive more relaxation By
putting brachial plexus in relaxed pose as well as
upper extremity

12. Cont,
• Main advantage is that when patient tilt pelvis anteriorly; lumbar
spine will extend & head will slightly flexed and shoulder or upper
body will move toward feets
• Or when the patient tilt the pelvis posteriorly alignment of body
segment become normal
Result :
>There is little or no movement seen in cervical spine,head & shoulder
> If patient experience low back pain while doing this then the amount
of pelvic tilt can be reduced

13. Cont,
(B) Diaphragmatic breathing with paired lower extremity movement:
position of patient is similar to that of first exercise.
It is performed in two stage
First stage : patient lying supine with knee extended & hip externally
rotated and slightly abducted. Breathing pattern is same as first
exercise
Second stage : patient is lying supine and follow the same pattern of
Breathing as demonstrate in first exercise. In addition there is external
rotation of hip during inhalation & internal rotation during exhalation.

14. Cont,
Result :
> During extension there is a full body stretch occur.
Some patient may experience in performing this
extended pose then place a rolled towel under
knee to slightly flex the knee.

15. (C) First rib mobilization with ball &
stick: Patient is supine with ball is in
posterior aspect of 1st rib and the
stick end touching the wall.
As the patient inhale along with
anterior tilting of pelvis.pushes the
patient away from ball & vice versa.
This exercises combine the effect of
diaphragmatic Breathing with
caudal mobilization of 1st rib.

16. (D) Supine breathing with air bag : It
is performed in 3 stages. Patient
position is same and breathing
pattern is also same.
First stage : air bag is placed under
hip
Second stage : air bag is placed
under lumbar spine
Third stage : air bag is placed under
thoracic spine

17. Seated ball exercise
• It is performed in 3 stages
(A)Seated ball exercise : patient is in
sitting over exercise ball with
back straight and head facing
forward. Patient is instructed to
initiate the diaphragmatic
breathing while moving the ball
in forward – backward direction,
side to side direction, circulatory
direction.

19. (B) Seated ball with pelvic tilt :
Patient sit over the exercises ball
and Tilt the pelvis anteriorly when
inhale and vice versa
https://youtu.be/Y2TLxsGVcU4?si=
W8V7B6tabIZneVyV

20. (C) Supine ball exercise: First patient
sit over ball with back straight
(thinker pose). By sliding back over
ball. During exhalation patient
extend his neck and arms backward
and while inhaling regain previous
pose in diaphragmatic
pattern.https://youtu.be/Y2TLxsGVc
U4?si=W8V7B6tabIZneVyV

21. Foam roll exercises &
thoracic mobilization
• Patient lying supine over foam roller
with hips flexed so that feets touches
the ground and place upper
extremity folded so that scapula
remain protracted and ribcage or
spine is fully exposed. Patient can
use a towel roll to support head if
uncomfortable. Then instruct the
patient to slowly inhale via nose and
then exhale in diaphragmatic pattern
while doing this they can roll the
roller to move laterally

22. Cont,
• Transverse foam roll exercises: patient
lying over roller at mid scapular level and
hands placed below the neck to support
head. Thoracic spine may be extended or
flat and hips or knee flexed so that feets
touches the ground. Patient my touch or
not touch there buttocks to ground.
Patient is instructed to roll upward or
downward while doing diaphragmatic
breathing. Rolling should be done
between inferior angle of scapula to
upper thoracic spine.
• https://youtu.be/NS73eSohTbc?si=AU2fy
-esFN5APsrT

23. • Three inch roller at sacrum and
lumbothoracic spine : Place a
3inch diameter roller at sacrum
and instruct the patient to laterally
rotate the knee After this patient
is asked to place roller at L5-S1
level and asked to roll till lower
thoracic spine to sacrum. Caution
should be considered if patient
has low back condition or spine
disease. You can place a wedge
below hip to flaten lower spine

24. Strengthening exercises
• Strengthening exercises for home are not advised ultil patient
condition stabilized.
• Specific exercises should be selected based on patient tolerance
• Scapular & rotator cuff strengthening should be done
• Bicep and tricep crul may be added
• Slowly patient progress to lift weight in over head exercise
• Push ups or pull ups added later in program as per patient need
• Core strengthening or low extremity strengthening may be done as
per patient need.

25. Stretching & neural
mobilization
• Nerve Stretching & nerve flossing
technique are directed
• It is not recommended that to
continue nerve Stretching
exercises along with strengthening
exercises
• https://youtu.be/oYOASLgip28?si=
bb6CsMVuJ_nSmpu_

26. Postural training
• Ask patient to sit with back
straight to improve breathing
pattern
• Slouched sitting is avoided
because it may compress the
nerves & abdomen
• It is found that thinker position is
beneficial

27. Cardiovascular
training
• It is recommended to walk 3 to 4
times a day 20 min at 3mph
• Help to reduce pain & enhance
arm swinging
• It include myofacial
release,Trigger point
therapy,Cross fiber
friction,Stripping, gentle passive
stretching
Manual therapy

28. Tapping
• Kinesio taping for scapular
stabilization is used to reduce
symptoms of TOS

29. Congenital Torticollis[Neck region]
• It is the condition in which sternocleidomastoid
muscle gets contracture.so that neck move to the
opposite side by the pulling action of tightened scm.
• Tumor Palpable at birth or during first two
Week of life.
• More common on right side.
• Usually contracture develop at site of clavicle
Attachment
• It attain maximum size in 1-2 month.

30. Continue

31. Physiotherapy management
• Passive stretching- Physiotherapists often teach parents how to
perform passive stretching exercises to gently stretch the tight neck
muscles. These stretches should be done multiple times a day. Stretch
include lateral rotation & flexion.
• Active Range of Motion Exercises: As the baby gets older, active range
of motion exercises can be introduced to encourage the infant to
move their head in both directions.
• Tummy Time: Placing the baby on their stomach when awake and
supervised helps in developing neck strength and control.
• Positioning: Proper positioning of the baby during feeding, sleeping,
and playtime is crucial. Using a headrest or pillow to support the non-
affected side can help.

32. Continue
• Parent Education: Educating parents about the condition, the
importance of consistent home exercises, and monitoring the baby’s
progress is a key aspect of physiotherapy.
• Orthotic Devices: In some severe cases, orthotic devices like collars or
helmets may be recommended to help maintain proper head
position.
• Transcutaneous Electrical Nerve Stimulation (TENS): TENS units
deliver low-level electrical currents to the skin’s surface, which may
help with pain relief in cases where congenital torticollis causes
discomfort. It could be used in combination with other physical
therapy techniques.
• Electrical Muscle Stimulation (EMS): EMS can be used to facilitate
muscle contractions and might have a role in strengthening and re-
educating the neck muscles in congenital torticollis, especially in older
children.

33. Continue
• Heat Therapy: Although not strictly electrotherapy, the application of
moist heat through hydrocollator packs or warm compresses may
help relax tight neck muscles and improve the effectiveness of
stretching exercises.
• Ultrasound Therapy: Ultrasound therapy can promote tissue
relaxation and potentially aid in reducing muscle tension. It may be
used in conjunction with manual therapy techniques.
• Kinesio taping : To apply kinesio tape to the SCM: on the affected
side, place tape from insertion to origin of SCM with 5-10% tension;
on the unaffected side place tape from origin to insertion with 10-
15% tension

34. Continue
• https://youtu.be/LxGenW5EHxU?si=Px_7cLKDckTkLN5a ( for stretch)
• https://youtu.be/uLTv1_j1eMQ?si=QJn9oZQm06LFZVZa( for orthotic)
• https://youtu.be/zsGtgofNJuw?si=Gnma_POmeyJbURPD ( for kinesio
taping)
• Home care advice : place toys/decorations to encourage infant to turn
to other side
• position the crib or changing table, so the infant must turn to the
other side to see / interact with caregivers

35. Coxa vara
• 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.
This results in the leg being shortened and the development of a limp.
• It cause adduction and external rotation of hip
• Idiopathic
• congenital: mild or severe coxa vara, with associated congenital
anomalies: see associations
• developmental: progressive, usually appearing between the ages of
two and six years, with characteristic radiographic features
• rachitic: usually associated with active rickets
• adolescent: secondary to the slipped capital femoral epiphysis
• traumatic: usually following fracture of the femoral neck (rare in
children)
•

36. Continue
• Inflammatory: secondary to tuberculosis or other infection
• secondary to other underlying bone diseases such as:
• osteogenesis imperfecta
• cretinism
• dyschondroplasia
• Paget’s disease
• osteoporosis
Symptoms:
• It restrict Abduction,internal rotation
• Pain in the leg and/or hip
• A one-sided limp or “waddling walk”
• Stiffness when trying to move the leg out
• A slight difference in leg length

37. Physiotherapy management
• Post operative pain,oedema & swelling: Cryotherapy, kinesiotaping, soft tissue
mobilization
• Range of Motion Exercises: Physiotherapists will work on improving the range of
motion in the affected hip joint through gentle and controlled exercises. These
exercises help maintain flexibility and prevent joint stiffness. Emphasizes will be
given to increase internal rotation & abduction. Hot packs, soft tissue massage
and NMES should be done
• Strengthening Exercises: Strengthening the muscles around the hip joint,
especially the abductors, adductors, and gluteal muscles, can help provide
stability and support for the hip. Strengthening exercises may involve resistance
bands or bodyweight exercises.

38. Cont,
• Balance training: Static & dynamic balance training should be given
• Stretching: Gentle stretching exercises can help alleviate muscle tightness
and improve hip mobility. These may include stretches for the hip flexors,
hamstrings, and quadriceps.
• Assistive Devices: In some cases, crutches or other assistive devices may be
recommended to reduce the load on the affected hip joint and improve
mobility
• Gait Training: Physiotherapists may focus on correcting walking and
standing posture to alleviate stress on the hip joint and promote more
efficient movement patterns. Re-education in walking to eliminate pelvis
drop and waddling gait

39. Congenital talipes equinovarus
• Congenital talipes equinovarus, also known as clubfoot, is a
congenital condition in which a baby is born with one or both feet
turned inward and downward.
Types of CTEV

42. Physiotherapy management
• Ponseti Method or kite method: The Ponseti method is the most widely used
technique for treating clubfoot. It involves a series of manipulations, followed
by casting of the foot in an improved position. This process is repeated over
several weeks to gradually correct the deformity.
• Stretching Exercises: Physiotherapists teach parents or caregivers how to
perform gentle stretching exercises on the baby’s foot to maintain flexibility
and prevent recurrence.
• Casting: After each manipulation, a cast is applied to maintain the corrected
position and gradually shift the foot to a more normal alignment.
• Bracing: Once the foot is corrected, a brace (commonly the Denis-Browne
bar) is used to maintain the correction. This is usually worn for a few years,
especially at night.

43. Pes cavus
• Pes cavus is a deformity
characterized by an excessively
high longitudinal arch that results
from an equinus position of the
forefoot in relation to the hind
foot
• In this condition finger can be
slipped under the navicular bone
and it penetrates a distance of
greater than 2 cm from the
vertical edge of the foot.

44. Cause of pes cavus :
• Congenital
• Acquired: neurological, orthopedic &
neuromascular condition
• Muscle imbalance
• Muscle weakness
• Club foot
• Post traumatic bone malformation
• Contracture of calf
• Charcot-Marie-Tooth (CMT) disease, spinal
dysraphism, polyneuritis, Intraspinal
tumors, poliomyelitis, syringomyelia,
Friedreich ataxia, cerebral palsy, and spinal
cord tumors, can cause muscle imbalances
that lead to elevated arches

45. Cont,

46. Physiotherapy management
• Correction of the primary deformity which is equinus and pronation
of the foot is done first. Secondary deformities like contracted plantar
fascia, clawed toes and varus of the heels are corrected next.Early
stages Require conservative line of treatment.Late stages Surgery is
required and it consists of soft tissue release in children and bony
surgeries in adults.
• Lateral heel cup orthotic & High arched shoes are prescribed to
prevent rubbing of the foot.
• Bracing is given if foot drop also occur.
• If patient has sensory defect due to neurological condition Plastazote
lining in brace is provided

47. Cont,

48. • For increasing flexibility & ROM: contrast bath to relief stiffness,
Stretching of gastrocnemius , plantar fascia & tibialis posterior, Joint
mobilizations, ROM exercise.
• For increasing muscle strength: Strengthening exercises of peroneal
muscle & tibialis anterior is beneficial
• For reducing pain : Cryotherapy after therapy to restore damage &
prevent inflammatory soreness and hot packs or electrical stimulation
• For skin integrity: patient edu & refer to skin specialist
• Balance & gait training : by using balance bord & assistive devices are
given to prevent fall

49. • Functional Training: as per patient
need task are given.
• Night splinting & casting are done
• https://youtube.com/shorts/gw8
wipktv1k?si=CwyzBIlecvrICw2M

50. Pes planus
• Disorder of foot characterized by
loss of medial longitudinal arch of
foot
• Also know as flat foot

51. Cont,

52. Physiotherapy
management
• Rest
• Cryotherapy
• Heat Therapy
• Soft tissue Manipulation
• Combo therapy : Ultrasound &
pulsed electrical stimulation
• Increasing flexibility: PROM,
Stretching of gastrocnemius & soleus
& peroneal brevis muscle
• Increase arch : ball rolling under foot
• Plyometric exercise

53. • Strengthening exercises:To
prevent valgus and
flattening of the anterior
arch, muscles such as the
anterior and posterior
tibialis muscles, the flexor
hallucis longus, the intrinsic,
the interosseus plantaris,
and the abductor hallucis
are strengthened.

54. Links
Strengthening of tibialis posterior-
https://youtu.be/AMasoQG4Id0?si=k--bmTQaJ0y0lh6-
Strengthening of tibialis anterior -
https://youtu.be/CZhPw__uulw?si=yFQR0kww3rP69n6E
Strengthening of peroneal muscles-
https://youtube.com/shorts/gw8wipktv1k?si=NSwwUu1PokV_4jYq
Strengthening of Flexor hallucis longus-
https://youtube.com/shorts/zz8r9_F9jKI?si=P_Oy8unGRpKnro7-

55. Cont,
• Arch lift /short foot
exercisehttps://youtu.be/vcx_NNR7b1k?si=yEck0qqu0ZC74mN7
• Towel crul exercises
• Stair arch raise
https://youtube.com/shorts/Ur4PR_vXuxs?si=wulPltP9vTuHTKyN
• For proprioception-
1. Toe & heel walking
2. Single leg weight bearing
3. Toe extension & Toe spreading

57. • Kinesio taping -
https://youtu.be/ZLtAUy6GhNs?si
=ITI7CGiu5vT3u98T
• Extra arch support also used

58. Home care advice
• Encourage patient to walk on outer edge of foot
• Encourage to walk over sand
• Advice for hot water immersion exercise
• Within cast slight movement of moveable joint is encouraged
• Procedure to make cast -
https://youtu.be/NI6Dt9Ud9G0?si=uEqaW3NSC_Xnr_NM
• Children who are not engage in physical activity should be
encouraged to maintain enough strength of muscle to maintain arch
• Adolescents whose foot is not developed should be advised to not
participate in overloaded activity

59. Cont,
• They could engage in high leg lifting, jumping activities (such as rope
skipping, long jump, high jump, vertical take-off, etc.), and climbing
activities (such as climbing ladders, using balance beams, rope
climbing, pole climbing, etc.) to fully exercise the muscles and
ligaments of the arch of the foot
• Tibialis posterior muscle was strengthened with resistance band, 3-4
sets and 10 repetitions per set, stretching of iliopsoas was in 30-
second hold each time and three times in total. Towel curl exercise
was performed 100 repetitions.
• Some research say hip & knee strengthening improve foot pressure

60. THANK YOU