Rickets is a disease characterized by softening and weakening of bones in children, caused by a vitamin D deficiency or impaired metabolism of calcium or phosphorus. It most commonly affects children between 6-24 months old and can lead to fractures and bone deformities. While historically more prevalent, rickets decreased in developed countries in the 20th century but remains common in developing nations and populations with dark skin where access to vitamin D-fortified foods is limited. Treatment involves increasing dietary intake of calcium, phosphorus and vitamin D through supplements, exposure to sunlight, or vitamin D-fortified foods and formula. Physical therapy can help reduce bone and muscle pain through stretching and strengthening exercises.

1. RICKETS IN CHILDREN
JINU JANET VARGHESE
GROUP :4, YEAR :6
TBILISI STATE MEDICAL UNIVERSITY

2. • RICKETS IS DEFECTIVE MINERALIZATION OF BONES BEFORE
EPIPHYSEAL CLOSURE IN INFANTS DUE TO DEFICIENCY OR
IMPAIRED METABOLISM OF VITAMIN D PHOSPHORUS OR CALCIUM,
POTENTIALLY LEADING TO FRACTURES AND DEFORMITY. RICKETS
LEADS TO SOFTENING AND WEAKENING OF THE BONES AND IS
SEEN MOST COMMONLY IN CHILDREN 6-24 MONTHS OF AGE.

4. EPIDEMIOLOGY
• AS A RESULT OF THERAPEUTIC DEVELOPMENTS IN THE 20TH CENTURY, THE
PREVALENCE OF RICKETS DECREASED, PARTICULARLY IN DEVELOPED COUNTRIES
SUCH AS THE UNITED STATES, THE UNITED KINGDOM, AND AUSTRALIA, WHERE
IT EVENTUALLY BECAME RARE. TODAY THE DISTRIBUTION AND PREVALENCE OF
RICKETS ARE ALIGNED PRIMARILY WITH RISK FACTORS. HENCE, IT IS MOST
PREVALENT IN PEOPLES WHO ARE DARK-SKINNED AND IN DEVELOPING
COUNTRIES WHERE ACCESS TO VITAMIN D-FORTIFIED FOODS IS LACKING.
AFRICA, THE MIDDLE EAST, AND PARTS OF ASIA RANK AMONG THE WORLD’S
MOST HEAVILY AFFECTED REGIONS.

5. SIGNS AND SYMPTOMS
• BONE TENDERNESS
• DENTAL PROBLEMS
• MUSCLE WEAKNESS (RICKETY MYOPATHY)
• INCREASED TENDENCY FOR FRACTURES (EASILY BROKEN BONES), ESPECIALLY
GREENSTICK FRACTURES
• SKELETAL DEFORMITY (BOWED LEGS, KNOCK-KNEES)
• CRANIAL DEFORMITY (SUCH AS SKULL BOSSING OR DELAYED FONTANELLE
CLOSURE)
• PELVIC DEFORMITY
• SPINAL DEFORMITY (SUCH AS KYPHOSCOLIOSIS OR LUMBAR LORDOSIS)

6. • GROWTH DISTURBANCE
• CHEST X RAY SHOWING CHANGES CONSISTENT WITH RICKETS. THESE CHANGES
ARE USUALLY REFERRED TO AS "ROSARY BEADS" OF RICKETS.
• HYPOCALCEMIA (LOW LEVEL OF CALCIUM IN THE BLOOD)
• TETANY (UNCONTROLLED MUSCLE SPASMS ALL OVER THE BODY)
• CRANIOTABES (SOFT SKULL)
• COSTOCHONDRAL SWELLING (AKA "RICKETY ROSARY" OR "RACHITIC ROSARY")
• HARRISON'S GROOVE
• DOUBLE MALLEOLI SIGN DUE TO METAPHYSEAL HYPERPLASIA
• WIDENING OF WRIST RAISES EARLY SUSPICION, IT IS DUE TO METAPHYSEAL
CARTILAGE HYPERPLASIA.

8. TYPES
• NUTRITIONAL RICKETS
• VITAMIN D-RESISTANT RICKETS
• VITAMIN D-DEPENDENT RICKETS
• TYPE I
• TYPE II

9. TREATMENT AND PREVENTION
• THE TREATMENT AND PREVENTION OF RICKETS IS KNOWN AS ANTIRACHITIC.
THE MOST COMMON TREATMENT OF RICKETS IS THE USE OF VITAMIN D.
HOWEVER, SURGERY MAY BE REQUIRED TO REMOVE SEVERE BONE
ABNORMALITIES.
• DIET AND SUNLIGHT: TREATMENT INVOLVES INCREASING DIETARY INTAKE OF
CALCIUM, PHOSPHATES AND VITAMIN D. EXPOSURE TO ULTRAVIOLET B LIGHT
(MOST EASILY OBTAINED WHEN THE SUN IS HIGHEST IN THE SKY), COD LIVER
OIL, HALIBUT-LIVER OIL, AND VIOSTEROL ARE ALL SOURCES OF VITAMIN D.

10. • SUPPLEMENTATION: SUFFICIENT VITAMIN D LEVELS CAN ALSO BE ACHIEVED
THROUGH DIETARY SUPPLEMENTATION AND/OR EXPOSURE TO SUNLIGHT.
VITAMIN D3 (CHOLECALCIFEROL) IS THE PREFERRED FORM SINCE IT IS MORE
READILY ABSORBED THAN VITAMIN D2. ACCORDING TO THE AMERICAN
ACADEMY OF PEDIATRICS (AAP), ALL INFANTS, INCLUDING THOSE WHO ARE
EXCLUSIVELY BREAST-FED, MAY NEED VITAMIN D SUPPLEMENTATION UNTIL
THEY START DRINKING AT LEAST 17 US FLUID OUNCES (500 ML) OF VITAMIN D-FORTIFIED
MILK OR FORMULA A DAY.

11. SUPPLEMENTATION RECOMMENDATIONS
AGE FEMALE MALE PREGNANCY
0-12 Months 400 IU
( 10 mcg)
400 IU
(10 mcg)
1-13 Years 600 IU
(15 mcg)
600 IU
(15 mcg)
14-18 Years 600 IU
(15 mcg)
600 IU
(15 mcg)
600 IU
(15 mcg)
19-50 Years 600 IU
(15 mcg)
600 IU
(15 mcg)
600 IU
(15 mcg)
51-71 Years 600 IU
(15 mcg)
600 IU
(15 mcg)
> 70 Years 800 IU
(20 mcg)
800 IU
(20 mcg)

12. PHYSICAL THERAPY MANAGEMENT
• IF LEFT UNTREATED, THE CHILD CAN DEVELOP SPINAL CURVATURES, SEIZURES,
AND OSTEOPOROSIS. CHILDREN WHO ARE SOLELY BREAST-FED ARE MORE AT
RISK TO RICKETS DUE TO THE ABSENCE OF VITAMIN D IN BREAST MILK .
• ONCE THE CHILD BECOMES OLDER, AND STILL CANNOT ABSORB VITAMIN D, IT
IS VERY IMPORTANT FOR THEM TO TRY AND INCREASE BONE GROWTH AS
MUCH AS POSSIBLE. EXERCISES WHILE STANDING CAN HELP INCREASE BONE
GROWTH BUT DUE TO OSTEOPOROSIS MAY ALSO BE AT RISK FOR FRACTURES.
PHYSICAL THERAPY CAN HELP TO ALSO REDUCE ANY BONE OR MUSCLE PAIN
THROUGH STRETCHING AND STRENGTHENING EXERCISES AS WELL AS HANDS
ON MANUAL TECHNIQUES. TREATMENT TO RELIEVE OR CORRECT SYMPTOMS
MAY INCLUDE WEARING BRACES TO REDUCE OR PREVENT BONY DEFORMITIES

13. • IF A PATIENT IS ABLE, NO ACTIVITY RESTRICTIONS ARE NEEDED. AFFECTED
INDIVIDUALS OBVIOUSLY SHOULD NOT ENGAGE IN CONTACT SPORTS UNTIL RICKETS
IS COMPLETELY HEALED.
• THERE ARE NO DIRECT PHYSICAL THERAPY INTERVENTIONS FOR VITAMIN D
DEFICIENCY. PATIENT WILL BE REFERRED TO PHYSICAL THERAPY FOR TREATMENT OF
IMPAIRMENTS THAT MAY BE A CAUSE OF VITAMIN D DEFICIENCY SUCH AS DECLINE
IN MUSCLE STRENGTH, DECLINE IN PHYSICAL FUNCTIONING, OR FALLS PREVENTION.
(SEE CLINICAL PRESENTATION)
• PHYSICAL THERAPISTS CAN TAKE A TEAM APPROACH WITH MEDICAL MANAGEMENT
THROUGH PATIENT EDUCATION ON:
• FOODS HIGH IN VITAMIN D
• IMPORTANCE OF FOLLOWING MEDICAL RECOMMENDATIONS FOR VITAMIN D INTAKE
• IMPORTANCE OF PROPER SUN EXPOSURE WITH RISKS OF OVEREXPOSURE