Postural deviation

Lateral view –postural deviations

Lateral view

Claw toes Hammer toes Flexed knee posture Hyper extended knee

posture(genu recurvatum)

Excessive anterior pelvic tilt

lordosis kyphosis Forward head posture

Anterio posterior view 

Pes planus(flat foot) Pes cavus Hallus valgus Genu valgum Genu varum Squinting or cross

eyed patella Grosshoppers eyed

patella scoliosis

Claw toes is a deformity of the toes characterized by hyperextension of  the metatarsophalangeal joint (MTP) combined with flexion of the proximal (PIP) and distal (DIP) interphalangeal joints. 

Claw toes

Sometimes the proximal phalanx may subluxate dorsally on the metatarsal head. A callus may develop on the dorsal aspects of the flexed phalanges.

Etiologies for this condition are as follows:◦Restrictive effect of shoes◦A cavus – type foot◦Muscular imbalance◦Ineffectiveness of intrinsic foot muscles◦Neuromuscular disorders◦Age–related deficiencies in the plantar structures

Claw toes

It is a deformity characterized by hyperextension of the metatarsophalangeal (MTP) joint, flexion of the proximal interphalangeal (PIP) joint, and hyperextension of distal interphalangeal (DIP) joint.

Hammer toes

Callosities (painless thickening of epidermis) may be found on the superior surface of the proximal interphalangeal (PIP) joints over the heads of the 1st phalanges as a result of pressure from shoes or on the tips of the distal phalanges because of abnormal weight bearing

HAMMER TOES

The flexor muscles are stretched over the metatarsophalangeal (MTP) joint and shortened over the interphalangeal (IP) joint.

The extensor muscles are shortened over the metatarsophalangeal (MTP) joint and stretched over the interphalangeal (IP) joint.

If the long and short toe extensors and lumbricales are selectively paralyzed, the intrinsic and extrinsic toe flexors acting unopposed will buckle the proximal (PIP) and distal (DIP) interphalangeal joints and cause a hammer toe deformity

Hammer toes

Mild to moderate form proper shoes(lower heels, softer

leather, wider toe boxes, and gym shoes ) Severe corrective surgery

Claw toes & hammer toes treatment

In the flexed knee standing posture the line of gravity falls posterior to the knee joint axes.

The posterior location of the line of gravity creates a flexion moment at the knees that must be balanced by activity of the quadriceps muscles to maintain the erect position.

The increase in quadriceps muscle activity subjects the tibiofemoral and patellofemoral joints to greater than normal compressive forces.

Because knee flexion in upright stance is accompanied by hip flexion and ankle dorsiflexion, the location of the line of gravity also will be altered in relation to these joint axes.

Flexed Knee Posture

Flexed knee posture

At the hip, the line of gravity will fall anterior to the hip joint axes.

Activity of the hip extensors may be necessary to balance the gravitational flexion moment acting around hip.

At the ankle, the line of gravity will fall anterior to the ankle joint axes.

Increase soleus muscle activity may be required to counteract the increased gravitational dorsiflexion moment at the ankle.

The additional muscle activity subjects the hip and ankle joints to greater than normal compression stress. Thus, the increased muscle activity would appear to substantially increase the energy requirements for stance.

Flexed knee exercises

HYPER EXTENDED KNEE

GENU RECURVATUM

The hyperextended knee posture is one in which the line of gravity is

located considerably anterior to the knee joint axis.

The anterior location of the line of gravity causes an increase in the

gravitational extensor moment acting at the knee, which tends to increase the hyperextension deviation and put the posterior joint capsule under considerable tension stress.

A continual adoption of the hyper extended knee posture is likely to result in adaptive lengthening of the posterior capsule.

The anterior joint surfaces on the femoral condyles and anterior

portion of the tibial plateaus are subject to degenerative changes of the cartilaginous joint surfaces .

Hyperextended Knee Posture (Genu Recurvatum):

A defined disorder of the connective tissue• Laxity of the knee ligaments• Instability of the knee joint due to ligaments and joint capsule injuries• Irregular alignment of the femur and tibia• A deficit in the joints• A discrepancy in lower limb length• Certain diseases: Cerebral Palsy, Multiple Sclerosis, Muscular Dystrophy• Birth defect/congenital defect

CAUSES OF GENU RECURVATUM

Measure the patient's heel heights. If there is a normal contralateral (opposite)

knee to compare to, an increase in heel height can be diagnostic for genu recurvatum

Genu recurvatum- measurement

QUADRICEPS STRENGTHENING EXERCISES

IF SEVERE TIBIAL OSTEOTOMY

POST OP BRACES

LIMITING HYPEREXTENSION

TREATMENT FOR GENU RECURVATUM

In posture in which the pelvis is excessively tilted anteriorly, the lower lumbar vertebrae are forced anteriorly. The upper lumbar vertebrae move posteriorly to keep the head over the sacrum, thereby increasing the lumbar anterior convexity (lordotic curve).

The line of gravity, therefore, is at a greater distance from the lumbar joint axes than is optimal and the extension moment in the lumbar spine is increased.

The posterior convexity of the thoracic curve increases and become kyphotic to balance the lordotic lumbar curve and maintain the head over the sacrum.

Excessive Anterior Pelvic Tilt:

Excessive anterior tilt

the anterior convexity of the cervical curve increases to bring the head back over the sacrum.

In optimal posture the lumbar discs are subject to anterior tension and posterior compression in erect standing. A greater diffusion of nutrients into the anterior compared to the posterior portion of the disc occurs in the optimal erect posture.

Increases in the anterior convexity of the lumbar curve during erect standing increases the compressive forces on the posterior annuli and may adversely affect the nutrition of the posterior portion of the intervertebral discs.

Also excessive compressive forces may be applied to the zygapophyseal joints.

Stretching back extensors hip flexors Strengthening gluteals and hams abdominals

Corrective exercises for anterior pelvic tilt

Back extensor stretching

Abdomen strengthening

Lordosis is an excessive anterior curvature of spine

Pathologically it is exaggeration of the normal curves found in the cervical and lumbar spines

Lordosis

Lordosis causes:› Postural deformity› Lax muscles (esp.

abs)› Heavy abdomen› Compensatory

mechanisms› Hip flexion

contracture› Spondylolisthesis› Congential

problems› Fashion (high

heels)

Lordosis

Observe sagging shoulder

Medial rotation of leg

Head poking forward

The normal pelvic angle(30degree) is increased with lordosis

Lordosis

Lengthening the muscles that create anterior pelvic tilt and making them more flexible

Strengthening and shortening the muscles that create posterior pelvic tilt

Learning to control normal pelvic position

Postural correction exercises-Lordosis

Increased pelvic inclination (40)

Typically includes kyphosis

Swayback deformity

It is excessive posterior curvature of spine Pathologically it is exaggeration of the

normal curve found in the thoracic spine

Kyphosis

Kyphosis◦ Excessive posterior

curvature of the spine Round back Humpback/gibbus Flat back Dowager’s Hump

kyphosis

Long rounded curve with ed pelvic inclination and thoraco lumbar kyphosis

O/E Tight (hip ext &

trunk flexors) Weak(hip flexors

&lumbar extensors)

Kyphosis-Round back

Localised sharp posterior angulation of thoracic spine

Kyphosis –Hump back/Gibbus

Decreased pelvic inclination (20 degrees)

Mobile lumbar spine

Kyphosis –Flat back

Older patient Causes-

osteoporosis Where thorocic

vertebral bodies degenerates and wedge in anterior direction

Kyphosis-Dowagers Hump

Exercises to maintain normal pelvic position – to create a basis for correct alignment of the spine.

Exercises to stretch and lengthen the chest muscles (pectoralis major/pectoralis minor)

Strengthening the upper back muscles, the deep erector spinae and the shoulder extensors

Corrective exercises for kyphosis

Breathing exercises for increasing range of respiration (especially inhalation).

In addition to the chest muscles mentioned above, movement of the joints connecting thorax and ribs (the sterno-costal joints) and those linking ribs and vertebrae (the costo-vertebral joints)is of great importance for maintaining chest fl exibility and optimal respiratory functioning

Corrective exercises for kyphosis

Mobility exercises for the thoracic vertebrae (T1–12) on all movement planes, from a variety of starting positions

Exercises to increase hamstring fl exibility and thus improve functional pelvic mobility on the sagittal plane (in anterior and posterior pelvic tilt).

Awareness and relaxation exercises.

Kyphosis exercises

Exercise to maintain normal pelvic position – for optimal alignment of the spine and for encouraging anterior pelvic tilt on the sagittal plane

• Hamstring fl exibility and lengthening exercises, to improve anterior pelvic tilt

• Strengthening hip flexors• Exercise to improve general lower back

vertebral mobility

Corrective exercises-Flat back

A forward head posture is one in which the head is positioned anteriorly at an increased distance from the line of gravity and the normal anterior cervical convexity is also increased with the apex of the lordotic curve is considerable distance from the line of gravity compared to optimal posture.

Forward Head Posture

The constant assumption of a forward head posture causes unrelieved increased compression on the posterior zygapophyseal joints and posterior portions of the intervertebral discs and narrowing of the intervertebral foramina in the lordotic areas of the cervical region.

The cervical extensor muscles may become ischemic because of the constant isometric contraction required to maintain the head in forward position

Forward head posture

The posterior aspect of the zygapophyseal joint capsules may become adaptively shortened and the narrowed intervertebral foramen may cause nerve root compression.

In addition, the structure of the temporomandibular joint may become altered by the forward head posture and as a result the joint’s function may be disturbed.

In forward head posture the scapulae may rotate medially, a thoracic kyphosis may develop, the thoracic cavity may be diminished, vital capacity can be reduced, and overall body height may be shortened

Stretch◦ Pectoralis◦ Upper trapezius and

levator scapulae Strengthen

◦ Neck flexors◦ Rhomboids and

serratus anterior

Exercises to correct forward head posture

Pectrolis and upper trapezius stretch

Neck flexors and rhombhoids strenghtening

Antero posterior view postural deviations

Normally the plumb line should lie equidistant from the malleoli, and the malleoli should appear to be of equal size and directly opposite from one another.

When one malleolus appears more prominent or lower than the other and calcaneal eversion is present, it is possible that a common foot problem known as pes planus, or flatfoot, may be present.

Flatfoot, which is characterized by a reduced or absent arch, may be either rigid or flexible.

Pes planus(flat foot)

FLAT FOOT

TYPES> A rigid flatfoot is a structural deformity

that may be hereditary. In this the medial longitudinal arch is absent in non-weight bearing, toe standing, and normal weight bearing situations.

In flexible flatfoot, the arch is reduced during normal weight bearing situations, but reappears during toe standing or non-weight bearing situations.

TYPES OF FLAT FOOT

In either the rigid or flexible type of pes planus, the talar head is displaced anteriorly, medially, and inferiorly.

The displacement of the talus causes depression of the navicular, tension in the plantar calcaneonavicular (spring) ligament and lengthening of the tibialis posterior muscle.

The pronated flatfoot results in a relatively overmobile foot that may require muscular contraction to support the osteoligamentous arches during standing.

It also may result in increased weight bearing on the 2nd through 4th metatarsal heads with subsequent plantar callus formation, especially at the 2nd metatarsal.

The rigid form of flatfoot interferes with push-off during walking because the foot is unable to assume the supinated position and become a rigid lever for push-off in gait.

Weight bearing pronation in the erect standing posture also causes medial rotation of the tibia and may affect knee function

FLAT FOOT

The arch may develop spontaneously in children under 10 years with flexible pes planus

Heel cord stretching Orthotics (inserts or insoles, often custom-

made) may be used

TREATMENT FLATFOOT

Hallux valgus is deformity in which there is a medial deviation of the 1st metatarsal at the tarsometatarsal joint and a lateral deviation of the phalanges at the metatarsophalangeal joint

Hallus valgus

The bursa on the medial aspect of the 1st metatarsal head may become inflamed and form bunion in response to an increase in contact forces between the shoe and the side of the 1st metatarsophalangeal joint.

In addition, bony overgrowth may occur on the medial aspect of the joint in an attempt by the body to increase the joint surface area.

HALLUS VALGUS

The combination of excess bone and bunion formation and possible metatarsophalangeal dislocation not only enlarge the joint but also are a source of pain and may require surgical intervention.

The mot common cause of hallux valgus is abnormal pronation in combination with forefoot adducts, which leads to a hypermobile first ray.

Flexor muscles are stretched over the metatarsophalangeal joints and shortened over the proximal interphalangeal joints. The extensor muscles are shortened over the metatarsophalangeal joints and stretched over the proximal interphalangeal joints.

Conservative;◦ Shoe modifications, ◦ foot padding, ◦ anti-inflammatory medication,◦ orthoses, and occasionally injections

Hallus valgus treatment

Genu valgum, commonly called "knock-knees", is a condition where the knees angle in and touch one another when the legs are straightened.

GENU VALGUM

Rickets Osteomalacia Rheumatoid Arthritis Muscular paralysis of

semimembranosus or semitendinosus Fracture May be secondary to flat foot, 

osteoarthritis

CAUSES OF GENU VALGUM(KNOCK KNEE)

In genu valgum the mechanical axes of the lower extremities are displaced laterally. If genu valgum exceeds 30° and persists beyond 8 years of age structural changes may occur.

As a result of the increased torque acting around the knee, the medial knee joint structures are subjected to abnormal tensile or distraction stress, and the lateral structures are subjected to abnormal compressive stress.

The patella may be laterally displaced and therefore predisposed to subluxation.

GENU VALGUM (KNOCK KNEES)

The foot also is affected as the gravitational torque acting on the foot in genu valgum tends to produce pronation of the foot with an accompanying stress on the medial longitudinal arch and its supporting structures as well as abnormal weight bearing on the posterior medial aspect of the calcaneus.

Additional related changes may include flatfoot, lateral tibial torsion, lateral patellar subluxation, and lumbar spine contralateral rotation

The degree of knock knee is measured by the distance between the medial malleoli at the ankle when the child lies down with the knees touching each other

MEASUREMENT OF GENU VALGUM

In mild cases of Genu Valgum in young children, wearing of boots with the inner side of heel raised by 3/8" inch and elongated forward heel (Robert Jones heels) corrects the deformity.

TREATMENT FOR GENU VALGUM

In more complicated cases, the child requires a supracondyles closed wedge osteotomy.

Post operative Physiotherapy Gradual knee mobilization is the main part of

the treatment.  heat modalities may be given for relief of pain. Strengthening exercises for quadriceps,

hamstrings and gluteus muscles are given. When the patient is able to walk, he is given

correct training for standing, balancing, weight transferring and walking

TREATMENT FOR GENU VALGUM

Genu varum (also called bow-leggedness or bandiness), is a deformity marked by medial angulation of the leg in relation to the thigh, an outward bowing of the legs, giving the appearance of a bow.

GENU VARUM

Due to defective growth of the medial side of the epiphyseal plate.

It is commonly seen unilaterally and Seen in conditions such as Rickets, Paget's

disease and severe degree osteoarthritis of the knee

The degree of deformity is measured by the distance between the two medial femoral condyles when the patient is lying.

Genu varum is a condition in which the knees are widely separated when the feet are together and malleoli are touching.

Physiologic bowing is symmetrical and involves both the femur and the tibia.

Cortical thickening on the medial concavity of both the femur and tibia may be present as a result of the increased compressive forces and the patellae may be displaced medially.

.

GENU VARUM(BOW LEGS)

Some of the more commonly suggested cause of genu varum are vitamin D deficiency, renal rickets, osteochondritis, or epiphyseal injury

Generally, no treatment is required for idiopathic presentation as it is a normal anatomical variant in young children.

Treatment is indicated when its persists beyond 3 and half years old, Unilateral presentation, or progressive worsening of the curvature.

During childhood, assure the proper intake of vitamin D to prevent rickets.

TREATMENT OF BOW LEGS

Mild degree of deformity can be treated by wearing surgical shoes with 3/8" outer raised and with a long inner rod extending to the groin and leather straps across the tibia and the knee.

Corrective operations can also be performed, if necessary. The person would need to wear casts or braces following the operation

Post op management same as genu valgum

TREATMENT OF BOW LEGS

Squinting or cross-eyed patella (in-facing patella) is a tilted/rotated position of the patella in which the superior medial pole of the patella faces medially and the inferior pole points laterally.

This altered patella position may be present in one or both knees and may by a sign of increased medial femoral torsion or medial tibial rotation.

The Q angle may be increased in this condition and patella tracking may be adversely affected.

Squinting or cross-eyed patella

Grasshopper eyes patella refers to a high, laterally displaced position of the patella in which the patella faces upward and outward.

An abnormally long patella ligament may be responsible for the higher than normal position of the patella (patella alta).

The medially rotated position of the patella is due to either femoral retroversion or lateral tibial torsion.

Grasshopper eyes patella leads to abnormal patellar tracking and a decrease in the stability of the patella.

Grasshopper eyes patella

Grosshopper eye patella

Scoliosis› Nonstructural› Structural› idiopathic

scoliosis

Non-Structural and structural scoliosis

Non structural Structural

FUNCTIONALRELATED TO LIMB

LENGTH DISCREPANCYNO BONY DEFORMITYSIDEBENDIG IS USUALLY

SYMMETRICFORWARD FLEXION –

SCOLIOTIC CURVE DISAPPEARS

NON PROGRESSIVE

CONGENITAL/ACQUIRED

MAY BE IDIOPATHIC BONY DEFORMITY SIDE BENDING –

ASYMMETRIC FORWARD FLEXION-

SCOLIOTIC CURVE DOES NOT DISAPPEAR

PROGRESSIVE

70-85% of all structural scoliosis Fixed rotational prominence on convex side RAZOR BACK SPINE

IDIOPATHIC SCOLIOSIS

Demographic data, Anthropometric tests Height of acromia Scapula–spine distance S1–acromia distance Biacromial diameter Height of the anterior superior iliac spine

(ASIS) Lower limb length

Objective measurement

Functional tests LATERAL BENDING TEST FLEXIBILITY TEST OF SHOULDER GIRDLE X-rays (COBB angle).

1.Symmetrical exercises aimed to strengthen back and abdominal muscles and for functional improvement in ranges of joint motion.

2. Breathing exercises to increase lung volume and thorax mobility and flexibility.

3. Asymmetrical exercises for lengthening muscles on the concave (shortened) side, and for contracting muscles on the convex (lengthened) side. Asymmetrical exercises are also designed to encourage specific movement of spinal column vertebrae in desired

directions (mainly for moderating or balancing rotation in cases of structural scoliosis). 4. Static exercises which also make use of body weight (various “hanging” and traction exercises) for releasing tension along the

spine

Corrective exercises for scoliosis

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