deviations

3. 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

4.  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.

5.  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

6.  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.

7.  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

8.  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

9.  Mild to moderate form
proper shoes(lower heels, softer leather, wider toe
boxes, and gym shoes )
 Severe
corrective surgery

10. 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.

12.  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.

14.  HYPER EXTENDED
KNEE

15.  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.

16.  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

17.  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

18.  QUADRICEPS
STRENGTHENING
EXERCISES
 IF SEVERE TIBIAL
OSTEOTOMY
 POST OP
BRACES LIMITING
HYPEREXTENSION

19.  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.

21.  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.

22.  Stretching
back extensors
hip flexors
 Strengthening
gluteals and hams
abdominals

25.  Lordosis is an excessive anterior curvature of spine
 Pathologically it is exaggeration of the normal curves
found in the cervical and lumbar spines

26.  Lordosis causes:
› Postural deformity
› Lax muscles (esp. abs)
› Heavy abdomen
› Compensatory
mechanisms
› Hip flexion contracture
› Spondylolisthesis
› Congential problems
› Fashion (high heels)

27.  Observe sagging
shoulder
 Medial rotation of leg
 Head poking forward
 The normal pelvic
angle(30degree) is
increased with lordosis

28.  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

29. Increased pelvic inclination
(40)
 Typically includes kyphosis

30.  It is excessive posterior curvature of spine
 Pathologically it is exaggeration of the normal curve
found in the thoracic spine

31.  Kyphosis
◦ Excessive posterior
curvature of the spine
 Round back
 Humpback/gibbus
 Flat back
 Dowager’s Hump

32.  Long rounded curve
with ed pelvic
inclination and thoraco
lumbar kyphosis
 O/E
 Tight (hip ext & trunk
flexors)
 Weak(hip flexors
&lumbar extensors)

33.  Localised sharp
posterior angulation of
thoracic spine

34.  Decreased pelvic
inclination (20 degrees)
 Mobile lumbar spine

35.  Older patient
 Causes-osteoporosis
 Where thorocic
vertebral bodies
degenerates and wedge
in anterior direction

36.  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

37.  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

38.  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.

40.  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

41. 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.

42.  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

43.  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

44.  Stretch
◦ Pectoralis
◦ Upper trapezius and
levator scapulae
 Strengthen
◦ Neck flexors
◦ Rhomboids and serratus
anterior

48.  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.

50.  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.

51.  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.

52.  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

53.  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

54.  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

55. 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.

56.  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.

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

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

59.  Rickets
 Osteomalacia
 Rheumatoid Arthritis
 Muscular paralysis of semimembranosus or
semitendinosus
 Fracture
 May be secondary to flat foot, osteoarthritis

60.  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.

61.  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

62.  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

63.  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.

64. 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

65.  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.

66.  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

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

68.  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.
.

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

70.  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.

71.  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

72.  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.

73.  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.

75.  Scoliosis
› Nonstructural
› Structural
› idiopathic

76. Non structural Structural
FUNCTIONAL
RELATED TO LIMB LENGTH
DISCREPANCY
NO BONY DEFORMITY
SIDEBENDIG IS USUALLY
SYMMETRIC
FORWARD FLEXION –
SCOLIOTIC CURVE
DISAPPEARS
NON PROGRESSIVE
 CONGENITAL/ACQUIRE
D
 MAY BE IDIOPATHIC
 BONY DEFORMITY
 SIDE BENDING –
ASYMMETRIC
 FORWARD FLEXION-
SCOLIOTIC CURVE
DOES NOT DISAPPEAR
 PROGRESSIVE

77.  70-85% of all structural scoliosis
 Fixed rotational prominence on convex side
 RAZOR BACK SPINE

78.  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

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

80. 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

81. THANK U