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Postural deviations


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Postural deviations

  1. 1. 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
  2. 2.  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.
  3. 3.  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
  4. 4.  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.
  5. 5.  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
  6. 6.  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
  7. 7.  Mild to moderate form proper shoes(lower heels, softer leather, wider toe boxes, and gym shoes )  Severe corrective surgery
  8. 8. 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.
  9. 9.  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.
  11. 11.  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.
  12. 12.  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
  13. 13.  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
  15. 15.  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.
  16. 16.  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.
  17. 17.  Stretching back extensors hip flexors  Strengthening gluteals and hams abdominals
  18. 18.  Lordosis is an excessive anterior curvature of spine  Pathologically it is exaggeration of the normal curves found in the cervical and lumbar spines
  19. 19.  Lordosis causes: › Postural deformity › Lax muscles (esp. abs) › Heavy abdomen › Compensatory mechanisms › Hip flexion contracture › Spondylolisthesis › Congential problems › Fashion (high heels)
  20. 20.  Observe sagging shoulder  Medial rotation of leg  Head poking forward  The normal pelvic angle(30degree) is increased with lordosis
  21. 21.  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
  22. 22. Increased pelvic inclination (40)  Typically includes kyphosis
  23. 23.  It is excessive posterior curvature of spine  Pathologically it is exaggeration of the normal curve found in the thoracic spine
  24. 24.  Kyphosis ◦ Excessive posterior curvature of the spine  Round back  Humpback/gibbus  Flat back  Dowager’s Hump
  25. 25.  Long rounded curve with ed pelvic inclination and thoraco lumbar kyphosis  O/E  Tight (hip ext & trunk flexors)  Weak(hip flexors &lumbar extensors)
  26. 26.  Localised sharp posterior angulation of thoracic spine
  27. 27.  Decreased pelvic inclination (20 degrees)  Mobile lumbar spine
  28. 28.  Older patient  Causes-osteoporosis  Where thorocic vertebral bodies degenerates and wedge in anterior direction
  29. 29.  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
  30. 30.  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
  31. 31.  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.
  32. 32.  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
  33. 33. 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.
  34. 34.  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
  35. 35.  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
  36. 36.  Stretch ◦ Pectoralis ◦ Upper trapezius and levator scapulae  Strengthen ◦ Neck flexors ◦ Rhomboids and serratus anterior
  37. 37.  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.
  38. 38.  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.
  39. 39.  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.
  40. 40.  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
  41. 41.  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
  42. 42.  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
  43. 43. 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.
  44. 44.  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.
  45. 45.  Conservative; ◦ Shoe modifications, ◦ foot padding, ◦ anti-inflammatory medication, ◦ orthoses, and occasionally injections
  46. 46.  Genu valgum, commonly called "knock-knees", is a condition where the knees angle in and touch one another when the legs are straightened.
  47. 47.  Rickets  Osteomalacia  Rheumatoid Arthritis  Muscular paralysis of semimembranosus or semitendinosus  Fracture  May be secondary to flat foot, osteoarthritis
  48. 48.  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.
  49. 49.  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
  50. 50.  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
  51. 51.  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.
  52. 52. 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
  53. 53.  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.
  54. 54.  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
  55. 55.  The degree of deformity is measured by the distance between the two medial femoral condyles when the patient is lying.
  56. 56.  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. .
  57. 57.  Some of the more commonly suggested cause of genu varum are vitamin D deficiency, renal rickets, osteochondritis, or epiphyseal injury
  58. 58.  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.
  59. 59.  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
  60. 60.  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.
  61. 61.  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.
  62. 62.  Scoliosis › Nonstructural › Structural › idiopathic
  64. 64.  70-85% of all structural scoliosis  Fixed rotational prominence on convex side  RAZOR BACK SPINE
  65. 65.  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
  66. 66.  Functional tests  LATERAL BENDING TEST  FLEXIBILITY TEST OF SHOULDER GIRDLE  X-rays (COBB angle).
  67. 67. 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
  68. 68. THANK U