Deformity

• An abnormal position or abnormal development of a bone or joint

• Congenital
• Acquired
• Trauma
• Muscle imbalancs endocrine disorder
• Metabolic disorder
• Infection
• Bone disease
Deformity of hip
congenital dislocation of hip
• Also known as developmental dysplasia of hip
• It occur when a child born with unstable hip
• It’s caused by abnormal formation of the hip joint during their early
stages of fetal development
• The hip is a "ball-and-socket" joint. The ball is loose in the socket and
may be easy to dislocate
• Although DDH is most often present at birth, it may also develop
during a child's first year of life
• In all cases of DDH, the socket (acetabulum) is shallow, meaning that the ball of the
thighbone (femur) cannot firmly fit into the socket. Sometimes, the ligaments that
help to hold the joint in place are stretched. The degree of hip looseness, or
instability, varies among children with DDH.

• Dislocated. In the most severe cases of DDH, the head of the femur is completely out
of the socket.
• Dislocatable. In these cases, the head of the femur lies within the acetabulum, but
can easily be pushed out of the socket during a physical examination.
• Subluxatable. In mild cases of DDH, the head of the femur is simply loose in the
socket. During a physical examination, the bone can be moved within the socket, but
it will not dislocate.
causes

• DDH tends to run in families. It can be present in either hip and in any individual. It
usually affects the left hip and is predominant in:

• Girls
• Firstborn children
• Babies born in the breech position (especially with feet up by the shoulders). The
American Academy of Pediatrics now recommends ultrasound DDH screening of all
female breech babies.
• Family history of DDH (parents or siblings)
• Oligohydramnios (low levels of amniotic fluid)
symptoms

• Some babies born with a dislocated hip will show no outward signs.

• Contact your pediatrician if your baby has:

• Legs of different lengths

• Uneven skin folds on the thigh
• Less mobility or flexibility on one side
• Limping, toe walking, or a waddling gait
• When DDH is detected at birth, it can usually be corrected with the
use of a harness or brace. If the hip is not dislocated at birth, the
condition may not be noticed until the child begins walking.
• Treatment methods depend on a child's age.

• Newborns. The baby is placed in a soft positioning device, called a Pavlik

harness, for 1 to 2 months to keep the thighbone in the socket. This special
brace is designed to hold the hip in the proper position while allowing free
movement of the legs and easy diaper care. The Pavlik harness helps tighten
the ligaments around the hip joint and promotes normal hip socket formation.

• Baby in Pavlik harness

• Newborns are placed in a Pavlik harness for 1 to 2 months to treat DDH.
• 1 month to 6 months. Similar to newborn treatment, a baby's thighbone
is repositioned in the socket using a harness or similar device. This
method is usually successful, even with hips that are initially dislocated.

• How long the baby will require the harness varies. It is usually worn full-
time for at least 6 weeks, and then part-time for an additional 6 weeks.

• If the hip will not stay in position using a harness, your doctor may try
an abduction brace made of firmer material that will keep your baby's
legs in position.
• In some cases, a closed reduction procedure is required. Your doctor
will gently move your baby's thighbone into proper position, and then
apply a body cast (spica cast) to hold the bones in place. This
procedure is done while the baby is under anesthesia.
• 6 months to 2 years. Older babies are also treated with closed
reduction and spica casting. In most cases, skin traction may be used
for a few weeks prior to repositioning the thighbone. Skin traction
prepares the soft tissues around the hip for the change in bone
positioning. It may be done at home or in the hospital
• Slipped capital femoral epiphysis (SCFE) is a hip condition that occurs in indvidulas who
are still growing.
• , the ball at the head of the femur (thighbone) slips off the neck of the bone in a
backwards direction.
• This causes pain, stiffness, and instability in the affected hip.
• The condition usually develops gradually over time and is more common in boys than
girls.

• Treatment for SCFE involves surgery to stop the head of the femur from slipping any
further. To achieve the best outcome, it is important to be diagnosed as quickly
aspossible. Without early detection and proper treatment, SCFE can lead to potentially
serious complications, including painful arthritis in the hip joint.
anatomy
•.
description
• SCFE is the most common hip disorder in adolescents.
• In SCFE, the epiphysis, or head of the femur (thighbone), slips down
and backwards off the neck of the bone at the growth plate, the weaker
area of bone that has not yet developed.
• In boys, this most commonly occurs between the ages of 12 and 16; in
girls, between the ages of 10 and 14.

• Sometimes SCFE occurs suddenly after a minor fall or trauma. More

often, however, the condition develops gradually over several weeks or
months, with no previous injury.
• Types of SCFE include:

• Stable SCFE. In stable SCFE, the patient is able to walk or bear weight on the
affected hip, either with or without crutches. Most cases of SCFE are stable slips.
• Unstable SCFE. This is a more severe slip. The patient cannot walk or bear
weight, even with crutches. Unstable SCFE requires urgent treatment.
Complications associated with SCFE are much more common in patients with
unstable slips.
• SCFE usually occurs on only one side; however, in up to 40 percent of patients
(particularly those younger than age 10) SCFE will occur on the opposite side, as
well—usually within 18 months.
causes
• The cause of SCFE is not known.
• Risk factors include
• Excessive weight or
• Family history of SCFE
• An endocrine or metabolic disorder, such as hyperthyroidism—
Symptoms
• Symptoms of SCFE vary, depending upon the severity of the condition.

• A patient with mild or stable SCFE will usually have intermittent pain in the groin, hip,
knee and/or thigh for several weeks or months. This pain usually worsens with activity.
The patient may walk or run with a limp after a period of activity.
• In more severe or unstable SCFE, symptoms may include:

• Sudden onset of pain, often after a fall or injury

• Inability to walk or bear weight on the affected leg
• Outward turning (external rotation) of the affected leg
• Discrepancy in leg length—the affected leg may appear shorter than the opposite leg
• Pain with extremes of motion
• Limited range of motion in the hip--especially limited internal rotation
• Involuntary muscle guarding and muscle spasms
• Your doctor will also observe your child's gait (the way he or she
walks). A child with SCFE may limp or have an abnormal gait.
treatment
• The goal of treatment is to prevent the mildly displaced femoral head
from slipping any further. This is always accomplished through surgery.

• Early diagnosis of SCFE provides the best chance of stabilizing the hip
and avoiding complications. When treated early and appropriately, long-
term hip function can be expected to be very good.

• Once SCFE is confirmed, your child will not be allowed to bear weight on
his or her hip and will probably be admitted to the hospital. In most
cases, surgery is performed within 24 to 48 hours.
• The surgical procedure your doctor recommends will depend upon the
severity of the slip. Procedures used to treat SCFE include:

• In situ fixation. This is the procedure used most often for patients with
stable or mild SCFE. The doctor makes a small incision near the hip,
then inserts a metal screw across the growth plate to maintain the
position of the femoral head and prevent any further slippage.

• Over time, the growth plate will close, or fuse. Once the growth plate is
closed, no further slippage can occur
• Open reduction. In patients with unstable SCFE, the doctor may first
make an open incision in the hip, then gently manipulate (reduce) the
head of the femur back into its normal anatomic position.

• The doctor will then insert one or two metal screws to hold the bone
in place until the growth plate closes. This is a more extensive
procedure and requires a longer recovery time.
•.
Complication
• Avascular necrosis
• chondrolysis
recovery
• Weight bearing
• After surgery, child will be on crutches for several weeks
• A physical therapist will provide specific exercises to help strengthen
the hip and leg muscles and improve range of motion.
Prethes disease
• Perthes disease is a rare childhood condition that affects the hip. It occurs when the blood supply to
the rounded head of the femur (thighbone) is temporarily disrupted. Without an adequate blood
supply, the bone cells die, a process called avascular necrosis.

• Although the term "disease" is still used, Perthes is really a complex process of stages that can last
several years. As the condition progresses, the weakened bone of the head of the femur (the "ball"
of the "ball-and-socket" joint of the hip) gradually begins to collapse. Over time, the blood supply to
the head of the femur returns and the bone begins to grow back.
• Treatment for Perthes focuses on helping the bone grow back into a more rounded shape that still
fits into the socket of the hip joint. This will help the hip joint move normally and prevent hip
problems in adulthood.

• The long-term prognosis for children with Perthes is good in most cases. After 18 to 24 months of
treatment, most children return to daily activities without major limitations.
• Perthes disease — — typically occurs in children who are between 4
and 10 years old.
• It is five times more common in boys than in girls, ,
• it is likely to cause more extensive damage to the bone in girls.
• In 10% to 15% of all cases, both hips are affected.
• There are four stages in Perthes disease:

• Initial / necrosis. In this stage of the disease, the blood supply to the femoral head is disrupted and bone
cells die. The area becomes intensely inflamed and irritated and your child may begin to show signs of
the disease, such as a limp or different way of walking. This initial stage may last for several months.
• Fragmentation. Over a period of 1 to 2 years, the body removes the dead bone beneath the articular
cartilage and quickly replaces it with an initial, softer bone ("woven bone"). It is during this phase that
the bone is in a weaker state and the head of the femur is more likely to collapse into a flatter position.
• Reossification. New, stronger bone develops and begins to take shape in the head of the femur. The
reossification stage is often the longest stage of the disease and can last a few years.
• Healed. In this stage, the bone regrowth is complete and the femoral head has reached its final shape.
How close the shape is to round will depend on several factors, including the extent of damage that
took place during the fragmentation phase, as well as the child's age at the onset of disease, which
affects the potential for bone regrowth.
• Cause
• The cause of Perthes disease is not known it could be genetic
• Symptoms
• One of the earliest signs of Perthes is a change in the way your child walks and runs. This is often
most apparent during sports activities. Your child may limp, have limited motion, or develop a
peculiar running style, all due to irritability within the hip joint. Other common symptoms include:

• Pain in the hip or groin, or in other parts of the leg, such as the thigh or knee (called "referred
pain.").
• Pain that worsens with activity and is relieved with rest.
• Painful muscle spasms that may be caused by irritation around the hip.
• Depending upon your child's activity level, symptoms may come and go over a period of weeks or
even months before a doctor visit is considered.
 doctor will assess your child's range of motion in the hip. Perthes
typically limits the ability to move the leg away from the body
(abduction), and twist the leg toward the inside of the body (internal
rotation).
• X-rays.
• The goal of treatment is to relieve painful symptoms, protect the shape of the femoral head, and
restore normal hip movement. If left untreated, the femoral head can deform and not fit well within
the acetabulum, which can lead to further hip problems in adulthood, such as early onset of arthritis.

• There are many treatment options for Perthes disease. Your doctor will consider several factors when
developing a treatment plan for your child, including:

• Your child's age. Younger children (age 6 and below) have a greater potential for developing new,
healthy bone.
• The degree of damage to the femoral head. If more than 50% of the femoral head has been affected
by necrosis, the potential for regrowth without deformity is lower.
• The stage of disease at the time your child is diagnosed. How far along your child is in the disease
process affects which treatment options your doctor will recommend.
• Observation. For very young children (those 2 to 6 years old) who show few changes in the
femoral head on their initial x-rays, the recommended treatment is usually simple
observation. Your doctor will regularly monitor your child using x-rays to make sure the
regrowth of the femoral head is on track as the disease runs its course.

• Anti-inflammatory medications. Painful symptoms are caused by inflammation of the hip

joint. Anti-inflammatory medicines, such as ibuprofen, are used to reduce inflammation, and
your doctor may recommend them for several months. As your child progresses through the
disease stages, your doctor will adjust the dosage or discontinue the medication.

• Limiting activity. Avoiding high-impact activities, such as running and jumping, will help
relieve pain and protect the femoral head. On occasion, your doctor may also recommend
crutches or a walker to prevent your child from putting too much weight on the joint.
• Physical therapy exercises. Hip stiffness is common in children with
Perthes disease and physical therapy exercises are recommended to
help restore hip joint range of motion. These exercises often focus on
hip abduction and internal rotation. Parents or other caregivers are
often needed to help the child complete the exercises.
• Hip abduction. The child lies on his or her back, keeping knees bent and feet flat. He or
she will push the knees out and then squeeze the knees together. Parents should place
their hands on the child's knees to assist with reaching a greater range of motion.
• Hip rotation. With the child on his or her back and legs extended out straight, parents
should roll the entire leg inward and outward.
• Casting and bracing. If range of motion becomes limited or if x-rays or other image
scans indicate that a deformity is developing, a cast or brace may be used to keep the
head of the femur in its normal position within the acetabulum.

• Petrie casts are two long-leg casts with a bar that hold the legs spread apart in a
position similar to the letter "A." Your doctor will most likely apply the initial Petrie
cast in an operating room in order to have access to specific equipment.
• Arthrogram. During the procedure, your doctor will take a series of special
x-ray images called arthrograms to see the degree of deformity of the
femoral head and to make sure he or she positions the head accurately. In
an arthrogram, a small amount of dye is injected into the hip joint to make
the shape of the femoral head even easier to see.
• Tenotomy. In some cases, the adductor longus muscle in the groin is very
tight and prevents the hip from rotating into the proper position. Your
doctor will perform a minor procedure to release this tightness — called a
tenotomy — before applying the Petrie casts. During this quick procedure,
your doctor uses a thin instrument to make a small incision in the muscle.
• After the cast is removed, usually after 4 to 6 weeks, physical therapy
exercises are resumed to restore motion in the hips and knees. Your
doctor may recommend continued intermittent casting until the hip
enters the final stage of the healing process.
• Coxa vara is as a varus deformity of the femoral neck. It is defined as the angle between the
neck and shaft of the femur being less than 110 – 120 ° (which is normally between 135 ° - 145
°) in children. [2]

• Coxa vara is classified into several subtypes:

• Congenital coxa vara, which is present at birth and is caused by an embryonic limb bud
abnormality.
• Developmental coxa vara occurs as an isolated deformity of the proximal femur. It tends to go
unnoticed until walking age is reached, when the deformity results in a leg length difference or
abnormal gait pattern.
• Acquired coxa vara is caused by an underlying condition such as fibrous dysplasia, rickets, or
traumatic proximal femoral epiphyseal plate closure. [3]
• ongenital coxa vara results in a decrease in metaphyseal bone as a result of abnormal maturation
and ossification of proximal femoral chondrocyte. As a result of congenital coxa vara, the inferior
medial area of the femoral neck may be fragmented. A progressive varus deformity might also
occur in congenital coxa vara as well as excessive growth of the trochanter and shortening of the
femoral neck. [4]

• A review on the development of coxa vara by Currarino et al showed an association with

spondylometaphyseal dysplasia, demonstrating that stimulated corner fractures were present in
most instances. [5]

• Ashish Ranade et al also showed that a varus position of the neck is believed to prevent hip
subluxation associated with femoral lengthening. An associated dysplastic acetabulum can lead to
a hip subluxation. In this case study, the acetabulum is abnormal in coxa vara. Acetabular index
(AI) and sourcil slope (SS) are significantly different than in the normal acetabulum.
• Femoral neck fractures, less than 1 % of all pediatric fractures in children, are
associated with a high incidence of complications. The most serious ones with high
and long term morbidity being osteonecrosis and coxa vara. [7]

• A retrospective study of femoral neck fractures in children show the following

complications: [8]
• 1) avascular necrosis (14.5%)
• 2) limb shortening in seven (11.3%)
• 3) coxa vara (8%) and premature epiphysis fusion (8%)
• 4) coxa valga (3.2%), arthritic changes (3.2%).
• 5) non-union in one (1.6%)
• Premature epiphyseal closure is described as one of the ethiological
factors of coxa vara. Incidences of premature physeal closure
reported in the literature range from 6 % to 62 %. Another possible
explanation for the high occurrence of coxa vara is the loss of
reduction after initial fracture reduction of implant failure in unstable
fractures. Developmental coxa vara is a rare condition with an
incidence of 1 in 25 000 live births. [9] Incidence of coxa vara can be
decreased by using internal fixation such as pins or screws.
• Clinically, the condition presents itself as an abnormal, but painless gait
pattern. A Trendelenburg limp is sometimes associated with unilateral
coxa vara and a waddling gait is often seen when bilateral coxa vara is
present. Patients with coxa vara often show:

• Limb length discrepancy

• Prominent greater trochanter
• Limitation of abduction and internal rotation of the hip.
• Patients may also show femoral retroversion or decreased anteversion.
• Snapping hip is a condition in which you feel a snapping sensation or hear
a popping sound in your hip when you walk, get up from a chair, or swing
your leg around.

• The snapping sensation occurs when a muscle or tendon (the strong tissue
that connects muscle to bone) moves over a bony protrusion in your hip.

• Although snapping hip is usually painless and harmless, the sensation can
be annoying. In some cases, snapping hip leads to bursitis, a painful
swelling of the fluid-filled sacs that cushion the hip joint.
• The hip is a ball-and-socket joint formed where the rounded end of the
thighbone (femur) fits into a cup-shaped socket (acetabulum) in the pelvis. The
acetabulum is ringed by strong fibrocartilage called the labrum that creates a
tight seal and helps to provide stability to the joint.

• Encasing the hip are ligaments that surround the joint and hold it together.
Over the ligaments are tendons that attach muscles in the buttocks, thighs,
and pelvis to the bones. These muscles control hip movement.

• Fluid-filled sacs called bursae are located in strategic spots around the hip to
provide cushioning and help the muscles move smoothly over the bone.
• Snapping hip can occur in different areas of the hip where tendons and muscles slide
over knobs in the hip bones.

• Outside of the hip. The most common site of snapping hip is at the outer side where the
iliotibial band passes over the portion of the thighbone known as the greater
trochanter.
• When the hip is straight, the iliotibial band is behind the trochanter. When the hip
bends, the band moves over the trochanter so that it is in front of it. Theiliotibial band is
always tight, like a stretched rubber band. Because the trochanter juts out slightly, the
movement of the band across it creates the snap you hear.
• Eventually, snapping hip may lead to hip bursitis. Bursitis is thickening and inflammation
of the bursa, a fluid-filled sac that allows the muscle to move smoothly over bone.
• Front of the hip. Another tendon that could cause a snapping hip runs from the front of the thigh up
to the pelvis (rectus femoris tendon). Snapping of the rectus femoris tendon is felt in the front of the
hip. As you bend the hip, the tendon shifts across the head of the thighbone, and when you straighten
the hip, the tendon moves back to the side of the thighbone. This back-and-forth motion across the
head of the thighbone causes the snapping. In addition to the rectus femoris tendon at the front of
the hip, the iliopsoas tendon can catch on bony prominences at the front of the pelvis bone.
• Back of the hip. Snapping in the back of the hip can involve the hamstring tendon. This tendon
attaches to the sitting bone, called the ischial tuberosity. When it moves across the ischial tuberosity,
the tendon may catch, causing a snapping sensation in the buttock region. This is not as common as
other forms of snapping hip
• Cartilage problems. The labrum that lines the socket of the hip can tear and cause a snapping
sensation. Damaged cartilage can loosen and float in the joint causing the hip to catch or "lock up."
Even though this is not a true snapping hip caused by a muscle outside the joint, some of the
symptoms may be similar. Symptoms due to a torn labrum, however, may cause more pain deep in the
groin then a typical snapping hip.
causes
• Snapping hip is most often the result of tightness in the muscles and
tendons surrounding the hip. People who are involved in sports and
activities that require repeated bending at the hip are more likely to
experience snapping hip. Dancers are especially vulnerable.

• Young athletes are also more likely to have snapping hip. This is
because tightness in the muscle structures of the hip is common
during adolescent growth spurts.
• Physical Therapy
• Your doctor may prescribe exercises like the ones below to stretch and strengthen the
musculature surrounding the hip. Guidance from a physical therapist may also be
recommended.

• Iliotibial band stretch

• Stand next to a wall for support
• Cross the leg that is closest to the wall behind your other leg.
• Lean your hip toward the wall until you feel a stretch at the outside of your hip. Hold the
stretch for 30 seconds.
• Repeat on the opposite side.
• Perform 2 to 3 sets of 4 repetitions on each side.
• Piriformis stretch
• Lie on your back with bent knees and feet flat on the floor.
• Cross the foot of the affected hip over the opposite knee and clasp
your hands behind your thigh.
• Pull your thigh toward you until you feel the stretch in your hip and
buttocks. Hold the stretch for 30 seconds.
• Repeat on the opposite side.
• Perform 2 to 3 sets of 4 repetitions on each side.
• Corticosteroid Injection
• If you have hip bursitis, your doctor may recommend an injection of a
corticosteroid into the bursa to reduce painful inflammation.
Genu valgus
• Genu valgus commonly called "knock-knee" is a condition in which
the knees angle in and touch each other when the legs are
straightened.
• Individuals with severe valgus deformities are typically unable to
touch their feet together while simultaneously straightening the legs.
Genu varum
• Genu varum (also called bow-leg, bandy-leg, and tibia vara), is a varus
deformity marked by (outward) bowing at the knee, which means
that the lower leg is angled inward (medially) in relation to the thigh's
axis, giving the limb overall the appearance of an archer's bow.
• Genu valgum is a normal developmental variation. At birth the knee is
usually in a bowlegged posture (genu varum). By age 2 the angle of
the upper leg bone relative to the lower leg bone starts to straighten.
The knee then goes into a knock-kneed posture progressively until it
maximizes at approximately age 4. The knock-kneed appearance then
lessens into a more adult value by age 10-12.
• How is it evaluated?
• The distance between the bones on the inside of the ankle is measured
(intermalleolar distance). At age one the distance between the inner aspects of
the knees is approximately 0 and the distance between the inner ankle bones
(intermalleolar distance) is approximately 2 cm. By age 3-4 it is approximately
4 cm and slightly decreases into adulthood. X-rays may also be taken of the
entire lower extremity and the angle made of the upper leg bone relative to
the lower leg bone is evaluated. At birth the angle is towards a bowlegged
appearance. The angle approaches neutral (0 degrees) by approximately age 2.
By age 3-4 it is approximately 4 cm, slightly decreases into adulthood. If
intermalleolar distance can be considered within normal limits up to 8 cm
between the ages of 2 and 11
Genu varum
• Genu Varum is also known as Bow Leg. It is a deformity wherein there
is lateral bowing of the legs at the knee. This is usually 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.
management
• 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.

• 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 operative physical therapy
• Gradual knee mobilization is the main part of the treatment.
• Some 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.
• Osteochondritis dissecans (os-tee-o-kon-DRY-tis DIS-uh-kanz) is a joint condition in which bone underneath the
cartilage of a joint dies due to lack of blood flow. This bone and cartilage can then break loose, causing pain and
possibly hindering joint motion.

• Osteochondritis dissecans occurs most often in children and adolescents. It can cause symptoms either after an
injury to a joint or after several months of activity, especially high-impact activity such as jumping and running, that
affects the joint. The condition occurs most commonly in the knee, but also occurs in elbows, ankles and other
joints.

• Doctors stage osteochondritis dissecans according to the size of the injury, whether the fragment is partially or
completely detached, and whether the fragment stays in place. If the loosened piece of cartilage and bone stays in
place, you may have few or no symptoms. For young children whose bones are still developing, the injury might
heal by itself.

• Surgery might be necessary if the fragment comes loose and gets caught between the moving parts of your joint or
if you have persistent pain
symptoms
• Depending on the joint that's affected, signs and symptoms of osteochondritis
dissecans might include:

• Pain. This most common symptom of osteochondritis dissecans might be triggered

by physical activity — walking up stairs, climbing a hill or playing sports.
• Swelling and tenderness. The skin around your joint might be swollen and tender.
• Joint popping or locking. Your joint might pop or stick in one position if a loose
fragment gets caught between bones during movement.
• Joint weakness. You might feel as though your joint is "giving way" or weakening.
• Decreased range of motion. You might be unable to straighten the affected limb
completely.
causes
• The cause of osteochondritis dissecans is unknown. The reduced
blood flow to the end of the affected bone might result from
repetitive trauma — small, multiple episodes of minor, unrecognized
injury that damage the bone. There might be a genetic component,
making some people more inclined to develop the disorder.
Risk factor
• Osteochondritis dissecans occurs most commonly in children and
adolescents between the ages of 10 and 20 who are highly active in
sports.
• Complications
• Osteochondritis dissecans can increase your risk of eventually
developing osteoarthritis in that joint.
prevention
• Adolescents participating in organized sports might benefit from
education on the risks to their joints associated with overuse.
Learning the proper mechanics and techniques of their sport, using
the proper protective gear, and participating in strength training and
stability training exercises can help reduce the chance of injury.
Osgood-Schlatter Disease (Knee Pain)
• Osgood-Schlatter disease is a common cause of knee pain in growing adolescents. It is an
inflammation of the area just below the knee where the tendon from the kneecap (patellar
tendon) attaches to the shinbone (tibia).

• Osgood-Schlatter disease most often occurs during growth spurts, when bones, muscles,
tendons, and other structures are changing rapidly. Because physical activity puts additional
stress on bones and muscles, children who participate in athletics — especially running and
jumping sports — are at an increased risk for this condition. However, less active
adolescents may also experience this problem.

• In most cases of Osgood-Schlatter disease, simple measures like rest, ice, over-the-counter
medication, and stretching and strengthening exercises will relieve pain and allow a return
to daily activities.
description
• The bones of children and adolescents possess a special area where the bone is growing
called the growth plate. Growth plates are areas of cartilage located near the ends of
bones. When a child is fully grown, the growth plates harden into solid bone.

• Some growth plates serve as attachment sites for tendons, the strong tissues that connect
muscles to bones. A bony bump called the tibial tubercle covers the growth plate at the end
of the tibia. The group of muscles in the front of the thigh (called the quadriceps) attaches
to the tibial tubercle.

• When a child is active, the quadriceps muscles pull on the patellar tendon which, in turn,
pulls on the tibial tubercle. In some children, this repetitive traction on the tubercle leads to
inflammation of the growth plate. The prominence, or bump, of the tibial tubercle may
become very pronounced.
symptoms
• Painful symptoms are often brought on by running, jumping, and
other sports-related activities. In some cases, both knees have
symptoms, although one knee may be worse than the other.

• Knee pain and tenderness at the tibial tubercle

• Swelling at the tibial tubercle
• Tight muscles in the front or back of the thigh
examination
• During the appointment, your doctor will discuss your child's
symptoms and general health. He or she will conduct a thorough
examination of the knee to determine the cause of the pain. This will
include applying pressure to the tibial tubercle, which should be
tender or painful for a child with Osgood-Schlatter disease. In
addition, your doctor may also ask your child to walk, run, jump, or
kneel to see if the movements bring on painful symptoms.

• Your doctor may also order an x-ray image of your child's knee to help
confirm the diagnosis or rule out any other problems.
trearment
• Treatment for Osgood-Schlatter disease focuses on reducing pain and swelling. This typically requires
limiting exercise activity until your child can enjoy activity without discomfort or significant pain
afterwards. In some cases, rest from activity is required for several months, followed by a strength
conditioning program. However, if your child does not have a large amount of pain or a limp,
participation in sports may be safe to continue.

• Your doctor may recommend additional treatment methods, including:

• Stretching exercises. Stretches for the front and back of the thigh (quadriceps and hamstring muscles)
may help relieve pain and prevent the disease from returning.
• Nonsteroidal anti-inflammatory medication. Drugs like ibuprofen and naproxen reduce pain and
swelling.
• Ice. Icing the inflamed area may reduce pain and swelling. Use cold packs for 20 minutes at a time,
several times a day. Do not apply ice directly to the skin.
pellegrini stieda lesion
• Pellegrini-Stieda lesions are ossified post-traumatic lesions at (or
near) the medial femoral collateral ligament adjacent to the margin of
the medial femoral condyle. One presumed mechanism of injury is a
Stieda fracture (avulsion injury of the medial collateral ligament at the
medial femoral condyle). Calcification usually begins to form a few
weeks after the initial injury.
• Most patients are asymptomatic while a small proportion will have
medial knee pain
Clubfoot (Talipes Equinovarus)
• Clubfoot, also known as talipes equinovarus (TEV), is a common foot
abnormality, in which the foot points downward and inward. The condition
is present at birth, and involves the foot and lower leg. It occurs twice as
often (2:1) in males than in females. It may affect one or both feet (50 % are
bilateral). For parents with no family medical history of clubfoot, and no
other children with clubfoot, the chance of having a child with clubfoot
(random occurrence), is 1 in 1,000. However, if they already have a child
with clubfoot, their future children have a 3% (3 in 100) chance of having the
same abnormality. Parents who had clubfoot themselves have a 20-30%
chance of having a child with clubfoot. Care and management of this is a
long process beginning as early as 1 week old and lasting to 4-5 years old or
older in some cases.
symptoms
• Stiff, rigid, foot of varying degrees.
• Short and/or tight Achilles tendon (heel cord), with foot pointing
downward.
• The heel is turned in.
• Deep heel crease; soft, puffy heelpad; wide front foot area and overall
smaller foot
causes
• Most causes of clubfeet are unknown (idiopathic). The main point to remember is that the mother
did nothing to cause this. However, there is a familial tendency noted (passed down from the
biologic family) through genes. There are also many associated disorders or syndromes such as
developmental hip dysplasia, spina bifida, arthrogryposis, or myotonic dystrophy. The pediatric
orthopedist will take a full history and perform a thorough exam to determine if any other testing or
referrals are necessary at the first visit.

• This foot abnormality can be multi-factorial in nature, meaning there could be several different pre-
disposing factors

• Extrinsic: This type is usually mild and supple. The cause can be due to intrauterine compression
(large baby, abnormally shaped or small uterus, or abnormal intrauterine fluid levels).
• Intrinsic: This type is commonly more severe, rigid and the calf muscle is smaller. The foot may be
smaller and there can be a bone deformity of the talus.
• In the past, very few treatments were available to correct this condition. Over the last century, advances have
been made in non-operative treatments, such as casting and bracing as well in surgical techniques. Current
treatment consists of casting and bracing or a combination of casting, bracing and surgery. Dr. Ignacio Ponseti
developed the Ponseti method for treatment of clubfeet over 60 years ago. The pediatric orthopedic surgeons
at Nationwide Children’s Hospital, use this method exclusively. Today, we begin serial casting in most patients,
using the “Ponseti method”, as soon as possible after birth or as early as the child and family are available for
exam and treatment. The success of treatment depends on the overall flexibility of the foot and parents’
compliance with appointments for casting and brace wear for 4 years or so.

• The bones in a newborn foot are mostly cartilage, therefore they are easily moldable/manipulated.
• We use the casting to slowly stretch the tissues and move the foot into correct position.
• This set of long leg casts requires weekly visits to the Orthopedic Center to change the foot position in an
orderly method.
• There are typically 3-6 casts required to complete the process.
• Infants will need to be sponge bathed during this time.
• This process will not affect how they are transported in car seats.
• Many times, we will ask you to bring the infant hungry, ready to be fed by a bottle (if possible)
during office visits. This will help calm the child and provide better leg positioning if they are still. A
pacifier and/or toys are also very helpful.
• The baby should be dressed in a “onesie” with bulky clothing to go over the casts or an infant
sleeper sack-type of outfit.
• Please bring extra diapers and wipes as the plaster can adhere to the diaper and skin as we apply
the cast. The plaster does not hurt the skin when we wipe it off.
• Eighty to Ninety percent of patients with clubfeet, (not associated with other conditions), that are
treated with the Ponseti technique, will need a small surgery (see surgical treatment section).
• Ten to twenty percent of patients will require reconstructive foot surgery when the child is 1-2
years old. This number can be as high as 40%-50% if the shoes and bar are not used for a full 4
years after casting.
• Denis-Browne Bar and Shoes
• A child’s foot will continue to grow, change and shape for several years. Once the casting is
completed, the child will be transitioned into a set of special shoes to keep the foot in correct
alignment. This next step in the treatment process is the longest and most important. The
special pair of shoes with a bar attached at the bottom will be made for the baby. These are
called Denis-Browne Shoes and Bar and they are fit at an orthotist office. The bar, not the
shoes, is the main workhorse of this treatment and must be used at all times. The shoes allow
for the bar to be attached to the feet so the foot/feet can be rotated outward, maintaining
the correct alignment of the pre-bone cartilage as the foot grows. These will be worn 23 of 24
hours per day until the baby begins to stand/walk. At this point, the shoes will be used during
naps and bedtime (12 hours a day). This routine will be maintained until the child is 4 to 5
years old or older. If the shoes and bar are worn correctly, as instructed by your doctor, larger,
more invasive surgeries can be avoided. It is important for parents/care-givers to recognize
the need for continued treatment. Without proper follow-up, the deformity will likely reoccur.
Pes Planus
• Pes planus also known as flat foot is the loss of the medial longitudinal arch of the
foot, heel valgus deformity, and medial talar prominence.[1] In lay terms, it is a
fallen arch of the foot that caused the whole foot to make contact with the
surface the individual is standing on. The deformity is usually asymptomatic and
resolves spontaneously in the first decade of life, or occasionally progresses into a
painful rigid form which causes significant disability. All at birth has flat feet and
noticeable foot arch are seen at around the age of 3years.[2]

• It is of two forms; flexible flat foot and rigid flat foot. When the arch of the foot is
intact on heel elevation and non-bearing but disappears on full standing on the
foot, it is termed flexible flat foot while rigid flat foot is when the arch is not
present in both heel elevation and weight bearing.[3]
causes
• The etiology of flatfoot has several factors implicated. depending on etiology pes planus can be divided into
types, namely congenital and acquired. These factors are:

• Talipes equinovarus deformity, ligamentous laxity, foot equinus deformity, tibial torsional deformity, presence
of the accessory navicular bone,[9] congenital vertical talus, and tarsal coalition.
• Diabetes[10] and obesity[11] are also probable factors related to pes planus.[12][13][2]
• Foot and ankle injury such as rupture or dysfunction of the posterior tibial tendon
• Genetic malformation such as Down syndrome and Marfan syndrome[3]
• Familial factors[14]
• Arches weakness due to overuse and certain forms of foot condition or injuries
• Some medical conditions such as arthritis, spina bifida, cerebral palsy, Arthrogyroposis, and muscular
dystrophy.[15]
• Flat feet can also occur as a result of pregnancy.[16][17]
• Iatrogenic factors such as posterior tibialis tendon (PTT) transfer.[15][
• he major symptom of flat feet is foot pain due to strained muscles and
connecting tissues; Pain along the course of the posterior tibial tendon
(PTT) and inability or pain upon attempts to perform a single-leg heel rise

• Some individuals with flat feet have an inwards turned ankles with most
of the weight bearing on the foot deviated medially.

• The detorted weight bearing could result in abnormal lower limbs

biomechanics thus, may predispose the arch of the foot, calf, knee, hip,
lower back and lower legs to pain
• tiffness of one or both arches of the feet.

• Contractures of feet and ankle muscles att the lateral compartment

• Uneven distribution of body weight with resultant one-sided wear of

shoes leading to further injuries.

• Difficulty in walking[15
• Co-morbidities include but not limited to neurological conditions such
as cerebral palsy; genetics e.g downs syndrome, Marfan syndrome or
Ehlers Danos; charcot joint; tibialis posterior dysfunction; Obesity;
arthropathies;[21] Shprintzen-Goldberg syndrome.[22]
• The aim of Physical therapy is to minimize pain, increase foot flexibility, strengthen
weak muscles, train proprioception, and patient education and reassurance.

• Pain management includes rest, activity modification, cryotherapy, massage, and

nonsteroidal anti-inflammatory medication. Ultrasound and pulsed electrical
stimulation can also be used for pain relief. Electric stimulation will aid blood
circulation, promoting healing processes and diminishing discomfort and oedema.

• Flexibility exercises are passive ROM exercise of the ankle and all foot joints;
Stretching of gastrocnemius soleus complex and peroneus brevis muscles to facilitate
varus and foot adduction; Heel-cord stretch for the Achilles tendon and calf muscles
to relief tight heel cord.[27]
• Strengthening Exercises:

• Strengthening exercises are given to anterior and posterior tibialis

muscles and the flexor hallucis longus, Intrinsic, interosseus plantaris
muscles, and the abductor hallucis to prevent valgus and flattening of
the anterior arch. Arch muscle strengthening exercise with theraband

• Global activation of the muscles known to support the medial

longitudinal arch and the varus with and without resistance.
• Single leg weight bearing

• Toe walking

• For Proprioception, Toe and heel walking, Single leg weight bearing, and Descending an inclined surface are exercises that could be
prescribed.

• Also, Toe clawing of towel and pebbles, forefoot standing on a stair, toe extension and toe fanning/spreading, and heel walking are all
good exercises to maintain viable foot arches.

• Counselling on proper footwear, recommendation on motion control shoes, orthotics and braces are also needed. Foot orthotics such as
shoe inserts are used to support the arch for foot pain secondary to pes planus alone or combination with leg, knee, and back pain.

• Obese and overweight individuals should be counseled on weight loss through exercise and dieting; Possibly refer to a dietician for
appropriate insight.

• Other co-morbidities amenable to physiotherapy can also be treated following a proper examination and treatment plan.
Pes cavus
• Pes cavus is a foot with an abnormally high plantar longitudinal arch. People who have
this condition will place too much weight and stress on the ball and heel of the foot
while standing and/or walking.

• Pes Cavus [1]

• The spectrum of associated deformities observed with pes cavus includes clawing of
the toes, posterior hind foot deformity (described as an increased calcaneal angle),
contracture of the plantar fascia, and cock-up deformity of the great toe. This can
cause increased weight bearing for the metatarsal heads and associated Metatarsalgia
and calluses. </ref>[2]

• Etiology
• The etiology can be attributed to the brain, spinal cord, peripheral nerves, or structural problems
of the foot. When motor imbalance begins before maturation of the skeleton, there can be a
substantial change in healthy bone morphology. When cavus is acquired after skeletal maturity,
there may be little or no change in the morphology. Two-thirds of adults with symptomatic cavus
foot have an underlying neurologic condition, most commonly: 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[3]. A patient with a new-onset unilateral deformity but without a history of
trauma must be evaluated for spinal tumors.

• The cause and deforming mechanism underlying pes cavus are complex and not well understood.
Factors considered influential in the development of pes cavus include muscle weakness and
imbalance in neuromuscular disease, residual effects of congenital clubfoot, post-traumatic bone
malformation, contracture of the plantar fascia, and shortening of the Achilles tendon [4]
• Also known as Hereditary Motor and Sensory Neuropathy (HMSN), it is genetically heterogeneous and usually
presents in the first decade of life with delayed motor milestones, distal muscle weakness, clumsiness, and
frequent falls. By adulthood, Charcot-Marie-Tooth disease can cause painful foot deformities such as pes
cavus. Although it is a relatively common disorder affecting the foot and ankle, little is known about the
distribution of muscle weakness, severity of orthopaedic deformities, or types of foot pain experienced. There
are no cures or effective courses of treatment to halt the progression of any form of Charcot-Marie-Tooth
disease[6]

• The development of the cavus foot structure seen in Charcot-Marie-Tooth disease has been previously linked
to an imbalance of muscle strength around the foot and ankle. A hypothetical model proposed by various
authors describes a relationship whereby weak evertor muscles are overpowered by stronger invertor
muscles, causing an adducted forefoot and inverted rearfoot. Similarly, weak dorsiflexors are overpowered by
stronger plantarflexors, causing a plantarflexed first metatarsal and anterior pes cavus[7]

• A man is a preventive factor for hollow feet( pes cavus), but a risk factor for flat feet. There is a statistically
significant difference due to sex in the prevalence of hollow feet[8].
• Three main types of pes cavus are regularly described in the literature: pes cavovarus, pes calcaneocavus,
and ‘pure’ pes cavus. The three types of pes cavus can be distinguished by their aetiology, clinical signs
and radiological appearance[9]

• Pes cavovarus, the most common type of pes cavus, is seen primarily in neuromuscular disorders such as
Charcot-Marie-Tooth disease and, in cases of unknown aetiology, is conventionally termed ‘idiopathic’.
[10] Pes cavovarus presents with the calcaneus in varus, the first metatarsal plantarflexed, and a claw-toe
deformity.[5] Radiological analysis of pes cavus in Charcot-Marie-Tooth disease shows the forefoot is
typically plantarflexed in relation to the rearfoot.[11]
• pes calcaneocavus foot, which is seen primarily following paralysis of the triceps surae due to
poliomyelitis, the calcaneus is dorsiflexed and the forefoot is plantarflexed. Radiological analysis of pes
calcaneocavus reveals a large talo-calcaneal angle.
• pes cavus, the calcaneus is neither dorsiflexed nor in varus and is highly arched due to a plantarflexed
position of the forefoot on the rearfoot.[12] A combination of any or all of these elements can also be
seen in a ‘combined’ type of pes cavus that may be further categorized as flexible or rigid.[13]
• Symptoms and clinical presentation
• Patients complain pain , instability , difficulty walking and problems with footwear .The symptoms vary with the degree of
deformity .[17] also can present with lateral foot pain from increased weight bearing on the lateral foot.

• The range of complaints reported in the literature include metatarsalgia, pain under the first metatarsal, plantar fasciitis, painful
callosities, ankle arthritis, and Achilles tendonitis [18]
• keratosis
• lateral Ankle instability[19]
• hindfoot varus
• The forefoot plantar flexion
• hindfoot varus[2]
• lower limb stress fractures[20]
• knee pain[21]
• iliotibial band friction syndrome[22]
• back pain[23]
• tripping[24]
• Physiotherapy management
• Suggested conservative management of patients with painful pes cavus typically involves
strategies to reduce and redistribute plantar pressure loading, with the use of foot orthoses
and specialized cushioned footwear. The orthoses for pes cavus needs to accomplish several
specific goals:

• Increasing plantar surface contact area The overload on the metatarsal heads is a result of
limited plantar surface contact due to high arch and limited ankle joint dorsiflexion.
Increasing the plantar surface contact ensures the foot to bear more weight in the arch
while the metatarsal heads bear less weight during activity.[24] (Evidence level 4)
• Resisting against excessive supination Lateral ankle stability and laterally deviated subtalar
joint axis (STJ) are frequently associated with high-arched feet. This position results in an
excessive supinator torque around the subtalar joint axis.
• Resisting against recessive pronation and supination forces Rearfoot instability is caused by an
extension of the laterally deviated subtalar axis. In flexible pes cavus, midtarsal flexibility complicates
the later portion of the stance phase of gait. The forefoot pathology produces midtarsal joint
supination, that leads to excessive pronation of the rearfoot. Some pes cavus patients suffer from
both lateral ankle instability at midstance and rearfoot pronation at late midstance. stretching and
strengthening of tight and weak muscles, debridement of plantar callosities, osseous mobilization,
massage, chiropractic manipulation of the foot and ankle, and strategies to improve balance[25]
• (Evidence 5)
• Orthotics with extra-depth shoes to offload bony prominences and prevent rubbing of the toes may
improve symptoms. For varus deformities, a lateral wedge sole modification can improve function.
Bracing for supple deformities or foot drop may allow patients to ambulate; however, in patients
with sensation deficits, Plastazote linings in the brace are required and frequent inspection of the
skin for ulceration is warranted.[26] (Evidence 1b)
• Surgical Management
Pes Planovalgus
• Physiologic variant consisting of a decrease in the medial longitudinal arch and a valgus
hindfoot and forefoot abduction with weightbearing
• Epidemiology
• incidence
• unknown in pediatric population
• 20% to 25% in adults
• Pathoanatomy
• generalized ligamentous laxity is common
• 25% are associated with gastrocnemius-soleus contracture
• Prognosis
• most of the time resolves spontaneously
classification
• Hypermobile flexible pes planovalgus (most common)
• familial
• associated with generalized ligamentous laxity and lower extremity rotational
problem
• usually bilateral
• associated with an accessory navicular
• correlation is controversial
• Flexible pes planovalgus with a tight heel cord
• Rigid flatfoot & tarsal coalition (least common)
• no correction of hindfoot valgus with toe standing due limited subtalar motion
presentation
• Symptoms
• usually asymptomatic in children
• may have arch pain or pretibial pain
treatmemt
• observation, stretching, shoewear modification, orthotics
• indications
• asymptomatic patients, as it almost always resolves spontaneously
• counsel parents that arch will redevelop with age
• techniques
• athletic heels with soft arch support or stiff soles may be helpful for symptoms
• orthotics do not change natural history of disease
• UCBL heel cups may be indicated for symptomatic relief of advanced cases
• rigid material can lead to poor tolerance
• stretching for symptomatic patients with a tight heel cord
• Metatarsalgia (met-uh-tahr-SAL-juh) is a condition in which the ball of
your foot becomes painful and inflamed. You might develop it if you
participate in activities that involve running and jumping. There are other
causes as well, including foot deformities and shoes that are too tight or
too loose.

• Although generally not serious, metatarsalgia can sideline you.

Fortunately, at-home treatments, such as ice and rest, often relieve
symptoms. Wearing proper footwear with shock-absorbing insoles or arch
supports might prevent or minimize future problems with metatarsalgia.
• Symptoms of metatarsalgia can include:

• Sharp, aching or burning pain in the ball of your foot — the part of
the sole just behind your toes
• Pain that worsens when you stand, run, flex your feet or walk —
especially barefoot on a hard surface — and improves when you rest
• Sharp or shooting pain, numbness, or tingling in your toes
• A feeling of having a pebble in your shoe
• Causes
• Sometimes a single factor can lead to metatarsalgia. More often, several factors are involved, including:

• Intense training or activity. Distance runners are at risk of metatarsalgia, primarily because the front of the foot absorbs significant
force when a person runs. But anyone who participates in a high-impact sport is at risk, especially if your shoes fit poorly or are
worn.
• Certain foot shapes. A high arch can put extra pressure on the metatarsals. So can having a second toe that's longer than the big
toe, which causes more weight than normal to be shifted to the second metatarsal head.
• Foot deformities. Wearing too-small shoes or high heels can cause your foot to be misshapen. A downward-curling toe
(hammertoe) and swollen, painful bumps at the base of your big toes (bunions) can cause metatarsalgia.
• Excess weight. Because most of your body weight transfers to your forefoot when you move, extra pounds mean more pressure on
your metatarsals. Losing weight might reduce or eliminate symptoms.
• Poorly fitting shoes. High heels, which transfer extra weight to the front of your foot, are a common cause of metatarsalgia in
women. Shoes with a narrow toe box or athletic shoes that lack support and padding also can contribute to the problem.
• Stress fractures. Small breaks in the metatarsals or toe bones can be painful and change the way you put weight on your foot.
• Morton's neuroma. This noncancerous growth of fibrous tissue around a nerve usually occurs between the third and fourth
metatarsal heads. It causes symptoms that are similar to metatarsalgia and can also contribute to metatarsal stress.
• Risk factors
• Almost anyone can develop metatarsalgia, but you're at higher risk if you:

• Participate in high-impact sports that involve running and jumping

• Wear high heels, shoes that don't fit properly or shoes with spikes, such as
cleats
• Are overweight or obese
• Have other foot problems, including hammertoe and calluses on the bottom
of your feet
• Have inflammatory arthritis, such as rheumatoid arthritis or gout
• Complications
• Left untreated, metatarsalgia might lead to pain in other parts of the
same or opposite foot and pain elsewhere in the body, such as the
low back or hip, due to limping (altered gait) from foot pain.
• To help ease your metatarsalgia pain, try these tips:
• Rest. Protect your foot from further injury by not stressing it. ...
• Ice the affected area. ...
• Take an over-the-counter pain reliever. ...
• Wear proper shoes. ...
• Use metatarsal pads. ...
• Consider arch supports.
Hallux valgus
• Hallux valgus is the most common foot deformity[1].

• It is a progressive foot deformity in which the first metatarsophalangeal (MTP) joint is affected and
is often accompanied by significant functional disability and foot pain[2],[3].
• This joint is gradually subluxed (lateral deviation of the MTP joint) resulting in abduction of the
first metatarsal while the phalanges adduct.[2],[4].
• This often leads to the development of soft tissue and bony prominence on the medial side of
what is called a bunion [5] (exostosis on the dorsomedial aspect of the first metatarsal head). [6]
• At a late stage, these changes lead to pain and functional deficit: i.e. impaired gait (lateral and
posterior weight shift, late heel rise, decreased single-limb balance, pronation deformity) [4].
• There is a high prevalence of hallux valgus in the overall population (23% of adults aged 18-65
years and 35.7% of adults over 65 years of age).
• More in female
• Etiology is not well established - certain factors have been considered to play a role in the development
of hallux valgus;

• Gender (10x more frequent in women)

• Footwear (tight pointed shoes) Wearing tight shoes and/or heeled shoes between 20 and 39 years of
age can be crucial in the development of hallux valgus in later years.
• Congenital deformity or predisposition
• Chronic achilles tightness
• Severe flatfoot
• Hypermobility of the first metatarsocunieform joint
• Systemic disease
• Possible that abnormal muscle insertions are partly responsible for hallux valgus
• Hallux valgus is also associated with hip and knee OA and is inversely associated with a higher BMI
• n this foot deformity:
• Distal end of the first metatarsal drifts medially and the proximal phalanx deviates laterally.
• First MTP becomes subluxed, leading to a lateral deviation of the hallux and medial
displacement of the distal end of the first metatarsal
• Bony enlargement of the first metatarsal head [2].
• Mechanism behind this hallux valgus formation

• Starts with the stretching of the abductor hallucis muscle (for example as a result of wearing
tight shoes).
• Base of the first proximal phalanx (PP) starts to lateralise and abducts.
• During gait, the forefoot is turned into pronation, which stretches the medial collateral
ligament and the capsular structures of the first MTP joint.
• First MTP joint consists of multiple bones, ligaments, sesamoid bones and nearby muscles, all
influencing other structures as they move or stretch.
• Once a threshold degree of valgus of the first PP is reached, the first metatarsal bone starts his way
into a varus position.
• Hallux is pushed into a valgus position.
• Capsule gets weaker and the abductor hallucis tendon turns into a flexor of the hallux.
• As the condition progresses multiple muscles tend to worsen the situation as their axis of pull is
lateralized.
• As a bunion appears, friction is raised when shoes are worn.

• There may be irritation of the MCL ligament of the first MTP joint, which leads to inflammation and
calcification of the joint.
• This worsens the pain and bunion size.
• In an early stage, this leads to tenderness of the bunion due to
footwear.
• The skin over the bunion is hard, warm and red. Later on, the patient
may have other complaints due to osteoarthritis.
• The bunion keeps moving medially and the pain gets worse. [5] [16]
• Hallux Valgus.png
• A common problem in people with hallux valgus (pre-operative), is
one or more disorders in their gait pattern due to the deformity of the
first metatarsophalangeal joint.
• A hereditary factor or predisposition (for example as a result of a
generalized ligamentous laxity) is not preventable but other things
are. For example, wearing shoes that fit properly (not too tight) and
avoiding high heels can be important factors in preventing hallux
valgus
• The first treatment option is non-operative care:

• Adjustment of footwear to help in eliminating friction at the level of the medial

eminence (bunion) e.g., patients should be provided of a shoe with a wider and
deeper toe box
• The condition of pes planus may be helped by an orthosis. Severe pes planus can
lead to a recurrence of hallux valgus following surgery.
• Achilles tendon contracture may require stretching or even lengthening [6]
• This type of treatment can be applied in the early stage when the secondary
contractures of the soft tissues and the alterations of the articular surfaces have
not become permanent [25].
• Six weeks of non-weightbearing
• Discomfort
• immobilization in a modified shoe
• Swelling might last up to six months
• You can provide the patient with reading resources to make sure they
understand the surgery and its complications.
• The postoperative management shouldn't be exclusive on managing
pain and restoring local mobility. It should have a wider view to assess
and manage any other associated issues[26]
• The condition can be extremely painful but there are many treatments available to
ease the pain.

• A hammer toe is a toe that has an abnormal bend in its middle joint, making the
toe bend downward to look like a hammer.

• This painful condition forms due to an imbalance in the surrounding muscles,

tendons, or ligaments that normally keep the toe straight.

• Hammer toes are flexible to begin with. If hammer toe is not treated promptly,
they may become fixed and require surgery to correct them.
Fast facts
• Hammer toe is caused by a muscle imbalance in the toes.
• The primary symptom is a bent toe, resembling a hammer.
• Without prompt treatment, hammer toes get progressively worse.
• Simple exercises can treat and prevent hammer toe.
• Causes of hammer toe include the following:

• Certain shoes – wearing high heels or shoes that are too tight through the box can force
toes into a flexed position. When worn repeatedly, the toes may not be able to straighten,
even when barefoot.
• Sex – women are more likely to develop hammer toe than men.
• Injuries – When a toe is broken, stubbed, or jammed, it may be more likely to develop
hammer toe.
• Age – risk increases with age.
• Toe length – if the second toe is longer than the big toe, hammer toe is more likely to occur.
• Certain diseases – people suffering from conditions like arthritis or diabetes are more likely
to develop foot problems, including hammer toe
• Genetics – sometimes, hammer toe is hereditary and may run in families.
• The symptoms of hammer toe are often very visible. The affected toe will be bent,
looking like a hammer.

• Other symptoms of hammer toe include:

• Pain in the affected toe, especially when moving it or wearing shoes.

• Corns and callouses on top of the middle joint of the hammer toe.
• Swelling, redness, or a burning sensation.
• Inability to straighten the toe.
• In severe cases, open sores may develop on the toe.
• Risk factors and complications
• Hammer toes are progressive, worsening over time. If not promptly
treated, the toe joint may become fixed and require surgery to
straighten it.

• The more a person with hammer toe wears improper footwear and
the longer the person ignores the developing hammer toe, the more
likely the toe will require surgery to release the tendons.
• Treatment for mild hammer toe
• If the hammer toe is treated while the toe is still flexible, a doctor may recommend the following:

• Exercises such as picking up marbles with the toe.

• Switching to proper footwear with low heels and a roomy box.
• Gently stretching the toe manually several times a day.
• A podiatrist may be able to create a shoe insert to reduce pain and stop the hammer toe from
worsening.
• Using over-the-counter corn pads and foot straps to relieve some of the painful symptoms.
• Sometimes a doctor might use a cortisone injection to relieve pain.
• It is important not to pop any blisters that might occur on the foot as this can lead to infection.
• What Is Hallux Rigidus?
• Normal function of the joint at the base of the big toeHallux rigidus is a disorder of the joint located at
the base of the big toe. It causes pain and stiffness in the joint, and with time, it gets increasingly harder
to bend the toe. Hallux refers to the big toe, while rigidus indicates that the toe is rigid and cannot
move. Hallux rigidus is actually a form of degenerative arthritis.

• This disorder can be very troubling and even disabling since we use the big toe whenever we walk,
stoop down, climb up or even stand. Many patients confuse hallux rigidus with a bunion, which affects
the same joint, but they are very different conditions requiring different treatment.

• Because hallux rigidus is a progressive condition, the toe’s motion decreases as time goes on. In its
earlier stage, when motion of the big toe is only somewhat limited, the condition is called hallux limitus.
But as the problem advances, the toe’s range of motion gradually decreases until it potentially reaches
the end stage of rigidus, in which the big toe becomes stiff or what is sometimes called a frozen joint.
causes
• Common causes of hallux rigidus are faulty function (biomechanics) and structural
abnormalities of the foot that can lead to osteoarthritis in the big toe joint. This
type of arthritis—the kind that results from wear and tear—often develops in
people who have defects that change the way their foot and big toe functions. For
example, those with fallen arches or excessive pronation (rolling in) of the ankles
are susceptible to developing hallux rigidus. In some people, hallux rigidus runs in
the family and is a result of inheriting a foot type that is prone to developing this
condition. In other cases, it is associated with overuse, especially among people
engaged in activities or jobs that increase the stress on the big toe, such as workers
who often must stoop or squat. Hallux rigidus can also result from an injury, such as
stubbing your toe. Or it may be caused by inflammatory diseases, such as
rheumatoid arthritis or gout. Your foot and ankle surgeon can determine the cause
of your hallux rigidus and recommend the best treatment.
• Early signs and symptoms include:

• Pain and stiffness in the big toe during use (walking, standing, bending, etc.)
• Pain and stiffness aggravated by cold, damp weather
• Difficulty with certain activities (running, squatting)
• Swelling and inflammation around the joint

• Rigid deformity of the big toe caused by Hallux Rigidus

• As the disorder gets more serious, additional symptoms may develop, including:

• Pain, even during rest

• Difficulty wearing shoes because bone spurs (overgrowths) develop
• Dull pain in the hip, knee or lower back due to changes in the way you walk
• Limping (in severe cases)
•
• Nonsurgical Treatment
• In many cases, early treatment may prevent or postpone the need for surgery in the future.
Treatment for mild or moderate cases of hallux rigidus may include:

• Shoe modifications. Shoes with a large toe box put less pressure on your toe. Stiff or rocker-
bottom soles may also be recommended.
• Orthotic devices. Custom orthotic devices may improve foot function.
• Medications. Oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may
be recommended to reduce pain and inflammation.
• Injection therapy. Injections of corticosteroids may reduce inflammation and pain.
• Physical therapy. Ultrasound therapy or other physical therapy modalities may be
undertaken to provide temporary relief.