Hallux Valgus Deformity And Treatment :


Hallux Valgus Deformity

Hallux valgus 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.


Foot Deformity- Hallux Valgus

Bunions are a widespread foot ailment that can be caused by a number of factors including genetics
Excess weight gain,
Activity level, and
Ill-fitting shoes.
Other less common causes of bunions include trauma to the
MTP joint (sprains, fractures, and nerve injuries),
Neuromuscular disorders,
Limb-length discrepancies.
Some studies report that bunions tend to occur ten times more frequently in women than in men, primarily as the result of wearing narrow, pointy, tight fitting, and/or high-heeled shoes over a significant period of time. Repetitive stresses to the foot can also cause bunions.

Your big toe points toward your second toe, or your second toe overlaps your big toe
A prominent bump on the inside of the MTP or big toe joint
Pain on the inside of your foot at the big toe joint when wearing any kind of shoe
Pain each time the big toe flexes when walking
Redness, swelling , or thickening of the skin on the inside of the big toe joint


Hallux Valgus Angle Measurement

Radiographic exmatination show the angle formed between longitudinal bisection of the 1st Metatarsal and proximal phalanx.
A big toe position with an angle of up to 10° is still considered normal.
A minor hallux valgus defect is 16-20°.
A moderate hallux valgus deformity has a deviation of 16-40°.
A severe hallux valgus deformity has a deviation of over 40°.
Magnetic resonance imaging (MRI) will detect cartilage damage, trapped soft tissue and bone damage.


Splinting In Hallux Valgus

Adjusted footwear with wider and deeper tip
Increase extension of MTP joint
Relieve weight-bearing stresses (orthosis)
Sesamoid Mobilization:The physical therapist performs grade III joint mobilizations on the medial and lateral sesamoid of the affected first MPJ. One thumb is placed on the proximal aspect of the sesamoid and is used to apply a force from proximal to distal that causes the sesamoid to reach the end range of motion (distal glides). These are performed with large-amplitude rhythmic oscillations. No greater than 20° of movement of the MPJ should be allowed during the technique.

Strenthening Exercise In Hallux Valgus

Strengthening of peroneus longus
Electrotherapy Modalities – Ultrasound, ice, electrical stimulation, MTJ mobilizations and exercises. This is more effective than physical therapy alone. The combination will result in a increase in ROM of the MTP joint, strength and function, and also a decrease in pain .
Pain is the main reason that patients seek treatment for a bunion. Inflammation is best eased using ice therapy, techniques (e.g. soft tissue massage, acupuncture, unloading taping techniques) or exercises that unload the inflamed structures. Anti-inflammatory medications may help. Orthotics can also be used to offload the bunion.

For Restoring the Normal Joint Of Motion –

images jgh
Gripping Muscle Of Foot Active Exercise

Joint mobilisation (abduction and flexion) and alignment techniques (between the first and the second metatarsal)
Muscle and joint stretches
Bunion splint or orthotics
bunion stretch and soft tissue release.

For Strenghting Of Muscles –
Towel curls The patient spreads out a small towel on the floor, curling his/her toes around it and pulling the towel towards them.
The ends of the band are either held by an assistant or secured against an immovable object (e.g. a table leg). The patient then dorsiflexes the ankle, pulling “towards their nose,” working against the resistance of the band.


Deltoid muscle

Deltoid Muscle :In human anatomy, the deltoid muscle is the muscle forming the rounded contour of the shoulder.

Anatomically, it appears to be made up of three distinct sets of fibers though electromyography suggests that it consists of at least seven groups that can be independently coordinated by the central nervous system.

It was previously called the deltoideus (plural deltoidei) and the name is still used by some anatomists. It is called so because it is in the shape of the Greek letter Delta (triangle). It is also known as the common shoulder muscle, particularly in lower animals (e.g., in domestic cats). Deltoid is also further shortened in slang as “delt”.

A study of 30 shoulders revealed an average mass of 191.9 grams (6.77 oz) (range 84 grams (3.0 oz)–366 grams (12.9 oz)) in humans.


Deltoid Muscle
(proximal attachments)
a. Anterior head: anterior surface of the lateral clavicle.
b. Middle head: acromion process and spine of the scapula.


(distal attachments)
a. Deltoid tuberosity of the humerus.


Anterior head:
a. Flexes the arm at the shoulder.
b. Medially rotates the arm at the shoulder.
Middle head:
a. Abducts the arm at the shoulder.


Nerve supply:

a. Nerve: Axillary nerve
b. Nerve roots: C5 and C6


Applied Anatomy :

  Rupture of the deltoid muscle


Anatomy: The large Deltoid muscle (M Deltoideus) is a thick triangular muscle, emanating around the shoulder, covering the shoulder joint and forming the rounding of the shoulder. The muscle is fastened on the humerus. The various parts of the deltoid muscle take part in nearly all movements of the shoulder joint.


Cause: When a muscle is subjected to a load beyond the strength of the muscle (butterfly swimming, weight training, weight lifting) a rupture occurs. Most ruptures in athletes are partial ruptures. The rupture can be located both in the front and the back as well as at the attachment to the upper arm (humerus).

Symptoms: In light cases a localised tenderness can be felt following the load (“muscle strain”, “imminent pulled muscle”). In more severe cases sudden shooting pains in the muscle can be felt (“partial muscle rupture”) and in the worst cases a sudden snap is felt, rendering the muscle unusable (“total muscle rupture”) this is very rare, and is almost only seen in conjunction with other damage in the shoulder. With muscle injuries the following three symptoms are characteristic: pain upon pressure, stretching and activating against resistance.

Acute treatment: Acute treatment starts as quickly as possible after the injury has been incurred. The objective of the acute treatment is primarily to prevent additional injury and reduce bleeding as much as possible. Effective acute treatment will reduce bleeding, formation of scar tissue, the number of complications, which can arise, and the rehabilitation period.
Treatment follows the so-called “RICE” principles:                                                                               R;-   Continued sports activity is immediatel  stopped(Rest)                                                                                                                                                               B:- As soon as is possible, Ice should be placed on the injured area. The cold ice makes the blood vessels contract, thereby stopping the bleeding. Cold spray has no effect in such circumstances. The ice must not come into direct contact with the skin, which should be covered with a thin layer of, for example, elastic bandage. Ice treatment should be given for twenty minutes in each of the first three hours after injury.

I:- As far as is possible the treatment should furthermore comprise:                                              

C-:   A Compression bandage should be applied, however, must not be so tight as to prevent the blood flow. The compression bandage should be removed at night, but applied again each morning until the swelling goes down. The effect of the compression can be enhanced if a piece of felt, for example, of approx. one cm. thickness is placed under the bandage and directly above the haemorrhaging.                                                                                                                                             

E:-  The injured area is kept as high as possible, and preferably above the heart (Elevation). The haemorrhaging will stop when it comes above the level of the heart. Elevation of the affected area should be performed as much as possible as long as swelling is in evidence.


Examination: Light cases with only minimal tenderness and no discomfort when using the arm do not necessarily require medical examination. The extent of the tenderness is, however, not always a mark of the degree of the injury. In case of more pronounced tenderness medical examination is advised with the aim of securing a correct diagnosis and treatment. Pain will be present when pressure is applied to the damaged muscle, which will be aggravated when the muscle is activated against resistance and when the muscle is stretched. Ultrasound is well suited to ensure the diagnosis.

Treatment: The treatment primarily involves relief, discontinuance of the injury inducing activity, stretching and increasing fitness training.

Rehabilitation: INSTRUCTION
Complications: If satisfactory progress is not made, a physician should be consulted to ensure that the diagnosis is correct and that no complications have arisen. Amongst others the following should be considered:

Rupture of the upper shoulder blade muscle
Inflammation of the upper shoulder blade muscle
Rupture of the lower shoulder blade muscle
Tendon sheath inflammation of the biceps
Luxation in the joint between the shoulder blade and the collarbone
Partial luxation in the shoulder joint
Frozen shoulder
Muscle infiltrations
Sprained shoulder (distorsio art. humeroscapularis)
Meniscus lesion in the shoulder (laesio labrum glenoidale)
Nerve entrapment on the back of the shoulder blade


In human anatomy, the trapezius is a large superficial muscle that extends longitudinally from the occipital bone to the lower thoracic vertebrae and laterally to the spine of the scapula (shoulder blade). Its functions are to move the scapulae and support the arm.

The trapezius has three functional regions: the superior region (descending part), which supports the weight of the arm; the intermediate region (transverse part), which retracts the scapulae; and the inferior region (ascending part), which medially rotates and depresses the scapulae.Structure


The trapezius muscle resembles a trapezium (trapezoid in American English), or diamond-shaped quadrilateral. The word “spinotrapezius” refers to the human trapezius, although it is not commonly used in modern texts. In other mammals, it refers to a portion of the analogous muscle.

Position of trapezius and its parts.

  Superior fibers of the trapezius

  Middle fibers of the trapezius

  Inferior fibers of the trapezius

The superior or upper (or descending) fibers of the trapezius are formed from the external occipital protuberance, the medial third of the superior nuchal line of the occipital bone (both in the back of the head), the ligamentum nuchae, and the spinous processes of C1-C7. From this origin they proceed downward and laterally to be inserted into the posterior border of the lateral third of the clavicle.

The middle fibers, or transverse of the trapezius arise from the spinous process of the seventh cervical (both in the back of the neck), and the spinous processes of the first, second, and third thoracic vertebrae. They are inserted into the medial margin of the acromion, and into the superior lip of the posterior border of the spine of the scapula.

The inferior or lower (or ascending) fibers of the trapezius arise from the spinous processes of the remaining thoracic vertebrae (T4-T12). From this origin they proceed upward and laterally to converge near the scapula and end in an aponeurosis, which glides over the smooth triangular surface on the medial end of the spine, to be inserted into a tubercle at the apex of this smooth triangular surface.

At its occipital origin, the trapezius is connected to the bone by a thin fibrous lamina, firmly adherent to the skin. The superficial and deep epimysia are continuous with an investing deep fascia that encircles the neck and also contains both sternocleidomastoid muscles.

At the middle, the muscle is connected to the spinous processes by a broad semi-elliptical aponeurosis, which reaches from the sixth cervical to the third thoracic vertebræ and forms, with that of the opposite muscle, a tendinous ellipse. The rest of the muscle arises by numerous short tendinous fibers.

Origin:- external occipital protuberance, nuchal ligament, medial superior nuchal line, spinous processes of vertebrae C7-T12
Insertion:-posterior border of the lateral third of the clavicle, acromion process, and spine of scapula
superficial branch of transverse cervical artery or superficial cervical artery
accessory nerve (motor)
cervical spinal nerves C3 and C4 (motor and sensation)
Actions:-     rotation, retraction, elevation, and depression of scapula

sternoclaidomastoid muscle

The sternocleidomastoid  muscle:-

In human anatomy, the sternocleidomastoid muscle also known as sternomastoid and commonly abbreviated as SCM, is a paired muscle in the superficial layers of the anterior portion of the neck; it is one of the largest and most superficial cervical muscles.

Structure:-The sternocleidomastoid passes obliquely across the side of the neck.

It is thick and narrow at its central part, but broader and thinner at either end.

    The medial or sternal head is a rounded fasciculus, tendinous in front, fleshy behind, which arises from the upper part of the anterior surface of the manubrium sterni, and is directed superiorly, laterally, and posteriorly.

    The lateral or clavicular head, composed of fleshy and aponeurotic fibers, arises from the superior border and anterior surface of the medial third of the clavicle; it is directed almost vertically upward.

The two heads are separated from one another at their origins by a triangular interval (supraclavicular fossa) but gradually blend, below the middle of the neck, into a thick, rounded muscle which is inserted, by a strong tendon, into the lateral surface of the mastoid process, from its apex to its superior border, and by a thin aponeurosis into the lateral half of the superior nuchal line of the occipital bone.usculus sternocleidomastoideus


    Manubrium sterni and medial portion of the clavicle


    Mastoid process of the temporal bone, superior nuchal line


    Occipital artery and the superior thyroid artery

Nerve:-    Motor: accessory nerve

                       sensory: cervical plexus

Actions:-     Unilaterally; cervical rotation to opposite side, cervical lateral flexion to same side
Bilaterally; cervical flexion, raises the sternum and assists in forced inspiration.

Subclavius muscle:-The subclavius is a small triangular muscle, placed between the clavicle and the first rib. Along with the pectoralis major and pectoralis minor muscles, the subclavius muscle makes up the anterior wall of the axilla.

Structure:-It arises by a short, thick tendon from the first rib and its cartilage at their junction, in front of the costoclavicular ligament.

The fleshy fibers proceed obliquely superolaterally, to be inserted into the groove on the under surface of the clavicle between the trapezoid ligament and conoid ligaments, which collectively form the coracoclavicular ligament.

Innervation:-The nerve to subclavius (or subclavian nerve), which arises from the point of junction of the fifth and sixth cervical nerves, where is called the upper trunk of brachial plexus, innervates the muscle .

Insertion into coracoid process instead of clavicle or into both clavicle and coracoid process. Sternoscapular fasciculus to the upper border of scapula. Sternoclavicularis from manubrium to clavicle between pectoralis major and coracoclavicular fascia.


The subclavius depresses the shoulder, carrying it downward and forward. It draws the clavicle inferiorly as well as anteriorly.

The subclavius protects the underlying brachial plexus and subclavian vessels from a broken clavicle – the most frequently broken long bone.

first rib and cartilage

subclavian groove of clavicle (inferior surface of middle third of clavicle)

thoracoacromial trunk, clavicular branch

nerve to subclavius

Actions:-     depression of clavicle


ACL TEAR & PHYSIOTHERAPY MANAGEMENT :Anterior Cruciate Ligament (ACL) InjuriesOne of the most common knee injuries is an anterior cruciate ligament sprain or tear.

Athletes suffer from this injury the most
If you have injured your anterior cruciate ligament, you may require surgery to regain full function of your knee. This will depend on several factors, such as the severity of your injury and your activity level.

Anatomy :

Three bones meet to form your knee joint: your thighbone (femur), shinbone (tibia), and kneecap (patella). Your kneecap sits in front of the joint to provide some protection.
Bones are connected to other bones by ligaments. There are four primary ligaments in your knee. They act like strong ropes to hold the bones together and keep your knee stable.
Collateral Ligaments

These are found on the sides of your knee. The medial collateral ligament is on the inside and the lateral collateral ligament is on the outside. They control the sideways motion of your knee and brace it against unusual movement.
Cruciate Ligaments

These are found inside your knee joint. They cross each other to form an “X” with the anterior cruciate ligament in front and the posterior cruciate ligament in back. The cruciate ligaments control the back and forth motion of your knee.

The anterior cruciate ligament runs diagonally in the middle of the knee. It prevents the tibia from sliding out in front of the femur, as well as provides rotational stability to the knee.


About half of all injuries to the anterior cruciate ligament occur along with damage to other structures in the knee, such as articular cartilage, meniscus, or other ligaments.Injured ligaments are considered “sprains” and are graded on a severity scale.

Grade 1 Sprains. The ligament is mildly damaged in a Grade 1 Sprain. It has been slightly stretched, but is still able to help keep the knee joint stable.

Grade 2 Sprains. A Grade 2 Sprain stretches the ligament to the point where it becomes loose. This is often referred to as a partial tear of the ligament.

Grade 3 Sprains. This type of sprain is most commonly referred to as a complete tear of the ligament. The ligament has been split into two pieces, and the knee joint is unstable.

Partial tears of the anterior cruciate ligament are rare; most ACL injuries are complete or near complete tears.

 Cause :

Acl injury

The anterior cruciate ligament can be injured in several ways:

  •     Changing direction rapidly
  •     Stopping suddenly
  •     Slowing down while running
  •     Landing from a jump incorrectly
  •     Direct contact or collision, such as a football tackle

Several studies have shown that female athletes have a higher incidence of ACL injury than male athletes in certain sports. It has been proposed that this is due to differences in physical conditioning, muscular strength, and neuromuscular control. Other suggested causes include differences in pelvis and lower extremity (leg) alignment, increased looseness in ligaments, and the effects of estrogen on ligament properties.


Symptoms of a severe and sudden (acute) anterior cruciate ligament (ACL) injury include:

  •     Feeling or hearing a “pop” in the knee at the time of injury.
  •     Sudden instability in the knee. …
  •     Pain on the outside and back of the knee.
  •     Knee swelling within the first few hours of the injury.
  •     Limited knee movement because of swelling and/or pain.
  • Knee Giving Out/Instability

After an acute injury, you will almost always have to stop the activity you are doing, but you may be able to walk.
special tests:Abnormal Examination:
Your doctor can assess the ligaments of your knee with specific tests. The most commonly used tests to determine the presence of an ACL tear include:

  •     Lachman Test:    The Lachman test is performed to evaluate abnormal forward movement of the tibia. By pulling the tibia forward, your surgeon can feel for an ACL tear.
  •     Pivot Shift Maneuver:    The pivot shift is difficult to perform in the office, it is usually more helpful in the operating room with a patient under anesthesia. The pivot shift maneuver detects abnormal motion of the knee joint when there is an ACL tear present.

Test Results:
Your physician will also evaluate x-rays of the knee to assess for any possible fractures, and a MRI may be ordered to evaluate for ligament or cartilage damage. However, MRI studies may not be needed to diagnose an ACL tear. In fact, the physical examination and history are just as good as a MRI in diagnosing an ACL tear!

Nonsurgical Treatment:Nonsurgical management of isolated ACL tears is likely to be successful or may be indicated in patients:

  •     With partial tears and no instability symptoms
  •     With complete tears and no symptoms of knee instability during low-demand sports who are willing to give up high-demand sports
  •     Who do light manual work or live sedentary lifestyles

    •     Whose growth plates are still open (children)



      to regain the bend (flexion) of the knee.

      to maintain muscle tone in the thigh (quadriceps)muscles and straighten the knee.

      to straighten extend the knee

      The quality of the muscle contraction in this exercise
      is what counts the most, not just the ability to
      lift the leg!  

    • stationary bicycle


    • standing hamstring curl :

    • hip abduction:

    • standing toe raise: 


    • wall slides:


Samarpan Physiotherapy Clinic :


vastral physiotherapy clinic

Samarpan Physiotherapy Clinic : has started in march-2008 with a simple vision: To provide first class physiotherapy care & treatment at right place, right cost & to be the organization of choice and a motto: to treat others as you would expect to be treated yourself. Today, the clinic has quickly developed in to one of ahmedabad’s premier physical therapy and rehabilitation center.

The SAMARPAN  Physiotherapy Clinic is run by highly specialized physiotherapist in  AHMEDABAD,GUJARAT. who has extensive experience in the assessment and treatment of musculo-skeletal, neurological, gynecological and life style management cases. 


    Orthopaedic conditions: like , joint problems, Backache, arthritis, Post knee/hip replacement ,ligament sprains,etc Special program for arthritis
    Neurological conditions: like stroke/ paralysis,parkinsonism,cerebral palsy(cp), spinal trauma, balance disorder,etc
    Gynecological Condition:   Pregnancy exercises, breathing techniques for delivery and post delivery exercises, Weight care exercise,Menopausal problems: like incontinence, osteoporosis,etc.
     Geriatrics Condition:  Old age problems: like arthritis, falls, walking problems,etc

    Work related physical disorders: like backache, neck pain, etc
    Vascular conditions: like varicose veins, atherosclerosis, swollen limbs after surgery, etc.


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