Kines I Therapy

Dubravka Ciliga
Tatjana Trošt Bobić
KINESITHERAPY
reviewed teaching materials
University of Zagreb
Faculty of Kinesiology
Dubravka Ciliga
Tatjana Trošt Bobić
KINESITHERAPY
Reviewed teaching materials
University of Zagreb
Faculty of Kinesiology
Zagreb, 2013
Publisher : University of Zagreb, Faculty of Kinesiology
For the Publisher: Prof. Damir Knjaz, PhD, Dean
Authors: Prof. Dubravka Ciliga, PhD and Tatjana Trošt Bobić, PhD
Reviewers:
Prof. Branka Matković,Ph.D. University of Zagreb Faculty of Kinesiology
Prim. Senka Rendulić-Slivar, Ph.D., Special hospital for medical rehabilitation

Lipik
Edition: 1st Internet edition
URL: http://kif.hr/predmet/kin_a
Date of publication on the internet: 17th January 2014
ISBN: 978-953-317-022-0
Available in the digital catalog of the National and University Library in Zagreb
Copyright © 2013. University of Zagreb Faculty of Kinesiology. All rights reserved.

Except for use in a review, the reproduction or utilization of this work in any form or by
any electronic, mechanical, or other means, now known or hereafter invented, including
xerography, photocopyng, and recording, and in any information storage and retrieval
system, is forbidden without the written permission of the publisher.
FOREWORD
As an area of applied kinesiology and a clinical discipline, kinesitherapy encompasses the

implementation of different kinds of exercise modalities in order to rehabilitate a person.
“The healing proprieties of movement“ were recognized many years ago, and has been
used, in the form of kinesitherapeutic sessions in order to help people with different kinds
of illness or diseases. Kinesitherapeutic programs are widely used in Physical medicine and
rehabilitation (physiotherapy, physiatry, rehabilitation medicine), orthopaedics, pulmology,
cardiology, neurology, geriatrics, paediatrics and many other areas of medicine.
As a scientific discipline, as well as an academic field of study though within the master
university program at the Faculty of Kinesiology it covers many interdisciplinary areas,
primarily linked with different fields of medicine. It represents an interdisciplinary field
where the basic kinesiological knowledge is linked with the knowledge of medicine in order
to better understand the effects of different transformational processes on human health.
This handbook is aimed at helping international students to better follow the classes and
understand the part of kinesitherapy concerning the field of orthopaedics. It explains the
characteristics and causes of the more common poor postures and deformities of the loco-
motor system. It also explains the possible approaches in correcting poor posture or
slowing down the progression of deformities. Basic notes of the kinesitherapy approaches
are given at the end of every chapter with the aim of introducing the students to the
teaching materials that will successively be taught in the gym, during the practical lessons.
Basic knowledge of functional rehabilitation of the most common sports injuries is also
given.
The aim of preparing this handbook/workbook is to help international students, who might
not be native speakers of English, to follow the classes and better prepare for the written
and oral exams. In order to make attending classes easier, space has been provided for
students’ notes. In such a way, students may make a note of the professor’s explanations
about the already given text. Also, at the end of each chapter there is a list of recommended
reading material that might help students to enlarge their knowledge and prepare for the
exam. Key questions or topics for discussion for every chapter are also given with the same
aim.
The intention behind the creation of this handbook/workbook was to help students to focus
their attention on what is taught during the lessons, rather than only writing down the
lecturer’s words. Here, systematized notes are given, and students are asked to follow the
lecture actively and make additional notes of their own thoughts about the subject being
taught. By doing so, the authors hope to help students to think about kinesitherapy as a
specific field of applied kinesiology in which they may use new as well as already learned
knowledge about transformational processes, in different rehabilitation protocols for the
loco-motor system. By using this handbook during the classes, making notes in the space
provided and answering the given key questions throughout the lessons, students are
encouraged to become active participants of the kinesitherapy classes. Additionally, by
enlarging their knowledge using the recommended reading, students may discover
knowledge beyond the given key questions and if interested, enrol in the selective module
of kinesitherapy that lasts for two academic years.
CONTENTS
1. INTRODUCTION TO KINESITHERAPY
1.1. Definition of kinesitherapy
1.2. History of kinesitherapy
1.3. Objective of kinesitherapy
1.4. Basic and secondary operators in kinesitherapy
1.5. Physiotherapy
1.6. Principles of kinesitherapy
1.7. Working methods in kinesitherapy
1.8. Organizational forms of work
1.9. Indications and contraindications
2. THE HUMAN FOOT

2.1. The evolution of the foot
2.2. Functional anatomy of the foot
2.3. The arches of the foot
2.4. Flat feet
2.5. Methods for the evaluation of flat feet
2.6. Kinesitherapy for flat feet
3. FOOT DEFORMATIONS
3.1. Types of foot deformities
3.2. Pes equinovarus
3.3. Pes cavus
3.4. Pes equinus
3.5. Pes calcaneus
3.6. Hallux valgus
4. LEG DEFORMATIONS
4.1. Genua vara
4.2. Genua valga
4.3. Genua recurvata
5. ANKLE AND KNEE INJURY REHABILITATION

5.1. Ankle injury rehabilitation
4.1.1 Functional anatomy of the ankle
4.1.2 Lateral ankle sprain
4.1.3 Degree of severity of an ankle sprain
4.1.4 Overuse injury
5.2. Knee injury rehabilitation
4.2.1 Functional anatomy of the knee
4.2.2 Knee injuries
4.3 Rehabilitation protocol
4.3.1 The acute stage of rehabilitation
4.3.2 The functional stage of rehabilitation
6. THE HIP
6.1. Functional anatomy of the hip
6.2. Degenerative changes in the hip
6.3. Hip development
6.4. Hip luxation
6.5. Hip luxation therapy
7. LORDOTHIC AND KIPHOTIC POOR POSTURE

7.1. Upright posture
7.2. Causes of poor posture
7.3. Kyphotic poor posture and kyphosis
7.4. Lordotic poor posture and lordosis
8. SCOLIOSIS
8.1. Definition of scoliosis
8.2. Types of scoliosis
8.3. Symptoms of scoliosis
8.4. Scoliosis examination
8.5. Methods to determine the degree of the curvature
8.6. Treatment for scoliosis
9. THORACIC DEFORMITIES
9.1. Pectus carinatum
9.2. Causes of pectus carinatum
9.3. Treatment for pectus carinatum
9.4. Pectus excavatum
9.5. Causes of pectus excavatum
9.6. Treatment for pectus excavatum
10. LOW BACK PAIN

10.1. Definition of lower back pain
10.2. Causes of lower back pain
10.3. Possible symptoms
10.4. Treatment of lower back pain
11. CERVICOBRACHIAL SYNDROME

11.1. Definition of the cervico-brachial syndrome
11.2. Causes of neck pain
11.3. Possible symptoms
11.4. Treatment of neck pain
12. TORTICOLLIS
12.1. Causes of torticollis
12.2. Symptoms of torticollis
12.3. Treatment of torticollis
13. SHOULDER INJURY REHABILITATION

13.1. Functional anatomy of the shoulder
13.2. Shoulder injuries
13.3. Traumatic shoulder injury mechanism
13.4. Overuse injury mechanism
13.5. Shoulder injury rehabilitation
14. LITERATURE
22.1.2014.
1st chapter
INTRODUCTION TO
KINESITHERAPY
- healing through movement -
1st chapter – Introduction to kinesitherapy
After attending the class and mastering this chapter

students will be able to:
• Define kinesitherapy
• Describe the history and development of kinesitherapy
• Define the specific goals of kinesitherapy
• Describe the basic operators in kinesitherapy
• Explain the possible differences between kinesitherapy
and physiotherapy
• Define the principles of kinesitherapy
• Discuss methods and organisational forms of work in
kinesitherapy
• Discuss indications and contraindications for
kinesitherapy
1
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1st chapter – Introduction to kinesitherapy: definition
1.1 DEFINITION OF KINESITHERAPY

• Kinesitherapy - as an area of applied kinesiology and a
clinical discipline, encompasses the implementation of
different exercise modalities for therapeutic aims (Ciliga, 1998).
Greek words:
Kinesis "κίνησις“ - movement, motion
Therapeia “θεραπεία”– therapy, medical treatment
• Kinesitherapy is an interdisciplinary field that combines

medical and kinesiological knowledge.
• Kinesitherapy is a well-estabilished discipline in

kinesiology.
• Physical medicine uses exercise in different
rehabilitation processes (Jajić, 2000). Therefore
kinesitherapy is also well-estabilished in the field of
medicine.
http://www.topnews.in/health/exercise http://www.concorde.edu/program
2
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IS THERE ANY DIFFERENCE ?
• Corrective gymnastics
• Medical gymnastics
• Therapeutic gymnastics
http://www.jasonwhitetherapy.com
• Orthopedic gymnastics
• Kinesitherapy
• Kinesiotherapy
• Physiotherapy http://www.mdsportscare.com/
aquatic-therapy http://www.webmd.com
1st chapter – Introduction to kinesitherapy: history
1.2 HISTORY OF KINESITHERAPY
• China - 2700 BC – the book Kong-Fu – elements of

therapeutic gymnastics: descriptions of active,
passive and combined exercises as well as massage.
• The Chinese physician - Hua Tuo - medical Daoyin

exercise.
• The Chinese believe that exercising is the most

important factor in preventive medicine (Svetina, 2010).
3
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• In ancient India, yogis used at least 800

different breathing exercises with the
aim of preventing and treating different
diseases.
http://images.trulia.com/blogimg/0/2/a
• In ancient Greece, Hippocrates and

/4/191364_1331336358785_o.jpg
Asklepios recommended exercise as a

compulsory part of therapeutic and
preventive prophylaxis.
• In ancient Rome, therapeutic exercise

http://www.benessere.com/remise/r
was particularly well developed (Mathys, emise_en_forme/bagno_turco.htm
1987).
• Galen was a Roman physician for gladiators, often

known as the first athletic team physician.
• Galen organized exercise classes in specialized gyms
as a part of the therapeutic treatment or prevention
of different locomotor systems` problems.
– among other things, in the therapeutic sessions
he prescribed activities such as rowing and
walking.
• In the edition of "The Art of
returning to health“ he wrote:
"Thousands and thousands of
times I returned health to
patients through exercise."
http://www.lookandlearn.com/history-
images/XM10058085/Galen-and-Gladiators
4
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• Abu Ali Ibn Sina (Avicenna) in his books “Canon of

Medicine” and “Book of Healing”, he describes in detail
the treatment and prevention of various diseases with
the help of medical gymnastics.
• Nikolas Andry, a French physician who published the

book “Orthopédie” in 1741, used to teach students
methods of preventing and correcting deformities in
children.
• In 1780. the published work of Tissot of France

“Medical and surgical gymnastics”, set out descriptions
of various physical exercises, and their use for treating
all sorts of diseases.
• Per Henrik Ling (1776 – 1839) was a Swedish http://wyattfleming.hubpages.co

m/hub/Per-Henrik-Ling-10Z3H1
physical therapist (Physiotherapist), developer

and teacher of medical-gymnastics.
• Ling's system of medical gymnastics also

influenced later institutions and systems. The
Gymnastic Orthopedic Institute was founded in
Stockholm in 1822 (Svetina, 2010).
5
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1st chapter – Introduction to kinesitherapy: the objective
1.3 THE OBJECTIVE OF KINESITHERAPY
• To improve health through different exercise

modalities. To apply kinesiological knowledge in
therapeutic sessions (Ciliga, 1998).
http://www.gazzetta.it/Fitness/Corpo_psiche http://kiransawhney.wordpress.com/ http://www.nba.com/features
1st chapter – Introduction to kinesitherapy: the objective
• CORRECTION
http://thepilateshundred.blogspot.com/20
11/04/posture-201-kyphosis.html
• REHABILITATION
http://breakingmuscle.com/health-medicine/ankle-
injuries-secret-preventing-and-healing-them
• PREVENTION
http://www.thermalon.com/article-12-
arthritis-prevention.php
6
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1st chapter – Introduction to kinesitherapy: operators
1.4 BASIC AND SECONDARY OPERATORS

IN KINESITHERAPY
1.4.1 BASIC OPERATORS
MOVEMENT - EXERCISE
• STATIC • PASSIVE
• DYNAMIC • SUPPORTING
• ACTIVE
• ACTIVE WITH RESISTANCE
1st chapter – Introduction to kinesitherapy: operators
1.4.2 SECONDARY OPERATORS

• Mechanotherapy (hidrotherapy, kinezitherapy,
massage, manipulation, mobilization)
• Thermotherapy
• Electrotherapy
• Phototherapy
• Natural healthy remedies
http://www.fitandtherapy.it/massaggio% http://www.fisiomedica.org/trattamenti http://www.medrehab.info/medical

20cervicale.php _services/4/rehabilitation.html
7
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1st chapter – Introduction to kinesitherapy: physiotherapy
1.5 PHYSIOTHERAPY
• PHYSIOTHERAPY (PT) is a field of physical medicine

that uses different physical aids for therapeutic
issues (Prentice, 1986; Myrer, Drapper & Durrant, 1994; Jzuluaga i sur., 1995; ajić, 2000;
Monedero & Donne, 2000; Trošt, Šimek, Grubišić, 2005).
http://www.fisiomedica.org/trattamenti http://www.fisiomedica.org/trattamenti http://www.fisiomedica.org/trattamenti
• Hydrotherapy - use of water for treating

illness. Using jets, hydrotherapy in the
pools, underwater massage and thermal
mineral baths (balneotherapy), cold
baths, thalassotherapy, Hubbard tank…
http://www.operepubbliche.regione.umbri
• Thermotherapy - the application of heat a.it/Mediacenter/FE
to the body. Peripheral (paraffin, mud,

thermal warm baths) and deep
(therapeutic ultrasound, shortwave
diathermy) thermotherapy.
Kriotherapy (the application of ice to
the body) may also be considered a part http://fisioterpia-salud.blogspot.com/
2010/06/termoterapia.html
of thermotherapy.
8
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• Phototherapy – or Light therapy

consists of exposure to daylight or
to specific wavelengths of light.
The most commonly applied are
infrared rays (sunlight and solux http://www.maquet-
lamp), infraviolet rays (sunlight and dynamed.com/inside_sales
sun lamp) and laser.

• Electrotherapy - use of various
modalities of electric current
(galvanism, electrostimulation, low,
middle and highly frequenty
http://www.kingsvillehomerehab.com/modalities/el
current) as a medical treatment. ectrotherapy.aspx
• Therapeutic ultrasound
refers generally to any type of
procedure that uses
ultrasound for therapeutic
benefit (HIFU).
http://www.osteopathuk.co.uk/ultrasound.htm
• Magnet therapy,
(magnetotherapy, or
magnotherapy)- the use of
static magnetic fields as a
medical treatment. http://www.fisiomedica.org/trattamenti
9
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1st chapter – Introduction to kinesitherapy: principles
1.6 PRINCIPLES OF KINESITHERAPY
• Principle of motivation
• Principle of beginning early
• Principle of exercise analysis http://www.spala.cos.pl/91,rehabilitation-

and-health-care.html
• Principle of understanding the exercise
• Principle of avoiding pain
• Principle of progression
http://besport.org/sportmedicina/hydro
1st chapter – Introduction to kinesitherapy: principles
• Principle of pragmatism
• Principle of continuous exercising
• Principle of active participants` involvement
• Principle of persistence
• Principle of avoiding monotony
• Principle of following and recording the results
10
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1st chapter – Introduction to kinesitherapy: working methods
1.7 WORKING METHODS IN KINESITHERAPY
• Movement
• Exercise
• Sports games
• Elements of sports http://coloradosportschiro.com/custom_cont
ent/c_84976_sports_medicine.html
http://health.howstuffworks.com/wellness/diet- http://www.terviseparadiis.ee/treatment___r
fitness/exercise/cardio-vs-weight-training.htm elaxationen/loogastused_raviden
1st chapter – Introduction to kinesitherapy: organizational forms
1.8 ORGANIZATIONAL FORMS OF WORK
Individual Group exercise
http://www.webmd.com http://www.gazzetta.it/Fitness/Corpo_psiche
11
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1st chapter – Introduction to kinesitherapy: indications & contraindications
1.9 INDICATIONS AND CONTRAINDICATIONS
1.9.1 INDICATIONS
• Areas
– Cardiopulmonary
– Geriatric
– Neurological
– Pediatric
– Orthopedic
– Physical medicine and rehabilitation
(physiotherapy, physiatry, rehabilitation
medicine)
1st chapter – Introduction to kinesitherapy: indications & contraindications
1.9.2 CONTRAINDICATIONS
• infectious disease
• febrile status
• malignant disease
• inflammation process in the body
12
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QUESTIONS
• What is kinesitherapy?
• What is the main goal of kinesitherapy?
• What are the primary and secondary operators in
kinesitherapy?
• Describe the principles of kinesitherapy.
• How can a kinesitherapy session be organized according
to the number of individuals involved?
• What are the indications and contraindications for
kinesitherapy?
• What is the difference between a poor posture and a
deformation of the locomotor system?
The following additional literary titles are

recommended:
• Ćurković, B., Tepšić, N. (2004). Basics of kinesitherapy (in Croatian).
Osnove kineziterapije. U: Ćurković i sur. (ur.) Fizikalna i rehabilitacijska
medicina. Zagreb: Medicinska naklada, str. 72-73.
• Mathys, F.K. (1987). The history of sports medicine (continuation and
end). Olympic Review, 242, 650-653.
• Mathys, F.K. (1987). The history of sports medicine (part I). Olympic
Review, 241, 582-585.
• Prentice, W.E. (1986). Therapeutic modalities in sports medicine. St.
Louis: Times Mirror/Mosby College.
• Zuluaga, M., Briggs, C., Carlisle, J., McDonald, V., McMeeken, J.,
Nickson, W., Oddy, P, Wilson, D. (1995). Sports Physiotherapy: Applied
Science and Practice. Melbourne: Churchill Livingstone.
13
2nd chapter
THE FOOT
2nd chapter – The foot

• Discuss the filogenetic evolution of the human foot
• Discuss the static and dynamic function of the human foot
• Locate the three main weight bearing points of the foot
• Describe the arches of a healthy foot
• Describe flattened medial or lateral foot arches and explain the
consequent foot position and Achilles tendon convexity
• Define the three phases of a flattened foot
• Explain the methods used for the evaluation of a flattened foot
• Describe plantography and draw the different methods for the
evaluation of a flattened foot on the plantogram
• Discuss a possible kinesitherapy program for the correction of
a flattened foot
1
2nd chapter – The foot: evolution
2.1 THE EVOLUTION OF THE FOOT
• During human phylogenetic evolution, the foot has

changed due to numerous factors.
• The upright position has contributed to drastic

changes.
• The evolution is still going on.
http://www.abovetopsecret.com/for
um/thread315579/pg1
2nd chapter – The foot: evolution
• The foot has experienced a lot of changes, but it is still

not adapted for the upright position in conditions of
hard straight surfaces.
• Some anatomic and functional adaptations have not

yet occurred.
• Footwear, being overweight and artificial surfaces

have contributed to the development of flat feet.
http://www.livescience.com/19331-unknown-hominin-
species-bipedalism.html
2
2nd chapter – The foot: functional anatomy
2.2 FUNCTIONAL ANATOMY OF THE FOOT
PASSIVE AND ACTIVE SUPPORT
•26 bones
•ligaments
•muscles
http://library.thinkquest.org/J0111100/
graphics/bones2.html
•Active support is assured by the foot muscles and by the

muscles of the lower leg.
http://www.eorthopod.com/content/foot-anatomy http://www.projectswole.com/weight-training/the-top-5-best-calf-exercises/
3
THE FOOT HAS TWO BASIC FUNCTIONS:
• The static function - through

the talus it absorbs the whole
body weight
http://heart-of-light.blogspot.com/
2009_05_01_archive.html
• The dynamic function –

elastic regulator of forces
acting during physical activity
http://www.annsrunningcommentary.com/
MOVEMENTS
• Plantar flexion - recently also called plantar
extension because of the adapted function of
the foot in an upright (bipedal) position (Keros &Pećina, 2007).
• Dorsal flexion
• Abduction
• Adduction
• Eversion
• Inversion
4
While standing, the foot has three weight bearing

points:
1. Back contact point

2 3
2. Frontal medial contact point
3. Frontal lateral contact point
Lifting the heel 2 cm should arrange the

1
body weight uniformly on all three contact
points.
ACTIVE
TRIANGLE
PASSIVE
TRIANGLE
http://www.chichester-march.org.uk/html/walking.html
5
2nd chapter – The foot: the arches
2.3 THE ARCHES OF THE FOOT
When the three weight bearing points

are linked together, they form four
foot arches. 3
1. Medial longitudinal arch (10-15 mm)

1 2
2. Lateral longitudinal arch (2-3 mm)
3. Frontal transversal arch
4. Back transversal arch
4
http://www.answers.com/topic/arches
2nd chapter – The foot: flat feet
2.4 FLAT FEET

If the foot and lower leg muscles are weak, the arches
become less pronounced (Wearing i sur., 2012; Kosinac, 2005). Their
primary function as dynamic weight regulators is
compromised and the foot slowly flattens.
THREE PHASES OF FLATTENED FOOT
1. The muscle phase
2. The ligament phase
3. The bone phase
6
http://www.drfoot.co.uk/flat.htm
PES VARUS
•Lateral longitudinal foot arch flattened
•Foot inversion
•Achilles tendon`s lateral convexity
PES VALGUS
•Medial longitudinal foot arch flattened
•Foot eversion
•Achilles tendon`s medial convexity
PES VARUS PES VALGUS
7
PES PLANUS
• All arches flattened
http://www.copabones.com/ankle_foot.htm
2nd chapter – The foot: flat feet assesement and evaluation
2.5 METHODS FOR THE ASSESEMENT

AND EVALUATION OF FLAT FEET
1. Inspection
2. Palpation
3. X ray http://texashealthathlete.wordpress.co
m/2011/12/08/should-i-wear-orthotics/
4. Gypsum contour
5. Plantography
6. Pedobarography
7. Podometer
8. Force plates http://www.medicalfootgroup.com/services/advance
d-diagnostics/
8
•PLANTOGRAPHY is a method used to take a foot print

called a PLANTOGRAM.
•Several methods are used to determine the grade of

flattened feet on a plantogram (Kosinac, 2005).
Mayer`s method
42
Clark`s method
9
A B B C
Müller`s method
The modified Russian author`s method
10
• A FORCE PLATE – measures the distribution of the whole

body weight, the centre of pressure (CP) distribution.
• Static and dynamic measurements (Pedobarography).
• Force plates enable:

- An easier detection of a
flattened transversal foot
arch
- Better indications for the
individual construction of http://www.thehealthybackblog.com/category/c
hiropractic/chiropractor/page/10/
footwear and an insole
- Prevention
2nd chapter – The foot: kinesitherapy
2.6 KINESITHERAPY FOR FLAT FEET
• An individual kinesitherapy program according to:

- the grade of flattened feet
- the flattened arch
- the age
• STATIC exercises (lying down position, sitting

position, standing position).
• DYNAMIC exercises.
• Use different tools
11
2nd chapter – The foot: kinesitherapy
• The targeted muscles are:

- foot muscles
- lower leg muscles
http://www.eorthopod.com/ http://www.projectswole.com/weight
content/foot-anatomy -training/the-top-5-best-calf-
exercises/
• Combine kinesitherapy and a

corrective insole (active and
passive treatment) (Evans & Rome, 2011;
Jimenez-Ormeño et al., 2011).
• Massage is not effective.

http://www.chirofirst.ca/index.php?page=service_sub4
QUESTIONS
• Describe the foot functional anatomy.

• Name and describe the foot arches and their function.
• How would you interpret the Achilles’ Tendon convexity in
the evaluation of flat feet?
• Which are the stages of flat feet?
• Which are the methods used for the evaluation of flat feet.
• Explain the terms plantography and plantogram. Describe
the Clark method.
• Describe a kinesitherapy program for flat feet. At what age
should kinesitherapy be prescribed?
12

recommended:
• Evans, A. M., & Rome, K. (2011). A cochrane review of the evidence
for non-surgical interventions for flexible pediatric flat feet. European
Journal of Physical and Rehabilitation Medicine, 47(1), 69-89.
• Jimenez-Ormeño, E., Aguado, X., Delgado-Abellan, L., Mecerreyes, L.,
& Alegre, L. M. (2011). Changes in footprint with resistance exercise.
International Journal of Sports Medicine, 32(8), 623-628.
• Wearing, S. C., Grigg, N. L., Lau, H. C., & Smeathers, J. E. (2012).
Footprint-based estimates of arch structure are confounded by body
composition in adults. Journal of Orthopaedic Research, 30(8), 1351-
1354.
13
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3rd chapter
FOOT DEFORMATIONS
3rd chapter – foot deformations

• Define the most common foot deformations
• Describe the aetiology of the most common foot
deformations
• Describe the role of footwear in the process of foot
deformation
• Discuss a possible treatment for the most common
foot deformations
1
22.1.2014.
• Foot deformities have a decisive influence on the

functional state of the loco-motor system, especially
the lower extremities.
• Pain, limited mobility of the

joints.
• Problems only localized in

the foot or in other areas of
the body.
http://www.myseveralworlds.com/2007/07/11/suffering-for-
beauty-graphic-photos-of-chinese-footbinding/
3.1 TYPES OF FOOT DEFORMITIES
• Congenital
• Acquired
– Static
– Traumatic
– Inflammatory
2
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3rd chapter – foot deformations: acquired foot deformities
3.2 ACQUIRED FOOT DEFORMITIES
Static:
• Inappropriate footwear (short, tight, narrow,
pointed, or high heels) that puts pressure on the feet
and keeps toes in an unnatural bent and/or squashed
position.
• Excessive body weight
• Hypokinesis, hyperkinesis
http://www.mendmeshop.com/toe/deformity-causes.php
• Traumatske: traume, saobraćajne nesreće...
• Upalne: upalne reakcije, čirevi, Mb Bürger ...
http://leviuqse.blogspot.com/2008/09/one-with-
http://escapebookclub.blogspot.com/2012/05/wednesday-2nd-may-2012-snow-
japanese-geisha-shoes.html
flower-and.html
3
22.1.2014.
Traumatic:
• Previous toe injuries or poor foot mechanics and
movement
• Partial or complete dislocation of one of the toe joints
http://www.swiga.com/blog/catalog.asp?cate=19
Inflammatory:
• Rheumatoid arthritis
• Psoriatic arthritis
• Arthritis urica
http://www.health.com/health/diseases-conditions/
4
22.1.2014.
3rd chapter – foot deformations: foot deformities, pes equinovarus
3.2 PES EQUINOVARUS (clubfoot)

• It is a congenital foot deformity.
• Clubfoot primarily affects three bones: the calcaneus
(the heel bone), talus ( the ankle bone) and the
navicular bone.
• Other bones can be involved as the deformity can
affect the growth of the entire foot to some degree.
• The foot is turned under and towards the other foot.
http://www.eorthopod.com/content/clubfoot http://www.eorthopod.com/content/clubfoot
3rd chapter – foot deformations: pes equinovarus
• The ligaments between the

bones are shortened.
• The joints between the tarsal
bones do not move as they
should.
• The bones are deformed.
• A very tight stiff foot that
cannot be placed flat on the
ground for walking.
• A child must walk on the
outside edge of the foot
http://www.healthofchildren.com/C/Clubfoot.html
5
22.1.2014.
3rd chapter – foot deformations: pes equinovarus
TREATMENT OF PES EQUINOVARUS:

• Non surgical, conservative treatment - foot
manipulation and casting, therapeutical exercise or
kinesitherapy (Horn & Davidson, 2010).
http://www.eorthopod.com/content/clubfoot
• Surgical treatment
3rd chapter – foot deformations: pes cavus
3.3 PES CAVUS

• Characterized by a high foot arch, as there is a fixed
plantar flexion of the foot (foot extension). There is a
limited dorsal foot flexion. Characteristic “non
elastic” walking.
Three main types of pes cavus are:

1. Pes cavovarus
- seen primarily in neuromuscular
disorders and in cases of unknown
aetiology (idiopathic)
-The front of the foot is typically http://www.healingfeet.com/blog/foot-
plantar flexed in relation to the care/hi-arch-cavus-foot
rear of the foot (foot extension).
6
22.1.2014.
2. Pes calcaneocavus
- seen primarily following paralysis of m. triceps
surae due to poliomyelitis.
- the calcaneus is dorsi-flexed and the front of the
foot is plantar-flexed (extended).
3. Pes cavus
- the calcaneus is neither dorsi-flexed or in varus,
and is highly-arched due to the plantar-flexed
(extended) position of the front of the foot on
the rear of the foot.
TREATMENT OF PES CAVUS:

• Non surgical, conservative treatment
- foot orthotics
- specialized cushioned footwear
- stretching and strengthening of the weak muscles
- osseous mobilization
- massage, chiropractic manipulation of the foot
- specific exercises aimed to improve the ankle strategy
in maintaining balance
• Surgical treatment (soft-tissue procedures , osteotomy,

bone-stabilising procedures)
7
22.1.2014.
3rd chapter – foot deformations: pes equinus
3.4 PES EQUINUS

• Lack of dorsi-flexion in the ankle joint
• Excessive plantar-flexion (extension) in the ankle joint
• This creates problems during the swing phase of gait
• causes instability during the stance phase
• Typically seen in neuromuscular disorders
http://www.uni-kiel.de/orthop/kinder.html
3rd chapter – foot deformations: pes equinus
TREATMENT OF PES EQUINUS:

- strengthen the dorsal foot flexors muscles
- stretch the plantar flexors (extensor) muscles
- foot orthotics to control instability
- botox injections (to relax spastic overactive muscles)
- manipulation
• Surgical treatment (lengthening the Achilles tendon and

shortening the m. tibialis anterior tendon).
8
22.1.2014.
3rd chapter – foot deformations: pes calcaneus
3.5 PES CALCANEUS
• The ankle is dorsi-flexed

• The toes are elevated
• Body weight primarily borne on the heel
• Poor foot functionality during walking
• Calcaneovalgus and calcaneovarus are also possible
http://www.fachgebaerdenlexikon.de/index.php?id=2140
3rd chapter – foot deformations: treatment of pes calcaneus
TREATMENT OF PES CALCANEUS:

- stretch the dorsal foot flexor muscles
- strengthen the plantar flexor (extensor) muscles
- foot orthotics to control instability
- manipulation
• Surgical treatment (lengthening the m. tibialis anterior

tendon).
9
22.1.2014.
3rd chapter – foot deformations: hallux valgus
3.6 HALLUX VALGUS

• Hallux= big toe; Valgus= veering outward from the
body sagittal plane.
• In more severe cases, the large/big toe either
overlaps or underlaps the subsequent lesser
(smaller) toes especially the second one (the
adjacent toe).
• Commonly hereditary but it
may become worse by
using improperly fitting
shoes and may worsen
slowly over time.
http://www.hygenicblog.com/2010/04/28/thera-band-
exercises-beneficial-after-surgery-to-correct-hallux-valgus/
3rd chapter – foot deformations: treatment of hallux valgus
TREATMENT OF HALLUX VALGUS:

• Non surgical, conservative treatment (may be passive
and active or kinesitherapy).
- Abduction of the large/big toe in relation to the 2nd toe
(dividing the bog toe from the 2nd toe)
Passive non surgical treatment: Wear night and day
orthoses, anatomical and comfortable shoes (avoid
pressure on the large/big toe) (Matanović i sur., 2011).
Active non surgical treatment:
kinesitherapy, big toe abduction
in relation to the other toes.
• Surgical treatment. http://www.halluxvalgustips.com/hallux-
valgus-deformity/
10
22.1.2014.
QUESTIONS
• Name the most common foot deformations (English and
Latin names).
• Describe pes equinovarus and its possible treatment
options.
• Describe pes cavus and its possible treatment options.
• Describe pes equinus and its possible treatment options.
• Describe pes calcaneus and its possible treatment
options.
• Describe hallux valgus and its possible treatment
options.

recommended:
• Horn, B. D., & Davidson, R. S. (2010). Current treatment of clubfoot
in infancy and childhood. Foot and Ankle Clinics, 15(2), 235-243.
• Matanović, D. D., Vukasinović, Z. S., Zivković, Z. M., Spasovski, D. V.,
Bascarević, Z. L., & Slavković, N. S. (2011). Physical treatment of foot
deformities in childhood. Acta Chirurgica Iugoslavica, 58(3), 113-
116.
11
4th chapter
LEG DEFORMATIONS
- the knee -
4th chapter – Leg deformations

• Name and describe the three most common leg
deformations
• Discuss possible changes of the foot arches as a
consequence of different leg deformities
• Describe the possible aetiology of lower leg deformities
• Name the most common causes of leg deformities
• Describe the test of maximal flexion
• Explain possible therapy approaches for lower leg
deformities
• Discuss a possible kinesitherapy program for the
correction of genua vara, genua valga and genua
recurvata
1
• The deformations may include the knee, the distal

part of the upper and the proximal part of the lower
leg (Fabry, 2010).
- Genua vara, crura vara (O knees/bandy-legged)
- Genua valga (X knees/knock-kneed)
- Genua recurvata (knee hyperextension)
• Knee injuries include traumas of the collateral

ligaments, cruciate ligaments, kneecup, menisci…
(Bartel, Davy, Keaveny, 2006).
4th chapter – Leg deformations: genua vara, crura vara
4.1 GENUA VARA, CRURA VARA

• O KNEES (bandy-legged)
• They are related to the flatness of the lateral
longitudinal arch of the foot.
• Lateral convexity.
2
ETIOLOGY
• Congenital deformation
• Acquired deformation
• Usually both legs are affected
• Rarely one leg
(bad femur reposition)
Špišić, 1952
It may affect the distal part of the upper leg or the

proximal part of the lower leg.
• Genua vara – the deformity is in the distal part of the

upper leg.
• Crura vara – the deformity is in the proximal part of
the lower leg.
3
SYMPTOMS:
• The functional capacity of the legs is reduced.
• Muscle fatigue.
• Pain may encompass the area of the lower leg, upper

leg, hips and lumbar spine.
• School children with severe deformities should be

spared the activities of jumping and running for long
periods of time.
THERAPY:
• Conservative
• Operative (surgery)
CONSERVATIVE TREATMENT:
• Anti-rachitic therapy
• Ultraviolet rays
• Passive correction (corrective tracks, braces)
• Kinesitherapy
Walking on the inner side of a corrective board
designed in the shape of the letter «V».
4
4th chapter – Leg deformations: genua valga
4.2 GENUA VALGA (CRURA VALGA)

• X KNEES (knock-kneed)
• They are related to the flatness of the medial
longitudinal arch of the foot.
• Medial convexity.
• More usual in women.
POSSIBLE CAUSES: Špišić, 1952
• Vitamin D deficiency
• Heredity
• Different professions
• Sport
• Overweight
• Static loads
• Inflammatory processes
• Bad re-setting of a fractured femur
5
THERAPY:
• Conservative
• Operative
• Kinesitherapy
Walking on the outer side of a corrective board
designed in the shape of the letter «A».
4th chapter – Leg deformations: test of maximal flexion
TEST OF THE MAXIMAL FLEXION
A person lies in a prone position with one knee flexed.
If the projection of the heel falls:
• In the middle of m. gluteus – no deformation

• Outside m. gluteus of the flexed leg - X knees
(knock-kneed)
• On the m. gluteus of the extended leg – O knees
(bandy-legged)
6
4th chapter – Leg deformations: genua recurvata
4.3 GENUA RECURVATA
• KNEE HYPER-EXTENSION Špišić, 1952 Špišić, 1952
• The convexity is located on

the back part of the leg.
• The deformity may be
bilateral or only one leg
may be affected.
• It may be acquired or
congenital.
• CAUSES OF CONGENITAL GENUA RECURVATA:
1. Lack of the kneecup, hypoplasia and/or

dysplasia of the kneecup
2. Fetal myodystrophy of the quadriceps femoris
muscle
3. Hereditary causes
Špišić, 1952 Špišić, 1952

Špišić, 1952
7
THERAPY:
• Conservative
• Operative
• Kinesitherapy
Strenghtening the flexors of the lower leg.
QUESTIONS
• Describe the knee functional anatomy.

• Name the most common knee deformations (English and
Latin names with convexity and concavity sides).
• What are the characteristics of genua vara and how does
this deformation affect the foot arches?
• What are the characteristics of genua valga and how
does this deformation affect the foot arches?
• What are the causes of genua recurvata?
• What do the terms hypoplasia and dysphasia mean? How
are they linked with a knee deformation?
• Describe the test of maximal flexion.
• Describe a kinesitherapy program for the studies’ knee
deformations. At what age should they be prescribed?
8

recommended:
• Bartel, D.L., Davy, D.T., Keaveny, T.M. (2006). Orthopaedic
Biomechanics: Mechanics and Design in Musculoskeletal Systems /
Edition 1. Prentice Hall publisher.
• Fabry, G. (2010). Clinical practice: Static, axial, and rotational
deformities of the lower extremities in children. European Journal
of Pediatrics, 169(5), 529-534.
9
22.1.2014.
5th chapter
ANKLE AND KNEE INJURY

REHABILITATION
5th chapter – Ankle and knee injury rehabilitation
After attending the class and mastering this chapter students will be
able to:
• Discuss the specificity of passive and active ankle stabilizers with regard to the
risk of ankle injury
• Describe the mechanism of lateral and medial ankle injury
• Explain the difference between an acute ankle injury and an overuse injury
• Define the symptoms of an ankle sprain of 1st, 2nd and 3rd grade
• Discuss the specificity of passive and active knee stabilizers with regard to
their mechanisms of injury
• Define a knee injury according to the number of injured tissues
• Discuss the reasons for the more usual anterior cruciate ligament tear in
women than in men
• Define the difference between artography and arthroscopy
• Explain the main goal of the acute stage of the rehabilitation protocol after an
ankle or knee injury
• Explain the phases of the RICE method used in the acute stage of rehabilitation
• Define the four main goals of the functional stage of the rehabilitation
protocol after an ankle or a knee injury
• Discuss the possible progression in a functional rehabilitation after a lateral
ankle sprain or a knee injury
• Describe the specificities of kinesitherapy in the acute stage of the
rehabilitation protocol as well as during the functional stage
1
22.1.2014.
5th chapter – Ankle and knee injury rehabilitation: functional anatomy of the ankle
5.1 ANKLE INJURY REHABILITATION
5.1.1 FUNCTIONAL ANATOMY OF THE ANKLE
• The true ankle joint is

composed of 3 bones: the
tibia the fibula and the
talus.
• The sub-talar joint is

under the true ankle joint
and consists of the talus on http://www.scoi.com/anklanat.htm
top and calcaneus on the

bottom.
• The true ankle joint is responsible for the plantar

and dorsal flexion of the foot.
• The sub-talar joint is responsible for the inversion

and eversion of the foot.
DORSAL FLEXION EVERSION
INVERSION
PLANTAR FLEXION
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22.1.2014.
• The lateral malleolus is long and narrow, while the

medial is short and wide.
• Such bone anatomy of the true ankle joint makes it

unstable during movements of plantar flexion and
inversion.
• On the lateral side: the talofibular ligaments.
• On the medial side: the deltoid ligament.
LATERAL VIEW http://www.bartleby.com/107/95.html MEDIAL VIEW
3
22.1.2014.
5th chapter – Ankle and knee injury rehabilitation: lateral ankle sprain
5.1.2 LATERAL ANKLE SPRAIN
• A sprain is the most frequent joint injury (Frontera, 2003)
• The real ankle joint (ankle sprain)
• 15% medial sprain

http://morphopedics.wikidot.com/la
teral-ankle-sprain
• 85% lateral sprain
• The anterior talofibular ligament

(Janković & Trošt, 2004)
http://www.webbfitness.net/training-and-
sports-medicine
• The mechanism of a lateral ankle sprain describes a

plantar flexion (extension) and inversion of the foot.
http://drseanmiller.wordpress.com/category/cold-laser/ http://www.dubinchiro.com/features/ankle1.html
4
22.1.2014.
• foot inversion – lateral ankle sprain – talofibular

ligament.
http://docpods.com/lateral-ankle-ligament-sprain
• Foot eversion – medial ankle sprain – deltoid ligament.
http://docpods.com/lateral-ankle-ligament-sprain
• A possible cause for the more frequent lateral ankle

sprain may be found in the weak dorsal foot flexors
compared to the plantar foot flexors (extensors)
muscles.
• In the rehabilitation process after an ankle sprain the
m. peroneus and m. tibialis anterior should be
strengthened.
5
22.1.2014.
5.1.3 DEGREE OF SEVERITY OF AN ANKLE SPRAIN

• Grade I - stretch and/or minor tear of the ligament
without laxity (loosening).
• Grade II – partial tear of ligament and some laxity
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• Grade III - complete tear of the affected ligaments (very

loose)
http://www.aafp.org/afp/2001/0101/p93.html
7
22.1.2014.
• Symptoms (Wolfe i sur., 2001):
Sign/symptom Grade I Grade II Grade III

Tendon No tear Partial tear Complete tear
Loss of function Minimal Some Great
Pain Minimal Moderate Severe
Swelling Minimal Moderate Severe
Bruising Usually not Frequently Yes
Difficulty bearing No Usually Almost always
weight
• The duration and the content of the rehabilitation

process changes depending on the ankle sprain grade.
5.1.4 OVERUSE INJURY
• tendinitis
• bursitis
• stress fractures
http://orthoinfo.aaos.org/topic.cfm?topic=a00379
http://www.coreconcepts.com.sg/mcr/when-is-
achilles-tendonitis-not-achilles-tendonitis-when-
it-is-retrocalcaneal-bursitis/
• Causes: poor posture or foot deformations, hard surfaces,

bad footwear, excessive-training, hormonal factors…
8
22.1.2014.
5th chapter – Ankle and knee injury rehabilitation: functional anatomy of the knee
5.2 KNEE INJURY REHABILITATION

5.2.1 FUNCTIONAL ANATOMY OF THE ANKLE
The meniscii have several functions:

l
Stability - As secondary stabilizers, the intact meniscii

interact with the stabilizing function of the ligaments.
s
Lubrication and nutrition - The meniscii act as spacers

between the femur and the tibia. By doing so, they prevent
friction between these two bones and allow for the diffusion
of the normal joint fluid and its nutrients.
i
Shock absorption - lower the stress applied to the articular

cartilage, and thereby have a role in preventing the
development of degenerative arthritis.
5th chapter – Ankle and knee injury rehabilitation: functional anatomy of the knee
• The hamstring muscles control the tibial anterior

shift preventing the anterior cruciate ligament (ACL)
from tearing (Fellenberg i sur., 2000).
http://www.daviddarling.info/encyclopedia/H/ham
string_muscles.html http://www.daviddarling.info/encyclopedia/H/hamstring_muscles.html
9
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5th chapter – Ankle and knee injury rehabilitation: knee injuries
5.2.2 KNEE INJURIES
• Isolated: only one element injured

• Combined: two elements injured
• Complex trauma of the knee joint: three or
more elements injured
• Example of a complex trauma of the knee joint.
10
22.1.2014.
• The medial meniscus is more movable than the

lateral. It could be injured during the internal
rotation of the lower leg accompanied by knee
flexion.
• The lateral meniscus could be injured during the

external rotation of the lower leg accompanied by
knee flexion
http://www.aclsolutions.com/theacl_3.php
• The rehabilitation protocol of an injured meniscus,

and especially the kinesitherapy part differs
depending on the surgical modalities.
11
22.1.2014.
• Mechanism of medial knee injuries
http://www.physioroom.com/injuries/knee/medial_collateral_ligament_sprain_full.php
• Mechanism of lateral knee injuries
http://www.physioroom.com/injuries/knee/lateral_collateral_ligament_sprain_full.php
12
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ACL (anterior cruciate ligament) tear
• happens more frequently in women (Wahl i sur., 2012).
http://louisvilleorthopedics.com/libr http://www.nismat.or
ary/patient-education/acl-tears/ g/ptcor/female_knee/
Knee examination
• X-RAY EXAMINATION – painless test that uses a small amount of

radiation to make an image of the joint.
• ULTRASOUND EXAMINATION - painless test that uses ultrasound

technology to make an image of the joint.
• MRI (magnetic resonance imaging) – a technique that uses a

magnetic field and radio waves to create detailed images in
slices of the examined joint. 3D images may also be produced.
• CT (computed tomography) - a radiologic imaging that uses

computer processing to generate an image of tissue density in
slices through the examined joint.
• ARTHROSCOPY - a minimally invasive surgical procedure.
13
22.1.2014.
5th chapter – Ankle and knee injury rehabilitation: rehabilitation protocol
5.3 THE REHABILITATION PROTOCOL
The rehabilitation protocol consists of two main stages

(Frontera, 2003):
1. The acute stage

2. The functional stage
• The main goal of the acute stage is to prevent bruising,

swelling and to maintain the joint’s range of motion.
5th chapter – Ankle and knee injury rehabilitation: rehabilitation protocol, the acute stage
5.3.1 THE ACUTE STAGE OF REHABILITATION

• The RICE method
R - rest
I - ice
C - compression
E - elevation http://www.physiosupplies.com.au/fitness/Aircast-
Cyrocuff-Cooler.html
• In the acute stage, methods using warmth or massage

should not be applied (Knight i sur., 1995; Wolfe, Tim & McCluskey, 2001).
14
22.1.2014.
5th chapter – Ankle and knee injury rehabilitation: rehabilitation protocol, the acute stage
• In the acute stage, weight

bearing should be avoided or
minimal (use of crutches).
• Dynamic Knee/ankle orthosis

should be used at the http://www.braceshop.com/productcart/pc/Baue
rfeind-CaligaLoc-Ankle-Brace-17p884.htm
beginning of the
rehabilitation.
• The injured athlete has to walk

as normally as possible.
http://www.shustuff.com/Catalogue.htm
5th chapter – Ankle and knee injury rehabilitation: rehabilitation protocol, the functional stage
5.3.2 THE FUNCTIONAL STAGE OF REHABILITATION
• It can begin immediately after the injury and it lasts

until the injured athlete can perform without pain
(Renstrom, 1994; Frontera, 2003).
• Consequences of an improper rehabilitation:

diminished movement amplitude, chronic pain, chronic
swelling, chronic instability…
• Long-lasting immobilisation is a frequent mistake.
15
22.1.2014.
5th chapter – Ankle and knee injury rehabilitation: rehabilitation protocol, the functional stage
The four main goals of the functional stage (Renstrom, 1994; Frontera,
2003).
1. Complete recovery of the full range of motion without

pain,
2. Progressive muscle strengthening
3. Restoration of neuromuscular coordination
4. A gradual return to everyday activities
• The RETURN TO PLAY CRITERIA are based on the

satisfaction of these aims (Trošt Bobić & Rakovac, 2010).
5th chapter – Ankle and knee injury rehabilitation: rehabilitation protocol
Exercise modalities used in the functional stage
• Stretching exercises
• Strength exercise
• Proprioception, balance exercise
• Agility, plyometric exercises
• Running exercises
• Specific exercises
16
22.1.2014.
QUESTIONS
• Why does a lateral ankle sprain happen more often than a medial one?
• How long does the rehabilitation of an ankle sprain of the 1st, 2nd and 3rd
grade last?
• Name an acute injury and an overuse injury of the ankle and the knee.
• Explain the difference in the aetiology of an acute injury and an overuse
injury.
• Describe the mechanisms of a lateral ankle sprain. Is the mechanism of
a medial ankle sprain more often contact or non-contact?
• Describe the mechanisms of an anterior cruciate ligament tear.
• How can a knee injury be defined according to the number of injured
elements?
• Which muscles control the anterior tibial shift? And what ligament?
• What are the two main phases of a rehabilitation protocol and what are
their goals?
• What does the RICE method encompass?
• Describe the kinesitherapy exercise progression in the functional phase
of rehabilitation of an ankle and knee injury.
The following additional literary titles are recommended:

• Phisicians, 1;63(1), 93-105. Fellenberg, J., Mau, H., Nedel, S., Ewerbeck, V.,
& Debatin, K. (2000). Hamstrings and iliotibial band forces affect knee
kinematics and contact pattern. Journal of Orthopaedic Research, 18(1),
101-108.
• Frontera, W.R. (2003). Rehabilitation of sports injuries. Malden: Blackwell
Scientific Publications.
• Knight, K.L. (1995). Initial care of acute injuries: the RICE technique. In:
Cryotherapy in sport injury management. Champaign, Il.: Human Kinetics.
• Pećina,M., Bojanić, I. (2003).Overuse injuries of the musculoskeletal
system. Boca Raton, London, New York, Washington D.C.: CRC Press.
• Renstrom, P.A.F.H. (1994). Clinical practice of sports injury prevention and
care. Oxford: Blackwell Scientific Publications.
• Wahl, C. J., Westermann, R. W., Blaisdell, G. Y., & Cizik, A. M. (2012). An
association of lateral knee sagittal anatomic factors with non-contact ACL
injury: Sex or geometry? Journal of Bone and Joint Surgery - Series A, 94(3),
217-226.
• Wolfe, M.W., Tim, L. i McCluskey, L.C. (2001). Management of ankle sprain.
American Family Physician, 63, 93-104.
• Wolfe, M.W., Uhl, T.L., Mattacola, C.G., McCluskey, L.C. (2001).
Management of ankle sprains. American Family
17
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6th chapter
THE HIP
6th chapter – The hip

• Describe the functional anatomy of the hip and discuss it
with regard to a possible hip luxation
• Explain the possible causes of an acquired hip luxation
• Explain the possible causes of a congenital hip luxation
• Describe the symptoms of a hip luxation
• Discuss possible treatment options for a hip luxation
• Describe the principles of passive corrective tools used in
hip luxation
• Discuss a possible kinesitherapeutic program for a hip
luxation according to the existing symptoms
1
22.1.2014.
6th chapter – The hip: functional anatomy
6.1 FUNCTIONAL ANATOMY OF THE HIP
• The hip is a multiaxial joint

• The convex surface is the femoral head,
while the concave surface is the
acetabulum.
• Flexion, extension, abduction,
adduction, rotation, circumduction.
http://www.adventistrehab.com/adam/Surgery
%20and%20Procedures/13/100006.html
6th chapter – The hip: functional anathoy
http://www.netterimages.com/image/4654.htm
2
22.1.2014.
6th chapter – The hip: osteophytes
6.2 OSTEOPHYTES
• When on the femoral head ostheophytes form, (bone
growth) then arthrosis begins.
• Osteophytes form because of excessive loadings,
especially in sport. The cartilage reacts with the
production of bone nodules.
Ostheophytes
http://www.museumoflondon.org.uk/Collections-Research/LAARC/Centre-for- http://www.flickr.com/photos/museumoflondon/3239465304/
Human-Bioarchaeology/Resources/Photographs/bermondseyabbey.htm
6th chapter – The hip: development
6.3 HIP DEVELOPMENT

The acetabulum of a newborn child is very shallow, and
its shape is modified under the influence of standing
and walking.
1st year 42%

2nd year 54%
5th year 100%
http://www.fyp.emmettconroy.com/site/about-ddh?page=2
The constant contact of the two joint surfaces brings

about the lowering of the acetabulum causing a better
joint development and stabilization.
3
22.1.2014.
6th chapter – The hip: luxation
6.4 HIP LUXATION

If the hip development does not follow this dynamic a
hip luxation may happen.
1. Congenital luxation (developmental hip damage)- more

often bilateral (40%). Unilateral luxation happens more
often on the left side and in women (Noordin et al., 2010).
2. Acquired luxation – after different diseases or accidents
…
©Roche lexikon Medizin, 4. Aufl. Urban & Fischer, 1999
Two main reasons of hip luxation:
1. Dysplasia – deformity of the developing hip

(Developmental Dysplasia of the Hip – DDH)
- Irregular growth of the femoral head
- Irregular growth of the acetabulum
2. Hypoplasia – insufficient development of the joint

surfaces
- Insufficient growth of the femoral head
- Insufficient growth of the acetabulum
4
22.1.2014.
Possible symptoms of a luxated hip:
1. Hip and knee flexed, emphasized adduction of the upper

leg, external rotation of the foot
2. Spinae iliacae anterior superior are not at the same
level (at the same line)
3. Limited abduction
4. Limited internal rotation of the foot
5. Limited leg extension
6. Joint crepitation
7. Assimetrical gluteal crease
8. Walking ploddingly
9. Increased lumbar lordosis
6th chapter – The hip: therapy
6.5 HIP LUXATION THERAPY
Possible options:
1. Conservative
2. Surgical
• Hip dysplasia is treated surgically.
• Hip hypoplasia is firstly treated with conservative

therapy (Ihme i sur., 2003).
In hypoplasia, if the acetabulum develops properly by
the third year, the conservative treatment is
considered successful.
5
22.1.2014.
Different equipment is used in

conservative treatment:
Abduction pants
Pavlic harness
Abduction pillow
Different hip splints http://www.shopmedvet.com/product/hip-
pillow-abduction-large-each/closeout-
products-closeout-orthopedic-products
http://www.marwell.cz/en/vyhody.htm http://fyp.emmettconroy.com/sites/default/files/ima http://www.hellotrade.com/trulife-

gecache/add-image-500px/Pavlik%20Farness.jpg ireland/orthotics-hip-dynamic-hip-splint.html
• An early diagnosis is crucial (Homer i sur., 2000).
• The optimal relation between the femoral

head (convex joint surface) and the
acetabulum (concave joint surface) is 90°
angle.
• This position helps to ensure the closure

of the acetabulum.
http://www.emedicinehealth.com/script/main/art.asp
?articlekey=135633&ref=128554
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22.1.2014.
• Referring to luxation, there are some muscles

contractures:
- Flexors of the leg

- Adductors of the leg
- External rotators of the foot
KINESITHERAPY
- Leg extension
- Leg abduction
- Foot internal rotation
QUESTIONS
• Describe the hip functional anatomy.

• Describe the difference between an acute hip luxation
and arthritic changes of the hip.
• How do we divide a hip luxation, according to its
aetiology?
• What are the causes of an acquired hip luxation?
• How may hypoplasia or dysphasia cause a hip luxation?
• Describe the position of the leg on the side of the luxated hip.
• Which movements are limited in the luxated hip?
• Describe a kinesitherapy program for the rehabilitation of
a hip luxation.
7
22.1.2014.

recommended:
• Homer, C. J., Baltz, R. D., Hickson, G. B., Miles, P. V., Newman, T. B.,
Shook, J. E., Sunshine, P. (2000). Clinical practice guideline: Early
detection of developmental dysplasia of the hip. Pediatrics, 105(4
I), 896-905.
• Ihme, N., Schmidt-Rohlfing, B., Lorani, A., & Niethard, F. U. (2003).
Nonsurgical treatment of congenital dysplasia and dislocation of
the hip. [Die konservative therapie der angeborenen hüftdysplasie
und-luxation] Orthopade, 32(2), 133-138.
• Noordin, S., Umer, M., Hafeez, K., Nawaz, H. (2010).
Developmental dysplasia of the hip. Orthopedic Reviews,
23;2(2):e19.
8
22.1.2014.
7th chapter
Lordotic and kyphotic
poor posture
7th chapter – Lordotic and kyphotic poor posture
After attending the class and mastering this chapter students

will be able to:
• Define the function of active and passive spine stabilizers in

maintaining an upright posture
• Distinguish a good from a bad posture
• Name the possible causes for a poor posture
• Discuss critical life periods for the development of a poor posture
• Describe the symptoms of a kyphotic and lordotic poor posture
• Discuss the difference between a lordotic poor posture and
lordosis as a spine deformation
• Discuss the difference between a kyphotic poor posture and
kyphosis as a spine deformation
• Discuss possible treatment for kyphotic and lordotic poor posture
• Define the role of kinesitherapy in the treatment of kyphotic and
lordotic poor posture
• Give basic guidelines for a kinesitherapy program for the
correction of kyphotic and lordotic poor posture
1
22.1.2014.
7th chapter – Lordotic and kyphotic poor posture: upright posture
7.1 UPRIGHT POSTURE
• Active and passive stabilizing elements
 ACTIVE – muscles Changes occur

 PASSIVE– bones, joints, under the
tendons influence of
exercising and
aging
• The quality of these elements depends on their
flexibility, stength etc.
• The human spine has a “double S” shape in the

sagittal plane.
• This is very important for the human spine’s

biomechanics.
• It is necessary to differ physiological from

pathological posture.
The limit of differentiation:
– Toracal kyphosis
– Lumbar lordosis
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22.1.2014.
• The stability and existence of sagital human spine

curvatures are determined by the interaction of :
– The bones
– The ligaments
– The muscles http://soshable.com/tag/human-evolution-and-social-media/
PHYSIOLOGICAL SPINE CURVATURES
• ...? lordosis
• ...? kyphosis
• ...? lordosis
When these curves

become smaller or bigger,
a poor posture, or a
deformation may occur.
http://nicktumminello.com/2010/05/an-inside-look-at-spinal-
osteoporosis-scoliosis-and-osteophytosis/
3
22.1.2014.
• The correct relation between the different parts of

the body leads to a GOOD POSTURE
This means a correct relation between :
 639 muscles
 206 bones
 Dozens of organs
 Hundreds of nerves
 5 litres of blood
http://www.medpedia.com/news_analysis/388-Sanodox/entries/79104-
Improving-Posture-and-Ergonomics
7th chapter – Lordotic and kyphotic poor posture: causes for poor posture
7.2 CAUSES OF POOR POSTURE
Different factors may play a role in the creation of a

poor posture (Ku et al, 2012).
• The weakness or tension of certain muscle groups

• A non-rehabilitated injury
• The illness of organs or different body parts and the
nutritional state
• Osteoporosis
• Different psychological conditions e.g. fatigue
• Heredity
• Improper shoes
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22.1.2014.
• The line that differs a good from a bad posture
http://artshineqc.blogspot.com/2011/07/week-six-posture-stretching.html
• Muscles play a major rule in the maintenance of

a human’s upright body posture.
• Leg, hip, abdominal and back muscles, as well as

the ligamentar and bones’ structures work
against gravity.
• In conditions of fatigue (long lasting standing or

sitting) the body relaxes and a poor posture
habit may originate.
http://symmetrygymdubai.com/blog/
5
22.1.2014.
There are several critical life periods for the

development of poor posture (Gonçalves & Arezes, 2012).
• First – 1st and 2nd year (start to walk)
• Second –5 - 7 years of age (a child starts school)
• Third – puberty (sudden growth)
• Fourth – at a later age (sarcopenia, different diseases
etc.)
• There are three different poor postures i.e.

deformations:
http://www.ivline.info/2010/10/clinical-examination-of-spine.html
http://www.richmondchiro.net/health-conditions/scoliosis/
6
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7th chapter – Lordotic and kyphotic poor posture: kyphotic poor posture and kyphosis
7.3 KYPHOTIC POOR POSTURE AND KYPHOSIS
• The curvature of the

physiological thoracal kyphosis
grows in the anteroposterior
plane.
• The muscles of the back are

elongated, while the muscles of
the frontal part of the trunk are
shortened.
• The convexity is in the back. http://www.activeforever.com/a-2620-kyphosis.aspx
• Kyphotic poor posture often affects skinny people,

often boys.
• It mostly begins at the level of the 5th thoracic

vertebra.
• It can be cured/improved with kinesitherapy and

wearing different corsets.
http://thepilateshundred.blogspot.com/2011/04/posture-201-kyphosis.html
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22.1.2014.
KYPHOTIC POOR POSTURE
• No structural deformation of the spine
• Flexible (changes with muscular contraction)
http://accessdanceforlife.com/blog/
SYMPTOMS of kyphotic poor posture:
• Trunk anteflexion (arcus posterior)

• Head lowered towards the chest
• Rounded shoulders
• Chest retracted
• Outlined abdomen
• Reduced neck lordosis
• Emphasized lumbar lordosis
• Knees slightly flexed
http://www.aurorabaycare.com/health-
• Pelvis reclination info/display.aspx?URL=432311.html
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22.1.2014.
Treatment of kyphotic poor posture (Kado, 2009; Lou i sur., 2002).
KINESITHERAPY
• Mirror correction of poor posture
• Strengthen the back muscles
• Strengthen the abdominal muscles if necessary
• Stretch the pectoral muscles
PASSIVE CORRECTION … ?
Špišić, 1952
http://www.farosmedikal.com/page3.php
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22.1.2014.
KYPHOSIS (as a structural deformation) may be

congenital and acquired
CAUSES:
• Weak back muscles
• Different rheumatoidal illnesses
• A progressive muscular illness
• Tumours
• Long lasting immobilization
• Rachitis
• Senile kyphosis
• Abnormal vertebra shape http://www.orthoneuro.com/medical-conditions/kyphosis
THE WEDGED VERTEBRA

A vertebra with an abnormal shape
Situated in the middle of the curvature
The wedged side is turned towards the concavity
http://chospine.com/2011/02/09/compression-
http://www.sdspineinstitute.com/index.php/site/conditions/category/kyphosis/ fracture/
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22.1.2014.
According to the shape

and location we
distinguish:
• Low kyphosis
• High kyphosis
http://www.working-well.org/articles/bounce_ball.html
• Partial kyphosis
• Total kyphosis
7th chapter – Lordotic and kyphotic poor posture: lordotic poor posture and lordosis
7.3 LORDOTIC POOR POSTURE AND LORDOSIS
• Increased lumbar lordosis.
• Elongated abdominal
muscles and shortened back
muscles.
• The convexity is forward.
http://www.healthopedia.com/pictures/lordosis.html
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22.1.2014.
• A shortened iliopsoas (m. psoas maior and m.

iliacus) may cause lordotic poor posture
http://doubleyourgains.com/amazing-abs-101-core-training-system
SYMPTOMS of lordotic poor posture:
• Trunk retroflexion (arcus anterior)

• Enhanced lumbar and neck lordosis
• Head retroflexed
• Shoulders rounded backward
• Outlined abdomen
• Pelvis anterior rotation
• Knees slightly flexed
http://www.spineuniverse.com/conditions/
osteoporosis/spinal-fractures-
spondylolisthesis-scoliosis
12
22.1.2014.
Treatment of lordotic poor posture
KINESITHERAPY
• Mirror correction of poor posture
• Strengthen the abdominal muscles
• Strengthen the paravertebral musculature
• Stretch back muscles
• Stretch m. iliopsoas
• Kyphotic and lordotic poor posture may form per se, or

may develop as a compensation to other poor posture
(Imagama i sur., 2011; Pećina, 2004; Špišić, 1952).
• Poor posture and deformation should be distinguished
• KYPHOTIC POOR POSTURE ≠ KYPHOSIS
• LORDOTIC POOR POSTURE ≠ LORDOSIS
• functional stage ≠ structural stage
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22.1.2014.
QUESTIONS
• Functional anatomy pf the human spine. What are the active and
passive stabilizing elements of a human spine?
• What may cause a spine poor posture?
• What are the critical life periods for the development of a poor posture?
• Define a lordotic poor posture. Where is the convexity located and
which muscles are stretched?
• Define a kiphotic poor posture. Where is the convexity located and
which muscles are stretched?
• What are the symptoms of a kiphotic poor posture?
• What are the symptoms of a lordotic poor posture?
• Is there any difference between a lordotic poor posture and a lordosys
as a deformation?
• Is there any difference between a kiphotic poor posture and a kiphosys
as a deformation?
• What are the causes of kiphosys?
• Describe the shape, location and orientation of the wedged vertebra in
kiphosys and lordosis.
• How do we distinguish kiphosys according to its shape and location?
• What are the causes of lordosys?
• How may m. Iliopsoas affect the lumbar lordosys?
• Describe a kinesitherapy program for the correction of kiphotic and
lordotic poor posture.
The following literary titles are recommended:

• Gonçalves, M. A., & Arezes, P. M. (2012). Postural assessment of
school children: An input for the design of furniture. Work,
41(SUPPL.1), 876-880.
• Imagama, S., Matsuyama, Y., Hasegawa, Y., Sakai, Y., Ito, Z., Ishiguro,
N., & Hamajima, N. (2011). Back muscle strength and spinal mobility
are predictors of quality of life in middle-aged and elderly males.
European Spine Journal, 20(6), 954-961.
• Kado, D. M. (2009). The rehabilitation of hyperkyphotic posture in
the elderly. European Journal of Physical and Rehabilitation Medicine,
45(4), 583-593.
• Ku, P. X., Abu Osman, N. A., Yusof, A., & Wan Abas, W. A. B. (2012).
Biomechanical evaluation of the relationship between postural
control and body mass index. Journal of Biomechanics, 45(9), 1638-
1642.
• Lou, E., Raso, J., Hill, D., Durdle, N., & Moreau, M. (2002). Spine-
straight device for the treatment of kyphosis. Studies in Health
Technology and Informatics, 91, 401-404.
14
22.1.2014.
8th chapter
SCOLIOSIS
8th chapter – Scoliosis

• Define structural and non structural scoliosis
• Describe different types of scoliosis according to the number of
curvatures
• Describe different types of scoliosis according to the their
aetiology
• Discuss the difference between primary and compensatory
curvatures
• Discuss possible kinds of idiopathic scoliosis
• Describe the symptoms of scoliosis
• Describe the examination protocol
• Determine the side of the scoliosis
• Explain the methods frequently used to determine the degree
of the curvature
• Discuss possible treatments of scoliosis
• Explain the EDF principle
• Explain the role of kinesitherapy in the treatment of scoliosis
1
22.1.2014.
8th chapter – Scoliosis: definition
8.1 DEFINITION OF SCOLIOSIS
• Scoliosis – lateral (side-to-side) curve of the spine.
http://morphopedics.wikidot.com/spinal-scoliosis
• Structural - usually combined with a rotation of

the vertebrae.
• Non structural – scoliotic poor posture
≠
http://www.wecreatewellness.com/services/c http://movementsafootblog.com/2008/12/07/u
hiropractic/education/scoliosis/ neven-shoulder-blades/
2
22.1.2014.
Scoliosis may develop:

• In the whole spine (total scoliosis)
• Only in one part of the spine (partial scoliosis)
http://physioclinic.sg/conditions-treated/postural-pain/scoliosis/
Scoliosis may be:

• Simplex
• Duplex
• Triplex
– with primary and
compensatory curves
http://www.orthopediatrics.com/docs/guides/scoloisis.html
3
22.1.2014.
8th chapter – Scoliosis: types of scoliosis
8.2 TYPES OF SCOLIOSIS
1. IDIOPATHIC – the cause is unknown.

2. NEUROMUSCULAR – is due to loss of control of the
nerves or muscles that support the spine. The most
common causes of this type of scoliosis are cerebral
palsy and muscular dystrophy.
3. DEGENERATIVE – may be caused by the breaking
down of the intervertebral discs that separate the
vertebrae or by arthritis in the joints that link them.
4. CONGENITAL – due to an abnormal formation of the
bones of the spine and is often associated with other
organ defects.
8th chapter – Scoliosis: types of scoliosis
IDIOPATHIC SCOLIOSIS (Weinstein et al., 2008; Asher & Burton, 2006).
1. INFANTILE – Curvature appears before the age of

three.
2. JUVENILE – Curvature appears between the ages of
three to ten.
3. ADOLESCENT– Curvature usually appears between the
ages of ten to 13, near the beginning of puberty
4. ADULT - Curvature begins after physical maturation is
completed.
http://orthoinfo.aaos.org/topic.cfm?topic=a00353
4
22.1.2014.
8th chapter – Scoliosis: symptoms
8.3 SYMPTOMS OF SCOLIOSIS
1. Lateral deviation of the spine
http://www.healthgrouponline.com/scoliosis.html
2. Longitudinal rotation of the vertebrae

• Procesus spinosus rotates towards the concavity, while
the body of the vertebrae rotates towards the
convexity.
• The body of the vertebrae is wedged on the side of the
concavity.
• The spine changes its shape and way of functioning.
http://www.drerrico.com/html/scoliosis.html
http://medicaldictionary.thefreedictio
nary.com/Dextroscoliosis
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22.1.2014.
3. When the vertebrae rotates, the ribs also rotate,

therefore a rib hump occurs.
http://www.umm.edu/patiented/articles/how_scoliosis_diagn http://www.iscoliosis.com/treatment-surgical-thoracoplasty.html
osed_000068_6.htm
4. The intercostal space is reduced on the concave side

(the ribs become closer).
5. The intervertebral space is narrower on the concave
side, and wider on the convex side.
http://www.youngwomenshealth.org/scoliosis-
article.html
6
22.1.2014.
6. The vertebral canal is narrower on the convex

side.
http://www.rad.washington.edu/academics/academic-sections/msk/teaching-materials/online-
musculoskeletal-radiology-book/scoliosis
7. Constriction of the vertebrae: the wedge of the

vertebrae is situated on the concave side; the bigger
wedge is located at the apex of the deformation.
http://www.jaaos.org/content/12/4/266/F1.expansion
7
22.1.2014.
• The apical vertebra –is in a curve, and is the vertebra

most deviated laterally from the vertical axis that
passes through the patient's sacrum, i.e. from the
central sacral line
http://www.srs.org/professionals/glossary/SRS_revised
_glossary_of_terms.htm
http://stronglifts.com/lamar-gant-long-limbs-
deadlift/
http://espn.go.com/high-school/girl/story/_/id/7624664/logan-mcgill
http://chaimaaseesit.wordpress.com/2012/02/20/livin
g-with-scoliosis/
http://www.saspine.org/conditions/scoliosis.htm
8
22.1.2014.
8th chapter – Scoliosis: examination
8.4 EXAMINATION OF SCOLIOSIS
• Bend forward test

• Uneven Lorens` triangle
http://www.umm.edu/patiented/articles
/what_symptoms_of_scoliosis_000068_5 http://www.kmle.co.kr/search.php?Search=Nonstructural%20scoliosis
.htm
• Scoliosis is determined according to the convex side.

• The Lorens` triangle is bigger on the concave side.
LEFT SCOLIOSIS
RIGHT SCOLIOSIS
http://www.chop.edu/healthinfo/scoliosis.html
9
22.1.2014.
• Scoliosis thoracalis
dextroconvexa
• Scoliosis thoracalis dextra
• Cervical
• Cervicotoracal
• Toracal
• Toracolumbar
• Lumbar
• Lumbosacral
http://rebuildhealth.com/kyphosis-lordosis
8th chapter – Scoliosis: curvature degree
8.5 METHODS TO DETERMINE THE

DEGREE OF CURVATURE
• Based on an X ray of the spine
1. Cobb method
2. Risser-Ferguson method
http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=45531
10
22.1.2014.
1. THE COBB METHOD
http://www.aafp.org/afp/2002/0501/p1817.html
• With these methods the degree of curvature is

determined according to which the curvature is classified
into seven groups of scoliosis:
GROUP DEGREE OF FLEXION

1. 0 - 20
2. 21 - 30
3. 31 - 50
4. 51 - 75
5. 76 - 100
6. 101 - 125
7. 126 and more
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22.1.2014.
THE PROGNOSIS DEPENDS ON:
• Type
• Location
• Etiology
• Age
http://www.healingbackpain.co.uk/scoliosis/scoliosis-prognosis/
8th chapter – Scoliosis: treatment
8.6 TREATMENT OF SCOLIOSIS

• Surgical or conservative treatment
In conservative treatment different approaches are
used (D'Astous i Sanders, 2007; Everett i Patel, 2007; Radaš & Trošt Bobić, 2011; Mordecai &
Dabke, 2012)
• KINESITHERAPY
• PASSIVE CORRECTION
http://health.nytimes.com/health/guides/disease/scoliosis/print.html
12
22.1.2014.
• KINESITHERAPY
http://www.spineharmony.com/exercises
http://www.fitness-programs-for-
life.com/scoliosis_exercises.html
http://www.yelp.com/biz_photos/xOOu5krC
PsBPTu79MvF9eA?select=2xgNiTCtCzf7c12N
HFAg8g#2xgNiTCtCzf7c12NHFAg8g
• BRACES (Milwaukee, Boston, Spinecor etc.) passive

correction
http://www.bracingscoliosis.com/milwaukee-brace.html
http://www.orthoticsprostheticsne.com/home/index.php/O
rthotics-Prosthetics/pediatric-orthotics.html
http://www.spinecorscoliosisbrace.com/
13
22.1.2014.
EDF principle
• Elongation – The brace elongates the trunk by

lowering the pelvis and elevating the head.
• Derotation – Derotation of the rotated vertebrae
towards the normal position by creating a pressure
on the rib hump.
• Flexion (lateral) – flexion of the spine towards the
convex side.
QUESTIONS
• Describe the scoliosis as a deformation and scoliotic poor
posture.
• How do we define scoliosis according to the number of
curvatures?
• What are the primary and compensatory curvatures?
• Name the main types of scoliosis and describe their
aetiology.
• How do we divide the idiopathic scoliosis according to the
patient’s age?
• What are the symptoms of scoliosis?
• What are apical and the wedged vertebra?
• How do we determine the side of the scoliosis?
• What are the most commonly used methods to determine
the degree of the curvature? Learn how to draw them.
• What are the possible treatments for scoliosis?
• Describe the EDF principle and the Milwaukie brace.
14
22.1.2014.

• Asher, M.A., Burton, D.C. (2006). Adolescent idiopathic scoliosis:
natural history and long term treatment effects. Scoliosis, 31;1(1):2.
• d'Hemecourt, P. A., & Hresko, M. T. (2012). Spinal deformity in
young athletes. Clinics in Sports Medicine, 31(3), 441-451.
• Everett CR, Patel RK. A systematic literature review of nonsurgical
treatment in adult scoliosis. Spine. 2007;32(19 Suppl):S130-134.
• Mordecai, S. C., & Dabke, H. V. (2012). Efficacy of exercise therapy
for the treatment of adolescent idiopathic scoliosis: A review of the
literature. European Spine Journal, 21(3), 382-389.
15
22.1.2014.
9th chapter
THORACIC DEFORMITIES
9th chapter – Thoracic deformities

• Define the most common chest deformations
• Describe the characteristics of pectus excavatum and
pectus carrinatum
• Explain the possible causes of an aquired pectus
carrinatum
• Explain the possible causes of a congenital pectus
excavatum
• Discuss possible treatments for pectus excavatum and
pectus carrinatum
• Explain the characteristics of the respiratory exercises
for the treatment of pectus excavatum and pectus
carrinatum
• Discuss the kinesitherapy program for the conservative
treatment of pectus excavatum and pectus carrinatum
1
22.1.2014.
There are several kinds of thoracic deformities in

children, with the two most common being pectus
carinatum and excavatum (Saxena, 2005)
• PECTUS EXCAVATUM CHEST WALL
• PECTUS CARINATUM ABNORMALITY
http://www.gamekyo.com/media24160.html http://medicina.forum.st/t159-pectus-excavatum
9th chapter – Thoracic deformities: pectus carinatum
9.1 PECTUS CARINATUM
1. Congenital deformation
2. Acquired deformation
http://med.brown.edu/pedisurg/Brown/IBImages/Thorax/PectusCarin.html
2
22.1.2014.
CHARACTERISTICS
• protrusion of the sternum and ribs.
Sternum protrusion
http://doctorshosp.adam.com/content.aspx?productId=39&pid=1&gid=003321
• The sternum is protruded and it pulls the ribs forward.

Therefore the chest is flattened laterally (Obermeyer & Goretsky, 2012).
http://risen-wind.blogspot.com/2008/02/pectus-excavatum-e-pectus-carinatum.html
3
22.1.2014.
• The heart and lungs usually develop normally, but

there could be some problems with their functioning.
http://www.pectuscarinatum.com.tr/eng/
9th chapter – Thoracic deformities: causes of pectus carinatum
9.2 CAUSES OF PECTUS CARINATUM
• Rachitis
• Mucopolysacharidosis
• Tuberculosis of the
thoracic vertebra
• After a bad repositioning of

a fractured sternum.
http://www.scielo.br/scielo.php?pid=s1806-
37132007000400017&script=sci_arttext&tlng=en
4
22.1.2014.
9th chapter – Thoracic deformities: treatment for pectus carinatum
9.3 TREATMENT FOR PECTUS CARINATUM
• Firstly solve the cause (antirachitic therapy)
• CONSERVATIVE TREATMENT
- Braces (passive) (Frey i sur., 2006; Lee i sur., 2008)
- Kinesitherapy (active) (Cahill, Lees & Robertson, 1984).
- breathing exercises
- corrective gimnastic
- swimming …
• SURGICAL TREATMENT (rarely)
http://www.wcbl.com/product-spotlight/pectus-carinatum-2/
5
22.1.2014.
http://www.cincinnatichildrens.org/health/p/pectus-carinatum/
http://www.cincinnatichildrens.org/health/p/pectus-carinatum/
• Kinesitherapy:
Respiration exercises – prolonged inhalation
Strengthening of the abdominal muscles
http://www.umm.edu/imagepages/19072.htm http://chickscope.beckman.uiuc.edu/explore/e
mbryology/day15/focuson_humans.html#blank
6
22.1.2014.
9th chapter – Thoracic deformities: pectus excavatum
9.4 PECTUS EXCAVATUM

1. Congenital deformation
2. Acquired deformation
http://www.uwhealth.org/healthfacts/
• It may develop on the xifoidal procesus or on the

sternum body.
http://deepresentaza.blogspot.com/2010/12/pectus-excavatum.html
7
22.1.2014.
• Internal organs may change position
http://www.uwhealth.org/healthfacts/ http://bjr.birjournals.org/content/75/895/627.full
8
22.1.2014.
9th chapter – Thoracic deformities: causes of pectus excavatum
9.5 CAUSES OF PECTUS EXCAVATUM
• Fetal position
• Lack of space in the uterus in the case of twins
• The retrosternal and suprasternal ligaments drag the

procesus xifoideus inwards
• Genetic factor (35%)
9th chapter – Thoracic deformities: treatment of pectus excavatum
9.6 TREATMENT FOR PECTUS EXCAVATUM

• CONSERVATIVE TREATMENT
- Braces (passive)
- Kinesitherapy (active) (Cahill, Lees & Robertson, 1984).
• SURGICAL TREATMENT (very often)
http://www.gundluth.org/?id=2691&sid=1
9
22.1.2014.
9th chapter – Thoracic deformities: treatment for pectus excavatum
• Kinesitherapy:
Respiration exercises – prolonged exhalation (singing,
laughing)
Strengthening of the back muscles
Strengthening of the abdominal muscles
http://chickscope.beckman.uiuc.edu/expl
http://www.umm.edu/imagepages/19072.htm ore/embryology/day15/focuson_humans.
html#blank
QUESTIONS
• Which are the most common thoracic deformities?
• What causes pectus carrinatum?
• What causes pectus excavatum?
• Which respiration phase should be stressed in a
kinesitherapy program for pectus carrinatum? Why?
• Which respiration phase should be stressed in a
kinesitherapy program for pectus excavatum? Why?
10
22.1.2014.

• Cahill, J. L., Lees, G. M., & Robertson, H. T. (1984). A summary of
preoperative and postoperative cardiorespiratory performance in
patients undergoing pectus excavatum and carinatum repair. Journal
of Pediatric Surgery, 19(4), 430-433.
• Frey, A. S., Garcia, V. F., Brown, R. L., Inge, T. H., Ryckman, F. C., Cohen,
A. P., Azizkhan, R. G. (2006). Nonoperative management of pectus
carinatum. Journal of Pediatric Surgery, 41(1), 40-45.
• Lee, S. Y., Lee, S. J., Jeon, C. W., Lee, C. S., & Lee, K. R. (2008). Effect of
the compressive brace in pectus carinatum. European Journal of
Cardio-Thoracic Surgery, 34(1), 146-149.
• Obermeyer, R. J., & Goretsky, M. J. (2012). Chest wall deformities in
pediatric surgery. Surgical Clinics of North America, 92(3), 669-684.
• Saxena, A. K. (2005). Pectus excavatum, pectus carinatum and other
forms of thoracic deformities. Journal of Indian Association of
Pediatric Surgeons, 10(3), 147-157.
11
22.1.2014.
10th chapter
LOW BACK PAIN
10th chapter – Low back pain

• Describe the possible causes for a low back pain
• Describe the symptoms of a low back pain syndrome
• Explain the characteristics of a dynamical vertebral
segment
• Discuss the aetiology of the most common degenerative
changes in a dynamical vertebral segment
• Explain what the Lasègue`s sign is
• Discuss the intervertebral discus anatomy and its
relationship with lumbar back pain. Explain what is a
protrusion and what is a prolaps
• Explain the possible location of pain
• Discuss possible treatment for a lumbar back pain with
special emphasis on the role of kinesitherapy before and
after an eventual surgery
1
22.1.2014.
10th chapter – Low back pain: definition
10.1 DEFINITION OF LOW BACK PAIN
• Low back pain – a common musculoskeletal

symptom that may be acute or chronic. Affects the
lumbar spine.
• Sacroiliac pain – when pain radiates in the sacrum

region.
• Sciatica (sciatic nerve pain) – pain involves the sciatic

nerve and is felt in the lower back, the gluteal region,
the back of the thigh and may radiate to the foot.
10th chapter – Low back pain: definition
• Sciatica
http://www.umm.edu/patiented/articles/what_causes_pain_low_back_pain_or_sci
atica_000054_2.htm
2
22.1.2014.
10th chapter – Low back pain: causes
10.2 CAUSES OF LOW BACK PAIN
• It may be caused by a variety of diseases and

disorders that affect the lumbar spine.
http://www.zimmer.com/z/ctl/op/global/action/1/id/7753/template/IN
• Degenerative changes
• Hypomobility
• Hypermobility
• Internal organs’ diseases
• Muscular dystrophy
• Postural problems
• Trauma
• Compressive fractures
• Spine tumors
http://www.yinovacenter.com/blog/archives/4582/
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22.1.2014.
• Degenerative changes may occur at three different

locations:
1. At the vertebral body

2. At the intervertebral disc
3. At the procesus vertebralis (transversus, spinosus)
http://www.d-connect.cz/en/descriptions-of-surgeries.php
• Possible degenerative problems of the spine:

NORMAL DISC
DISC WITH
DEGENERATIVE
CHANGES
DISC PROTRUSION
DISC PROLAPS
THIN DISCUS http://thebackdr.com.au/custom_content/c_95227_slipped_disc.html
DISCUS
DEGENERATIVE
CHANGES AND
OSTEOPHYTES
http://www.bhpain.com/low_back_pain
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22.1.2014.
• Two main causes of pain that implies the pressure of

the spinal cord or the pressure of the root of the nerve.
1. Protrusion
2. Prolapse or discus herniation
http://www.holladayphysicalmedicine.com/patient_information/patient_conditions/lumbar_disc_syndrome.htm
10th chapter – Low back pain: symptoms
10.3 SYMPTOMS OF LOW BACK PAIN

• Pain in the lumbo-sacral area is the primary symptom of
lower back pain, althought other symptoms may be
present. Nerve root
Pain
Numbness
Motor Extension of Dorsiflexion of Plantar flexion

quadriceps great toe and (extension) of
weakness
foot great toe and foot
http://www.chirobase.org/07Strategy/AHCPR/ahcprclinician.html
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22.1.2014.
Degenerative changes
on 4th and 5th Degenerative changes
lumbar vertebrae on 5th lumbar and
1st sacral vertebrae
Compression of the Compression of the

5th lumbar nerve 1st sacral nerve
This can cause an inability to

A person is unable to raise the plantar flex (extend) the foot.
big toe upwards A person has difficulties in
standing on his/her toes or
moving the foot downwards.
LASÈGUE 'S SIGN
http://www.pic2fly.com/Lasegue.html
6
22.1.2014.
10th chapter – Low back pain: treatment
10.3 TREATMENT OF LOW BACK PAIN

• Conservative
• Operative
• Acute stage
• Subacute stage
• Chronic stage
http://www.doctorvlad.com/lowerbackpainexercises/index.php/2010/ http://www.webmd.com/back-pain/sleeping-positions-for-people-
05/lower-back-pain/ with-low-back-pain
10th chapter – Low back pain: treatment
• KINESITHERAPY
1. Strengthen the paravertebral muscles (Timm, 1999; Keller, 2006;
Wininger, 2010; Vela, Haladay, & Denegar, 2011).
2. Strengthen the abdominal muscles (Timm, 1999; Keller, 2006)

3. Strengthen the back muscles (Wininger, 2010)
4. Assure optimal range of motion with enough
muscle control (Vela, Haladay, & Denegar, 2011).
http://doubleyourgains.com/core-muscle-strength-my-new-favorite-core-exercise
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22.1.2014.
QUESTIONS
• Describe the functional anatomy of the lumbar spine.
• What are the causes of low back pain and which nerve
is primarily involved?
• How do we differentiate low back pain according to
pain location?
• What is the dynamic vertebral segment?
• On which structure may degenerative changes occur in
the lumbar spine?
• What are the symptoms of lumbar back pain?
• What is the Lasegue sign?
• What is a protrusion?
• What is a prolaps?
• What are the possible treatments for low back pain?
• Describe a kinesitherapy program for the rehabilitation
of low back pain.
• Keller, K. (2006). Exercise therapy for low back pain: A narrative

review of the literature. Journal of Chiropractic Medicine, 5(1), 38-
42.
• Timm, K. E. (1999). Therapeutic exercise guidelines for
rehabilitating lumbar spine injuries in athletes. Athletic Therapy
Today, 4(2), 17-21.
• Vela, L. I., Haladay, D. E., & Denegar, C. (2011). Clinical assessment
of low-back-pain treatment outcomes in athletes. Journal of Sport
Rehabilitation, 20(1), 74-88.
• Wininger, K. L. (2010). The lumbosacral spine: Kinesiology, physical
rehabilitation, and interventional pain medicine. Clinical
Kinesiology, 64(3), 22-50.
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22.1.2014.
11th chapter
CERVICO-BRACHIAL SYNDROME
11th chapter – Neck pain

• Define the cervicobrachial syndrome

• Describe the symptoms of the cervicobrachal
syndrome
• Discuss possible degenerative changes in the cervical
spine that may led to neck pain
• Discuss possible treatment for neck pain with special
emphasis on the role of kinesitherapy
1
22.1.2014.
11th chapter – Neck pain: definition
11.1 DEFINITION
• Cervical-brachial syndrome is a nonspecific term
describing some combination of pain, numbness,
weakness, and swelling in the region of the neck and
shoulder.
• The word “syndrome” means a collection of
symptoms commonly seen together but for which
there is no known explanation.
• The term neck pain is often used.
11th chapter – Neck pain: definition
• According to the localization of different symptoms

several syndromes may be defined:
• Cervico-cephalic syndrome (neck and head)
• Cervical syndrome (neck)
• Cervicobrachial syndrome (neck and arm)
http://www.e-algos.com/cervical-radicular-pain/
2
22.1.2014.
11th chapter – Neck pain: causes
11.2 CAUSES OF NECK PAIN

• It may be caused by a variety of diseases and
disorders that affect the cervical spine.
• Degenerative problems of the spine, such as
osteophytes (spondylophytes) or discus herniations
may led to the pressure of:
– the spinal nerve roots

– the spinal cord
– the vertebral artery
11th chapter – Neck pain: symptoms
11.3 SYMPTOMS OF NECK PAIN

According to the location of the degenerative
changes, and therefore of the pressure, different
symptoms may be present.
http://www.backpain-guide.com/Chapter_Fig_folders/Ch06_Path_Folder/2ForaminalStenosis.html
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22.1.2014.
• Symptoms may be linked with sensation and

functionality (Carette & Fehlings, 2005).
INTERVERTEBRAL NERVE PAIN DISTRIBUTION MUSCLE WEAKNESS SENSORY LOSS REFLEX LOSS
LEVEL ROOT
MEDIAL SCAPULA DELTOID
LATERAL UPPER SUPINATOR
C4-C5 C5 LATERAL UPPER ARM SUPRASPINATUS
ARM REFLEX
DOWN TO ELBOW INFRASPINATUS
BICEPS BRANCHIALIS
THUMB AND
LATERAL FOREARM
C5-C6 C6 FOREFINGER BICEPS REFLEX
THUMB AND FOREFINGER BRACHIORADIALIS
WRIST EXTENSORS
MEDIAL SCAPULA
TRICEPS POSTERIOR
POSTERIOR UPPER ARM
C6-C7 C7 WRIST FLEXORS FOREARM TRICEPS REFLEX
DORSAL FOREARM AND
EXTENSOR DIGITORUM THIRD FINGER
THIRD FINGER
SHOULDER
C7-T1 C8 ULNAR PART OF FOREARM THUMB FLEXOR FIFTH FINGER
FIFTH FINGER
Pain in the neck area
Cervical
syndrome
http://phr.emrystick.com/patient-education.aspx?medical-
term=displacement-cervical-intervertebral-disc-without-myelopathy
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22.1.2014.
• Unilateral pain of the head

• Strong pain in the occipital region
• Buzzing in one ear Cervico-cephalic
• Eyes watering, vision problems (fogging) syndrome
• Skin sensitivity
• Nausea and vomiting
• Compression of arteria vertebralis
http://www.necksolutions.com/neck-pain.html
• Blood flow and sensory-motor changes in the

upper extremities.
• Sensitive disturbances such as hypesthesia,
anesthesia, paresthesia, hyperesthesia, also in the
upper extremities.
Cervical-brachial
syndrome
http://www.wellsphere.com/back-neck-pain-article/cervical-brachial-
syndrome-causes-neck-and-arm-pain/901762
5
22.1.2014.
11th chapter – Neck pain: treatment
11.3 TREATMENT OF NECK PAIN

• Operative or
Conservative
• Acute stage (rest, wear a brace, educate the
patient)
http://www.ortopediebaldinelli.it
• Subacute and chronic stage (educate the patient,

physical therapy, kinesitherapy)
11th chapter – Neck pain: treatment
• KINESITHERAPY
1. Strengthen upper back and shoulder muscles (Hagberg i sur.,
2000; Andersen et al., 2012).
2. Assure optimal range of motion (Hagberg i sur., 2000; Gross et al, 2012).
3. Improve muscular endurance in the neck and
shoulder regions (Hagberg i sur., 2000; Gross et al, 2012).
http://www.necksolutions.com/nec http://www.holistic-back-relief.com/neck-pain-relief.html http://www.prevention.com/fitness/strength-

k-exercises.html training/end-neck-pain-3-moves
6
22.1.2014.
QUESTIONS
• What is a syndrome?
• Describe the functional anatomy of the cervical spine.
• What are the causes of a cervicobrachial syndrome?
• What are the symptoms of a cervicobrachial syndrome?
• How do we differentiate the cervicobrachial syndrome
according to symptoms location?
• What are the long lasting symptoms of a cervicobrachial
sindrom?
• What are the possible treatments for cervicobrachial
sindrom?
• Describe a kinesitherapy program for the rehabilitation
of a cervicobrachial syndrome.
The following literature titles are recommended:
• Andersen, C. H., Andersen, L. L., Gram, B., Pedersen, M. T.,

Mortensen, O. S., Zebis, M. K., & Sjøgaard, G. (2012). Influence of
frequency and duration of strength training for effective management
of neck and shoulder pain: A randomised controlled trial. British
Journal of Sports Medicine.
• Carette, S., Fehlings, M.G. (2005). Clinical practice. Cervical
radiculopathy. The New England Journal of Medicine;353:392–399.
• Gross, A., Forget, M., St George, K., Fraser, M. M., Graham, N., Perry,
L., Brunarski, D. (2012). Patient education for neck pain. Cochrane
Database of Systematic Reviews (Online).
• Hagberg, M., Harms-Ringdahl, K., Nisell, R., & Wigaeus Hjelm, E.
(2000). Rehabilitation of neck-shoulder pain in women industrial
workers: A randomized trial comparing isometric shoulder endurance
training with isometric shoulder strength training. Archives of Physical
Medicine and Rehabilitation, 81(8), 1051-1058.
7
22.1.2014.
12th chapter
TORTICOLLIS
12th chapter – Torticollis

• Describe possible causes of a congenital and acquired

torticollis
• Describe the symptoms of torticollis
• Discuss different kinds of acquired torticollis referring
to their aetiology
• Discuss possible conservative treatments (passive and
active) of torticollis with special refer to a possible
kinesitherapeutic program
1
22.1.2014.
TORTICOLLIS – neck deformation causing lateral flexion of

the head and contracture of the cervical spine
musculature
http://drdanrae.wordpress.com/2012/04/23/chandler-chiropractor-talks-torticollis/
12th chapter – Torticollis: causes
12.1 CAUSES OF TORTICOLLIS

ETHIOLOGY:
CONGENITAL
Birth trauma Shortening or excessive
Intra-uterine malposition contraction of the
sternocleidomastoid muscle
ACQUIRED
Different diseases to the Shortening or excessive
neck region that happen contraction of the
during the life span sternocleidomastoid muscle
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22.1.2014.
CONGENITAL deformation
• During pregnancy – lack of space in the uterus
• Twins
http://contemporarypediatrics.modernmedicine.com http://contemporarypediatrics.modernmedicine.com
CONGENITAL deformation
http://gardenrain.wordpress.com/2009/10/15/torticollis/
3
22.1.2014.
ACQUIRED deformation
Non-congenital muscular
torticollis can result from
scarring or disease of the
cervical vertebrae, adenitis,
tonsillitis, rheumatism,
enlarged cervical glands, a
retro-pharyngeal abscess, or http://www.health-reply.com/with-
congenital-muscular-torticollis/
cerebellar tumors.
• Types of acquired torticollis
1. Dermatogenic torticollis
2. Desmogenic torticollis
3. Miogenic torticollis
4. Habitual torticollis
5. Neurogenic torticollis
http://explow.com/Torticollis
4
22.1.2014.
12th chapter – Torticollis: symptoms
12.2 SYMPTOMS OF TORTICOLLIS
• Latero-flexion of the head

and the neck on the side of
the shortened m.
sternocleidomastoideus
• Chin rotation on the side of

the elongated m.
sternocleidomastoideus
• Head slightly bent forward http://www.injurylawsourcepa.com/2012/06/torticollis-

pediatric-medical.html
12th chapter – Torticollis: treatment
12.3 TREATMENT OF TORTICOLLIS
1. CONSERVATIVE
a) Passive correction
 Schantz brace, collar
http://www.24-7pressrelease.com/press-
http://torticollistreatment.org/torticollis- release/disabled-inventor-revolutionizes-neck-brace-
treatment-how-to-treat-wryneck/ design-206022.php
5
22.1.2014.
1. CONSERVATIVE
b) kinesitherapy
 Chin de-rotation toward the elongated muscle,
 Head latero-flexion towards the stretched muscle,
 Head backwards (Ohman et al., 2011).
http://donna.tuttogratis.it/mamma/torcicollo-miogeno-
congenito-cause-e-sintomi/P237171/ http://byebyedoctor.com/torticollis/
2. OPERATIVE
SURGERY – kinesitherapy after surgery with special

emphasis on the strengthening of the lateral neck
muscles (Shim & Jang, 2008).
http://www.fpnotebook.com/nicu/ortho/trtcls.htm
6
22.1.2014.
QUESTIONS
• What are the causes of torticollis?

• What are the characteristics of torticollis according to
m. sternocleidomastoideus?
• Describe possible acquired neck deformations.
• How does a Shantz brace for the correction of the
torticollis work?
• Describe a kinesitherapy program for the correction of
torticollis.
• Ohman, A., Mårdbrink, E. L., Stensby, J., & Beckung, E. (2011).

Evaluation of treatment strategies for muscle function in infants
with congenital muscular torticollis. Physiotherapy Theory and
Practice, 27(7), 463-470.
• Shim, J. S., & Jang, H. P. (2008). Operative treatment of congenital
torticollis. Journal of Bone and Joint Surgery - Series B, 90(7), 934-
939.
7
22.1.2014.
13th chapter
SHOULDER INJURY
REHABILITATION
13th chapter Shoulder injury rehabilitation

• Describe the functional anatomy of the shoulder girdle in
relations to its possible acute and overuse injury
• Describe possible mechanisms of an anterior and
posterior shoulder luxation
• Discuss why the tendon of m. supraspinatus is frequently
injured
• Describe the symptoms of a rotator cuff overuse injury
• Discuss possible options for the treatment of an acute and
overuse shoulder injury
• Discuss the conservative treatment of an acute and
overuse shoulder injury with special reference to the
targeted muscles in a kinesitherapy session
• Discuss the main goals of the functional stage of the
rehabilitation protocol after an anterior shoulder luxation
• Explain the biomechanical progression of exercise in the
functional rehabilitation stage
1
22.1.2014.
13th chapter Shoulder injury rehabilitation: functional anatomy of the shoulder
13.1 FUNCTIONAL ANATOMY OF THE SHOULDER
Movements of the human shoulder represent the

result of a complex dynamic interplay of structural
bony anatomy and biomechanics, static ligamentous
and tendinous restraints, and dynamic muscle
forces.
http://www.zimmer.co.uk/z/ctl/op/global/action/1/id/391/template/PC/navid/10892
http://www.stetoskop.info/Povrede-ramena-4346-s13-content.htm
2
22.1.2014.
There are three main joints in the shoulder girdle:

1. Glenohumeral Joint (GHJ)
2. Acromioclavicular Joint (ACJ)
3. Sternoclavicular Joint (SCJ)
4. Scapulothoracic “joint” (musculotendinous articulation
in nature)
http://morphopedics.wikidot.com/shoulder-impingement-syndrome
13th chapter Shoulder injury rehabilitation: functional anathomy of the shoulder
• The shoulder joint (articulatio humeri) is a joint

between the head of the humerus and the cavity of
the scapula.
• The convex joint surface is at least twice greater than
the surface of the concave side.
http://www.shoulderandelbowcenter.com/sec_education_links.htm?education/arth.htm
3
22.1.2014.
• A wide number of deeper

and peripheral muscles
play an important rule in
the stabilization of the
shoulder.
http://www.eorthopod.com/content/shoulder-
anatomy
• They should all be

exercised in a functional
rehabilitation program.
http://www.britannica.com/EBchecked/media/119225/Muscles-of-the-shoulder
13th chapter Shoulder injury rehabilitation: shoulder injuries
13.2 SHOULDER INJURIES

Forces that act on the shoulder girdle during a
sports activity may cause:
• Chronic injuries (Littlewood et al., 2012)
• Acute injuries (Murray et al., 2012)
• Chronic joint instability
http://dimemag.com/2010/04/top-10-worst-basketball-injuries/ http://advancedbodydynamics.com/tag/muscle-activation-technique/
4
22.1.2014.
13th chapter Shoulder injury rehabilitation: traumatic shoulder injury mechanism
13.3 TRAUMATIC SHOULDER INJURY MECHANISM

There are three most frequent injury situations (Trošt & Stepanić, 2007) :
• A fall on the extended and abducted arm

(wrestling).
• A blocked extended arm while kicking the ball
(team handball).
• A direct fall on to the adducted shoulder (skiing,
downhill cycling).
5
22.1.2014.
Repeated injuries lead to chronic shoulder instability (Trošt & Stepanić, 2007)
http://www.sports-injury-info.com/bankart-lesion.html
A dislocation before being 20 years of age will, in 90% of

cases, result in a second dislocation later in life (Garth et al., 1987).
6
22.1.2014.
13th chapter Shoulder injury rehabilitation: overuseof injury mechanism
13.4 OVERUSE of INJURY MECHANISM

Shoulder impingement - lifting the arm above
shoulder height when rotating the shoulder (Littlewood et
al., 2012).
13th chapter Shoulder injury rehabilitation: overuse of injury mechanism
7
22.1.2014.
13th chapter Shoulder injury rehabilitation: overuse of injury mechanism
http://rockislandworkerscompensationattorney.wordpress.com/2010/11/16/how-
much-is-a-shoulder-injury-worth-in-illinois-workers-compensation/
• Impingement syndromes most commonly involve the

m. supra-spinatus tendon.
• The tendon of the m. biceps brachii (long head) is also
often involved.
13th chapter Shoulder injury rehabilitation: overuse of injury mechanisn
• There are several stages of overuse of injury

mechanism symptoms. Athletes usually report the
problems when the pain begins to be present during
activity, which prolongs the rehabilitation protocol.
STAGE PAIN FUNCTION
1st no normal
2nd when extremely loaded normal
3rd at the beginning and after a sport activity normal or slightly reduced
4th during and after a sport activity slightly reduced
5th while doing the sport – had to end the severely reduced
activity
6th while doing everyday activities impossible to do the sport
8
22.1.2014.
13th chapter Shoulder injury rehabilitation: shoulder injury rehabilitation
13.5 SHOULDER INJURY REHABILITATION

TREATMENT
• Operative
• Conservative
Conservative treatment usually includes:

• REST
• PHYSICAL AIDS
• MEDICAMENTS
• KINESITHERAPY
http://www.umm.edu/imagepages/19689.htm
FUNCTIONAL REHABILITATION
The main goals of functional rehabilitaion are
(Renstrom, 1994; Frontera, 2003). :
1. To regain a range of motion

2. Progressively to strengthen the muscles that
stabilize the shoulder
3. To develop neuro-muscular coordination
4. To prepare the athlete for a specific return to being
in the situation to play again
• The functional rehabilitation protocols for a traumatic
injury and an overuse syndrome of the shoulder differ
drastically (Hayes et al., 2002). This is due to their different
etiology.
9
22.1.2014.
KINESITHERAPY
STRETCHING – if there is a need
• Static
• PNF
• Dynamic
STRENGTH EXERCISES
• Isometric contraction
• Eccentric contraction
• Concentric contraction
• Exercise with elastic bands
• Exercise with apparatus
• Exercise with cow-bells…
• Closed open kinetic chain exercise
10
22.1.2014.
• Kinaesthetic and biomechanical progression
PROPRIOCEPTION
• Proprioceptive boards
• Fitball
• Dynadisc
• Proprioceptive matresses
• Open kinetic chain
PLYOMETRICS
• Ball
• Medicine ball
SPECIFICS
11
22.1.2014.
QUESTIONS
• Why does the anterior shoulder luxation happen more
often than the posterior one?
• Describe the mechanisms of anterior shoulder luxation.
• Name an acute injury and an overuse injury of the
shoulder and explain the difference between them.
• What is a rotator cuff overuse injury? What tendon is
frequently injured and why?
• Explain the difference in the kinesitherapy program for
the rehabilitation of an acute and an overuse shoulder
injury.
• What are the main goals of functional rehabilitation?
• Describe the biomechanical progression of exercise in the
functional stage of the rehabilitation protocol.
• Hayes, K., Callanan, M., Walton, J., Paxinos, A., & Murrell, G. A. C.
(2002). Shoulder instability: Management and rehabilitation. Journal of
Orthopaedic and Sports Physical Therapy, 32(10), 497-509.
• Littlewood, C., Ashton, J., Chance-Larsen, K., May, S., & Sturrock, B.
(2012). Exercise for rotator cuff tendinopathy: A systematic review.
Physiotherapy, 98(2), 101-109.
• Murray, I. R., Ahmed, I., White, N. J., & Robinson, C. M. (2012).
Traumatic anterior shoulder instability in the athlete. Scandinavian
Journal of Medicine and Science in Sports. Jun 28 (Epub ahead of print).
12
Literature
1. Andersen, C. H., Andersen, L. L., Gram, B., Pedersen, M. T., Mortensen, O. S., Zebis, M.
K., & Sjøgaard, G. (2012). Influence of frequency and duration of strength training for
effective management of neck and shoulder pain: A randomised controlled trial. British
Journal of Sports Medicine.
2. Asher, M.A., Burton, D.C. (2006). Adolescent idiopathic scoliosis: natural history and long
term treatment effects. Scoliosis. 31;1(1):2.
3. Bartel, D.L., Davy, D.T., Keaveny, T.M. (2006). Orthopaedic Biomechanics: Mechanics and
Design in Musculoskeletal Systems / Edition 1. Prentice Hall publisher.
4. Cahill, J. L., Lees, G. M., & Robertson, H. T. (1984). A summary of preoperative and
postoperative cardiorespiratory performance in patients undergoing pectus excavatum
and carinatum repair. Journal of Pediatric Surgery, 19(4), 430-433.
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155. http://www.scielo.br/scielo.php?pid=s1806-37132007000400017&script=sci_arttext&tlng=en
156. http://www.scoi.com/anklanat.htm
157. http://www.sdspineinstitute.com/index.php/site/conditions/category/kyphosis
158. http://www.shopmedvet.com/product/hip-pillow-abduction-large-each/closeout-products-
closeout-orthopedic-products
159. http://www.shoulderandelbowcenter.com/sec_education_links.htm?education/arth.htm
160. http://www.shustuff.com/Catalogue.htm
161. http://www.spala.cos.pl/91,rehabilitation-and-health-care.html
162. http://www.spinecorscoliosisbrace.com
163. http://www.spineharmony.com/exercises
164. http://www.spineuniverse.com/conditions/osteoporosis/spinal-fractures-spondylolisthesis-
scoliosis
165. http://www.sports-injury-info.com/bankart-lesion.html
166. http://www.srs.org/professionals/glossary/SRS_revised_glossary_of_terms.htm
167. http://www.stetoskop.info/Povrede-ramena-4346-s13-content.htm
168. http://www.swiga.com/blog/catalog.asp?cate=19
169. http://www.terviseparadiis.ee/treatment___relaxationen/loogastused_raviden
170. http://www.thehealthybackblog.com/category/chiropractic/chiropractor/page/10
171. http://www.thermalon.com/article-12-arthritis-prevention.php
172. http://www.topnews.in/health/exercise
173. http://www.umm.edu/imagepages/19072.htm
174. http://www.umm.edu/imagepages/19689.htm
175. http://www.umm.edu/patiented/articles/how_scoliosis_diagnosed_000068_6.htm
176. http://www.umm.edu/patiented/articles/what_causes_pain_low_back_pain_or_sciatica_00
0054_2.htm
177. http://www.umm.edu/patiented/articles/what_symptoms_of_scoliosis_000068_5.htm
178. http://www.uni-kiel.de/orthop/kinder.html
179. http://www.uwhealth.org/healthfacts
180. http://www.wcbl.com/product-spotlight/pectus-carinatum-2
181. http://www.webbfitness.net/training-and-sports-medicine
182. http://www.webmd.com
183. http://www.webmd.com/back-pain/sleeping-positions-for-people-with-low-back-pain
184. http://www.wecreatewellness.com/services/chiropractic/education/scoliosis
185. http://www.wellsphere.com/back-neck-pain-article/cervical-brachial-syndrome-causes-
neck-and-arm-pain/901762
186. http://www.working-well.org/articles/bounce_ball.html
187. http://www.yelp.com/biz_photos/xOOu5krCPsBPTu79MvF9eA?select=2xgNiTCtCzf7c12NHF
Ag8g#2xgNiTCtCzf7c12NHFAg8g
188. http://www.yinovacenter.com/blog/archives/4582
189. http://www.youngwomenshealth.org/scoliosis-article.html
190. http://www.zimmer.co.uk/z/ctl/op/global/action/1/id/391/template/PC/navid/10892
191. http://www.zimmer.com/z/ctl/op/global/action/1/id/7753/template/IN
192. http://wyattfleming.hubpages.com/hub/Per-Henrik-Ling-10Z3H1
9
Key words for the electronic search of the whole handbook: kinesitherapy,
physiotherapy, flat feet, foot deformations, leg deformations, ankle, knee, shoulder,
rehabilitation, injury, the hip, lordotic poor posture, kyphotic poor posture, scoliosis,
thoracic deformities, low back pain, cervicobrachial syndrome, torticollis.
Glossary:
Acquired deformity – a physical abnormality gained during life.
Active joint stabilizers – contractile joint elements (muscles).
Antalgic position – a position assumed in order to avoid or lessen pain.
Bilateral – involving both parts of the body (eg. the right and the left arm).
Cervicobrachial syndrome - a nonspecific term describing some combination of pain,

numbness, weakness, and swelling in the region of the neck and shoulder. In the cervico-
cephalic syndrome symptoms are located in the neck and head. In the cervical syndrome
symptoms are present in the neck. In the cervicobrachial syndrome symptoms are located in
the neck and arm.
Compensatory movement – a reflex movement that maintains a particular body position.
Concave - hollowed inward, curving in.
Congenital deformity – a physical abnormality existing from birth.
Conservative therapy – rehabilitation treatment that does not involve surgery.
Convex – bulging outward, curving out.
Deformation – structural deformation. A structural (bone) deformation of the locomotor

system (eg. scoliosis, kiphosis...).
Disc prolapse – a discus herniation. Describes the rupture of annulus fibrosus and leakage of
nucleus pusposus.
Disc protrusion - a common form of spinal disc deterioration in which part of the spinal disc
bulges out, causing pain.
Dysplasia – abnormality of development (eg. deformation of joint surfaces).

10
EDF principle – a principle used in the therapy of scoliosis, meaning elongation, derotation
and flexion.
Etiology - the cause of a disease or abnormal condition.
Foot arches – tarsal and metatarsal bones held together by tendons and ligaments, and
supported by foot and lower leg muscles.
Functional rehabilitation – a rehabilitation protocol that focus on the restoration of the

injured patient to an optimal functional level in all areas of activity, from everyday basic to
sport-specific motor tasks.
Genua valga – a knee deformation involving medial convexity.
Genua vara – a knee deformation involving lateral convexity.
Hypoplasia – incomplete development of an organ or tissue (eg. insufficient development of

the joint surfaces).
Injury mechanism – describes the circumstance in which an injury occurs (eg. a sudden
deceleration, an unexpected landing, valgus knee position…).
Kinesitherapy - as an area of applied kinesiology and a clinical discipline, encompasses the

implementation of different exercise modalities for therapeutic aims. It is an
interdisciplinary field that combines medical and kinesiological knowledge.
Kyphosis – a structural deformation of the spine involving a posterior convexity, with the
trunk bend forward, and vertebrae deformation.
Kyphotic poor posture – a postural change of the spine involving a posterior convexity, with
the trunk bend forward. Usually describes an increase of the physiological thoracal kyphosis.
Leg deformation – a physical abnormality that include the knee, the distal part of the upper
and/or the proximal part of the lower leg.
Lordosis – a structural deformation of the spine involving an anterior convexity, and

vertebrae deformation.
Lordotic poor posture – a postural change of the spine involving an anterior convexity.
Usually describes an increase of the physiological lumbar lordosis.
Low back pain – a common disorder representing the symptom of pain or discomfort felt in
the back or buttocks.
11
Luxation - a joint injury where the bones of a joint move out of position.
Osteophytes – small lumps of extra bone present in a joints damaged by arthritis.
Overuse injury – a cumulative trauma that results from repetitive minor damages over the
course of time. Usually the exact time of the first micro trauma is not known (eg. stress
fracture, tendinitis…).
Passive joint stabilizers – non contractile joint elements (bones, ligaments, cartilage...).
Pectus carrinatum – a chest wall abnormality involving protrusion of the sternum and ribs.
Pectus excavatum – a chest wall abnormality involving a frontal concavity.
Physiotherapy - a field of physical medicine that uses different physical aids for therapeutic
issues.
Poor posture – a non structural change in an individual posture. It involves changes on soft
(muscle tissue).
Posture - describes an individual way of standing (upright posture) or sitting (sitting

posture). It also implies mechanisms involved in the compensation of postural
perturbations.
Sacroiliac pain – describing the pain int he sacrum region, eg. when an initial lumbar pain
radiates in the sacrum region.
Sciatica (sciatic nerve pain) – pain that involves the sciatic nerve and is felt in the lower
back, the gluteal region, the back of the thigh and may radiate to the foot.
Scoliosis – a structural deformation of the spine involving lateral flexion of the spine,
vertebrae deformation and rotation.
Scoliotic poor posture – a postural change involving trunk lateral flexion, without bone
deformation.
Sport rehabilitation – a treatment of an injury that happened through sport participation,

performed on professional athletes or amateur. Usually encompasses a wide range of
multidisciplinary treatment techniques aimed to return to pre-injury activities.
Syndrome - a collection of symptoms commonly seen together but for which there is no
known explanation.
12
Torticollis – a neck deformation involving head lateral flexion, chin rotation with head
slightly bent forward.
Traumatic injury - an acute damage of a body part produced by a sudden shock, like a
collision, a fall ecc. Usually the time of injury is well known (eg. joint dislocation, rupture of a
ligament...).
Unilateral – involving only one part of the body (eg. the right arm).
Wedged vertebra – a vertebra that is wedged on one side. Usually the wedged side is turn
toward the concavity.
13

Kines I Therapy

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Kines I Therapy

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Dubravka Ciliga

Tatjana Trošt Bobić

For the Publisher: Prof. Damir Knjaz, PhD, Dean

Prof. Branka Matković,Ph.D. University of Zagreb Faculty of Kinesiology

Prim. Senka Rendulić-Slivar, Ph.D., Special hospital for medical rehabilitation

Edition: 1st Internet edition

Date of publication on the internet: 17th January 2014

Copyright © 2013. University of Zagreb Faculty of Kinesiology. All rights reserved.

As an area of applied kinesiology and a clinical discipline, kinesitherapy encompasses the

2. THE HUMAN FOOT

5. ANKLE AND KNEE INJURY REHABILITATION

7. LORDOTHIC AND KIPHOTIC POOR POSTURE

10. LOW BACK PAIN

11. CERVICOBRACHIAL SYNDROME

13. SHOULDER INJURY REHABILITATION

1st chapter – Introduction to kinesitherapy

After attending the class and mastering this chapter

1st chapter – Introduction to kinesitherapy: definition

1.1 DEFINITION OF KINESITHERAPY

• Kinesitherapy is an interdisciplinary field that combines

1st chapter – Introduction to kinesitherapy: definition

• Kinesitherapy is a well-estabilished discipline in

1st chapter – Introduction to kinesitherapy: definition

IS THERE ANY DIFFERENCE ?

1st chapter – Introduction to kinesitherapy: history

1.2 HISTORY OF KINESITHERAPY

• China - 2700 BC – the book Kong-Fu – elements of

• The Chinese physician - Hua Tuo - medical Daoyin

• The Chinese believe that exercising is the most

1st chapter – Introduction to kinesitherapy: history

• In ancient India, yogis used at least 800

• In ancient Greece, Hippocrates and

Asklepios recommended exercise as a

• In ancient Rome, therapeutic exercise

1st chapter – Introduction to kinesitherapy: history

• Galen was a Roman physician for gladiators, often

1st chapter – Introduction to kinesitherapy: history

• Abu Ali Ibn Sina (Avicenna) in his books “Canon of

• Nikolas Andry, a French physician who published the

• In 1780. the published work of Tissot of France

1st chapter – Introduction to kinesitherapy: history

• Per Henrik Ling (1776 – 1839) was a Swedish http://wyattfleming.hubpages.co

physical therapist (Physiotherapist), developer

• Ling's system of medical gymnastics also

1st chapter – Introduction to kinesitherapy: the objective

1.3 THE OBJECTIVE OF KINESITHERAPY

• To improve health through different exercise

http://www.gazzetta.it/Fitness/Corpo_psiche http://kiransawhney.wordpress.com/ http://www.nba.com/features

1st chapter – Introduction to kinesitherapy: the objective

1st chapter – Introduction to kinesitherapy: operators

1.4 BASIC AND SECONDARY OPERATORS

1st chapter – Introduction to kinesitherapy: operators

1.4.2 SECONDARY OPERATORS

http://www.fitandtherapy.it/massaggio% http://www.fisiomedica.org/trattamenti http://www.medrehab.info/medical

1st chapter – Introduction to kinesitherapy: physiotherapy

• PHYSIOTHERAPY (PT) is a field of physical medicine

http://www.fisiomedica.org/trattamenti http://www.fisiomedica.org/trattamenti http://www.fisiomedica.org/trattamenti

1st chapter – Introduction to kinesitherapy: physiotherapy

• Hydrotherapy - use of water for treating

• Thermotherapy - the application of heat a.it/Mediacenter/FE

to the body. Peripheral (paraffin, mud,

1st chapter – Introduction to kinesitherapy: physiotherapy

• Phototherapy – or Light therapy