Open Access Case

Report DOI: 10.7759/cureus.33907

Impact of Intensive Physiotherapy on an

Adolescent with Severe Genu Valgum
Received 10/07/2022
Deformities: A Case Report
Review began 11/02/2022
Review ended 01/11/2023 Ayush S. Agrawal 1 , Pratik Phansopkar 1
Published 01/18/2023

© Copyright 2023 1. Musculoskeletal Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Medical Sciences,
Agrawal et al. This is an open access article Wardha, IND
distributed under the terms of the Creative
Commons Attribution License CC-BY 4.0.,
Corresponding author: Ayush S. Agrawal, aayushagrawal1221@yahoo.com
which permits unrestricted use, distribution,
and reproduction in any medium, provided
the original author and source are credited.

Abstract
The genu valgum is one of the anomalies of the lower extremities in the coronal plane (knocked knees).
Children might be vulnerable to it as well. It may also be hereditary, with females being more likely to
develop it. A 14-year-old female patient had severe genu valgum anomalies of the bilateral lower
extremities. The patient is in pain, unable to stand, and sit on the ground. On the numerical pain rating
scale (NPRS), the level of pain was rated as 8/10 while activity and 5/10 during rest. The patient received
physiotherapy treatment for a total of six weeks, which included exercises, electrotherapy, and gait training.
As a result, the patient experienced a reduction in pain, which was rated 2/10 while activity and 1/10 during
rest, and an improvement in range of motion, and functional activities. Correcting the gait, enhancing the
quality of life, and restoring functional ability are all significantly impacted by physiotherapy. Based on the
current case study, conventional physical therapy improved functional goals gradually and significantly,
which in turn potentially aided in a successful recovery.

Categories: Physical Medicine & Rehabilitation, Orthopedics

Keywords: quality of life, electrotherapy, physiotherapy, gait training, genu valgum

Introduction
One of the biggest and most intricate joints in the human body is the knee. The knee connects the shin bone
(tibia) to the proximal end of the thigh bone (femur) [1]. Genu valgum is most usually noted as a knock-knee
[2]. Genu valgum is one of the lower extremity anomalies in the coronal plane (knocked knees) [3]. The most
prevalent cause of genu valgum is idiopathy. However, in developing and third-world countries, genu
valgum is common [1]. Rapid physical therapy results in the accomplishment of functional objectives. When
the legs are straightened, the knees in genu valgum (knock-knee) are bent toward the body's midline and
come into contact with one another [4]. Genu valgum is a cosmetic deformity that can also change gait by
repetitively contacting knees during jogging. It alters the Q angle and increases the risk of dislocation of the
patella. Weight-bearing moves to the medial side of the foot, producing the appearance of a flat foot and
necessitating regular footwear replacement [5]. In addition to being unable to walk or sit up, the patient had
been suffering from severe discomfort. Due to knee-knocking, lack of foot clearance, and pre-swing phase,
the gait pattern was impacted [6]. Early physical therapy results in the accomplishment of functional
objectives. In these situations, physiotherapy focuses primarily on correcting the malformation. For six
weeks, the patient underwent physiotherapy, which comprised exercises, electrotherapy, and gait training.
As a consequence, the patient's discomfort, range of motion, and functional activity improved.

Case Presentation
A 14-year-old female presented with severe genu valgum deformities of the bilateral lower extremities and
was associated with an uncoordinated gait. After consulting with an orthopedic surgeon, the patient was
managed with supracondylar osteotomy of the right femur with plate fixation three years back. In March
2022, the patient underwent other surgical treatment of the left lower limb managed by lateral wedge
osteotomy followed by hip spica cast application which was kept for 1.5 months. After that, the patient
started physiotherapy.

Radiological findings
On Inspection

After getting the full permission of the patient's parents, a thorough physical examination was performed
(Figure 1). The patient was examined in a supine and standing position. The attitude of patient was
apprehensive. The hip and knee joints were in a 70-degree flexion position. Diffuse swelling was seen over
the right knee joint. Skin appears tense and shiny. Healed surgical scars were extending from the distal thigh
centering over the patella seen in the previous surgery. Muscle wasting was seen over the right and left
thigh. On the numerical pain rating scale (NPRS), the intensity of pain was rated as 8/10 while exercising and

How to cite this article

Agrawal A S, Phansopkar P (January 18, 2023) Impact of Intensive Physiotherapy on an Adolescent with Severe Genu Valgum Deformities: A
Case Report. Cureus 15(1): e33907. DOI 10.7759/cureus.33907
 5/10 during rest.

FIGURE 1: Post-operative (32 days) radiological findings.

Box A shows the right knee; Box B shows the left knee.

On Palpation

On palpation, inspection findings were confirmed. The temperature was normal. Grade 2 tenderness was
present over the joint line. The patient is unable to extend her left leg. Dorsalis pedis and posterior tibial
artery pulsation were present. Soft tissue tightness in the muscles and ligaments in both upper limbs was
NIL. Severe posterior knee capsule tightness in the right knee was discovered during the lower limb soft
tissue tightness evaluation by actively performing a range of motion or giving resistance. By evaluating of
manual muscle testing, it shows restrictions of normal functional activity.

Manual Muscle Testing

Bilateral upper limb strength was assessed for muscular strength and found to be 4/5 on the standard
grading scale. On an Oxford grading system for muscular strength, the bilateral lower limb strength was
discovered to be 3+/5.

Range of Motion

Both upper limbs had a full and usable range of motion at the shoulder, elbow, wrist, hand, and fingers
(complete and pain-free). Tables 1, 2 show the pre- and post-rehabilitation range of motion for the lower
limbs.

2023 Agrawal et al. Cureus 15(1): e33907. DOI 10.7759/cureus.33907 2 of 5

 Joint Movement Right Left

Hip Flexion 0-110 0-100

Extension 0-15 0-10

Knee Flexion 0-110 0-125

Extension 110-0 110-0

Ankle Dorsiflexion 0-30 0-30

Plantarflexion 0-25 0-25

TABLE 1: Pre-rehabilitation range of motion

Joint Movement Right Left

Hip Flexion 0-130 0-130

Extension 0-15 0-12

Knee Flexion 0-130 0-135

Extension 130-0 135-0

Ankle Dorsiflexion 0-10 0-10

Plantarflexion 0-50 0-50

TABLE 2: Post-rehabilitation range of motion

Physical therapy management

We assessed the patient's strength, range of motion, tightness, and discomfort on the first day of treatment.
The patient received information about the surgical technique before therapy began. The patient has
emphasized the value of exercise for his speedy return to ADLs and improved rehabilitation. Gait training
was given to the patient and ergonomic advice was suggested which included posture correction. Table 3 has
further management.

2023 Agrawal et al. Cureus 15(1): e33907. DOI 10.7759/cureus.33907 3 of 5

 phase Physiotherapy regimen

Phase 1
To reduce pain -electrotherapeutic modality + Relaxation Training. To reduce inflammation-cryotherapy. To reduce
Immediate
swelling -speedy quadricep settings or electrical stimulation under pressure bandage with limb elevation; resistive ankle,
post-
foot movements, and SLR. To prevent reflex inhibition-sustain frequent isolated quadriceps setting withhold for 6-10
operative (3-
seconds. Supported relaxed knee passive swinging in a small range with the normal collateral leg.
5 days)

Phase 2
Gradual but definite progression of early measures in phase 1 along with Knee ratchet pedocycle or static exercise
Early healing
regimen, Weight transfers Supported or full weight-bearing ambulation Knee ROM should be around 120 degrees
(5-15 days)

Phase 3 Late Vigorous progressive resistive quadriceps exercise supported and guided functional positions. Floor squatting, cross leg-
healing (15- sitting, and prone heel sitting (kneeling). Standing on the affected leg alone, ambulation unsupported or with minimal
21 days) support, but no limp. Knee ROM should be around 120 degrees

Phase 4
High sitting, speedy isotonic full ROM, relaxed knee swinging. Progressive resistive quadriceps exercises. Balance
Conditioning
activities – proprioception. Gait training. Return to work
(3-5 weeks)

Phase 5
Functional
Spot running – by holding wall bars. Straight jogging. Straight running. Straight hopping. Agility drills (e.g. figure-of-eight
progression(6
running). Gradual return to sports
weeks
onwards)

TABLE 3: Physiotherapy management

SLR: Straight leg raise; ROM: Range of motion

Discussion
A common orthopedic condition in children is genu valgum [7]. The majority of these individuals come to
the hospital for a cosmetic issue. The majority of these patients with Physiological Genu Varum and
Physiological Genu Valgum progress through the typical developmental phases [6]. It can be genetic with a
higher incidence in females. Many surgeries have proven effective but are also associated with
physiotherapy management which deals with rehabilitation [8]. The standard treatment for these patients is
electrical modalities with cryotherapy, stretching, mobilization, strengthening, and open and close chain
exercises. Electrical modalities include interferential therapy, transcutaneous electrical nerve stimulation,
and ultrasound. Physiotherapy treatment goals depend upon the patient's primary problem and on deformity
correction. Various manual therapy techniques are also used for deformity correction, and strengthening is
given to a specific group of muscles to maintain muscle strength. While certain muscles seem to become
tighter, others deteriorate with time. So, the property of each muscle is identified and treated accordingly. It
helps significantly in pain management which leads to gaining confidence in patients. The main goal of the
physical therapy intervention was to improve the range of motion and keep the muscles strong and healthy
for walking. Cryotherapy has significantly reduced discomfort, encouraging patients to exert more
significant efforts [9]. Nutritional rickets and trauma are the primary causes of genu valgum deformity in
industrialized and developing nations [10]. An irregular gait, functional issues, early onset of arthritis,
anterior knee discomfort, patellar maltracking leading to patella-femoral dislocation, and trouble running
are all caused by persistent genu valgum [11]. Different distal femoral osteotomies have been documented in
the literature for the correction of valgus alignment in late adolescents and young adults. The purpose of
therapy is to restore proper limb alignment and stop further joint deterioration.

Conclusions
Early identification of the deformity and providing the correct management for the same is necessary.
Physiotherapy has a significant effect in correcting the gait and improving the quality of life and functional
ability. The above case report suggests that classic and prompt structural physical rehabilitation led to
improving the functional goals progressively and significantly which majorly leads to successful recovery.
The patient showed great cooperation during the intervention period and now the subject is able to walk
with the support of a walker. According to the case study, classic and speedy structural physical
rehabilitation improved gait and quality of life.

Additional Information
Disclosures

2023 Agrawal et al. Cureus 15(1): e33907. DOI 10.7759/cureus.33907 4 of 5

 Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In
compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services
info: All authors have declared that no financial support was received from any organization for the
submitted work. Financial relationships: All authors have declared that they have no financial
relationships at present or within the previous three years with any organizations that might have an
interest in the submitted work. Other relationships: All authors have declared that there are no other
relationships or activities that could appear to have influenced the submitted work.

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