Key Point

• Massage therapy alone can’t fix bony misalignments, but it can help manage soft-tissue disorders and symptoms associated with valgus and varus alignments.

As massage therapists, we play a vital role in deciphering and addressing structural misalignments that deviate from the norm. Our approach often hinges on visual cues, relying heavily on visual assessment and postural evaluation to craft effective treatment strategies. Let’s explore valgus and varus alignment issues, posing questions about intervention and the massage therapist’s role in treatment.

Knowing the Difference

Clients with valgus or varus misalignments can present with discomfort, tension, or dysfunction in the affected area and its surroundings. While these structural issues might manifest as soft-tissue disorders or pain symptoms, their impact can vary widely. Some cases exhibit clear causation that can be addressed; others pose little to no immediate harm. 

It is our responsibility to discern whether addressing these postural challenges is beneficial. Sometimes, despite recognizing the misalignment, it might not warrant intervention if it’s not causing harm to the client. Understanding the biomechanical implications of these alignments isn’t just a professional duty—it’s a pathway to enhancing our clients’ overall well-being.

Definitions

The terms valgus and varus describe the angular deviation of a bony segment from the body’s midline. A valgus alignment is one in which the distal end of a bony segment deviates in a lateral direction (Image 1A). Conversely, a varus alignment describes one in which the distal end of a bony segment deviates in a medial direction (Image 1B). The bone structures to which the term is referring depends on the body region. Let’s look at some common areas affected by both valgus and varus alignments. 

The Knees

Valgus and varus angulations are common at the knee, with genu valgum (knock-knee) and genu varum (bowleg) seen frequently. However, it is easy to get confused with how these terms apply to the knee, so let’s look at them individually. 

Genu valgum is a postural alignment in which the knees appear to bend inward (Image 2). It might be unclear which bones we are referring to because one bone (the femur) has its distal end deviating in a medial direction, while another bone (the tibia) deviates in a lateral direction. The critical point to remember with knee alignment terms is that they are always named for the direction in which the tibia deviates. So, genu valgum refers to the valgus deviation of the tibia.  

Genu valgum may contribute to conditions such as patellofemoral pain syndrome, meniscal damage, or medial knee ligament sprains. Knee alignment problems may also result in issues farther up or down the kinetic chain. 

In genu varum, the knees appear to bend outward (Image 3). Opposite to what is happening in genu valgum, there is a valgus angulation of the femur and a varus angulation of the tibia. Once again, the varus angulation refers to the position of the tibia, not the femur. As with genu valgum, this postural alignment can stress the knee as well as structures and tissues above and below the knee in the kinetic chain. Genu varum is frequently associated with osteoarthritis, meniscal tears, or iliotibial band syndrome.

The Feet

Calcaneal valgus, a primary component of overpronation, is a complex structural alignment issue in which the distal end of the calcaneus (bottom of the heel) deviates in a lateral direction (Image 4A). A foot maintained in a calcaneal valgus position places increasing stress on the foot’s soft tissues and lower extremity. This stress can lead to disorders farther down the kinetic chain, including plantar fasciitis, Achilles tendinopathy, medial tibial stress syndrome (shin splints), and stress fractures.

Calcaneal valgus often results in the foot rolling inward during weight-bearing activities like walking or running. This excessive inward roll, known as overpronation, can cause the arch of the foot to collapse and the ankle to roll inward during the stance phase of gait (there are three main phases of gait: heel-strike, stance [or midstance], and push-off). Over time, this altered alignment can lead to muscle imbalances, overuse injuries, and painful conditions in the feet, ankles, knees, hips, and lower back.

Calcaneal varus, a less common structural alignment issue, involves the distal end of the calcaneus (bottom of the heel) deviating in a medial direction with the foot rolling to the outer edge (Image 4B). This alignment issue is often associated with excess supination, which is the opposite of overpronation. With excess supination, more weight is placed on the outer edge of the foot during the weight-bearing stance phase of gait. This stress can lead to various disorders, such as lateral ankle sprains, peroneal tendinopathy, iliotibial band syndrome, and stress fractures.

The Elbows

Cubital valgus and cubital varus are alignment issues affecting the elbow and forearm. Cubital valgus is characterized by an increased carrying angle, in which the forearm angles away from the body (deviating laterally relative to the upper arm, as seen in Image 5). This alignment can be associated with conditions such as epicondylitis, ulnar nerve entrapment, and ligament injuries at the elbow, especially in throwing athletes.

The increased carrying angle in cubital valgus places additional tensile loads on the medial structures of the elbow, including the flexor muscles and tendons. This stress can lead to irritation in the common flexor tendon, resulting in medial epicondylitis. Furthermore, the altered alignment may cause the ulnar nerve to stretch or become compressed as it passes through the cubital tunnel at the elbow, leading to ulnar nerve pathology.

Cubital varus, also known as “gunstock deformity,” features a decreased carrying angle, with the forearm deviating medially relative to the upper arm (Image 6). This alignment can result from improperly healed supracondylar humerus fractures, particularly in children. The altered biomechanics associated with cubital varus can lead to increased tensile load on the lateral tissues of the elbow. It can also be associated with epicondylitis, ligament injury, or ulnar nerve pathology.

What Causes These Alterations?

Valgus and varus misalignments can develop due to genetic predisposition, muscle imbalances, kinetic chain forces, and ligament laxity. Genetic predisposition may involve skeletal or morphological issues, such as structural variations in bone shape or joint angles, which can influence the alignment of the affected joints. Adapted body movement patterns that are environmentally influenced rather than genetically determined can also contribute to developing misalignments over time. 

Muscle imbalances play a significant role in valgus and varus alignments. Chronic tightness or overactivity in certain muscle groups and weakness or inhibition in their antagonists can lead to abnormal joint positioning and altered biomechanics. For example, in genu valgum (knock-knees), tightness in the adductor muscles and weakness in the abductors could contribute to postural changes.

Another essential factor to consider is how these alignment conditions affect the forces moving up or down the kinetic chain. Misalignments in one area of the body can have a ripple effect, causing compensatory changes and altered stresses in other regions. For example, excessive foot pronation can cause internal rotation of the tibia, leading to increased valgus stress at the knee joint, potentially contributing to conditions like patellofemoral pain syndrome.

Ligament laxity, as seen in various hypermobile conditions like Ehlers–Danlos syndrome, can also contribute to developing valgus and varus misalignments. Overly lax ligaments may fail to provide adequate joint stability, allowing for excessive movement and abnormal alignment of the affected joints.

Valgus and varus misalignments can have far-reaching effects on the body’s overall biomechanics. A misaligned joint alters the distribution of forces and stresses on the surrounding soft tissues, including muscles, tendons, and ligaments. These effects can then lead to overusing or underusing certain muscle groups, resulting in imbalances, weakness, or tightness.

Detrimental Effects of Valgus and Varus Alignments

Misalignments can also cause compensatory movement patterns as the body adapts to the altered joint positioning. While these compensatory patterns may initially serve as a coping mechanism to maintain function, they can lead to further imbalances and strain on other body regions over time. For example, an individual with genu varum may develop a more pronounced gait pattern, placing excessive stress on the medial compartment of the knee and potentially leading to conditions like medial knee osteoarthritis.

Tendinosis, bursitis, and myofascial tension patterns are among the most common soft-tissue disorders associated with valgus and varus alignments. Genu varum, for instance, can increase the risk of developing iliotibial band syndrome, a condition characterized by irritation of a fat pad on the lateral side of the knee. The varus alignment causes the iliotibial band to rub against the fat pad, leading to irritation and pain. Similarly, calcaneal valgus with overpronation can contribute to numerous foot disorders, such as plantar fasciitis, or adverse neural tension in the foot, like tarsal tunnel syndrome, Baxter’s neuropathy, or Morton’s neuroma. 

Altered alignments can increase susceptibility to ligament sprains and joint injuries, particularly in the knee and ankle joints. Valgus knee alignment increases tensile stress on the medial collateral ligament (MCL). This alignment can lead to MCL sprains or tears during activities involving rapid direction changes or landing from jumps. Similarly, calcaneal valgus alignment can increase the risk of lateral ankle ligament injuries due to the increased tensile load on the lateral aspect of the ankle.

Massage Therapy’s Role

Massage therapy can help manage numerous soft-tissue disorders and symptoms associated with valgus and varus alignments. However, practitioners must understand the limitations of soft-tissue therapy in affecting structural alignments and approach these conditions with realistic expectations. Current evidence does not support the idea that massage therapy can significantly change most bony alignment issues by moving bones back into a particular position.

A multidisciplinary approach results in the best outcomes for clients with these alignments. Massage therapy is most effective when focused on the neurological aspects of reducing muscular hypertonicity, enhancing proprioception, and restoring neuromuscular balance. Changing neuromuscular patterns is the most effective way for massage to impact these alignments. 

For clients with genu varum and iliotibial band syndrome, targeted massage techniques applied to the hip abductor muscles can help alleviate pain, reduce hypertonicity in the hip abductors, and improve biomechanical coordination through enhanced proprioception. Similarly, in clients with calcaneal valgus or varus, specific massage applied to the plantar fascia and intrinsic foot muscles reduces pain and improves function. These treatments can enhance biomechanics and mitigate detrimental impacts of valgus or varus alignment. 

Massage mainly addresses neurological patterns. It does not mechanically alter posture by changing the position of bones. Soft-tissue treatment results won’t last without repeatedly reinforcing improved motor patterns. Long-term postural changes happen through targeted movement corrections, often learned with physical therapists; Feldenkrais, Alexander, Pilates, and yoga instructors; and other movement and exercise specialists.

A Comprehensive Approach

For the client’s benefit, massage therapists should collaborate with other health-care professionals, such as physical therapists, orthopedic specialists, and podiatrists, to develop comprehensive treatment plans that address soft-tissue disorders and underlying alignment issues. Effective treatments may involve other solutions, such as orthotics. 

In addition to providing therapeutic interventions, massage therapists play a valuable role in educating clients about preventive strategies to minimize the impact of valgus and varus alignments on their soft tissues. If trained, massage therapists can offer suggestions for improved body mechanics, ergonomics, and self-care techniques for clients to incorporate into their daily routines. By empowering clients with knowledge and tools to manage their conditions, massage therapists help them actively participate in their health and well-being.

Massage is crucial in managing the associated soft-tissue disorders and symptoms of valgus and varus alignment issues. By providing targeted therapeutic interventions, collaborating with other health-care professionals, and educating clients on preventive strategies, massage therapists significantly contribute to managing these conditions and improving their clients’ quality of life.