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255 Cards in this Set
- Front
- Back
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multidisciplinary service delivery model definition |
Team members conduct separate assessments |
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transdisciplinary service delivery model definition |
Fewest number of service providers to improve the child’s abilities conduct the assessment together
Parents are equal team members |
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Therapist’s Role Prior to Orthopedic Surgery
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-Assist family with formulating questions and obtaining information/evidence about intervention -Communicate with physician (next slide) -Consider frequency and duration of therapy indicated pre and post surgery -Assess for and obtain any new or specialized equipment that will be needed -Educate child/family/caregivers (2 slides) -Plan for return to normal life activities ASAP -Keep in touch with family |
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Therapist’s Role Prior to Orthopedic Surgery- communicate with physician characteristics |
-Have an opinion -Empower family/caregiver –Attend appointments if possible and if family agrees –Send written reports if you cannot meet with physician (include present level, concerns, interventions, questions) –Ask for written reports for you and family/caregiver |
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Therapist’s Role Prior to Orthopedic Surgery- educate child/family/caregivers characteristics |
-Surgical procedure –Patient rights –Incision care –Cast care –Bracing –Positioning –Mobility limitations (transfers, walking, transportation) –Precautions/Contraindications |
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Lower Extremity Splints and Orthotics general characteristics |
-Evidence not sufficient to document with certainty the effectiveness of orthoses but literature is improving -Used to improve alignment and positioning -Used to prevent contracture or progression of contracture -Dynamic splints and night splints can be used for prolonged static stretch |
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advantages of splints fabricated by therapist |
Cost effective
Easy to modify
Good for trials |
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disadvantages of splints fabricated by therapist |
Sensitive to heat
Difficult to gain same amount of control as orthotics
Only recommend for children up to age 5, then orthotics |
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Orthotics fabricated by an orthotist advantages |
Strong material
Attain good control
Better for older children
Orthotist becomes team member for the child |
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Orthotics fabricated by an orthotist disadvantages |
more expensive
more difficult to make modifications |
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Serial casting often used to |
Often used to gain ROM and/or correct equinus deformity |
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Serial casting procedure characteristics |
-Precast measurements -Cast removed and replaced every 1-2 weeks -Continue until desired range is obtained, typically 4-6 weeks |
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serial casting procedure results characteristics |
-Results can last from 8 weeks to 12-18 months -Difficult to maintain results with muscle imbalance and growth –Splinting/orthoses can be used for maintenance |
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Factors that can contribute to prenatal boney deformity |
-Limited space for fetus to move, including pregnancies with multiples -Decreased amniotic fluid -External forces from tightly stretched uterine and abdominal walls |
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Forces that influence bone development in young children |
-Compressive forces: weight bearing and muscle pulls -Asymmetrical forces can result in asymmetrical growth at the epiphyseal plate –Shear forces: muscle pulls -Results in torsional or twisting forces in bones |
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Lower Extremity Bone Development: Hip characteristics |
-Normal compressive forces help form the acetabulum and femoral head/neck to create stable hip joint -Muscle pulls- Active pull of the muscles while the infant and child are moving influences bony development –Abnormal muscle pull or bony torsion |
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Lower Extremity Bone Development: Hip clinical tests and measures |
-Craig’s test –Hip joint ROM –Positional or surgical depending on problem and level of function |
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Developmental Dysplasia of the Hip (DDH) definition |
Abnormal development of the hip, can result in subluxation or dislocation –Incidence 1 in 100 (subluxation) –Incidence 1 in 1000 (dislocation)
DDH can occur in utero or after birth |
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Developmental Dysplasia of the Hip (DDH) mechanical factors |
-Small intrauterine space –Breech presentation –Fetal hip positioned against mother’s sacrum |
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Developmental Dysplasia of the Hip (DDH) physiologic factors |
-Maternal hormonal influence of estrogen and relaxin on female infant’s ligaments –6:1 female to male incidence of DDH |
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Developmental Dysplasia of the Hip (DDH) environmental factors |
Children routinely kept in lower extremity extension have higher incidence of DDH than those in abduction and flexionq |
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Clinical Examination of DDH characteristics |
-Significant limitation of hip abduction with flexion (typical is 75-90 degrees) or asymmetry of ROM of 5-10 degrees –Hip abduction is the most reliable clinical finding in older infants (>1-3 months) & toddlers -Asymmetric thigh folds -Pistoning -Apparent femoral shortening with uneven knee heights -Hip stability testing for infants up to 3 months -Ultrasound imagery -positive ortolani's sign |
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barlows maneuver demonstrates an |
Demonstrates an unstable or dislocated hip |
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ortoloni's maneuver reduces a |
Reduces a dislocated hip |
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Ultrasound Imagery of Infant Hip |
-Shows cartilaginous portions of hip that are not visible on radiographs -Radiographs not helpful until 5-6 months of age -No radiation risk to baby |
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DDH Intervention- Pavlik harness characteristics |
-Soft Dynamic Brace- design is to tighten up ligaments and promote a deeper acetabulum –Birth to 9 months –Typically used 6-8 weeks –Typically worn 24 hours/day –Excellent prognosis- 90- 95% success with subluxation -85% success with dislocation |
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DDH Intervention- abduction orthoses designed for walking characteristics |
-Infants 9 months and older who are beginning to walk
-For dysplasia with or without subluxation |
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Surgical Intervention to Correct Hip Subluxation or Dislocation- when to use what |
-6-18 months old with dislocatable or dislocated hips open reduction is usually required
-18-24 months old open or closed reduction possible
-24 months and older open reduction required |
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Surgical Intervention to Correct Hip Subluxation or Dislocation types of surgical procedures |
Femoral varus rotational osteotomy (VRO)
Acetabuloplasty
Innominate (pelvic) osteotomy
Femoral head resection |
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Innominate Osteoplasty characteristics |
-Typically acetabulum face is too shallow and often faces too outward -Pelvis cut and rotated downward around the pubic symphysis -wedge of bone from innominate locks it in. -Doesn't change the shallowness (acetabuloplasty does that) -If spastic muscle is the cause (i.e.,iliopsoas) then it is lengthened |
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Femoral Varus Rotational Osteotomy (VRO) and Acetabuloplasty characteristics |
-Usually VROs are not to undo excess valgus, but to offset less vertically stable sockets. -Most commonly done to correct excessive femoral antetorsion (toeing in) –Unfortunately it typicallymakes the leg shorter and causes odd posturing of the LE in standing and sitting |
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Post Operative Care for DDH if casted characteristics |
-Hip spica cast or long leg casts with ABD bar –Address joints that aren’t casted –Monitor skin integrity and cast condition –Address hip and knee ROM as soon as cast is removed –Increase weight bearing as tolerated |
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Post Operative Care for DDH if not casted characteristics |
-Abduction wedge or hip abduction orthosis –Check ROM but do not adduct past neutral for 3+ weeks –Work on active motion and weight bearing as allowed by physician |
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Lower Extremity Bone Development: Knee typical development characteristics |
-Birth: genu varum normal in newborns and non-walking infants –1-2 years old: reach neutral alignment –2-4 years old: progress toward genu valgum (compensate with intoeing) –By 11 years old: genu valgum has decreased to an average of 5-6 degrees |
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Genu Varum & Genu Valgum of knee- intervention if problematic |
-Check for internal tibial torsion, hip angle/ROM, foot progression angle –Controversial tx: no treatment, splints/night wear, surgery if no improvement and significant |
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pathologic knee genu varum treatment characteristics |
May require HKAFO or KAFO
Surgical correction rare |
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pathologic knee genu valgus treatment characteristics |
if severe, surgical correction needed |
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Rickets characteristics |
-Severe genu varum -Vitamin D deficiency leading to soft bones -Rule out if genu varum is present after age 4 or if worsening over time -Often seen in malnourished children |
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Leg Length Inequality definition |
2.5 cm or greater difference in leg length |
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leg length inequality in children characteristics |
-trauma –congenital –neuromuscular –acquired diseases –infections causing physeal growth arrest –tumors –vascular disorders |
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Leg length inequality treatment characteristics |
Conservative treatment: observation and/or shoe lift
Surgical treatment: lengthening short bone and/or shortening long bone
PT following limb lengthening (see next slide)
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Leg length inequality treatment- PT following limb lengthening characteristics |
-Active assistive and isometric strengthening –Positioning –Functional activities training –Weight bearing and gait training –Pin care |
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Lower Extremity Bone Development: Foot influenced by |
Development of bones in foot is influenced by compressive forces (weight bearing) and muscle pulls |
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Flexible Flat Feet in children characteristics |
-Longitudinal arch disappears with weight bearing but is present in sitting and walking on toes -Caused by normal ligamentous laxity Children under 2 may appear to have flat feet due to plantar fat pad in medial foot that masks longitudinal arch -Children typically have rapid spontaneous longitudinal archdevelopment between 2-6 years of age |
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Flexible Flat Feet in children intervention characteristics |
-No intervention recommended for flat feet if they are not symptomatic –Shoes with good arch support will not correct flat feet but can reduce wear on shoes -Typically developing children should wear soft shoes when learning to walk |
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alipes Equinovarus (TEV) (AKA Clubfoot) characteristics |
-Forefoot curved medially, hindfoot in varus, equinus of the ankle, small calcaneus -Congenital clubfoot caused by restricted positioning in utero -Genetic influence is suggested -Bilateral in half of the cases -Often associated with myelomeningocele or arthrogryposis |
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alipes Equinovarus (TEV) (AKA Clubfoot) non-surgical interventions |
Non-invasive manipulation and serial casting •Most effective immediately after birth and in extrinsic (supple) clubfoot •When serial casting, first correct cavus then equinus •Often followed by surgery between 3-12 months |
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alipes Equinovarus (TEV) (AKA Clubfoot) surgical interventions |
Often needed for intrinsic (rigid) clubfoot
Usually follows manipulation and casting regimen
Soft tissue surgery- cast in best position following surgery and then serial cast if needed
Bony surgery of foot and ankle |
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Idiopathic Toe Walking characteristics |
-Variable degree of heel cord contracture in a child without history of prematurity, difficult delivery, cerebral palsy or other neurologic condition -Preferentially walk with toe-toe pattern but may heel-toe walk at times -Family history of toe walking possible -Speech or language deficits possible |
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idiopathic toe walking interventions |
-Passive and active triceps surae ROM –Ankle DF strengthening –Carbon fiber shoe inserts –Shoe wedge –Heel strike feedback (squeaky shoes) –Bracing -articulated AFO, night splints –Serial casting –Surgical release -risk of overlengthening |
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Congenital Muscular Torticollis (CMT) caused by a shortening of |
the SCM |
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CMT characteristics |
-SCM rotates head to opposite side and laterally flexes to same side -Named according to the side of the involved SCM. -Often seen with other conditions including hip instability (DDH), plagiocephaly, scoliosis and foot deformities. -Righting reaction delay |
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Increased incidence of CMT since what campaign? |
1992 "Back to sleep campaign"
1992 Bush-Clinton presidential campaigns? |
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4 subtypes of CMT |
-Sternomastoidtumor •Palpable mass, Radiographs normal –Muscular torticollis •Tightness, No tumor, Radiographs normal –Postural torticollis •No tightness, No tumor, Radiographs normal –Postnatal muscular torticollis •Environmental-induced •Plagiocephaly-induced •Positional preference-induced |
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CMT risk factors |
-Large birth weight •Male •1stborn •Breech position •Nuchal cord •Multiple births •Vacuum or forceps used during delivery •Maternal uterine abnormalities |
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CMT muscular causes |
-Birth trauma •Fetal malposition •Uterine compression •Inflammatory conditions •Palpable lump or pseuodotumor in SCM muscle in slightly more than 1/3 of cases (fibrous tumor) |
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CMT non-muscular causes |
-Cervical skeletal malformation •Subluxation of cervical vertebrae •Herniated disk •Ocular strabismus or nystagmus •Extra ocular muscle paresis •Gastroesophygeal reflux •Clavicle fracture and brachial plexus injury from difficult delivery |
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CMT infant activity limitations |
-Asymmetry of early reflexes –Neglect of ipsilateral hand and visual field –Delayed righting reactions –Limited vestibular, proprioceptive & sensorimotor development |
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CMT older child activity limitations |
–Asymmetric weight bearing in •Sitting, Crawling, Walking, Transitional movements –Incomplete development of automatic postural reactions –Increased compensatory strategies |
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CMT assessment components |
-History •Range of motion •Muscle tone assessment and palpation of SCM •Hip asymmetry •Facial asymmetry and plagiocephaly •Gross and fine motor development •Positioning and daily routine |
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Most effective type of treatment for CMT berfore year one? |
convervative treatment |
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intervention for CMT |
Work with family to create a home program
Tubular Orthosis for Torticolis (TOT Collar)
Surgery reserved for significant torticollis |
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intervention for CMT- Work with family to create a home program characteristics |
-Active and passive range of motion activities –Positioning program –Play activities that promote motor development and symmetry of movement –Keep simple, comfortable for child, and part of daily routine |
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intervention for CMT- Tubular Orthosis for Torticolis (TOT Collar) characteristics |
-Provides noxious stimulus to side of head to encourage neutral alignment –Used on children 4 months and older with head control –Not to be used when sleeping or in car seat |
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intervention for CMT- Surgery reserved for significant torticollis- when necessary? |
ROM deficit greater than 15°
No improvement after 6 months of conservative intervention |
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CMT Asymmetry of Craniofacial Features characteristics |
Skeletal –Masticatory & tongue muscles –Dental issues –Inferior and Posteriorly positioned ear, may be cupped –Occular –ipsilateral eye smaller –Chin deviation –Skull malformations |
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Plagiocephaly characteristics |
-Cranial asymmetry •80-90% of cases also have CMT diagnosis •Incidence has increased due to fear from SIDS and Back to Sleep Campaign (BSC) (incidence 1 in 300 prior to BSC; 1 in 60 after BSC) |
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Plagiocephaly interventions characteristics |
-Caregiver education •Can be treated conservatively with cranial orthosis from 3 months to 11 months of age –After 5-6 months of age, unlikely to resolve without orthosis use •May require surgical intervention if severe or not treated before 1 year of age –80% of skull growth prior to 1 year |
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Arthrogryposis Multiplex Congenita definition |
Non-progressive neuromuscular syndrome
1 in 3000 |
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Arthrogryposis Multiplex Congenita characteristics |
Severe joint contractures, Muscle weakness, Fibrosis
Weakness limits fetal movement causing joint contractures at birth
Children with AMC are typically very bright
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Arthrogryposis Multiplex Congenita different forms |
Anterior horn disorder, fibrous and fatty tissue replaces normal muscle development |
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Arthrogryposis Multiplex Congenita surgical intervention characteristics |
DDH, clubfoot, knee, elbow, wrist |
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Arthrogryposis Multiplex Congenita PT interventions characteristics |
Stretching •3-5 times per day •Daily lifelong commitment •Most critical in first 2 years and during growth spurts –Positioning –Strengthening through play/fxl activities –Bracing •Hip, knee, ankle/foot, elbow, wrist cock-up •Proper fit imperative to provide stretch and impede progression –Functional mobility •Gait trainers, walkers, crutches for household mobility •Power wheelchair for efficient community mobility –Assistive technology |
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Osteogenesis Imperfecta definition |
Inherited disorder that causes weak muscles, lax joints and diffuse osteoporosis with recurring fractures
Most children with OI have average to above avg intelligence but are overprotected due to recurring fractures |
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Osteogenesis Imperfecta 4 distinct types |
-Type I: generalized osteoporosis, joint hyperlaxity, hearing loss –Type II: often still born, extreme bone fragility, small bodies and short, curved limbs –Type III: severe, progressive deformity of long bones, skull and spine, hearing loss common, death occurs in childhood –Type IV: mild to moderate deformity, short stature, hearing loss variable, bone fragility varies, excellent prognosis for ambulation |
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Osteogenesis Imperfecta medical intervention |
-Surgical intervention to fix fractures or correct scoliosis
–Intravenous Pamidronate for improved bone density |
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Osteogenesis Imperfecta PT assessment |
History-be aware of past and present fractures –PROM contraindicated; assess AROM and/or functional ROM only –MMT contraindicated; assess strength through observing functional movement –Assess equipment for positioning, seating, transportation, mobility |
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Osteogenesis Imperfecta PT interventions |
-Parent and child education –Positioning -bracing -weight bearing -Strengthening and endurance through age appropriate, enjoyable activities –Assistive Technology (power mobility)
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Osteogenesis Imperfecta PT intervention- parent and child education characteristics |
Early parent education in handling and positioning (bathing, dressing, carrying, diapering, transporting, sleeping)
Foster independence and responsibility for health as child grows up |
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Osteogenesis Imperfecta PT intervention- positioning characteristics |
-change frequently •Allow for freedom of active movement •Comfortable play positions that promote development •NOT okay to put padding behind child in car seat; can use towel rolls at side of head or trunk |
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Osteogenesis Imperfecta PT intervention- bracing characteristics |
Used to reduce stress on osteoporotic bony deformities
Often introduced with standing activities |
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Osteogenesis Imperfecta PT interventions- weight bearing characteristics |
-Stress on bones through weight bearing is advocated •Emphasize protected weight bearing and independent mobility in preschool age children •Aquatic therapy appropriate; use splints to protect recovering fractures while in pool •Standing frame |
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Juvenile Idiopathic Arthritis characteristics |
-Autoimmune disorder that causes swelling of joint along with heat, limited motion, and/or pain with motion that lasts for more than 6 weeks •Onset prior to age 16 •Can lead to joint contractures, weakness, postural deviations and pain •Formerly called Juvenile Rheumatoid Arthritis. •New name includes juvenile psoriatic arthritis and juvenile ankylosing spondylitis as well |
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Juvenile Idiopathic Arthritis pharmaceutical interventions |
Goal to control arthritis to prevent joint erosion and extra-articular manifestations
NSAIDS, methotrexate, biologicals, glucocorticoids |
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Juvenile Idiopathic Arthritis surgical interventions characteristics |
Used if conservative treatment fails
Soft tissue release, synovectomy, osteotomy, growth plate stapling, total joint replacement |
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Juvenile Idiopathic Arthritis PT evaluation components |
-Stage of disease and joints currently active –Morning stiffness –AROM, PROM –Strength –Gait –Gross and fine motor –ADLs and school function –Pain behaviors |
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Juvenile Idiopathic Arthritis PT interventions |
-ROM ex's -Splinting -Strengthening -postural concerns -mobility -ADLs -Education |
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Juvenile Idiopathic Arthritis PT interventions ROM ex's characteristics |
Daily AROM very important for all joints
Avoid PROM in acutely inflamed or unstable joints; PROM indicated for contracture if at least partially muscular in nature and joint is not inflamed |
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Juvenile Idiopathic Arthritis PT interventions splinting characteristics |
Dynamic splinting may help reduce flexion contractures
Serial casting also an option |
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Juvenile Idiopathic Arthritis PT interventions strengthening characteristics |
Weakness from muscle disuse common •Concentric and eccentric exercises appropriate if tolerated. Use isometric exercises if child has pain with motion. •Resistance should be limited to less than a few pounds. Elastic bands are appropriate •Age appropriate play activities (ex. bike riding, swimming, cycling) •Contraindications: upper extremity weight bearing, tumbling, contact sports, high impact activities (ex. jogging) |
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Juvenile Idiopathic Arthritis PT interventions postural concerns characteristics |
Leg length discrepancy
Scoliosis, kyphosis, cervical lordosis, torticollis |
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Juvenile Idiopathic Arthritis PT interventions mobility characteristics |
-Comfortable and supportive foot wear important •AFOs may be helpful for ankle pain with weight bearing •Small percentage of children need assistive device for ambulation •Manual or power wheelchair may be needed for community mobility |
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Juvenile Idiopathic Arthritis PT interventions education characteristics |
Joint conservation-use bigger joints and protect smaller joints
Environmental modifications |
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idiopathic scoliosis characteristics |
unknown cause
Most common form of scoliosis
Can occur at any age in childhood |
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congenital scoliosis characteristics |
-Caused by anomalous vertebral development
–Environmental factors affect spinal development at 45-60 days after fertilization
–Often becomes stable and does not progress |
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nonsurgical treatment of scoliosis when |
Curves less than 25 degrees, nonsurgical curves in skeletally mature patients, and nonprogressive congenital curves should be monitored every 4-6 months |
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nonsurgical treatment of scoliosis components |
-Home exercise program for trunk and pelvic strength and flexibility -electrical stimulation -orthotic management |
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nonsurgical treatment of scoliosis- Home exercise program for trunk and pelvic strength and flexibility characteristics |
•Strengthen convex side & stretch concave side •Asymmetric exercise used to promote symmetry •Respiratory exercises •Maintain core strength during bracing •Not effective as sole treatment; may reduce progression |
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nonsurgical treatment of scoliosis electrical stimulation characteristics |
Controversial treatment, recent evidence shows no effect •Used on skeletally immature patients with 10-40 degree curves •Worn overnight until growth ceases |
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nonsurgical treatment of scoliosis orthotic management characteristics |
•Goal of use is to halt progression and gain correction •Indicated for children with idiopathic scoliosis with a curve of 30-40 degrees or a progressing curve of 20-29 degrees. Curve must be flexible and patient must be compliant with use. •Orthosis is typically used until curve is 40 degrees or more, curve progression persists or skeletal maturity is reached. Patient must be weaned of orthosis at skeletal maturity over 12 month period. |
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congenital and idiopathic scoliosis surgical intervention characteristics |
–Surgery indicated for progressive idiopathic curve of 45 degrees or greater –Goal is to halt progression and attain maximal correction in all three planes to avoid pain and pulmonary dysfunction –Posterior spinal fusion with instrumentation is current gold standard –Bone grafts and hardware (rods, screws, etc.)used for fixation |
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congenital and idiopathic scoliosis post-surgical interventions |
–5-7 day hospital stay, 2 weeks of limited activity, 4-6 weeksreturn to school, 3 months light activity (bicycling,swimming, driving), 6 months non contact sports, 1 year return to normal activity –Orthotic use after surgery depends on surgical method, stability and position of curve, and physician –Physical therapy |
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congenital and idiopathic scoliosis post-surgical interventions- PT characteristics |
•Trunk rotation contraindicated •Patient education/training on log rolling, bed mobility, transitions, ambulation, dressing (in tailor sitting), orthotic wear •General ROM and strengthening exercises without resistance for extremities -Incision care |
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osteosarcoma characteristics |
•A primary malignant tumor of bone •Represents 50% of bone cancers in children in the U.S. •Peak incidence with pubertal growth •Most frequently at metaphyseal portion of the most rapidly growing bones in adolescents (distal femur, proximal tibia, proximal humerus) |
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osteosarcoma S&S |
•Initial complaint is pain at site of tumor with or without a palpable mass or decreased ROM •Systemic symptoms rare unless metastatic •Symptoms present an average of 3 months before diagnosis •Diagnosed by radiologic evaluation •If child complains of pain that is often chronic with no history of injury or evidence of musculoskeletal abnormality, refer to physician to rule out bone tumor |
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osteosarcoma medical treatment components |
Medical treatment includes chemotherapy and surgery (limb sparing, amputation, rotationplasty) |
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osteosarcoma PT characteristics |
–Prevent secondary complications of cancer and medical treatment –Wound healing –Promote health, wellness, fitness, normal development and functional mobility –Use of prosthesis, assistive technology |
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Transient Synovitis characteristics |
•Most common cause of hip pain in children under 10 years •Affects males more than females, 4:1 •Gradual or acute onset of limp •Pain in hip or knee (referred) •Cause unclear but often follows an upper respiratory infection or other illness |
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Transient Synovitis treatment |
–Limit activities –Bed rest –Limit weight bearing by using crutches if child is old enough –NSAIDS for pain management –Symptoms usually resolve in about 7 days |
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Legg-Calvé-Perthes Disease characteristics |
•Avascular necrosis of the femoral head caused by loss of blood supply. Cause of blood supply loss is unknown but often follows repeated episodes of transient synovitis of the hip •Occurs in children ages 3-12 and is most common inboys ages 5-7 •Children are typically small for their age, very active and have a high incidence of learning disability •Bilateral in 20% of cases |
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Legg-Calvé-Perthes Disease assessment |
–Tend to limp and often have a positive Trendelenberg sign from pain or weakness –Limited ROM especially with hip abduction and internal rotation –Complain of pain in groin, hip, or knee (referred) –Muscle spasms common in early stages -confirmed ragiographically |
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Legg-Calvé-Perthes Disease treatment |
–self limiting and heals spontaneously in 1-3 years –Controversy on what, if any, treatment is needed –Treatment goal is to maintain femoral head shape and containment of femoral head in acetabulum (ROM exercises, Long leg casts with abduction bar or abduction orthosis, education to protect hip, Surgery-VDRO, pelvic osteotomy) |
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Slipped Capital Femoral Epiphysis definition |
Growth plate of proximal femoral physis is weak and becomes displaced from normal position |
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Slipped Capital Femoral Epiphysis acute subtype |
Acute: significant trauma causes immediate severe pain and restricted hip abduction and internal rotation |
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Slipped Capital Femoral Epiphysis acute-on-chronic subtype |
aching of hip, thigh or knee for weeks or months from chronic slip and then a trauma causes greater displacement and acute symptoms |
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Slipped Capital Femoral Epiphysis chronic subtype |
most common form; child has limp and pain for weeks or months and loss of hip motion |
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Slipped Capital Femoral Epiphysis cause and incidence characteristics |
•Cause is unclear but seems to be related to a generalized metabolic disorder of puberty •Typical age range is 10-15 years old •African Americans more frequently affected than Caucasians; males more than females; obesity reported in as many as 75% |
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Slipped Capital Femoral Epiphysis assessment |
–Child usually limps and complains of pain in groin often referred to anteromedial aspect of thigh and knee –Leg held in external rotation in both standing and supine –Decrease hip motion noted in flexion, abduction, and internal rotation –Attempts at active hip flexion results in external rotation –“Frog” position radiographs |
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Slipped Capital Femoral Epiphysis Treatment |
–Goal is to keep displacement to a minimum, maintain motion, and delay or prevent premature degenerative arthritis –Surgical fixation used to secure growth plate; refer to orthopedic surgeon if SCFE suspected •Typically NWB or PWB after surgery until growth plate is fused (3-4 months). –Most children with SCFE develop degenerative changes later in life |
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Osgood-Schlatter Syndrome characteristics |
•Activity related pain and swelling at the insertion of patellar tendon on tibial tubercle •Seen in children 11-18 years of age •More common in boys •Typically unilateral •Associated with patella alta •Child may have acute severe pain with limp or low grade discomfort over period of months brought on by sports •Reproducible pain with resisted knee extension |
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Osgood-Schlatter Syndrome treatment characteristics |
–Ice and rest –Decrease activity –Avoid squatting and jumping –Neoprene knee brace or knee strap may be helpful –Stretching hamstrings and quadriceps -Condition is self limiting and resolves when tubercle fuses to tibia (around age 15) |
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Pediatric sports injuries prevention characteristics |
–Children need proper strength, conditioning, and flexibility to safely participate in organized sports –Preparticipation examination to determine health, appropriate sports, and educate athlete –Training program to address athlete concerns as they relate to the sport –Appropriate supervision-coach, officials, medical personnel –Protection-proper equipment |
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pediatric sports injuries- lumbar spine |
Stress fractures from repeated flexion/extension |
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pediatric sports injuries- shoulder |
–Acromioclavicular sprains –Clavicle fractures –Proximal humerus fractures (more common in children than adults) –Rotator cuff impingement (tears less common in children) |
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pediatric sports injuries- elbow |
–Supracondylar fracture of humerus –Dislocation –Little league elbow and tennis elbow |
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pediatric sports injuries- wrist and hand |
–Fractures more common than dislocations
–Dorsal dislocation of thumb MCP joint is most common dislocation |
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pediatric sports injuries- pelvis and hip |
–High risk of hip injury due to ossification late in childhood –Fractures rare; overuse injuries more common –Avascular necrosis •Seen in 5-12 year olds, serious condition •Nonspecific hip pain, bracing or surgery may be required |
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pediatric sports injuries- knee |
–Most ACL tears in preteens are actually avulsion fractures at tibial insertion –Meniscal injury –Patellar mechanism disorders common •Osgood-Schlatter Syndrome |
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pediatric sports injuries- ankle and foot |
–Distal tibial and fibular growth plate injuries common
–Epiphyseal fractures more common than ankle sprains in young athletes |
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Amount of compressive forces at the hip produced by muscle activity during stance phase in normal walking speed |
300-400% of BW |
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Amount of compressive forces at the hip produced by muscle activity during stance phase during fast walking or jogging |
550% of BW |
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Amount of compressive forces at the hip produced by muscle activity during stance phase during a stumble |
870%
If you've been drinking, studies estimate closer to 967% |
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Femoral Head Deformation (aka CAM) characteristics |
-Abnormality at the level of the anterior femoral head, or the head-neck jxn, resulting in a non-spherical head and increased femoral neck/head-acetabular rim contact. •More common in young athletic men. •Cartilaginous lesions form along either the postero-inferior or superior aspects of the acetabulum, causing stiffness and limiting the range of motion -bony end-feel |
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Femoral Head Deformation (aka CAM) limitations |
There is limitation of flexion, adduction, and characteristically limited INTERNAL ROTATION, with a hard end-feel. •Fabere’s test is extremely limited and produces anterior groin pain |
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Acetabulum deformation (aka PINCER) characteristics |
-acetabulum gives increased coverage of the femoral head-femoral neck junction. •More common in middle-aged athletic women. •Limited range of motion of the hip, particularly EXTERNAL ROTATION of the flexed hip with a bony end-feel is characteristic. •The Fabere sign is strongly positive |
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Mixed Femoral and Acetabular Deformation characteristics |
•Nearly 90% of people who have Femeroacetabular Impingement Syndrome have the mixed form. •Both internal and external rotation are limited, with a bony end-feel. •Always with the characteristic sign: BONE ON BONE, HARD END-FEEL. -quite unexpected in the young person, and the arthritis associated with hard end-feel that we would expect to find simply isn't seen on x-ray |
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ortolani's maneuver characteristics |
only valid for the first few weeks after birth
Used to detect a hip that is dislocated but reducible |
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ortolani's maneuver steps |
•Relax the infant and place her in supine •Gently grasp the femur and flex the hips and knees to 90 degrees •Apply gentle flexion, abduction,and slight traction •A positive sign is a palpable clunk, indicating that the hip has moved back into the acetabulum •Restriction of abduction may indicate an irreducible dislocation |
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Barlow's maneuver characteristics |
•Assesses for a hip joint that is reduced but dislocatable •Often used with older children, primarily those with developmental disabilities •Hip instability is demonstrated by attempting to gently displace the hip out of the posterior acetabular rim |
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Barlow's maneuver steps |
•Relax the child and place him in supine •Gently flex and abduct the hip •Gently adduct the hip while applying pressure in a posterior direction •Palpate for movement of the femoral head out of the socket of the acetabulum •If the head of the femur subluxes, applying gentle traction while abducting the hip should provide reduction of the hip |
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stiffness definition |
The resistance present during the passive elongation of muscle and connective tissue
less flexible
muscles with greater stiffness develop more titin bridges that make it more difficult for muscle fibrils to slide along one another |
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"stiff" muscles clinical treatment |
Movement re-education/accurate strengthening of key muscle(s), manual therapy/TPDN, and stretching are clinically beneficial |
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The Integral Relationship of the Lumbar Spine, Pelvis, and Hip characteristics |
•Less motion at the hip likely translates to more motion at the lumbar spine, and vice- versa
•pelvis should provide a stable base from which the muscles affecting the hip can work (ie: abdominals and back extensors should stabilize the pelvis to allow femoral motion)
ASIS’s and PSIS’s remain in neutral position with active and passive leg movement
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single limb squat characteristics |
abdominals and back extensors must stabilize pelvis (ie: keep ASIS’s in same plane, avoid “pelvic drop”) for appropriate action of the gluteus medius and maximus |
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Supine hip flexion characteristics |
-performing a heel slide with foot on surface, progressing to foot off the surface and flexing hip and knee -Assess ASIS’s and the ability of the abdominals to keep them in the same plane to allow appropriate action of the hip and knee flexors. -Typically the heel slide is harder than foot off surface to maintain pelvic stability |
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supine lateral rotation characteristics |
-also known as a “bent knee fall-out” : the oblique abdominals must control the pelvis (keep ASIS’s in same plane) as the gluteus medius and/or TFL eccentrially allow the leg to fall out into lateral rotation |
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sidelying hip abduction characteristics |
-active hip abduction: lateral oblique abdominals and lateral back extensors (possibly including latissimis) should stabilize pelvis to allow gluteus medius to perform the motion -should be an isometric action of the obliques and lateral back extensors (keeping ASIS’s and PSIS’s in same plane) as opposed to a concentric action (which would produce elevation of the pelvis/ilial hiking) |
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Sidelying hip lateral rotation characteristics |
-“clam” movement: lateral oblique abdominals and lateral back extensors (possibly including latissimis) should stabilize pelvis (ASIS’s and PSIS’s stay in same/neutral plane) to allow gluteus maximus and deep lateral rotators to perform the motion |
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Quadruped reach characteristics |
-knees in line with hips (no abduction), hands under shoulders, spine in neutral, person reaches one arm directly forward (to the point of it being horizontal to the floor) -back extensors should work bilaterally to stabilize the pelvis and trunk to allow motion of the arm into shoulder flexion, PSIS’s , ASIS’s, and the trunk should stay in the same/neutral plane |
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Sahrmann identifies two types of syndromes that can cause hip pain/dysfunction: |
1. Pain that arises directly from the hip joint, characterized by a movement impairment of an accessory motion of the femur; ie: OA due to chronic imbalanced motion of the joint. 2. Pain caused by musculotendinous dysfunction |
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primary cause of musculoskeletal pain? |
Hypermobility is the primary cause of musculoskeletal pain |
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Common Patterns of Pain Related to Problems at the Acetabulo-femoral Joint |
Pain in the groin Pain deep in the joint Buttock pain Pain in the anterior thigh Pain in the posterior thigh Pain in the medial thigh Knee pain |
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What can overload the QL muscle? |
-stress of twisting motions/ rotational forces at the trunk such as those involved with golfing and running can overload this low back muscle
-Long distance driving and airplane rides can create stored tension in the low back muscles causing stiffness and pain |
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When Addressing Pain/Stiffness of the QL we have to rely on |
–The oblique abdominal muscles –The quadratus lumborum and the back extensors (poor anti-rotational structures!) –The iliopsoas (even worse than the back muscles!) –The facet joints themselves (which will wear over time and cause pain) |
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When Addressing Pain/Stiffness of the QL train the? |
-Train the obliques to maintain pelvic neutral while moving the legs –Bent-knee fall-outs –Heel slides progressing to bicycling legs |
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When Addressing Pain/Stiffness of the QL after you have gained fair Ext oblique strength quiet QL via? |
-quiet the QL (and the lumbar erector spinae) via stretching and manual release.
–Typically gaining oblique strength will allow the QL and erector spinae to quiet down on their own |
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Syndromes at the hip are named for? |
named for the direction of the movement that most consistently causes pain. |
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Deviations from Normal Postural Alignment at the Acetabulo-femoral Joint: Movement Impairment Syndromes |
•Femoral anterior glide with lateral or medial rotation •Femoral posterior glide with medial rotation •Multidirectional accessory hypermobility •Hypomobility with superior glide |
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snapping hip characteristics |
–TFL/Iliotibial band along with gluteus max
–Iliopsoas
Treatment for each of the above: Gain muscle length with strength |
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Hamstring strains often related too: |
–anterior femoral glide syndrome –hip extension with knee extension syndrome –hip lateral rotation syndrome –Stiff and tight hamstrings
All of which involve overuse injury of the overly-dominant hamstrings and weak gluteus maximus |
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Most commonly strained adductor? |
Adductor longus is most commonly injured |
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adductor strains often related to |
–hip adduction syndrome–MOI is usually an atypical/out-of-the ordinary activity for the individual |
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when assessing adductor strains check for: |
•Check for weakness in antagonist (gluteus medius)
•TFL may be overly short/tight |
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rectus femoris strains often related to? |
–Explosive hip flexion (sprinting or kicking) –Eccentric overload as the hip is extended (running or dancing) –Diminished attention to stretching |
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rectus femoris strain assessment check for? |
Check for weakness in iliopsoas |
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Treating grade 1 and mild grade II strains characteristics |
likely will resolve without rehab; ice and rest for 1-3 days, then gentle stretching and resume activity |
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Moderate Grade II strain characteristics |
–1 week: rest, anti-inflammatories, and physical modalities such as ice and pulsed ultrasound; Kinesiotaping for support may be helpful. –2-3 weeks: following gentle warm up, begin AROM and possible RROM of the antagonist muscle, which allows for gentle lengthening of the injured muscle; modify activity as needed to avoid pain and optimize healing/avoid re- injury –4 weeks: begin friction massage, gentle soft-tissue work to apply tension to the healing tissue, avoid being overly aggressive (recurrence of inflammation is a + sign), begin gentle, gentle AROM of injured muscle (no pain) –5 weeks: begin mild stretching the muscle (up to the point of pain, then back off; Norwegian Pump is very effective), continue AROM –6 weeks: progress stretching, RROM emphasizing the injured region of the muscle |
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Severe Grade II and Grade III strains characteristics |
•The part may be immobilized for up to five or six weeks •Physician and patient will need to decide if the injury will be treated surgically or non-operatively: many tears are not surgically re-attached, they are simply allowed to scar... which usually results in a certain number of adhesions to skin, other muscles, and bone. •Once optimal healing has occurred (whether surgical or non-op), begin AROM; be alert to adhesions and loss of strength/ROM as a result. Friction massage and other forms of manual therapy may help to decrease the problems associated with these adhesions. •The person may not achieve premorbid status if treated non-operatively |
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When assessing tendonitis check for? |
•Look for short and/or stiff muscles –Often the pain is at the tendon, but its source is stiffness/shortness of the muscle belly –Treat with manual therapy and exercise prescription •Be alert for biomechanical deviations –Movement impairment syndromes –Bony abnormalities |
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Tendonitis treatment characteristics |
•Address overuse–Strive to rest the part to allow it to heal –Prime movers: Gain length and strength –Eliminate substitutions: Movement re-education –Stretching program: Have the patient stretch 3-4 hours after significant exertion •Chronic inflammation? Possible injection, however be cautious |
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external snapping hip characteristics |
-Iliotibial band slips over greater trochanter; typically due to an imbalance between TFL (overly strong and short) and gluteus maximus and posterior gluteus medius (weak) -May cause inflammation of the ITB and/or the greater trochanteric bursa. |
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internal snapping hip characteristics |
–Iliopsoas tendon slips over the iliopectineal eminence and becomes inflammed; usually related to a short iliopsoas muscle |
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Intra-articular snapping hip characteristics |
–Loose body (bone fragment, portion of labrum, etc.) within the joint capsule of the hip
-May cause intermittent locking and pain |
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Femoracetabular Impingement (FAI) characteristics |
•Abutment between the proximal femur and the acetabular rim; •Due to anatomic variances in the femoral neck or acetabulum; •Results in repetitive contact between the femoral neck and the acetabular rim, which can lead to labral tears and damage to the acetabular articular cartilage; •Presents clinically as groin pain with little or no history of trauma. |
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Femoracetabular Impingement commonly effects which groups? |
•Affects active, young adults; •Some studies suggest a correlation between slipped capital femoral epiphysis in childhood (often undiagnosed) and acetabulofemoral impingement; •Commonly seen conjointly with movement impairment syndromes, particularly anterior femoral glide |
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Diagnosing femoracetabular impingement characteristics? |
•Clinically, the presentation is one of a "stiff, non-painful" hip, which is exacerbated by activities as well as long term sitting. •Positive Fabere’s test, with pain produced in the groin. •In each case, there is increased contact between the acetabular rim and the femoral head/neck junction. •In each there is restricted flexion and adduction of the flexed hip. Rotation produces bony end-feels, with restriction depending on the variance •Radiographs and MRI reveal anatomical variances |
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femoracetabular impingement surgical treatment characteristics |
•open procedure, or more common arthroscopic approach. –Chondral damage is excised or addressed with microfracturing –Osteophytes are resected –The cam/pincer/mixed lesion(s) are addressed: Femoral head is re-shaped to a more spherical configuration; acetabular recession is performed in which the labrum is detached, the acetabulum is re-shaped, then the labrum is reattached –Labral pathologies are addressed/repaired |
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femoracetabular impingement Post-op rehab phase 1 characteristics |
•Phase I: Protected weight-bearing (0-6 weeks) –Use of crutches or walker NWB or TTWB –Observe any ROM restrictions (if any) set by surgeon –At 6-8 weeks, begin gentle supine AROM athip including mm stretches –Gentle standing AROM at hip –Quadruped rocking backward |
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femoracetabular impingement Post-op rehab phase 2 characteristics |
•Phase II: Resume full weight-bearing (6–8 weeks) –Hip ROM should be at least 80% of opposite side –Promote more-normal walking pattern –Advancing L/E strength |
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femoracetabular impingement Post-op rehab phase 3 characteristics |
•Phase III: Advanced Exercises (8-10 weeks) –Hip ROM should be equal to opposite side –Involved side is 70% or greater when compared to uninvolved side –Improve cardiovascular endurance –Improve balance reactions –Strengthening exercises continue |
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femoracetabular impingement Post-op rehab phase 4 characteristics |
•Phase IV: Activity specific (10 + weeks) –Work on coordination, strength, agility, etc. –Specific requirements of activity/sport –Discharge |
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Femoracetabular impingement concerns when un-treated |
-in youth progresses to to pain, primarily in the groin, frequently radiating into the Adductor Magnus which becomes extremely tender -SI joint pain(hypermobility). •early degenerative changes of the acetabular labrum •Repetitive shock in sport between the femoral neck and the ant. wall of the acetabulum result in these degenerative changes and may result in an labral tears w/ sharp stabs of groin hip pain. •will develop osteoarthritis and may need joint replacement surgery |
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Acetabular Labral Tears mechanism of injury |
•Tearing of the labrum is typically due to a sudden pivoting or twisting action of the femur on the acetabulum or from repetitive trauma from impingement |
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acetabular labrum blood supply characteristics |
The acetabular labrum is similar to the meniscus in the knee: it has a good blood supply at its periphery and is relatively avascular centrally |
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acetabular labral tears diagnosis characteristics |
best diagnosed via magnetic resonance imaging, however they can still be missed; arthroscopic inspection is considered the gold standard, plus it affords the opportunity to resect or repair the tear |
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acetabular labral tears treatment characteristics |
•Resection: surgically removing or shaving of the labral defect •Repair: Using sutures or other means to stabilize the labral defect on the acetabulum •Significantly better long-term outcomes in individuals with repair versus resection •Post-op rehab is similar to that for FA impingement |
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3 main bursa at hip and pelvis |
–Trochanteric bursa
–Iliopsoas bursa
–Ischial bursa |
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hip bursitis characteristics |
-often misused to describe pain experienced at the hip -If true inflammation of the bursa exists, often related to repetitive motions andassociated with muscles that are too short/inflexible. -Direct trauma to the bursa mayalso cause inflammation, however fairly rare at the hip and pelvis, except (ischial bursitis) |
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2 most common bursa with hip bursitis |
–the subgluteus medius bursa
-the subgluteus maximus bursa- ITB tightness is often related to irritation of the bursa |
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hip bursitis commonly associated with |
commonly associated with a “snapping hip” |
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trochanteric bursitis S&S |
-chronic, intermittent, aching pain over the lateral hip -Walking or lying on the affected side exacerbates the pain -seated position, local tenderness is present over the greater trochanter or more posteriorly for deep bursa -Pain can be reproduced by hip adduction (superficial bursitis) or resisted active abduction (deep bursitis). •symptoms similar to L-5 radiculopathy, or the pain could radiate along an L-2 distribution to the knee -Swelling and tenderness to palpation over the trochanteric bursa is usually the primary complaint -may be aching pain after running due to overuse -SLR or femoral nerve stretch could be painful |
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iliopsoas bursitis S&S |
•Pain from iliopsoas bursitis radiates down the anteromedial side of the thigh to the knee and is increased on ext, add, and IR of the hip •Pain worsens slowly and may be the only symptom present. -Tenderness may occur anteriorly below the middle of the inguinal ligament and lateral to the femoral artery -palpable mass or visible edema may be found lateral to the femoral vessels. -Pulsations from the femoral artery are sometimes transmitted through this mass |
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Ischial bursitis characteristics |
•Inflammation commonly arises as a result of direct trauma, typically prolonged sitting on a hard surface or prolonged sitting in the same position (spinal cord injury). •Pain may radiate down the back of the thigh and mimic sciatic nerve inflammation. •pain can be reproduced by pressure over the ischial tuberosity. |
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Treating bursitis characteristics |
•Identify mechanism of injury and modify/eliminate •Address pain and inflammation •Assess soft tissue involvement •Manual therapy •Injection if no significant improvement in two weeks •In rare instances, bursectomy may be performed |
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stress fractures clinical findings characteristics |
-pinpoint tenderness and pain over area of the stress fracture. Initially radiographs may be normal -Hx:activities, changes in activity, and analysis of movement -cause must be determined and treated via relative rest, relief of weight bearing, avoiding stressful positions |
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avulsions treatment characteristics |
-usually requires internal fixation, unless the avulsion is incomplete, in which case immobilization is the preferred method of treatment -may ambulate with crutches, WB/activity altered depending on cause of avulsion -if muscular, prevent contractions until healing has progressed. -Well-leg and upper body exercise, after cast is removed: active rehabilitation |
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femoral neck fracture fixation/stabilization method depends on |
depends on the location and severity of the fracture as well as the age and physical condition of the person. Various devices are available for internal fixation |
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femoral neck fracture fixation/stabilization method- hip pinning characteristics |
-multiple threaded pins are applied at varying angles across the fracture site -may take 3-6 months for the fracture to heal, during which WB is limited or prohibited |
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femoral neck fracture fixation/stabilization method- compression plate characteristics |
-metal plates and screws are used to secure the fracture. At times the metal plate is removed following fracture healing, because the plate alters the normal weight bearing pattern of the bone and increases the potential for future fracture -If the plate is removed, there is a temporary weakening of the bone where the screws were removed, and weight bearing must be limited for a few weeks |
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femoral neck fracture fixation/stabilization method- intramedullary nail characteristics |
-IM nail is placed into the endosteal canal of the bone and performs load-sharing duties, which usually permits WB across the fracture site |
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femoral neck fracture fixation/stabilization method- compression screw plate |
-commonly called the Dynamic Hip Screw -often used for extracapsular fractures of the proximal femur -screw grips the femoral head, then slides telescopically into the barrel -Tightening of a screw in the base of the barrel creates compression across the bone fragments |
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Garden Stage Classification of Femoral Neck Fractures |
•Type 1: incomplete or impacted fracture (may not require surgical fixation) •Type 2: complete fracture without displacement (requires surgical fixation) •Type 3: complete fracture with partial displacement (usually addressed via THA) •Type 4: complete fracture with full displacement, continuity of fragments disrupted (usually addressed via THA). |
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Intertrochanteric Fractures MOI |
•Occur along a line between the greater and lesser trochanters and are more common among elders.
•Almost always is the result of a fall |
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Intertrochanteric Fractures treatment |
-typically internal fixation via pin and plate; frequently includes the useof intramedullary rods that run through the center of the bone to stabilize the fracture fragments -Failure of the fixation device and mal-union are the most common complications -WB status is usually touch down weight bearing |
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Subtrochanteric Fractures MOI |
•The least common and most unstable traumatic fracture, also the most difficult to treat because of the high mechanical stresses in this area of the femur.
•Subtrochanteric fractures are the result of direct trauma of considerable force, and is the most frequent femoral fracture in the younger population. |
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Subtrochanteric Fracture treatment characteristics |
•Treatment: usually intramedullary rod or plates, screws, or nails. -Zickel Nail is fairly commonly used -routinely non-WB or toe-touch WB for four to six weeks. •SLR are absolutely contraindicated |
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Shaft fractures of femur usually fixated via? |
-similar to fractures of other long bones.
-Shaft fractures are usually fixated internally via intramedullary (IM) rodding, or via external fixators, such as Hoffman devices |
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Intercondylar Fractures characteristics |
-usually the result of longitudinal stresses placed on the femur, such as falls in which the person lands on their feet. -Articular surfaces may be involved, depending on the location of the fracture within the condyle(s) -Nails, pins, screws, etc. may be used. At times a CPM may be utilized if articular surfaces are involved |
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minor pelvic fractures characteristics |
involve avulsions and simple bone disruptions, and are routinely not fixated, due to the stable nature of these injuries. |
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major pelvic fractures characteristics |
-multiple breaks in the pelvic ring and include displaced sacral injuries, and may involve internal fixation -Major fractures signify potential pelvic instability or serious associated complications -Typically require surgical fixation |
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Pelvic fracture treatment characteristics |
Treatment includes exercise within the framework of the injury and to patient tolerance, gait training with the most appropriate assistive device |
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Femoral and Pelvic Fractures: Rehab characteristics |
-Goals are to help the person achieve functional independence in their various life roles, with adherence to prescribed weight bearing status, and any precautions associated with the surgery -Gait training performed utilizing the most appropriate assistive device -Once there is radiographic evidence of healing, most patients are allowed to increase their WB to tolerance |
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Acetabulo-femoral Dislocation characteristics |
•Almost always traumatic in nature and involve injury to other soft tissue structures. •Posterior hip dislocations occur with hip flexion, adduction, and internal rotation. •Anterior dislocations occur with slight flexion, abduction, and external rotation. |
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Acetabulo-femoral Dislocation management |
-usually have some immobilization -Early treat inflammation, perform functional activities while protecting the hip, and maintain strength in uninvolved structures -isolated motions may begin as early as the second or third week post injury -4 weeks, more aggressive with exercise and activity prescription -No combined motions of dislocation until week 6-7 weeks |
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Osteoarthritis/Osteoarthrosis/Degenerative Joint Disease characteristics |
•most common disease process affecting the hip •joint degeneration from overuse, obesity, childhood issues such as developmental dysplasia, LCP, SCFE, problems arising from adulthood including chronic movement impairment syndromes, trauma, infection, etc. •Severe degeneration may require surgical intervention, most commonly arthroplasty. |
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hypomobility with Superior Glide symptoms |
Equivalent to diagnosis of hip osteoarthritis
Pain in groin or lateral anterior superior hip above the greater trochanter, pain in knee (medial) upon standing after sitting for a longer period of time |
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hypomobility with Superior Glide examination characteristics |
–loss of rotation accompanied by pain at the end of the range of motion
–Antalgic gait, likely with excessive lumbopelvic rotation |
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hypomobility with Superior Glide Tx characteristics |
–Minimize iliopsoas activity due to it’s compression moment –Have patient slide leg on bed versus lifting it –Wedge in chair decreases hip flexion and will reduce pain –Standing on step, hang leg with cuff weight over the edge > distraction will ease the person’s pain –Cane can decrease compression at hip 50% |
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Primary OA / DJD definition |
wearing down of the articular surfaces of the joint over time
Although you see primary osteoarthritis mostly in older adults, it is not a normal part of the aging process |
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Secondary OA / DJD definition |
arthritis that occurs due to previous damage (such as an intraarticular fracture), or mechanical disorders |
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Osteoarthritis/Osteoarthrosis/Degenerative Joint Disease clinical findings |
-onset of symptoms is usually gradual, and the person is unable to relate it to a specific mechanism of injury -patient typically feels pain in the groin, and as it progresses, into the anterior thigh and knee. -may experience morning stiffness, which decreases as they begin to move around -Many patients experience aching pain after moderate activity, such as walking |
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Osteoarthritis/Osteoarthrosis/Degenerative Joint Disease management characteristics |
-treat symptomatically -address capsular tightness via joint mobilization and/or stretching -assess performance of functional activity and alter or augment as needed -Strengthen the muscles around the joint, consider non weightbearing activities such as bicycling, swimming, or water aerobics |
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THA prosthesis design |
constraint |
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THA prosthesis fixation characteristics |
–Cemented
–Uncemented/porous coat
–Press-fit |
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Posterolateral approach hip precautions |
-Don't bend you hip past 90 degrees -Don't cross your legs -Don't turn the foot of your operated leg inward |
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Trigger point dry needling (TPDN) definition |
-form of manual therapy in which a small, sterile, fusiform needle is inserted into the muscle at the trigger point to cause the muscle to contract and then release, improving the flexibility of the muscle and therefore decreasing the symptoms of pain and dysfunction because of science |
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Trigger point definition |
hyperirritable spot of soft tissue, usually found within a taut band of skeletal muscle that is painful on compression and that can give rise to characteristic referred pain, tenderness, and autonomic phenomena |
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active vs. latent trigger points |
Trigger points may be active (ie: they are symptomatic with respect to pain, usually causing radiating pain when compressed) or latent (clinically quiet with respect to pain until compressed) |
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Myofascial Pain characteristics |
•A myalgic condition characterized by local and referred pain that originates in a myofascial trigger point
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TPDN ≠ Acupuncture characteristics |
–Acupuncture theorizes that insertion of multiple needles balances the flow of positive and negative energy (yin and yang aspects of chi) along specific lines/meridians
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Travell and Simons’ Energy Crisis Theory |
•Trauma causes an increase in the endplate release of Acetylcholine > leads to excessive release of CA from the sarcoplasmic reticulum > causes ischemia and increased contraction of the local segment of muscle |
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Motor End-plate Hypothesis (proposed to coexist with energy crisis theory) |
Needle EMG shows small parts of trigger points are electrically active > these are primarily located in the motor end-plate > the end-plate “noise” observed by EMG is thought to reflect increased Ach release from the nerve terminal > results in AP being propogated a small distance along the cell membrane > this small amount of propogation may be enough to cause activation of a few contractile elements and be responsible for muscle shortening |
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TPDN and Physical Therapy Practice in Oklahoma characteristics |
•within the scope of physical therapist practice. Acupuncture is not. |
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TPDN and Physical Therapy Practice in Oklahoma Reimbursement Considerations |
•Major insurance companies reimburse for TPDN (billed as intra-muscular manual therapy)
–Medicare is the only (important) exception |
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Risks of TPDN |
•Rare |
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TPDN contraindications |
•Skin lesions |
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TPDN precautions |
•Breast implants |
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Typical responses to needling |
•Motor twitch |
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atypical responses to needling |
•Fainting, dizziness, nausea, arousal |
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Deviations from Normal Postural Alignment at the Acetabulo-femoral Joint: Movement Impairment Syndromes |
•Femoral anterior glide with lateral or medial rotation |
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Femoral Anterior Glide Syndrome with Lateral or Medial Rotation occurs due to |
•Occurs due to inadequate posterior glide of the femoral head during hip flexion. This is very similar to the anterior humeral glide syndrome at the shoulder, often associated with impingement; often mis-diagnosed as iliopsoas tendonitis |
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Femoral Anterior Glide Sign characteristics |
•+ anterior glide test (SLR with index finger at inguinal crease / parallel to axis of rotation > pushed anteriorly with SLR) |
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Femoral Anterior Glide Syndrome with Lateral Rotation characteristics |
•Femoral head glides forward with hip movements, particularly flexion |
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Femoral Anterior Glide Syndrome with Lateral Rotation: Key Findings |
•Postural assessment reveals swayback posture and the lower extremities are in lateral rotation •Prone knee flexion: Reveals lateral femoral rotation |
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Femoral Anterior Glide Syndrome with Medial Rotation characteristics |
•Femoral head glides forward with hip movements, particularly flexion |
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Femoral Anterior Glide Syndrome with Medial Rotation: Key Findings |
•Postural assessment reveals swayback posture; pelvic torsion may be noted with TFL producing relative medial rotation of the hip on the affected side •Sidelying Abduction: TFL is dominant abductor and produces medial rotation; gluteus medius is weak > person may rock pelvis backward in an attempt to use TFL
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Femoral Posterior Glide with Medial Rotation charcteristics |
•Femoral head is relatively hypermobile and glides posteriorly with hip movements, particularly flexion |
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Femoral Posterior Glide with Medial Rotation: Key Findings |
•Postural Assessment (Sitting): •Prone Hip Extension: •Quadruped Rocking-back: |
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Multidirectional Accessory Hypermobility characteristics |
•“Mixture of anterior and posterior glide syndromes” |
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Multidirectional Accessory Hypermobility clinical findings |
•Postural Deviations: Combined elements of both anterior and posterior glide syndromes •Sitting |
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Femoral Anterior Glide Syndrome with Lateral Rotation- Address Postural, Habitual Positioning, and Muscle Imbalances |
•Thoracic extensors and abdominals are weak |
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Femoral Anterior Glide Syndrome with Medial Rotation- Address Posture and Muscle Imbalances and Movement Re-education: |
•Thoracic extensors and external obliques are weak Movement Re-education: |
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Uses of tape |
– hold on wound dressings -Only limit is your imagination |
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When is it not appropriate to tape? |
–further assessment needed –pre-puberty (Why???) |
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Principles of Taping Tape application |
•Select correct tape |
