Musculoskeletal Assessment & Tx in Pediatrics

How old does someone have to be for a MMT?

8

If someone is to young for a MMT, how do you measure strength?

Functional ability

What are the current PA recommendations for youth?

• At LEAST 60 min/day of moderate to vigoruous PA (vigorous at least 3 days/wk)

• At least 3 days/wk muscle strengthening

• At least 3 days/wk bone strengthening

What does a child need to be able to do to begin resistance training?

Participate in sports

What should be the focuses of resistance training in youth?

• Balance between muscle groups and across joints

• Large muscle groups

• Multi-join exercises

People under age ___ should not do year-round sport specialization

15 yrs

What are some risks of doing year-round sport specialization before the age of 15?

• Increased risk of overuse injuries and burnout

• Restricts movement experiences

• Doesn’t promote full range of phyiscal development

• Miss our on learning experineces and skills developed during informal play

What is the test you can do to check for scoliosis?

Adam’s test

For someone to be diagnosied with scoliosis, they need to have a curve of at least what?

10°

At what degree of spinal curvature is there a greater chance the abnormality can be seen?

20°

What are some signs of scoliosis?

• Uneven shoulders

• One shoulder blad more prominent than the other

• One hip higher than the other

• Rib hump

What are the different types of scoliosis?

• Idiopathic

• Congenital

• Neuomuscular

You do the Adam’s test with a patient. If they have more the ___° of a rib hump, they should probably get an x-ray.

5°

What is the most common form of scoliosis in children?

Idiopathic

The ____ angle is the degree formed by the most caphalad vertebra of a curve whose upper surface maximally tilts towards the curves concavity and the most causal vertebra with maximal tilt towards the convexity

Cobb angle

What Cobb Angle of an immature spine would warrant surgery?

>45°

A Cobb Angle of less than what would indicate that someone does not need surgery?

<25°

What brace is best at treating curves that have their apex at T7 or lower?

Boston brace

What brace has become the new gold standard for scoliosis treatment?

Providence brace

What makes the Providence brace so awesome?

• Prevents progression of scoliosis

• Only worn at night

What is the common brace given to people with scoliosis? Why does nobody like it?

Boston brace, nobody likes it cuz ya gotta wear it 22-23 hrs/day

What are the different ways you can measure a leg length discrepancy?

• Supine

  • ASIS to medial malleoli

• Standing

  • On graduated blocks (but not a good way to do it)

What are some interventions to do for someone with a pseudo LLD?

• Postural correction

• Pelvic alignment

• Core/gluteal strengthening

According to the book, how many cm difference in leg length does not warrant intervention?

0-2 cm

According to the book, what cm range in LLD requires a lift outside of a shoe?

2-6 cm

What is the preferred position for measuring hip IR/ER? Why?

Prone cuz it stabilizes the trunk and pelvis while also preventing wiggling

What position do you have someone in for the Ryder’s Method/Craigs test?

• Prone

• Knee flexed to 90°

Describe how you would perform Ryder’s Method/Craigs test

• Have patient go prone with knee flexed to 90°

• Palpate the greater trochanter with an open hand

• Move leg in and out of IR/ER

• When maximally palpable, measure the angle between the vertical and long axis of the tibia

What is the Ryder Method/Craigs Test looking at?

Femoral anteversion

What is a normal amount of femoral anteversion for an adult?

8-15

How much femoral anteversion is normal at birth?

40°

How much femoral anterversion is normal for someone between 8-10 yrs old?

15-20°

Which is a common cause of in-toeing, anteversion or retroversion?

Anteversion

The higher the angle you get in the Ryder Method/Craig test, the more retroversion someone has. True or false?

False! The higher the angle, the more anteversion. The lower the angle, the more retroversion

When might you first start to notice in-toeing in a child?

At 2 yrs old

What are some common signs that a child has femoral anteversion?

• Sit in “W” position

• Run with “egg-beater” or “wind-mill” pattern

Is femoral anteversion more common in males or females?

Females

When measuring hamstring length, what measurement should ya record?

ROM lacking from full knee extension

What is the name of the maneuver where you dislocate a child’s hip?

Barlow maneuver

What is the name of the test where you re-locate a child’s hip?

Ortolani maneuver

You can do the Barlow and Ortolani tests with children under what age?

1 yr

What is the Galeazzi test?

Hiposition dislocation screen that looks at difference in knee height in a supine hooklying p

When should you use the Galeazzi test?

When doing a hip dislocation screen with someone older than 1 year

What is the Shenton arc?

A line formed by the medial cortex of the femoral neck and the interior cortex of the superior pubic ramus

If a child has hip dysplasia, what is the goal of intervention?

Reduce and stabilize the femoral head in the acetabulum

What movements does the Pavlik Harness restrict?

• Hip extension

• Hip adduction

What position does the Palvik Harness put a child in?

• Hip flexion

• Hip abduction

When does the Pavlik Harness have a higher success rate, when it’s worn between 0-6 months or 6 months-2 years?

0-6 months

Legg-Calve-Perthes disease occurs between what ages?

4-8

In which condition do children tend to be shorter, Legg-Calve-Perthes disease or slipped capital femoral epiphysis?

Legg-Calve-Perthes disease

In which condition is treatment primarily conservative (involving PT and other such treatments), legg-clave-perthes disease or slipped capital femoral epiphysis?

Legg-Calve-Perthes disease

If someone with Legg-Clave-Perthes disease needs surgery, what surgery are they probably getting?

Femoral osteotomy

What age range can develop slipped capital femoral epiphysis?

10-15

Which condition more commonly happens in overweight children, Legg-Calve-Perthes disease or slipped capital femoral epiphysis?

Slipped capital femoral epiphysis

How is slipped capital femoral epiphysis normally treated?

Internal fixation with a screw

If someone has LCPD, how much hip abduction do you want them to be able to get?

45°

If you think someone has SCFE, they should not be WB until the dx is confirmed. True or false?

True!

After someone has surgery for SCFE, how long do they have to wait for RTS if it was a stable slip?

3-6 months

After someone has surgery for SCFE, how long do they have to wait to RTS if they had an unstable slip?

4-6

What are some ways to assess tibial torsion?

• Thigh foot angle

• Transmalleolar angle

How much tibial torsion is normal at birth?

-15° internal tibial torsion (ITT)

How much tibial torsion is normal at 3 yrs old?

5° ETT

How much tibial torsion is normal in mid-childhood?

10° ETT

What are some intervention ideas when treating tibial torsion?

• Have them wear flippers during ambulation

• Kinesiotape

• Gait training (tandem walking)

• Orthotics (only if needed)

• Repositioning within functional postures

By what age should abnormalities in tibial torsion resolve?

5 yrs

The thigh foot angle is a measure of what?

Tibial torsion

Describe how you would get a thigh foot angle

• Have pt go prone with knees flexed and subtalar neutral

• Put axis of Goni in center of calcaneus

• Align long arm of Goni with foot and moving arm with long axis of thigh

When would you use the transmalleolar angle test over the thigh foot angle to measure tibial torsion?

When forefoot adduction is present

Describe how you would perform the transmalleolar angle test

• Position pt in prone with knees flexed and subtalar joint neutral

• Align axis of Goni on center of calcaneus

• Have moving arm of Goni in a line perpendicular to the transmalleolar axis and the moving arm in line with he long axis of the thigh

Is genu varum, valgum, or neutral normal in children under 2?

Genu varum (aka bowed legs)

At what age does genu varum typically change to neutral?

Around 14 months

At what age does a child go from neutral to genu valgum?

3ish yrs

When does genu valgum go to normal physiologic valgus in a child?

Around 7

A tibiofemoral/Q angle is a test for what?

Genu varum/valgus

Describe how’d you have a Goni aligned for taking tibiofemoral/Q angle

• Axis: center of patella

• Stationary arm: Long axis of femur

• Moving arm: Long axis of tibia

How much genu varum is normal at birth?

15°

How much genu valgus is normal around 3-4?

10-15°

How much genu valgus is normal in adulthood?

5°

What are some interventions to do to help improve genu valgus?

• Gluteal strengthening

• Jumping and dynamic kinematics

What does an intra-malleolar/inter-condylar measurement test for?

Genu varum/vaglus

>___cm at an intra-condylar measurement would indicate someone has what?

Genu varum

>___cm indicates that someone has genu valgus

>8cm

What are the interventions more Blount’s Disease?

• 3+ years of orthotics

• Strengthening

• Gait training

Surgical outcomes are better for Blount’s Disease if the pt is ___+ yrs old

5

What causes Blount’s disease?

Delayed growth of posteromedial tibia

Is Blount’s disease more common in males or females?

Males

Without an x-ray, is is really hard to distinguish between what two conditions?

• Tibia vara

• Blount disease

Are newborns typically stuck in knee flexion or extension?

Knee flexion

Do newborns typically have excessive PF or DF?

DF

What is the preferred position for looking at DF?

Prone

What position do you have a pt in for the heel bisector method?

• Prone

• Knees flexed to 90°

How do you perform the heel bisector method test? What would normal be?

Draw vertical line bisecting the heel and if normal, should bisect 2nd and 3rd toes

You are doing the heel bisector method and the line is in the middle of the third toe. Is this mild, moderate, or severe metatarsus adductus?

Mild

What is the heel bisector method test measuring?

Metatarsus adductus

You are doing the heel bisector method with a patient and your line intersects between the 3rd and 4th toes. Is this mild, moderate, or severe metatarsus adductus?

Moderate

You are doing the heel bisector method with a pt and your line intersects between their 4th and 5th toes. Is this mild, moderate, or severe metatarsus adductus?

Severe

What are some interventions for abnormal metatarsus adductus?

• Stretching

• Joint mobs

• K-tape

• Orthotic

When looking at calcaneal alignment, what is one important thing?

They gotta be standing!!

What angle are you measuring when looking at calcaneal alignment?

Angle between vertical line and middle of calcaneus

What is the formula to determine the normal amount of pronation for a child?

8 - N (N is child’s age)