Musculoskeletal Examination/Intervention Lab

Lab Handout PTRS 833 Musculoskeletal Examination/Intervention

Scoliosis  Adams forward bend test (for scoliosis): The child bends forward with his/her arms hanging in front and knees straight. The therapist stands behind and then in front of the child to assess spine symmetry. This is a screening procedure and is not a definitive diagnosis of spine curvature. Bend slowly, explain the procedure to the family/patient. In scoliosis you will see a hump on one side at the level of the convexity. Leg Length Discrepency  Galleazi sign: Child is supine with knees bent and feet flat on the table or floor. ASIS’s are held level. Look to see if one knee is higher than the other. If so, leg length may need to be measured. The Galleazi sign may also be an indication of hip joint integrity—if a child has a dislocated hip, the femur will slide backward and the knee on that side will be lower. If one knee is lower than the other, that is probably the side that is shorter. To measure leg length discrepancies, use a tape measure. Go from ASIS to medial malleoli. Look for iliac crest height differences in standing or is one knee bent and the pelvis level?  Tape measurement: Child lies supine with hips and knees extended. Measure the distance from the most prominent point on the ASIS and the medial malleolus. Repeat on the other side and compare measurements. It is important that the child lie quietly during leg length measurements. Developmental dysplasia of the hip (DDH) The Ortalani and Barlow maneuvers are performed to detect DDH in newborn infants less than 12 weeks of age. Done when you see there is a leg length difference, to see if there is a hip subluxing. Most common in first born females, or when mom has a hx of DDH. Fetal position allows baby’s acetabulum to form properly.  Ortalani maneuver (sign of entry): accurate for the 1 st 6mo of life. The child is supine. The examiner places the tips of the long and index fingers over the greater trochanter with the thumb along the medial thigh. The infant’s leg is positioned in neutral rotation with 90 degrees of hip flexion, and is gently abducted while lifting the leg anteriorly. With abduction one can feel a clunk as the femoral head slides over the posterior rim of the acetabulum and into the socket. Bring legs out, (think Ortalani- Out)  Barlow maneuver (sign of exit): accurate for the 1 st 6 mo of life. Maintaining the same position as above, the leg is gently adducted while gentle pressure is directed posteriorly on the knee. A palpable clunk is noted as the femoral head slides over the posterior rim of the acetabulum and out of the socket. Bring legs in.  Galeazzi’s test (see above)  Asymmetric hip folds Hip abduction is assessed to detect DDH in infants ages 3-12 months.  Hip abduction: The child is in supine. The examiner places the hip in 90 degrees flexion with one hand stabilizing the pelvis. Each hip should easily abduct to 75 degrees and adduct to 30 degrees past midline. Limitation in hip abduction is indicative in DDH. Looking for quality of motion bilaterally Once a child is ambulatory, DDH can usually be identified through observation. There is usually a limp and the child may toe-walk on the affected side. There is a positive Trendelenberg sign when the child is asked to stand on the affected leg. Hip/Knee Range of Motion Bones grow faster in length than muscles can grow to keep up.  Thomas test (hip flexion contracture): Child is supine bring both knees to chest. lower one leg and foot so that it is hanging off the table. The opposite hip is flexed toward the abdomen and held there to flatten the lumbar spine. The resulting angle between the tested thigh and the table is the amount of hip flexion contracture.  Ober test (hip abduction contracture): Child is in sidelying with the bottom hip flexed toward the chest. The top knee is in extension or flexed 90 degrees. The top hip is pulled into extension and allowed to fall into adduction. If the hip cannot adduct, there is a hip contracture. Stabilize the pelvis with your top hand  Popliteal angle test (measure of physiological flexion in neonates): Infant is supine with hip and knee of measured lower extremity flexed to 90 degrees. The other hip is stabilized against the surface while Lab Handout PTRS 833 Musculoskeletal Examination/Intervention the knee of the testing leg is extended. Measure the angle between the thigh and leg when the knee is maximally extended. To measure, one arm along the femur, one along the tibia with axis at the knee.  Hamstring length: Same as above but measure the amount of ROM that is missing or lacking from full knee extension. To start, thigh should be perpendicular to table, to measure, one arm along femur, one along tibia, with axis at the knee. Subtract from 180.  Straight-leg test Torsional Deformity Torsional profile: Foot progression angle, internal rotation of hip, external rotation of hip, thigh-foot angle and foot shape are documented to determine if there are torsional deformities. The components that may contribute to in-toeing are femoral anteversion, internal tibial torsion, and metatarsus adductus. The components that may contribute to out-toeing are ER contractures of hip, femoral retroversion (rare), external tibial torsion, and calcaneovalgus. The following tests may be done to determine which component of the lower extremity is causing the deformity.  Craig’s (Ryder’s) test (femoral torsion): Child may be prone, supine or sitting. The hip may be flexed or extended, but the knee must be flexed to 90 degrees. The examiner holds the leg proximal to the ankle and rotates the hip medially and laterally while palpating the greater trochanter. When the trochanter reaches its most prominent lateral position, it is assumed that the head and neck of the femur are on the frontal plan. The amount of hip rotation is measured at this point. Add 20 degrees of internal rotation (-20 degrees) to your measurement to get an accurate measure of femoral torsion (internal rotation= femoral antetorsion; external rotation=femoral retrotorsion).  Hip internal and external rotation (femoral torsion): Should be measured in prone with the hip in neutral. Excessive internal rotation is indicative of femoral antetorsion and excessive external rotation is indicative of retrotorsion. The sum of hip IR and ER is 120 degrees up to age 2 and 95-110 degrees after age two.  Thigh-foot angle (tibial torsion): Child is in prone with the thighs parallel, in neutral rotation, the thighs extended and the knees bent 90 degrees. The ankle is allowed to fall into a neutral position of 90 degrees. The axis of the goniometer is placed over the center of the calcaneus. The stationary arm is placed along a visual bisection of the thigh. The moveable arm is placed on the long axis of the foot along the second metatarsal. The resulting angle is measured. If the foot points toward midline (internal tibial torsion), a negative value is given. Normal range is between 0-30 degrees throughout childhood.  Trans-malleolar angle (tibial torsion in children with forefoot disorder): The position is the same as above. A line is drawn across the plantar side of the foot that connects the medial and lateral malleoli. A second line, perpendicular to the first, that bisects the calcaneus is drawn. Measure the angle between the second line (bisecting the calcaneus) and the long axis of the femur.  Foot-progression angle: Angle between the longitudinal axis of the foot and a straight line of progression of the body. Can be assessed using pedographs or estimated based on observation. In- toeing is expressed as a negative value and out-toeing is expressed as a positive value. Normal range throughout life is -3˚ to +20˚.  Metatarsus adductus: The child stands on a photocopier and the foot is copied. In MTA, the forefoot is curved medially, the hindfoot is in the normal slight valgus position, and there is full dorsiflexion ROM. Graded as I (mild), II (moderate), or III (severe).  Calcaneovalgus: Positional deformity in which the forefoot is curved laterally, the hindfoot is in valgus, and there is full or excessive dorsiflexion. The dorsum of the foot may be touching the anterior surface of the leg. If calcaneovalgus is caused by a vertical talus , the forefoot is dorsiflexed and the hindfoot is plantarflexed. The foot bends at the instep and is very rigid. This is known as a rocker-bottom deformity. Angular Deformity  Genu-valgus: Child is in standing with the patella directly forward and the knees touching. Measure the distance between the medial malleoli. OR Child is in standing or supine with the patellae facing forward. The axis of the goniometer is over the patella and the proximal arm of the goniometer is placed over the long axis of the thigh in line with the ASIS. The distal arm of the goniometer is placed along the long axis of the tibia. Lab Handout PTRS 833 Musculoskeletal Examination/Intervention  Genu-varus: Child is in standing with the patella directly forward and the medial malleoli are touching. Measure the distance between the femoral condyles. OR Child is in standing or supine with the patellae facing forward. The axis of the goniometer is over the patella and the proximal arm of the goniometer is placed over the long axis of the thigh in line with the ASIS. The distal arm of the goniometer is placed along the long axis of the tibia