Goals • Identify structural or muscle imbalance anatomy that might predispose to musculoskeletal problems • Identify movement patterns or postures that suggest CNS pathology • Offer examination techniques to illustrate important muscle imbalances that can occur • Offer guidelines for who might benefit from further musculoskeletal evaluation in referral or testing
Focus Points • Developmental milestones • Locomotion is most important function • Standing posture probably reflects “lifestyle” postures in older children & adolescents • The foot is the contact point with the world & first in kinetic chain of ambulation • We weren’t designed to sit, we should be able to squat • You may need to play with them
Developmental milestones • Hand dominance emerges 18 mo, matures by 2-3 years • Belly crawl 7-9 mo • Hands & knee creep 9-11 mo • Cruise 11-12 mo • Walk alone 12-14 mo, mature gait by 2.5 yrs • Climb stairs on hands & knees ~15 mo • Run stiffly ~16 mo • Walk down steps, nonreciprocally 20-24 mo
Locomotion milestones cont…. • Alternating steps up stairs 3 yrs • Hop on one foot & broad jump 4 yrs • Skip 5 yrs • One foot balance 20 sec 6-7 yrs
Key anatomy areas • Foot/ankle mechanics in sagittal plane • Dorsiflexion range in late stance and squatting, forefoot extension in toe off • Tight heel cords will affect knee, reduce hip extension in late stance since tibia can’t advance over foot, leg will lift up early • Lateral border of foot should be straight, if convex think tibial torsion • Hip extension in sagittal plane • Loss may be postural and hip flexor shortening in older child • Excessive or lordotic gait may be glut maximus loss in MD • Hip stability in frontal plane • Glut medius strength – Trendelenburg gaits or waddling may occur till 3 yrs
Gait considerations • Limp = altered gait, often antalgic due to painful joint, kids won’t admit it. • Any joint in kinetic chain but hip most common, hardest to examine.
Anatomy areas…. • Hip rotation, knee flexion, ankle dorsiflexion in squatting, can they squat and walk? • Hip extension is frequently lost, do they extend during ambulation in the sagittal plane? • Supine hip extension range is important and helps localize tightness • Hip firing patterns are probably very important to identify, easy ways to check?
Compensations • Gower’s maneuver = walk up to standing using hands to make up for weak proximal extensor muscles.
Screening starts with gait • Sagittal plane mechanics most important, then frontal plain • Shoes on and off, out in the hall, let them run if able
Firing patterns • Hip abduction: Glut medius >> tensor fascia lata >> quadratus lumborum • Hip extensors: Glut maximus >> hamstrings >> spine extensors
Palpate for muscle contraction, timing and force relative to movement and other muscles