Musculoskeletal Lower Quarter Lecture - PDF

[00:00:10] Hey guys, welcome to week five of your musculoskeletal lower quarter course and the first time you're hearing me this time. So as you know, I'm Dr Pilgrim and today we'll be looking at the self-report measures for the hip. The objectives for this lecture are to identify patient se...

[00:00:10] Hey guys, welcome to week five of your musculoskeletal lower quarter course and the first time you're hearing me this time. So as you know, I'm Dr Pilgrim and today we'll be looking at the self-report measures for the hip. The objectives for this lecture are to identify patient self-report measures for patients with hip diagnoses. [00:00:32] And to identify key features of self-report measures including the MCID, MDC, and other identifying cut-points. This part of the lecture falls right into patient history and using those self-report measures to indicate what's happening so that you can inform your questions for patient history. As a bit of a refresher, we'll go over the minimal detectable change or MDC, and the minimal clinical important difference MCID. [00:01:06] The MDC is the minimum important change required for an outcome measure to exceed the anticipated measurement error and variability. So for example, if a scale is out of 30 and the MDC is 5, that means that when a score change from, let's say initial evaluation to after test is gone up by five or more, that indicates an actual change in outcome. [00:01:40] The MCID represents the minimum amount of change on an outcome measure that patients perceive as beneficial. So this is how much change on an outcome measure is enough to be meaningful for the patient. The self- reported measures that we'll be going over for the hip are the Lower Extremity Functional Scale. [00:02:05] The International Hip Outcome Tool or I-HOT 12. The Copenhagen Hip and Groin Outcome Score or HAGOS. The Hip Disability and Osteoarthritis Score or HOOS. And the WOMAC, or the Western Ontario and McMaster Universities Arthritis Index. So the LEFS is one of those questionnaires that you will see used very often in the clinic for most lower extremity diagnoses. [00:02:39] It consists of 20 questions that ask about the patient's ability to compete everyday tests. So like your ADLs and things that are required to complete them. A scale can be used to determine patients function at evaluation and then set the goals and then measuring the progress towards those goals. [00:03:00] Patients select an answer from the following scale for each activity listed. So they can range from extreme difficulty or they're unable to perform the activity, quite a bit of difficulty, moderate difficulty, a little bit of difficulty, and, of course, no difficulty that equates to the same that they were doing before. [00:03:21] Both of the MDC and the MCID scores are out of 24 for the LEFS and are 9 points. So that means that 9 point increase in the scale is a measurable difference, but also it indicates that it is a meaningful change for your patient with 9 points. The International HIP Outcome Tool or I-HOT12 is a 12 point questionnaire and 4 subscales. [00:03:54] The subscales are symptoms and function, sports recreation, job- related concerns, and social and lifestyle. Numerous studies have established the reliability, validity, and responsiveness of this study. In this case we have an MCID which is the patient outcome from meaningful change at 13 points. The Copenhagen Hip and Groin Outcome Score or HAGOS has 37 questions to assess pain symptoms, ADLs, physical function in sports and recreation, participation in physical activities, and quality of life for patients with hip and groin pain. [00:04:33] It has been established as a valid, reliable, and responsive patient reported outcome measure for young to middle age physically active individuals with hip and groin pain. Very specific group of individuals that this scale can be administered to so be mindful of that when you are in the clinic if you intend to use this score. [00:04:55] The max score is out of 100 and 100 is indicative of no symptoms where 0 is indicative of extreme symptoms. The MCID, which again is the patient or meaningful change to the patient is 5 per each subscale. The Hip Disability and Osteoarthritis Outcome Score or HOOS is best used for hip osteoarthritis and has 5 subscales that measure symptoms, pain, ADLs, sports recreation, and hip related quality of life. [00:05:28] This instrument has 40 items and it indicates that 100 is no symptoms and a score of 0 is indicative of extreme symptoms. The MDC, which is the minimum score that indicates an actual change is between 6 to 8 for each subscale. Here you'll see an example of the HOOS hip survey and it gives you an idea of how the patient would rank from never with the symptoms to always. [00:06:01] The Western Ontario and McMaster Universities Arthritis Index or WOMAC is used for hip and knee osteoarthritis. You will find this tool most often used in research and not necessarily in clinics, but I mention it here because as you become better able to become evidence based therapists you will be needing to understand how to interpret the results of this tool as you read studies. [00:06:26] So it includes 24 questions with three subscales that measure pain, stiffness, and physical function. The higher the score it indicates the worst pain, stiffness, and functional limitations, okay? The MCID which is meaningful for the patient is 21 for pain, 16 for function, 13 for stiffness and 17 for the total WOMAC. [00:06:50] The MDC 95 which is 95% accuracy is 23 for pain, 11 for function, 27 for stiffness, and 12 for the total WOMAC. So let's recap a little bit about how you use the information that you gather from these tools. So the first part is kind of determining if this patient is really appropriate for physical therapy evaluation and intervention. [00:07:16] Or if they are appropriate for physical therapy evaluation intervention with consultation with another healthcare provider, or if they're just not appropriate at all. And using these skills in collaboration with the measures that you will get will give you the answers to these. So in the first two, if they are eligible for evaluation and intervention, you can go ahead and classify the condition through evaluation of clinical findings suggestive of musculoskeletal impairments of the body in ICF and the associated tissue pathology and disease. [00:07:55] And if they're not, then you will help to get them referred to the correct healthcare provider. How do you use this information? Well the first thing is that it guides your physical examination. It helps you to determine the tests and measures that you would use in order to determine what is happening with your patient. [00:08:17] It guides the interventions and the plan of care and with that guides the goals that you would set for this patient because these self- reported measures give you an indication of where the patient thinks their biggest downfalls are based on their diagnosis. And you would assess in determining the prognosis for this patient. [00:08:38] And finally, you use it in re-evaluation. And so you can use it at the beginning and then re-evaluation to determine the progress towards goals and eventually to discharge. One of the things that you wanna remember when you go over these self-reported measures is really looking at are they diagnosis specific or are they FS? [00:09:01] Can it be used for multiple diagnoses and then what information you can gather from it in order to inform the rest of your evaluation process? See y'all in the next lecture. [00:00:00] Welcome to our lecture on patient history for hip diagnoses. The objectives for this lecture are to apply concepts discussed in patient history to hip diagnoses and to determine the physical therapy examination based on the patient history for hip diagnoses. In this lecture, patient history falls squarely in the history. [00:00:24] One of the things you'll see in this course is that a couple of the slides are repeated, and that's done intentionally. We want you to understand how having the basic knowledge that you've already acquired can then be made specific to the body part that you're in. So, for example, for patient history, you would ask the regular questions that you know for patient history. [00:00:45] But then when it comes to the hip, there are some special considerations. So one of those is your patient age. There are some diagnoses that you can consider when the patient falls within that age range. So, for example, you have congenital hip dysplasia, and this can occur in infants. [00:01:03] You have Legg-Calve-Perthes disease, which is an osteonecrosis, or basically dying of the proximal femoral epiphysis. And that can occur in children ages four to eight versus something like stiff capital femoral epiphysis, which is SCFE, and that happens in adolescence. Versus something like degenerative joint disease, where you're looking at individuals who are 50 years plus, and osteoporosis that can occur in your elderly. [00:01:31] The other thing to consider is the mechanism of trauma. So you're asking mechanism of injury, sorry. So you're asking questions like, was it a traumatic injury that you have an accident and it started? Or is it something insidious, you have no idea, no known cause for it? Is it a history of overuse, so someone who might have been a runner [COUGH] or someone who's a pocky player, and there's a bunch of activities that they have done over and over, and if that's what's leading to your diagnosis. [00:01:59] And also a history suggestive of degenerative joint disease is things like trouble crossing your legs. That can be something that indicates that it could be DJD. So on this slide, you see some of the most common hip diagnoses broken down by age. And we'll be going over quite a few of these as we go through the lectures. [00:02:21] But this gives you an indication of something that you can consider in your differential diagnosis when it comes to the age of your patient. So in previous lectures, you have gone over the SIMS network for your patient history and pain. And what we're going to consider now is the nature of that pain when it comes to the hip. [00:02:42] So is the pain mechanical or is it non-mechanical? What are the sources of pain? Is it anterior? Where is that pain? Hip joint, femoral head? Is it femoral neck pain? Is it muscles crossing over the hip? Referral from other structures? So if you go to your book Magee at figure 11.4, you will see a picture that shows some of the referral patterns that can refer to the hip joint and then referral from the hip joint to other areas. [00:03:12] So is that low back pain actually caused by the hip? Is the groin pain actually caused by the hip? Is that lateral thigh or anterior thigh pain caused by something happening at the hip like the greater trochanter or the ITB? Is it being referred to the knee even though it is coming from the hip joint? [00:03:30] And then is it radiating? And what does radiating pain indicate? Sometimes that can be nerve involvement. And these are things that, as you're going through the nature of the pain, you're also thinking in your differential diagnosis, where could this source be? Following up on the nature of the pain, you also need to look at how the symptoms behave. [00:03:49] So one of the things you wanna look at is what makes the symptoms worse? Is it worse with movement? What type of movement? Is it flexion? Is it extension? Is it worse with weight bearing? Is it worse with gait? Is it worse with stands? Is it worse with change of motion? [00:04:07] So coming up from sit to stand, these are the kinds of things that you're going to be looking at when you look at your patient history. Also things like is there a difficulty of crossing legs? As we discussed earlier, this could indicate that the person is experiencing some sort of hip OA, osteoarthritis. [00:04:24] And then is there snapping sound with motion? So we call that collectively snapping hip syndrome or coxa sultans. And some of the things that can cause that is the iliopsoas tendon over the lesser trochanter or the ITB over the greater trochanter. You can also have some snapping if there's some loose bodies intraarticular. [00:04:46] And then you wanna find out is this condition improving, unchanging, or worsening. This tells you how your treatment will be issued. What kind of treatment will you choose based on the status of their problem? So we talked a little bit about this in the nature of their pain, but now you're gonna talk a little bit more specifically about the particular motions or activities that are weak or difficult. [00:05:14] Is it climbing stairs? Is it walking? As we said, sit to stand, rising from a chair, what activities in their lives are being affected? So are they recreational tennis or pickleball players? Is that something that's bothering them when they do that? Is it when they sustain certain motions? [00:05:33] So is it sitting for too long? Is it standing for too long? And then also the repetitive motions, and this can be in regular ADL's activities of daily living, or it can be repetitive motions in their sports or things that they do in their life. This figure is taken directly out of your textbook, McGee, and it basically gives you an outline of the type of pain someone may feel when they have certain diagnoses. [00:06:01] Now, it's really important that you take this in consideration with your other aspects of your examination. This is not a be-all and end- all scenario. Someone could not have sharp, intense pain with weight bearing and still have a fracture. So just make sure that you are taking this data in consideration with all the rest that you're getting during your examination. [00:06:29] When taking your health history, it's really important that you get a comprehensive view of that patient. So one of the things that you need to consider is are there additional conditions or related injuries that may be affecting this pain that the patient is feeling? And it may be something that is related to a surgical history in another area. [00:06:49] So the lumbar, hip, knee, ankle, or there could be a past surgery in the hip that's now maybe causing something else. So let's say someone had a total hip replacement, and now they're experiencing years later, maybe some arthritis and stuff like that. And that's the things that you need to think about, additional conditions or related injuries. [00:07:11] The other thing you wanna think about is medications. We know that there are medications that are linked to decrease in strength of your ligaments and tendons. And that's something that you wanna consider while your patient is with you. And also, I mean, there's a gamut of things that you need to consider in terms of medications. [00:07:30] We don't expect that you're going to memorize and know the data for all, but in this program you're going to have a pharmacology course where you can learn about the different medications and how they may be affected. So if somebody's on a beta blocker, what does that mean for their activity? [00:07:46] What does that mean for their pain? And so those are things that you wanna consider as you're going through your history. Your systems review is really important, as you consider does this person start therapy or not? So one of the things in that green zone. Yes, they're ready to begin therapy does not mean that you are not still monitoring. [00:08:08] But you do realize that in your systems review, there's nothing that's really concerning that may prevent them at the beginning. The other part is just looking at the high end where there's an emergency referral. You call 911 and you stop. I'm gonna give you a little story here that I think is important and why you do a systems review and why you always check throughout treatment. [00:08:30] We had a patient at one of my clinics who was there for an orthopedic condition, did our systems review at the beginning, health history was fine. And then I think during one of the first treatment sessions, there seems to be some very odd symptoms called emergency services. And that person was on the way to having a heart episode. [00:08:54] Now, I don't know if ended up being a myocardial infarction or what, but they were having an episode that required emergency attention. I say this story really to be, yes, at the beginning, you may do a systems review and you don't say anything for concern. But you're always, as you treat, as you examine, always looking for things that may indicate something so that you can do further investigation while that patient is with you. [00:09:18] And it doesn't only end on the first day, it's throughout the period of care that they are with you. As you consider social history and patient goals, these are really what's going to inform your treatment process as well as the goals that you write in your notes for that patient. [00:09:36] So the first thing is to consider is your living environment. Well, the patient's living environment, are there stairs? Is the bedroom on the first floor or the second floor? Is there shower? Do they need to step into a tub? Also things like, is there carpet? Is there tile? [00:09:50] These things can make navigation at home very difficult, and it's very important for you in therapy to address so that person is able to function when they're not with you. In terms of occupation, you're gonna think of, well, what does the work actually entail? Are they sitting? Are they standing? [00:10:08] And when you get that, it's gonna really inform the ergonomics that you need to work on. So if they're sitting, are they at a chair that has good ergonomic posturing for them so that they have hip, knee, and ankle at 90 degrees? What are the activities that are included in their occupation? [00:10:25] Is there lifting? Is there a lot of heavy equipment? Is there a lot of computer riding and all of that? Those are things that you need to really consider, as your goal is really for your patient to be able to act efficiently and effectively in their own environment. [00:10:41] [COUGH] In terms of activity history, you gotta think of sports. Are they a weekend warrior? Are they someone who has had a past in professional sports? Are they currently in professional sports? Is it a contact versus a non-contact sport? What are the repeated activities? Is there a lot of cutting? [00:10:59] Is there a lot of running? These are the things that you need to consider when you think of where your treatment is gonna be. Is it gonna be more simple? Is it gonna have a lot more activities included in it? Have they fallen in the past? And a big part of fall is how did they fall? [00:11:16] Was there some dizziness before? Was there random syncope? And these are things that will be discussed more in your cardio course. But it's something that you want to start thinking about as you go through your patient's social history. And also the perceptions and expectations. So perceptions of relatives to previous imaging study, sorry, or family history. [00:11:42] If they have a family history of a certain disease, they may just be expecting that that's what's gonna happen. If they've had a family member who's gone through physical therapy and either been successful or not, they come in with their own misconceptions or expectations. And then finally, what's the patient's personal goal? [00:12:00] Because you can get all this information and think that your goal is to get them back to playing tennis on the weekend. And their goal is to be able to bend to the floor to pick up their grandchildren. So those are the things that are very specific that you need to get from the patient [COUGH]. [00:12:19] So patients may have imaging available for review at evaluation. And one of the things that you need to be aware of are the measurements of the hip on radiograph. So here you see the femoral head uncovering, so that's right here. You now look at the neck-shaft angle through here and then the head teardrop angle here. [00:12:40] One of the other things that's not pointed out here, but is the space between the acetabulum and the pelvis. Those are things that are affected usually during your radiograph, depending on diagnosis. So as Dr. Mischke went over in the lumbopelvic series, one of the things you're going to use your SIMS for is to come up with your most likely hypotheses and then prioritize your physical examination based on that. [00:13:06] So is it that you're going to examine only to the first onset or the change of pain? Or can you use sustainable, repeated, or combined motion? And that all is dependent on what you've gotten through your SIMS evaluation questions. It's really important that you always put on your listening ears because most likely the patient will say something or describe something that tells you what's wrong and often will give you the first line of intervention that you may need. [00:13:36] So definitely put on your listening ears as your patient speaks. And finally, as you go through your patient history, ask any clarifying questions based on what the patient has said and their concerns. Review your understanding of the patient history. So I like to personally go over what the patient has said to me with them to ensure that I understood what they were trying to say and that we're on the same page. [00:14:00] That also begins the relationship of your trust with the patient. Because then they realize that you are actually listening to what they're saying. And then you can transition into your physical exam. Remember, at this point is when your hands are going onto your patient. So you always want to make sure that you're one explaining exactly what needs to happen. [00:14:21] Having their informed consent and permission to proceed. Determine the test and confirm and negate possible PT diagnoses. So this is the part where your differential diagnosis, you're testing that out. So you may come out of the patient history thinking about two or three different things. And as you go through your tests, you're either confirming or negating the possible diagnoses that they could be. [00:14:45] Now that you've completed the patient history, we're gonna move into screening for pathologies that may give you red flags. And also go into some of the diagnoses that you'll see most commonly, both pediatric hip diagnoses as well as other diagnoses that affect any age. [00:00:00] In this lecture, we'll be going over some of the hip diagnoses that you need to be aware of. If you are seeing symptoms for these, they are considered red flag pathologies and your goal at that point is to refer to a different specialty. The objectives for this lecture are, evaluate a patient's sign and symptoms to determine whether a patient is appropriate for physical therapy or requires an outside referral. [00:00:26] Analyze a patient's signs and symptoms to determine the most appropriate healthcare practitioner for referral and most appropriate initial imaging if warranted. You've seen this chart before and in this lecture, what you will be looking at is this red section here that says the patient is not appropriate for physical therapy intervention and must be referred or consulted with an appropriate healthcare provider. [00:00:57] There are two pediatric hip pathologies that we will be looking at and there's a separate lecture that deals with both of these, those are legg-calf perths and slip capital femoral epiphysis. The seven red flag hip pathologies that we will be looking at septic hip arthritis, femoral neck fracture, avascular necrosis, inguinal hernia, appendicitis, colon cancer and ovarian cysts. [00:01:25] Septic hip arthritis is inflammation of the joint that is caused by a bacterial infection. The primary risk factor is an abnormal synovium from rheumatoid or degenerative conditions. There are some predisposing factors in adults in forming septic arthritis and that's found in the box on the right, box 25.3 from your Goodman and Filler textbook. [00:01:50] One of those is immunosuppression from either chemotherapy, HIV, diabetes mellitus that's poorly controlled alcohol or drug use and chronic renal failure. Septic hip arthritis results in an acute onset of joint pain, SW swelling, tenderness and loss of motion. When you do your examination your palpation, you'll feel warmth, swelling, redness and loss of function. [00:02:19] Those are typical signs that there's an affection present, you may have an increased body temperature, but you will for sure have that warmth at the area. The patient will have an unwillingness to weight bear at the joint and move the involved hip, it will move rapidly to intense pain for that patient. [00:02:42] The next diagnosis we will be covering is the femoral neck fracture, females who are above 70 years of age are most commonly affected and they usually report hip, groin, thigh or even knee pain. The most common way that these fractures occur is from a fall from standing and they're associated with an acute onset of pain. [00:03:07] Patients who have a history of falls or trauma are people that you should be looking at and trying to figure out if a femoral neck fracture is part of the differential diagnosis that you're going to conduct in their evaluation. They suffer from severe, constant aching groin or anterior thigh pain and it's worse with movement and weight bearing, so you will see an antalgic gait pattern and maybe some avoidance of weight bearing on that leg. [00:03:37] What you do need to note with femoral neck fractures is that the femoral neck bone stress fractures are most common in young athletes such as endurance athletes and runners. Military personnel and elderly who have osteoporosis, which affects women more than men, may also have stress factors. The next diagnosis that we're going to cover is avascular necrosis, and from the name you can get the root of the word. [00:04:08] So avascular is the lack of blood supply and necrosis stands for death, so it is the death of bone and bone marrow cellular components that results from a loss of blood supply and it is usually in the absence of infection. The other name for this is osteonecrosis or death of the bone, the femoral head is the most common site for avascular necrosis. [00:04:33] History of long-term corticosteroid use and AVN of the other hip is usually indicative of someone having AVN. They've also been associated with trauma such as after femoral neck fraction that may have gone undiagnosed and the blood supply was affected. The pain starts off mild and intermittent, but it rapidly progress and it may also refer down to the groin, thigh or medial knee. [00:05:02] It is worse with weight bearing, so you will see people who have an antalgic gait pattern and sometimes will avoid putting weight on that limb. There's a global loss of movement, especially especially in internal rotation, flexion and adduction. The patient will report that it was slowly progressive stiffening of the joint. [00:05:24] Cuz if you think of it, if it's the blood supply slowly cuts off till there's none, eventually you find that movement stiffening happening. And finally you'll see the crescent sign which is indicated in the slide here by where the arrows are so right there, and you can see it, I think much more clearly here on the left side, and that is where the crescent sign is on imaging. [00:05:52] Inguinal hernias are about 75% of all hernias and 25% of those affect men, you'll see a bulging of the content of the abdomen through weakness in the lower abdominal wall and it can either be intermittent or persistent. So as you look at this slide here you see the indirect inguinal hernia and the direct inguinal hernia. [00:06:20] And really you see how low on the abdominal wall that is affected on both of these slides versus looking at the femoral that comes through the femoral canal or even abdominal hernia. You'll find that the individuals will complain of groin pain and men will even say that they have testicular pain. [00:06:44] It's aggravated in females by menstruation, and key to these symptoms is that they worsen when you change position. So if somebody is going from lying down to sitting up or coughing, that Valsalva movement or sneezing, same thing with Valsalva. That can increase the pressure in the abdomen, therefore increasing the pain in the hernia and resisted sit up also causes pain, the tenderness is in the area directly over the inguinal canal. [00:07:16] So right lower quadrant pain that can be associated with anorexia, nausea, vomiting and a low grade fever can be indicative of appendicitis. The pain is constant, but I can tell you from personally having gone through this, the pain is constant, but then ever so often there's a sharp pain that goes across the area. [00:07:40] It's aggravated by increases in abdominal pressure, so just walking or bending over or coughing can increase that pain. The pain can refer down to the right thigh or testicle or testicle, but the best way to figure out if it is appendicitis is by rebound tenderness. So if you look at the picture right here, you will see McBurney's point, and if you push in lightly and then release, the pain is felt on the release for appendicitis. [00:08:13] Colon cancer is most common in individuals who are above the age of 50, 50. They'll have also associated bowel disturbances, so issues with going to the bathroom for number two, unexplained weight loss, anorexia and just general malaise. If they have a history of colon cancer in their family and also if they have not been going for colonoscopies, that may be something that you're thinking of in your history taking and differential diagnosis. [00:08:45] The pain is unchanged by position, so no matter how they lay, how they move, it is just a constant pain that is there. And you may, if you're using your stethoscope, hear either hypoactive or hyperactive bowel sounds from obstruction. It may present as abdominal pain, but the patient may also have some bleeding, some constipation or obstruction. [00:09:09] And in really bad cases, ascites, which is large amounts of fluid that can cause shortness of breath. The last diagnosis we'll be covering are ovarian cysts, so these are most common tumor of the ovaries, but they're mostly benign. They affect women of childbearing age, which is key in your differential diagnosis, you are not expecting this for women who are older and past childbearing age and it affects 3 to 7% of them. [00:09:40] The risk factors include people who are taking infertility medication, who are currently pregnant, have a diagnosis of endometriosis or severe pelvic infection. When they have symptoms, it may include some abdominal heaviness, pelvic groin, low back or buttock pain, breast tenderness not associated with an increase in density. They may have some dysmenorrhea, which is issues with their periods, or they may have lasting or recurrent genital pain, which is dysparneur that occurs just before, during or after sex. [00:10:17] The patient will report to you pelvic pain, nausea and vomiting, the key to this lecture is that all of these diagnoses constitute red flag pathologies that require referral to another specific specialty. What you are looking for is if somebody is complaining of any of these symptoms. So if they're complaining of a rapid onset of pain in the hip area and they can't weight bear through the leg, you may be thinking it might be a fracture. [00:10:48] Or you may be thinking this person has pain when they're changing positions, if they're coughing and they have pain so that's increased abdominal pressure, maybe they have a hernia. These are all the things that you're thinking of in order to determine is this person really fit for physical therapy. [00:11:08] If they are not, then your goal really is to get them to the right specialty to be taken care of. [00:00:00] In this lecture we will be covering the pediatric hip pathologies that constitute red flag pathologies in ortho. The objectives for this lecture are to understand the pediatric conditions associated with the hip joint. And to recognize signs and symptoms of pediatric hip conditions on examination and when a possible diagnosis requires referral. [00:00:24] I wanna stress to you that this is not all encompassing of all pediatric hip pathologies, but specifically the hip pathologies that constitute a red flag pathology and require referral. The diagnoses that we will be covering are developmental dysplasia of the hip, Legg- Calve Perthes disease, acute transient synovitis, slipped capital femoral epiphysis, and apophysitis. [00:00:51] The key to these is also recognizing the age group that are most commonly affected by these diagnoses. This is important when you're looking through your examination to kind of consider as you go through some of the questions. Remember that it is not all encompassing that somebody who does have Legg-Calve Perthes can maybe be a little bit older, but these are the general age groups that suffer from these diagnoses. [00:01:19] Developmental dysplasia of the hip is either unilateral or bilateral hip dysplasia and it can be unstable, which is the hip position normally, but can be dislocated by manipulation. It can be subluxation or incomplete dislocation. And this is when the femoral head remains in contact with the acetabulum but the head of the femur is partially displaced. [00:01:44] Or it can be a complete dislocation where the femoral head is completely outside of the acetabulum. The incidence for subluxation is 1 in 100 and dysplasia 1 to 5 in 1000. It affects females more than males and Native Americans more than white more than black. 25% of all cases are bilateral where the left is more affected than the right and that's 3 to 1. [00:02:12] There is not much research that says why this is the case, but it just is what it is. Their risk factors are a breech delivery, large neonate twins or multiple births. Usually the result of a mechanical physiologic or environmental factors. So if they're mechanical is the malposition in the womb, which is breech, so which is feet first. [00:02:36] Physiologic is in utero hormones, so depending on the estrogen and relaxin. And environmental could be cultural positioning of infants and swaddling. Clinically, developmental dysplasia of the hip presents with restricted or asymmetrical hip abduction. There's less mobility on the affected side. You'll find asymmetrical gluteal or thigh folds. So the gluteal fold, which is the buttock fold, is usually higher on the affected side. [00:03:06] And you'll see positive Barlow's or Otolani's tests and a positive Galeazzi sign. These tests you'll most likely do in your pediatric class. So for now you just be aware of the names and that they are positive when a child demonstrates developmental dysplasia of the hip. On the right, you will see an image of developmental dysplasia on the hip where you see the right. [00:03:30] The head of the femur is sitting laterally to the acetabulum. And the roof of the acetabulum appears to be dysplastic. And the proximal femur sits somewhat valgus in the joint. Interventions for this, so in younger patients there's abduction bracing and usually is worn for a month and then they'll reevaluate to see if that needs to be done further. [00:03:53] If you google the look of the Pavlik harness, you'll see that that's the dynamic abduction heart splint that's used for children under 6 months. 9 months or older, you may attempt some rigid abduction bracing and the reason that now you're getting rigid is that the child is developing a little bit more and it's before they begin gait. [00:04:18] You may also consider a close reduction immobilization with a spike or plinth if that is necessary. Legg-Calve Perthes disease is avascular necrosis of the proximal end of the femur. It's characterized by, as we talked about, lack of blood supply and death to the capital femoral epiphysis, which is the center of ossification for the femoral head. [00:04:47] It's prevalent 1 in 1200 children, primarily boys 5 to 1. Usually, they're in within the age of 5 to 8 years old. And it occurs 10 to 1 in those identifying as white to black. Reduction in blood flow to the femoral head leads to ischemia. So lack of blood supply there, which eventually leads to the death. [00:05:10] There are four stages and they last two to five years. If you look at the arrow in this picture, you'll see where you're seeing right here, the line where you're starting to see some necrosis. Clinically, Legg- Calve Perthes usually has an insidious onset. You'll see a limp with hip pain. [00:05:34] The patient may also complain of groin pain along the obturator nerve path, and can refer to the knee. If you do pinpoint tenderness or palpation, it will be over the hip capsule. And aggravated with any sort of weight bearing or activity. And of course, when they're not weight bearing or resting, that's when symptoms are relieved. [00:05:56] The patients present also with limited hip abduction and rotation in the late phases. The treatment for this is to reduce pain and restore and maintain hip mobility. So range of motion training, gait training, and education. And to really prevent deformity, so abduction, bracing, casting, and possibly surgery. Acute transient synovitis is an inflammation of the synovial joint of the hip joint and it does disappear usually after a few days. [00:06:25] It's an unknown etiology, but it could be related to an infection in another area of the body. Often, it is a viral upper respiratory or gastrointestinal tract infection. So the parent may say that the kid had a flu a couple days ago, so runny nose, cough, or they may have either constipation or diarrhea. [00:06:47] The epidemiology says that at peak frequency occurs around 5 or 6 years of age. It's the most common cause of acute hip pain and limp in this age group. So you really wanna start thinking about this if a kid is coming in around this age and limping. The person does have about a 5% chance of developing avascular necrosis or Legg-Calve Perthes. [00:07:11] In the clinic you will see acute onset of pain, well, you get a report of acute onset of pain. You'll see a refusal to weight bear, or they're walking with a limp. And decreased hip range of motion at end ranges. So at end ranges being that you're comparing one side to the other and they may be missing a couple degrees at the end range cuz that's when they're getting irritation. [00:07:34] Internal rotation is often the most limited. And no fever is associated. The treatment for acute transient synovitis initially involves bedrest and non-weight bearing. Remember, in your description we talked about the fact that this could disappear in a couple days. So really that bed rest gets rid of that initial pain and aggravation. [00:07:55] If the kid can walk with crutches, you can try some partial weight bearing with crutches. And the key here is really monitoring for Legg- Calve Perthes or avascular necrosis, which could involve radiographs. Depending on the state that you work in, you can either request those radiographs yourself or refer to another specialty for it. [00:08:17] Slipped capital femoral epiphysis is a posterior and inferior slippage of the proximal femoral epiphysis on the femoral neck through the epiphyseal plate. So it's a lot of words, but I think it's really clearly seen in the radiograph. So if you look right here, you see that it's a posterior, so back and down slippage of the femoral epiphysis on the femoral neck, which is here, and through the epiphyseal plate. [00:08:55] Patients that usually are affected by this are overweight as adolescents, usually through the ages of 9 to 17. And they have a recent growth spurt. There's groin pain made worse with weight bearing. And the involved leg, they hold it in external rotation. And limit hip internal rotation. And if you think about it as you're sitting there, if you turn your hip into internal rotation, it kind of grinds the femoral head against the acetabulum. [00:09:23] And so they avoid that motion because there is that slippage and it causes acute pain. So slipped capital femoral epiphysis is often referred to as SCFE. And you'll see that we talked in the previous slide about it happening in adolescents from usually about 9 to 17. It's most common in that age group, 11 to 16 years of age. [00:09:47] It affects males more than females 2 to 1. As we talked about, the patients are usually overweight and they usually fall within the 80th to the 100th percentile of that weight spectrum. It's more common in Black and Polynesian races. And approximately 40 to 50% are bilateral, okay? It's usually idiopathic and has an insidious onset that occurs, as we talked about again, in at growth spurts of puberty. [00:10:16] So if a patient comes in who's at puberty complaining of hip pain issues, walking, you see that external rotation of the hip. That's what you're really gonna start thinking about for SCFE. In the clinic, you find patients with SCFE who have either acute or chronic pain. The acute pain is within less than one month, and the chronic pain is up to six months, and they described it as gradually onsetting. [00:10:45] The pain increases gradually and there's often a limp. They may complain of pain referring down to the knee or the anterior thigh. They do have an antalgic gait, which is a painful gait. And as we talked about that, they kind of have that leg and external rotation at occasion. [00:11:02] You may see some limb length shortening. Definitely you'll have painful or not at all internal rotation, and of course that relieves with the opposite direction of external rotation. Even through flexion, you'll find it limited, and you will see that they deviate into external rotation and abduction. They present with a positive log roll test and a straight leg raise test with resistance testing. [00:11:26] To treat this it's really non-weight bearing on crutches initially and they may require surgical pinning. The last diagnosis we'll be dealing with is apophysitis, and this is a traction injury. So traction is pulling apart to the cartilage and bony attachment of tendons in children and adolescents. They usually get some irritation, inflammation, and or micro trauma to the apophyses. [00:11:53] In this diagram on the right, you see the major apophyses highlighted in blue. So you have the iliac crest, anterior superior iliac spine, anterior inferior iliac spine, the greater trochanter, lesser trochanter, ischial tuberosity, and the pubic symphysis. Even though these are all the sites that it could occur, the most common site at the hip of pelvis are the ischial tuberosities, the iliac crest, ESIS and AIIs occur after that, and then the greater and lesser trochanters. [00:12:28] Etiology, most often it's an overuse injury in children who are growing and have tight or inflexible muscle tendon joints. There's early specialization in a sport or they're doing a sport year round or multiple sports that include the same kind of activities in the same season. They have increased training demands and underlying biomechanical factors. [00:12:53] In the clinic, patients with apophysitis present with gradual onset of pain without a specific mode of injury. There's a localized pain with palpation to that apophysis. It worsens with repetitive activity, so as the season goes on, it gets worse. And the symptoms with resistance testing or passive stretching of contractile tissues is what you'll see. [00:13:14] So when you're doing your MMTs or you're doing stretching or MLT tests, you'll find that that's when you find the symptoms. The treatment is prevention. So they need to do proper warmup, warming up the muscles, stretching, improved biomechanics, so stretching and strengthening. Avoid playing through the pain, so once the pain occurs, there's stop no limping during or after the activity. [00:13:39] And education on multiple sports, how to do less in the season, cross training. So different types of sports to use different muscles cuz as you saw, it occurs with repetitive motions. So those are your pediatric red flag pathologies that may often require referral to another specialty. Again, you will go over some of these diagnoses in your pediatric course. [00:14:06] And the point here is to know what these symptoms are, know the age groups that may be affected. So that if someone comes in and they are presenting in these manners that you're able to refer out to the right specialty if needed. [00:00:00] Before we delve into hip diagnoses, this lecture is to reintroduce the framework for your differential diagnosis and how you think through those diagnoses. The objective is to understand key distinction of differential diagnosis for the hip. In this section we'll be discussing the diagnoses and they can fall into any of these measures. [00:00:22] So the first will be your history in listening to your patient, you won't be able to come up with what may be your PT diagnosis and of course prognosis from that. And of course you're planning your interventions based on what the PT diagnosis is. When looking at the hip, you want to think of intra articular and extra articular diagnoses and how they manifest intra articular means within the joint and extraarticular means external to the joint. [00:00:53] For example, how does pain differ when it is joint pain versus muscle pain? Joint pain will include pain with weight bearing, but muscle pain will be induced with activation of the muscle. Extra-articular diagnoses can include muscle but can also include tendons, fascia and bursa. The intra-articular diagnoses that we will cover in the hip are hip osteoarthritis, femoroacetabular impingement or labral tears. [00:01:28] The extra-articular diagnoses that we will cover are hip flexor or iliopsoas injury, greater trochanteric pain syndrome, piriformis syndrome, hamstring strain, and adductor strain. This table shows some of the most common hip diagnoses, those highlighted in yellow are the ones that we will be covering in this course. Versus those that are not highlighted, we will not be covering, but can provide additional resources for you should you need them both now and in the clinic. [00:02:01] When looking at hip pain distribution, the pain and its location can be an indication of the diagnosis. For example, anterior hip pain could indicate a femoral acetabular impingement or labral tear versus medial pain may indicate an adductor strain. Looking at pain alone will not suffice for your examination, this must be taken into consideration with other tests such as your special tests and your examination MMTs, MLTs in order to make your diagnosis. [00:02:37] The next couple lectures will go into specific diagnoses so that you're able to know the most common signs and symptoms when you are in your examination. [00:00:01] So first we'll be going over hip osteoarthritis which will be our first intra articular diagnosis. The objectives for this lecture are to identify key clinical findings associated with hip osteoarthritis and to understand appropriate treatment considerations based on clinical findings. As we go through the diagnoses, you'll see that we will cover aspects of the history, the tests and measures that can be performed and that will show a positive or negative for those diagnoses. [00:00:31] And then aspects of your evaluation that would lead to your physical therapy diagnosis, your plan of care and interventions. As you delve more and more into evidence based practice, you will find that some of the common diagnoses have clinical practice guidelines or CPGs that you can use for determining what you would do in the clinic. [00:00:57] Hip osteoarthritis is one of those and this resource can be found free with your APT membership but also will be located in the resources for this course. Osteoarthritis is also known as degenerative joint disease and can be found in any joint in the body. It is a slow evolving articular disease originating in the cartilage and affects the underlying bone, soft tissues and synovial fluid. [00:01:24] In the image on the right you will see the hip osteoarthritis and it shows a couple things. The first is complete degeneration of the joint, you see bone on bone as it is colloquially called, at the arrow here you can see an osteophyte coming out, so that's an additional growth of bone. [00:01:49] And then here in this white section here you see increased bone density that is also called buttressing or buttressing of the bone and that can be also seen in hip osteoarthritis. Hip osteoarthritis is the most common cause of hip pain in adults over 50 years of age, 0.4 to 27% of adults suffer from hip OA and it affects women more than men. [00:02:16] However, the prevalence of radiographic hip OE or hip OE that shows up on radiographs is more common in men than women. The risk factors for hip osteoarthritis are age, a history of hip developmental disorders, so one we discussed was hip dysplasia. Previous hip joint history, reduced hip range of motion, especially internal rotation, presence of osteophytes, lower socioeconomic status, higher bone mass and increased BMI associated with the risk of hip OA for both men and women. [00:02:52] Similarly, so one that I'd like to talk a little bit about is the lower socioeconomic status and it doesn't mean that a lower socioeconomic status just automatically equates to hip OA. What it does point out to us is that individuals who are from a lower socioeconomic status tend to have more manual labor jobs. [00:03:12] So that is more pressure and pain through the joint, weight bearing through the joint so that increase the risk of diagnoses occurring there. And also it's access to food that may end up being foods that are unhealthy and therefore increase the risk of BMI as well. In your examination, the first aspect you would use would be your self report questionnaires at the patient fills out. [00:03:40] The CPG recommends using validated outcome measures in the domains of hip pain and body function impairment, activity limitation and participation restriction. In the realm of hip pain, the CPG recommends WOMAC, the brief pain inventory, pressure pain threshold or the pain visual analog scale. In the realm of body function impairment, activity limitation and participation restriction, the CPG recommends using the WOMAC physical function subscale. [00:04:12] The hip disability and osteoarthritis outcome score or HOOS, the lower extremity functional scale or LEFS, or the harris hip score or HHS. Now remember, you do not need to have your patient fill out all of these, but you choose in your clinic one of each of these. So one from hip pain and one from the body functions scales and to have your patient fill out those. [00:04:38] So as you begin your examination, these are a couple of the clinical findings that you will see. You'll have moderate anterior or lateral hip pain with weight bearing activities. You'll see the C-sign and we will have a picture of that coming up but it's basically you ask the patient to show you where their hand is. [00:04:55] And they take the web space between their thumb and their finger and they place it on their hip and that will be right above the greater trochanter and that's the C-sign. Morning stiffness less than 1 hour in duration after waking, so they get up stiff and then as they move it kind of loosens up. [00:05:13] They have hip internal rotation of less than 24 degrees, internal rotation and hip flexion 15 degrees less than the non-painful side. So you'll find that those two compared to the contralateral side are much more decreased. You have increased hip pain associated with passive hip internal rotation and if you think about it, right. [00:05:36] Hip internal rotation causes almost like a decrease of that space in the hip, so it causes more grinding. So if they have less space there because of hip away, it causes more pain. There's absence of a history activity limitations and or impairments that are inconsistent with hip crepitus. [00:05:57] They have tenderness on pressure and joint effusion or swelling in the joint. As we said in the last slide this is a picture of the C-sign, as you can see, between the thumb and the index finger, that web space, they place it right above the greater trochanter. This slide gives you a summary of the main clinical findings you see. [00:06:18] So we did discuss that you'll have some degrees of motion limitations, but your key here really is that internal rotation range of motion. Which will be less than 24 degrees and it would be 15 degrees less than the contralateral side, that's a give or take. You have pain and stiffness at end range, decreased accessory mobility, passive accessories within the joint and of course you'll have some weak hip musculature joint. [00:06:42] That's because there's pain with weight bearing and pain with using this joint, so therefore they're not going to be doing as much muscle work. So when we talk about activity limitations, there are four tests that you would do clinically that will help you to figure out where your patient's baseline is. [00:07:01] And then you can do these as follow up for treatment and to see where that patient is going towards their goals. So the first one is the four square test, second is the step test, the third is your single limb stance test timed and your 32nd sit to stand test [COUGH]. [00:07:20] The first two tests we'll review for activity limitations for Hippo A are the four square test and the step test. The four square test, a patient stands in one of the corners of the square and they must step with both feet in every one of the squares, first in a clockwise direction and then a counterclockwise direction. [00:07:42] We time it and they are looking for 8 to 9 seconds with 1 to 8 seconds meaning a meaningful change or MDC, the patient must step and not hop or jump into the steps. The second test, the step test, uses a 15 centimeter step and we time for 15 seconds as the patient lifts only the uninvolved leg up to the step and down to the step. [00:08:09] They have a mean score of 14.6 and a change of 3 to be meaningful, they must step as fast as they can. This step really puts all of the weight into that involved leg and as you know, with hip away, that is something that causes irritation. So if they are very much affected, they will not last as long on the step. [00:08:31] The next two tests that we will be going through for activity limitations for hip OA are the single limb stance timed test and the 32nd sit to stand test. For the single limb test, the patient is standing on the involved leg with their hands on their hip and their uninvolved leg off the ground and bent at the knee so that the foot is posterior to the body. [00:08:53] You are timing the patient for how long they can stand here and you stop the timer if they remove their hands from the hip. If they use the uninvolved hip, a leg across the involved to get support, or if that uninvolved leg touches the ground. The average here is 21 seconds and you have an 8 second MDC for this test you do perform two trials. [00:09:18] For the 30 second sit to stand test, the patient is asked to scoot all the way forward on the chair with their feet flat on the ground and arms crossed across their body. You do go through one full trial of them standing all the way up and having a seat and then you start the timer for 30 seconds. [00:09:34] The average is 12.6 times for the sit to stand with an MDC of 3.5. When it comes to hip OA, plain film radiography is most often used and this is for both diagnosing and assessing the progress of hip OA. We did review this image already that you see on this slide, but let's go over it again. [00:09:57] We have here you have the decrease of the space between the femoral head and the acetabulum. You have an osteophyte building over here and you have some buttressing here that you see that shows up a little bit of darker white. When you're using the radiography, you can look for again joint narrowing. [00:10:16] As we pointed out, the presence of osteophytes, which we pointed out, and some subchondral sclerosis or cysts. And specifically subchondral sclerosis is thickening of the bone beneath the cartilage of the joint. So when we look at hip OA and what you see in front of you is really specific for mild to moderate hip OA, we look at four areas for management that are key. [00:10:42] So one is patient educated, functional gait, balance training and manual therapy, and then of course, exercises. So for patient education, you're really focusing on activity modification, encouraging them to exercise. If they did have a BMI that was higher, then you're looking at supporting weight reduction and maybe even helping to refer to a dietitian and of course methods of unloading the arthritic joint. [00:11:09] So maybe that may include using an assistive device, which you'll see in the functional and gait balance training. So as you go over gait, you're looking at balance, are they at risk for falls and if they are risk for falls, what can you give them that would support them being more steady? [00:11:27] So one of those is assistive devices manual therapy, so for mild to moderate hip OA you have joint mobility, flexibility and or pain [COUGH]. Therefore you can do thrust, non-thrust or soft tissue mobilization and usually your dosage is one to three times per week over a six week period of duration. [00:11:52] For exercises you're really looking at, as the hip motion improves, you start incorporating more and more exercises to increase flexibility, strengthening and endurance. You're looking at a dosage of 1 to 5 times per week for a 6 to 12 week duration. So this image is from the CPG and is just another way of looking at the information we just discussed and here it goes into a little bit more detail. [00:12:18] So take your time to go over what you will be doing for a patient with mild to moderate hip OA. So when we talked about treatment we discussed that it would be for mild to moderate OA. One of the things you need to consider is someone who has severe hip OA is most likely going to be a candidate for surgery and most likely a total hip replacement. [00:12:41] So we'll be discussing that when we do post op in your treatment lectures two weeks from now. [00:00:00] The next diagnosis we will be covering is femoroacetabular impingement syndrome and labral tears. The objectives for this lecture are to identify key clinical findings associated with femoral acetabular impingement syndrome, or FAI, and understand appropriate treatment considerations based on those clinical findings. As with all of the diagnoses that we cover, we will be covering questions for your history and information you can gather. [00:00:29] Tests and measures, how you can use that to come up with your PT diagnosis, plan of care and interventions. FAI does have a CPG. So FAI presents as hip pain secondary to mechanical impingement. It's usually due to abnormal anatomy involving either the proximal femur or the acetabulum, or both. [00:00:59] Rotation to arcs of extreme motion. So extreme rotation or when there's repetitive abnormal contact between the bony prominences can lead to soft tissue damage of the femoral acetabular joint. The labrum particularly is at risk of damage when the arthrokinematics of the joint are altered. 10 to 15% of adults suffer from FAI and the prevalence of symptomatic athletes is actually higher than that of the general population at 55%. [00:01:32] Pincer FAI is more common in women than men, and CAM FAI is more common in men than women. We'll be going over what these are in a little bit. Labral tears occur in up to 20% of athletes with groin pain. They've been observed in 96% of older individuals. [00:01:53] And 74.1% of labral tears are not associated with any known specific event. So, FAI is associated with any predisposing factors that alter the normal osseous anatomy or bony anatomy of the hip. These can include prior slipped capital femoral epiphysis, avascular necrosis, altered femoral head to neck junction configuration, acetabular retroversion, developmental hip dysplasia. [00:02:23] And it leads to pain with repetitive extreme ranges of motion. So there are two main types of FAI that we discussed in the slide before, one being CAM, the other being pincer. And then you can have a form of FAI where they are mixed, and you have both. [00:02:42] So, the CAM FAI is what you see right here, and that is an extra brony growth on the bump of the femoral head. So it makes the femoral head not round and it cannot rotate smoothly inside of the acetabulum. This can grind inside the acetabulum and can lead to tears that way. [00:03:03] The pincer is what you see here, and that is the abnormal bone or extra bone that extends over the rim of the acetabulum. In this version, the labrum can really be crushed under the prominent rim of the acetabulum. In the mixed FAI, you can see here you have both the CAM and the pincer deformities. [00:03:32] Here you have that picture blown up. And you will see here the explanations as found in your McInnes textbook of both the cam and the pincer FAI. In the radiography or image that you see here, you see a couple things. One, you see that darker or clearer white that indicates an excess of bone. [00:03:55] So that's your CAM deficiency there. And then you also see here, right here, osteophyte off of the acetabulum. And that can indicate a pincer FAI and therefore making this a little bit of a mixed FAI. So in your examination, you would perform the FABER and FADIR tests, and we will be going over these in your next week, when we talk about special tests for the hip. [00:04:25] You would get consistent imaging cuz as you can tell with the bony growth, you cannot see that with the eye. You do need to use outcome measures that assess the impact of impairments on activity limitations and participation restrictions. So a couple of those can be the I-HOT, we have been over the I-HOT 12 and the HAGOS. [00:04:47] And then you also have the HOS-ADL and the HOS-SRA. The patient will experience anterior groin pain and pain with activities that include kicking, sprinting or running and squatting. The examination for FAI and labral tears should also include objective and reproducible measures of hip pain, mobility, muscle strength and movement coordination. [00:05:14] And specifically perform measures of range of motion and strength for hip internal rotation, external rotation, flexion, extension, abduction and adduction. Be sure that you're always comparing this to both sides. Measures of function and postural control should also be included. Which performance tests such as single leg stands, star excursion, balance test, hop distance, single leg sit to stand, and timed measures of function, like a 6 meter walk test. [00:05:50] This slide is included, not so that you have to memorize all of it, but to show you where your brain is going as you work through. So you know that you have pain, you have anterior hip pain. And so now you need to rule out, is this osteoarthritis, is it a nerve entrapment, is it maybe a psoas abscess? [00:06:12] So, what you're doing as you choose your tests and measures, they are meant to help you to kind of knock off one of these diagnoses as you go through. That's part of the differential diagnosis and why you're choosing specific tests to ensure that you are getting the right diagnosis. [00:06:31] For FAI specifically, you will get sharp groin pain with hip flexion and internal rotation. And the reason for this is when you do those motions, you are getting decreased space in the hip joint and therefore more of that grinding motion. Anterior groin pain or lateral hip pain is also common. [00:06:52] You have a very painful squat. You have a positive FADIR and FABER, and you need to look at pain or it's asymmetrical for FABER. And the Thomas test here is used as a screening test and not as a diagnosis test. The CPG for FAI suggests the intervention strategies that you see below. [00:07:18] We will go into a more specific example of exercise and interventions for FAI in Week 7, [COUGH]. That concludes our lecture on FAI and it also includes the intra articular hip diagnoses that we will be using in this course. As you start building your knowledge on the hip diagnoses, I want you to start thinking about what is similar and what is different between the two. [00:07:47] So we know that they both have some anterior hip pain, but what is different. So, with your FAI, you have extreme rotation that causes sharp pain versus your hip osteoarthritis. Your pain is gradual and just with weight bearing and walking. So, this is how you're starting to build those differential diagnosis skills. [00:08:10] You're thinking of what is similar between them, but how can you differentiate between the two? So what tests can you do? In the case of these two, you'd do FABER and they'd be positive for both. But then you can do FADIR for FAI and have a positive test there. [00:08:26] That can help you to differentiate. And as you go through these diagnoses, I want you to start thinking about that. We'll talk a little bit about that in our sync sessions as well. [00:00:01] The next diagnosis we will be covering in the hip region is greater trochanteric pain syndrome. The objectives for this lecture are to identify key clinical findings associated with greater trochanteric pain syndrome and to understand appropriate treatment considerations based on those clinical findings. Repetition is key and so as you know with our diagnoses we will be covering history, test and measures how those can be used in your evaluation to come up with your PT diagnosis and prognosis and the plan of care, including interventions. [00:00:38] Greater trochanteric pain syndrome is actually caused predominantly by gluteus medius tendinopathy that presents with lateral hip pain. The pain occurs over the greater trochanter and may extend down to the lateral thigh. As you can see in the image to the right, the gluteal muscle of gluteus medius. It inserts onto the greater trochanter and therefore that is why that pain shows up as a lateral pain. [00:01:09] Often you will find that you see thickening or thinning of and tears in the gluteus medius and or the gluteus minimus tendons. You can also see changes in the bursal structure on ultrasound and MRI. Greater trochanteric pain syndrome is most common in people who are 40 years and older and it is more common in women than men. [00:01:37] As discussed previously, for this slide you are not expected to memorize all of these possible symptoms. What this is meant to do is to jog your thinking and memory on how lateral hip pain for different diagnoses presents. And how in your examination and what tests you can perform in your examination that will help you to differentiate if it is greater trochanteric pain syndrome versus possibly cancer or even a lumbar spine referral. [00:02:10] Part of this will occur when you're doing your systems review in the beginning to see if the pain is coming from the spine, the knee, the hip. When going into your examination, you will still be using the information from your self-report questionnaires for such things as your activities and participation limitations I've seen most often here the LEFS is used special tests. [00:02:37] You will have a positive over and a positive favor and again this should be jogging your memory. We've seen positive favor quite a few times in FAI and in hip OA. However, what has made it different is the other tests that are also positive with it. Here you'll perform single leg stance tests. [00:02:55] You'll have resisted IR and resisted Tests as well as resisted abduction tests that are positive and painful palpation over the greater trochanter. For your movement pattern, you'll see increased hip ab duction, a lateral pelvic tilt, hip internal rotation, and an overactive TFL. Your clinical findings, you'll find that pain over the greater trochanter can extend down the lateral thigh. [00:03:24] The patient will report difficulty lying on that side at night, standing, walking, and up and down stairs. Basically, weightbearing activities and sitting are also difficult for the patient. So how do we manage gluteal tendinopathy? The first phase is just load management. So as we talked about, the patient has difficulty with weightbearing activities and also laying on that side. [00:03:51] So one of the first things you can do is reducing that compression. It may include having to use assistive devices so you're not putting all the weight through the limb. And then nighttime posturing can include just not sleeping on that limb. But it can also include things like how you place pillows so that the patient is comfortable and not in pain. [00:04:10] Hip adduction stretches are really great for this, as well as modification of their recreation or sporting activities. There may be a point of not doing them so that you can have symptom relief and begin really rehabbing to be able to go back. The next part becomes exercise therapy. [00:04:29] So now you're restoring and loading them. So restorative loading in your exercises. So first you'll start off with just isometric exercises cuz again, you do not want to contract or eccentrically contract that muscle so that they get pain. So you're doing isometric exercises, low velocity, high load exercises. [00:04:52] So weightbearing is most effective, but you're not doing speed training. And then finally movement retraining and of course, functional loading. The final part is management of the modifiable risk factors and comorbidities. So interventions that can improve lumbar hip knee may be necessary, depending on how that affects their arthrokinematic movements. [00:05:22] As we continue to work through these diagnoses, again, I want to reiterate the point of looking at how these diagnoses are similar and how you can differentiate between them, cuz that's really going to help your differential diagnosis skills. The other part of it is I want you to start thinking about exercises that you do every day that can be used in rehab for these patients based on what the treatment plans look like. [00:05:49] So we'll go over that in week seven for exercises, but if you can start thinking of that now, it'll make it a lot easier then. [00:00:01] The next diagnosis that we are going to cover is piriformis syndrome, and it is one of the posterior hip pain diagnoses. The objectives for this lecture are to identify key clinical findings associated with piriformis syndrome, and understand appropriate treatment considerations based on those clinical findings. As with all of our diagnoses, we will cover aspects of the history, tests and measures, evaluation leading to your PT diagnosis and prognosis, and eventually your plan of care and interventions. [00:00:36] So piriformis syndrome is the first that is neuromuscular that we have covered for the hip and buttock pain. And it's resulting from a compression of the sciatic nerve, either completely or in part, in the deep gluteal space by the piriformis muscle. The sciatic nerve pierces the piriformis in about 16% of healthy individuals. [00:01:01] 5 to 36% of all cases of low back pain are piriformis syndrome and up to 17% of patients with chronic low back pain. It affects women more than men in a 6 to 1 incidence ratio, and the average age of a person suffering from piriformis syndrome is 37. [00:01:21] So clinically you will find that the patient suffers from deep gluteal pain, which can be chronic, and may also radiate along the sciatic nerve distribution. There's external tenderness over the greater sciatic notch, aggravation with sitting and driving. The symptoms are reproduced with palpation of the piriformis as well as stretching of the piriformis, that's the figure-four stretch. [00:01:44] There's a positive straight leg raise test with dorsiflexion which is what biases the sciatic nerve, and a positive FAIR or FADIR test. Patient in sidelying for this test with hip flex to 60 degrees, the knee flex from 60 to 90 degrees. And then you take the patient through passive hip adduction and internal rotation, and you see that here in the picture on the right. [00:02:13] The management for piriformis syndrome that you see on this slide is based on a case report from Tonley in 2010. In the line of research, this is the lowest level of research. But what this example is really good at is demonstrating specificity and also phasing of your exercises. [00:02:32] So in the first phase there was isolated muscle recruitment of the piriformis using the bridge with theraband and the clamshell with theraband. That moved from non-weight bearing to the second stage of weight bearing strengthening, which was squat with theraband, single- limb sit to stand, side step with the theraband and stepping down. [00:02:53] And the functional training now in stage 3 for forward lunge, lateral lunge at 45 degrees, double-limb vertical jumps and double-limb landing. The final thing was doubling jump and then single-limb land. So as I said, this is a very good example of phasing and very specific exercises for the muscle. [00:03:17] The other thing that I don't see here is manual therapy or stretches for the piriformis. So that is something that you would want to incorporate as well as this is something that would help to relax the muscle and then start with your strengthening. So as you think about piriformis syndrome and how you would treat it, I really want you to go back to what is the action of the muscle. [00:03:42] So piriformis muscle is primarily an external rotator, however it does help with adduction when the hip is flexed. So when you are working with this muscle and you need to strengthen it, what kinds of exercises would you do? And I really want you to start thinking about that as we prepare for week seven. [00:00:00] Welcome to the lecture on hamstring strain. The objectives for this lecture are to identify clinical findings associated with hamstring strain and to understand appropriate treatment considerations based on clinical findings. As with all of our diagnoses, we are looking at items of the history test and measure, evaluation and to be able to come up with your PT diagnosis and plan of care to include interventions. [00:00:28] For this lecture we'll be looking at the CPG for hamstring strain injury in athletes that you can find in your resources folder. For the pathophysiology, we'll talk a little bit about strains in general and then we'll go into a little bit more information about hamstring strains specifically. So strains refer to stretching or tearing of the musculotendinous unit, they may be partial or full. [00:00:53] They can be classified as mild, moderate, severe or complete tears or as injuries of first, second or third degree depending on the severity of tissue damage. Hamstring strain injuries specifically are common in activities that involve high speed running, jumping, kicking or explosive lower extremity movements and rapid changes in direction. [00:01:19] So this includes things like lifting off of the floor, so injuries usually happen in sports such as track and field, soccer, Australian football, American football and rugby. Most hamstring strains occur along the long head of biceps femoris. Really key for hamstring strains are re injury rates and this can occur anywhere from 13.9 to 60 63.3% across Australian rules football and track and field athletes. [00:01:53] A person who has had a history of hamstring strain has a 3.6 times higher likelihood of sustaining a future hamstring injury. The incidence of hamstring strains differ whether you are in a non-contact sport or a contact sport. So in non-contact sports the incidence per 1000 hours of exposure is 0.87 and in contact sports the incidence per 1000 hours of exposure is 0.92 to 0.96. [00:02:22] The incidence rate for professional male European soccer players can be divided out by competition hours versus training hours, so in competition hours it's 3 to 4.1 per 1000 and in training hours it's 0.4 to 0.5 per 1000. It occurs more in males than in females. In activities that involve eccentric overloading of the hamstring muscles in a lengthened position, they are not only associated with hamstring injury but also remain impaired after the injury. [00:02:55] The risk factors for development of hamstring strain are having had a previous injury to the hamstring age above 23 years old, having had anterior cruciate ligament injuries, calf strains or other knee and ankle ligament injuries. Hamstrings fascia length and strength but not flexibility and of course high speed running demands with abnormal trunk and pelvic posture and motor control could be a risk factor for developing hamstring injuries. [00:03:26] When looking at your examination for hamstring strain, there are a couple things you want to include. The first is knee flexor strength using a handheld or isokinetic dynamometer, assessing hamstring length by measuring knee extension deficit when the hip is flexed 90 degrees with an inclinometer. Using the length of muscle tenderness and the proximity to the ischial tuberosity to determine return to play. [00:03:50] And for both of these, the longer the time of muscle tenderness and the closer to the ischial tube, so more proximal has been linked to longer times before returning to play. So you wanna keep them in rehab longer before sending them back to play. There's also another study that's included in the CPG and it shows that there are a couple things linked to return to play most predictive for it. [00:04:16] One is the change in strength during the first week of the mid range test, peak isokinetic knee flexion torque of the uninjured leg on day one, pain level at the time of injury. Days to walk pain free playing soccer is predictive of when it does longer time to get back to return to play inner range hamstring strength at day one the presence or absence of pain on a single leg bridge on day seven. [00:04:46] Delay in physical therapy and percentage of strength in the outer range test compared to the healthy leg. Objective measures of individuals ability to walk, run and speak when documenting changes in activity and participation during treatment. And you want to use an outcome measure which is a functional assessment scale for acute hamstring injuries before and after interventions. [00:05:15] On this slide you see the functional assessment scale for acute hamstring injuries. You see the questions one to ten and you see the English and the German versions, both of these scales have been found to be valid and reliable. Clinically, you will find the following when someone has sustained a hamstring strain so they will report a pulled muscle during a quick eccentric demand on muscle during sporting activities. [00:05:41] Some of these can include sprinting, jumping, kicking and lunging. At the time of the injury, the patient felt a sudden sharp pain in the posterior thigh, there could be an audible or palpable popping sensation during activity that overloads or overstretches the hamstring. There's swelling or bruising, as we talked about a history of hamstring injury is usually a sign that you could be having a second injury to the hamstring. [00:06:08] Daily activities that stretch or contract the hamstring are painful, there's pain with palpation of the posterior thigh or the ischial region of the buttock and near the ischial tuberosity sometimes. Contraction of the hamstrings or knee flexion causes pain and a passive or active straight leg rage, which is a stretching of the hamstring, causes pain. [00:06:29] There's also delayed firing or weakness in the gluteals. So this slide is a picture of the decision tree for hamstring injury straight out of the clinical practice guidelines. A lot of this we have talked about and what we will be talking about in the next couple slides are the intervention strategies, but this is a good kind of summary of everything just in one place. [00:06:54] So let's talk a little bit about management for hamstring strain. The CPG recommends that clinicians use eccentric training to patient tolerance in addition to your regular stretching, strengthening stabilization and progressive running programs for improvement on return to sport time. They also suggest using a progressive agility and trunk stabilization program in addition to your comprehensive and normal impairment-based treatment program. [00:07:23] So you're stretching, strengthening functional exercises to reduce your re injury rate. Finally, they suggest that clinicians could perform neural tissue mobilization after injury to reduce adhesions to surrounding tissue. And use therapeutic modalities to help control pain and swelling in the early phases of rehab. What you see on the slide ahead of you is the Goom et al protocol for hamstring tendinopathies from 2016. [00:07:50] What I would love to see you do is take what you see on this screen looking at the CPG and see how one it includes the CPG and the knowledge gained from that. To what's left out and what you can add into these to improve the rehab for the hamstring strains. [00:08:08] And then maybe add a couple extra things that you think would be really specific to helping hamstring strain that you see either in research or that you've seen in practice. We'll talk a little bit about that in the synchronous lecture. [00:00:01] We will now move into the hip flexor strain, specifically iliopsoas strain. The objectives for this lecture are to identify key clinical findings associated with iliopsoas strain and understand appropriate treatment considerations based on those clinical findings. As with all of our diagnoses, we will be covering aspects of history, tests and measures. [00:00:28] How to use that information in your evaluation to come up with your PT diagnosis, your plan of care and the interventions that may help specifically for that disease. So iliopsoas tenderness can either be above or below the inguinal area and you have pain with resisted hip flexion and and or pain on stretching of the hip flexors. [00:00:55] So with this being one of the first extra articular diagnoses, you look that the symptoms are actually specific to the contraction of that muscle, in this case the iliopsoas. 12% to 36% of groin pain athletes is iliopsoas-related, 1.60 in 10,000 athletes have iliopsoas strain. The highest rates occur in Men's Soccer and Ice Hockey. [00:01:26] Higher rate of strain during competition than practice and as you can tell, why there is much more use of the muscle and strain on the muscle during competition. And complications of total hip arthroplasty in which 4.3% THA patients have iliopsoas tendonitis. So in your patient history you may have one of the following, pulled muscle during a quick, eccentric demand. [00:01:56] So the lengthening of the muscle during a sporting activity, blunt trauma to the hip myofascia or repetitive and, or overuse injury. Daily activities or sporting activities which stretch or contract the iliopsoas muscle are painful. So ADL such as getting out of a car, going upstairs or running for sports can be painful. [00:02:22] So for your examination you are going to test the hip flexors so you will get pain with palpation to the anterior hip. Contraction of the iliopsoas, especially with resistance will cause pain and pain with active hip extension or passive and that's because this causes a lengthening of the iliopsoas muscle. [00:02:43] So you've seen this slide before and it is the management for the hamstring strain and hamstring tendinopathy from Gum et al. What I want you to do here is taking the knowledge that you have learned on hamstring strain from the CPG. How can you create a program for hip flexor strain based on both Gu med al and the information that we learned about hamstring strain in treatments from the CPG? [00:03:13] I would love to see you create your own treatment protocol for hip flexor strain based on those two things. [00:00:00] Welcome to the final lecture of week five for your hip diagnoses, and this one is the adductor strain. The objectives for this lecture are to identify key clinical findings associated with adductor strain, and to understand appropriate treatment considerations based on those clinical findings. As with all of our diagnoses, we will be covering aspects of the history, test and measures, evaluation to your PT diagnosis, and and of course, plan of care to improve treatment. [00:00:34] An adductor strain is caused by a sudden stretch, weakness, or overuse of one or more of the adductor muscles. Adductor strains tend to really be an injury of athletes. So it occurs 38.63% of hip and groin pain injuries in NCAA Football players over a 10-year period, 67.2% of hip and groin injuries for NCAA Men's Ice Hockey players, and 24.5% of hip and groin injuries across 25 collegiate sports. [00:01:10] The most common sports that incur groin strains are men's soccer, Men's Ice Hockey, and Women's Ice Hockey. So during your examination, your patient will report that they pulled a muscle during a really quick eccentric demand on the adductor, so a really quick stretching contraction, a blunt trauma to hip myofascia. [00:01:35] Daily activities or sporting activities that stretch or contract the adductors are painful. There's involvement in sports that particularly use forceful abduction of the hip, like ice hockey. And you can give them the outcome measures of either the LEFS or HAGOS. So clinically, you will find that you have pain with palpation to the medial thigh. [00:01:58] Any contraction of the adductors, both eccentric and concentric, will cause pain, and passive and active hip abduction. Patient will report medial groin pain and pain with stairs, running, and jumping. You will find some hip adductor flexibility deficits when you compare to the contralateral side. There's weakness and pain with resisted hip adduction, weakness of the gluteals, so both glut medius and glut maximus, reduced hip internal rotation and bent knee fallout, and decreased Y-balance performance. [00:02:32] When it comes to management of adductor strain, I'm going to refer you back to the hamstring strain lecture and CPG, and you're going to use that framework as a reference point on how you would address adductor strain. This will be something that will come back up in week seven when we talk about management, and may also come up in your exams. [00:00:00] [MUSIC] [00:00:08] Welcome to week 6 and your hip examination and test and measures series. The first thing we'll be looking at is static and dynamic observation. When you think of static observation, you're thinking of your posturing. And when you think of dynamic, you're thinking of gait and other functional movements such as squatting, lunging. [00:00:27] In this lecture we'll be looking at gait. The objectives for this lecture are to apply foundational concepts of the hip static and dynamic observation and implement these concepts into patient cases. Integrate observation and posture assessment into the comprehensive physical examination. As we discussed in this lecture, we'll begin the test and measures series of the hip examination. [00:00:55] So when looking at the static observational posture for the lower extremity and really looking at the hip as well, you would observe the patient in stance. This is more applicable to life as your patient will be weight bearing for the most part in stance. The first thing you're looking at is the weight symmetrical on both legs or are they leaning one to one leg or the other? [00:01:17] You're looking at muscle mass. Next is they're wasting away of muscle or is it normal composition on both sides? And then you start looking at the innominate rotation anterior, posterior. So let's look at a couple things that could indicate something happening either at the femoral bone or the innominate. [00:01:35] So excessive toeing out could be due to external hip neck retroversion or SCFE in adolescence. We have gone over SCFE in the pediatric pathologies. So S-C-F-E or pelvic torsion, a posteriorly rotated innominate bone can cause lateral rotation of the leg. So the leg spaying outward, toeing in could be due to femoral neck anteversion. [00:02:03] When you look at pelvic obliquity, this is caused by unequal leg length or muscle contractures making one leg seem shorter than the other. Or it can be caused by scoliosis. The next thing you're looking at is can the patient achieve neutral pelvis? So if there is some sort of rotation, are they able to self correct? [00:02:22] Because that can indicate what your exercises are going into because it may require some muscle strengthening and stabilization exercises, or is it something that is structural? The last thing you're gonna look at is balance. And one of the tests you can do to see this is single leg stance. [00:02:41] And we will go over that in some of your other interventions. Make sure you're viewing the posture in both anterior, lateral and posterior and lateral from both sides. As you can see different things at different angles. You've seen this posture chart before and it's always a good time when you see this, come up again to look at your postures from head to foot as you'll see it multiple times and again in your upper quarter course. [00:03:13] Specifically for your pelvis and hips, you're looking to see if in the anterior view the pelvis is level or if it has an anterior or posterior tilt. For the hips, you're looking for coxa vara, coxa vulga, anteversion or retroversion. And then in the femurs you're looking for alignment or if there's some torsion. [00:03:33] In the lateral view, you're looking for lumbar lordosis, is it increased or decreased? And the pelvis looking for anterior or posterior tilt. In the posterior view, you will be looking at the hips to see if they are level or even at the sacrum, looking for the level of the base and the inferior lateral angles and the pelvis if there's any level or if there's level or any tilting. [00:04:04] As I said in the beginning, for dynamic balance, we'll be looking at gait. And I always like to remind our students at this point that gait is your bread and butter. There is no other profession that does gait analysis or helps with the aspects of gait. So this is really what the PT does that nobody else does. [00:04:23] So when you're looking at your patient walking, this happens from the beginning. The minute they stand up in the waiting room and walk into the examination room, you are looking from then to see how they're walking. Some of the things you're looking at are step length, are they equal on both sides? [00:04:41] Is the stance time equal on both sides? For instance, if somebody's in pain and they have an antalgic gait, the stance time on that leg that is affected is less, which is what we're talking about when you're looking at the stance, the step cadence. You have the trendelenburg gait where you can have an abductor lurch. [00:04:58] This picture on the right hand side is the picture taken from physioU for the trendelenburg sign where you see that dropping on the side that is weak and it indicates gluten medius weakness or if there's excessive rotation and that's just a couple of things that you're looking at. [00:05:18] We'll do a gait analysis in lab that you'll start looking at some other things as well. Remember to look over your videos in physioU for gait assessment. This concludes this lecture which is a very quick look into posturing and gait. The next lecture after this will be looking at functional gait assessment. [00:00:00] Hey welcome, everyone in this lecture, we'll be discussing functional and gait assessments specific to the lower leg, ankle, and foot, let's go. The objectives here are to apply the foundational concepts of the functional assessment, including gait analysis, and implement these concepts into patient cases. We also wanna be able to integrate the functional assessment, again, including gait analysis, into the comprehensive leg, ankle, and foot physical examination. [00:00:29] Within the clinical reasoning framework, as we analyze movement, function and gait, we'll remain in this tests and measures category. So this is just a review again from other previous lectures, with our functional testing, if our irritability is low and neurological deficit is not expected, we're typically gonna look at function first. [00:00:52] Again, we want the patient to be able to show us if they have issues performing a functional task or they have pain with the task. We don't wanna assume what that task looks like, we want that patient to show us. This helps to assist in our hypothesis testing and our differential diagnosis, and it's creating a patient meaningful test and retest again, what we call that functional reassessment sign. [00:01:20] Okay, so remember, with our walking gait analysis, we wanna look at big picture first, okay? So are there any major abnormalities that we see as we just look at the person walk and look at their whole body from head to toe, okay? We're gonna wanna do this not only in the sagittal plane, but also in the frontal plane as well. [00:01:37] After we get a good image of just the whole entirety of the person walking, let's go region specific. And for this lecture, we're focusing on below the knee, so we're looking at lower leg, ankle, and foot. So we're gonna wanna look at that region a little bit more in depth. [00:01:53] And that's where the patient's having symptoms or impairments based on, what we're talking about in this lecture in this week's content. So it's important for us to understand what normal is so we can observe abnormalities and recognize those. And so I would encourage you to review the tables in the Macgee text, I think they do a nice job of explaining kind of what normal should look like. [00:02:15] And then what are some common abnormalities, impairments that we may see in this region. I think, again, it's important that we make those features fit and we think about not only what are we seeing that's abnormal, but is what we're seeing, is it related to the symptoms that they're coming in for? [00:02:34] Or is it potentially just maybe something that they have in terms of their gait, that's maybe not what we would classically see in a normal gait pattern? But potentially it's unrelated to the symptoms that they're coming in for, so it's important that we make those features fit. Now specific to the foot and ankle, remember, the functions of the foot and ankle during gait. [00:02:55] Now, it serves as that base of support for us, okay? It's also a nice mobile adapter during weight acceptance. And so it's important that during weight acceptance, as we can see here, that the subtalar joint, is everting and that mid foot is increasing pliability to allow for adaptation to the ground surfaces. [00:03:20] And then as we move towards that pre swing positioning here, that foot should be, that subtalar joint should be inverting and increasing stability so that we have a rigid lever arm to push off with. And this includes subtailar joint locking. So it should be nice rigid lever to push off from, and a portion of this or a nice component of this is that windlass mechanism. [00:03:47] And so the windlass mechanism, as we extend those toes, we get tensioning through the plantar fascia, and that inverts our midfoot, that's the windlass mechanism. So those are important aspects or functions of the foot and ankle, and if a patient's not able to do these, well, that may relate to the symptoms that they're coming in for. [00:04:06] So it's important for us to understand what normal is and to be able to see an impairment with the functions of the foot and ankle during gait. Okay, recalling that with our gait analysis, we're gonna wanna see the patient walk in the frontal plane, both from the front and from the rear, and in the sagittal plane. [00:04:26] We may have them walk in their shoes, especially if they have symptoms while walking in their shoes, and we're definitely gonna wanna watch them walk barefoot. We wanna see exactly what's going on from the ankle down, so what's going on at the hind foot, the subtalar joint, the midfoot and the forefoot as they walk. [00:04:45] And it's oftentimes difficult to see that if a patient's in shoes. Again, like we said on that previous slide, I'd refer you to the table in the Magee text that talks about gait deviations at the ankle and foot secondary to specific ankle and foot impairments. All right, so after we watch the patient walk, we'll then have them perform some functional testing. [00:05:08] Again, this is gonna depend on their symptom irritability and their ability level, these are just four examples of what we may look at. You may look at other functional testing, again, depending on what the patient's having difficulty with. So as we look at a squat here, we're gonna wanna look at the manner in which they squat, Is the weight primarily through the heels or is it distributed through the mid and forefoot? [00:05:31] If it is distributed mainly through the heels, is it potentially because of a lack of dorsiflexion range of motion that makes them squat more posteriorly? From the frontal side with the squat or from the frontal plane, are they able to dorsiflex or are they primarily taking movement from the subtalar joint? [00:05:53] And are they excessively pronating of what we would typically see with the squat? And so just a couple things that we may look for there with our single leg stance, are they able to perform a single leg stance with a nice base of support? Thinking of first MTP, fifth MTP and calcaneus, are they able to maintain those three points flat on the floor as they stand on one leg? [00:06:21] Is there a lot of muscle activation that's really trying hard to maintain their medial longitudinal arch in their base of support? What's going on up at the pelvis and lumbar spine, do you see a lot of movement in the frontal plane there? With a single leg squat similar to a double leg squat, we're looking at their range of motion at the talocrural joint and what they use there. [00:06:44] Also what they're using at the subtalar joint, also wanna see the stability that they have both up at the hip and pelvis and lumbar spine as they perform a single leg squat? Similarly here with a lateral step down, both with the lateral step down and the single leg squat, we're looking at dynamic balance. [00:07:04] And so we're looking again at their stability of their foot as they perform a lateral step down. This can be graded out, this can be graded from zero to six, and that may be something that you see out in the clinic. But just to kind of qualitatively assess their lateral step down, you're looking at, again, can they use dorsiflexion motion or does that. [00:07:29] Do you see them use a little bit more subtalar motion and you see a movement of maybe the tibia moving in or medially, do you see the knee moving medially? Do we see pelvic stability, does that pelvis remain level as they drop down, and then are they able to keep their hands on their hips? [00:07:52] Or do they have to use their arms out just to change their base of support and the