Goals

1. Goals • Identify structural or muscle imbalance anatomy that might predispose to musculoskeletal problems • Identify movement patterns or postures that suggest CNS pathology • Offer examination techniques to illustrate important muscle imbalances that can occur • Offer guidelines for who might benefit from further musculoskeletal evaluation in referral or testing

2. Focus Points • Developmental milestones • Locomotion is most important function • Standing posture probably reflects “lifestyle” postures in older children & adolescents • The foot is the contact point with the world & first in kinetic chain of ambulation • We weren’t designed to sit, we should be able to squat • You may need to play with them 

3. Developmental milestones • Hand dominance emerges 18 mo, matures by 2-3 years • Belly crawl 7-9 mo • Hands & knee creep 9-11 mo • Cruise 11-12 mo • Walk alone 12-14 mo, mature gait by 2.5 yrs • Climb stairs on hands & knees ~15 mo • Run stiffly ~16 mo • Walk down steps, nonreciprocally 20-24 mo

4. Locomotion milestones cont…. • Alternating steps up stairs 3 yrs • Hop on one foot & broad jump 4 yrs • Skip 5 yrs • One foot balance 20 sec 6-7 yrs

5. Key anatomy areas • Foot/ankle mechanics in sagittal plane • Dorsiflexion range in late stance and squatting, forefoot extension in toe off • Tight heel cords will affect knee, reduce hip extension in late stance since tibia can’t advance over foot, leg will lift up early • Lateral border of foot should be straight, if convex think tibial torsion • Hip extension in sagittal plane • Loss may be postural and hip flexor shortening in older child • Excessive or lordotic gait may be glut maximus loss in MD • Hip stability in frontal plane • Glut medius strength – Trendelenburg gaits or waddling may occur till 3 yrs

6. Gait considerations • Limp = altered gait, often antalgic due to painful joint, kids won’t admit it. • Any joint in kinetic chain but hip most common, hardest to examine.

7. Anatomy areas…. • Hip rotation, knee flexion, ankle dorsiflexion in squatting, can they squat and walk? • Hip extension is frequently lost, do they extend during ambulation in the sagittal plane? • Supine hip extension range is important and helps localize tightness • Hip firing patterns are probably very important to identify, easy ways to check?

8. Compensations • Gower’s maneuver = walk up to standing using hands to make up for weak proximal extensor muscles.

9. Screening starts with gait • Sagittal plane mechanics most important, then frontal plain • Shoes on and off, out in the hall, let them run if able

14. Squatting and walking in older children

16. Are landmarks level?

18. Uni-pedal balance depends on age

19. Modified Thomas test

24. Firing patterns • Hip abduction: Glut medius >> tensor fascia lata >> quadratus lumborum • Hip extensors: Glut maximus >> hamstrings >> spine extensors

26. Palpate for muscle contraction, timing and force relative to movement and other muscles

31. Abdominal bracing may be the key to all low back pain

32. Thank you for your attention