Acquired disorders
Legg-Calve-Perthes disease
Medical confirmation is performed through physical examination, MRI, and X-ray. The condition is most common in children under 10 years old.
Phases of Legg-Calve-Perthes disease
- Necrosis: part of the femoral head has died
- Fragmentation: the body attempts to clean up the broken pieces of bone from the area
- Re-ossification: blood flow is restored to the femoral head, and the bone begins to regrow
- Remodeling: new bone is now in place
Each phase can last from months to years, but it indicates the body has the potential to heal itself once temporary blood flow is restored.
Symptoms
- Antalgic gait
- Pain/stiffness in thigh/groin
- Leg length discrepancy
- Limitations in range of motion — abduction, flexion, and internal rotation
Physical therapy interventions for Legg-Calve-Perthes disease
- Activity modifications
- Bracing/splinting to keep the femoral head in contact with the acetabulum
- Strengthening and range of motion activities of the hip
Medical management of Legg-Calve-Perthes disease
- Use of anti-inflammatory medications
- Surgical interventions to correct blood flow — not indicated for children under 6
Slipped capital femoral epiphysis (SCFE)
Etiology can be due to hormonal changes during puberty, a growth spurt, obesity, weakening of the growth plate, and family history. The most common age of injury is between 10-16 years of age.
Symptoms
- Inability to bear weight on the extremity
- Pain in the groin/thigh
- Leg length discrepancy
- Limitations in range of motion — flexion, internal rotation, and abduction
Medical management for SCFE
Surgery is indicated once confirmed through physical examination and X-ray imaging. Delay in intervention can cause serious damage such as avascular necrosis, arthritis, or deformity of the hip joint. Surgery entails the implementation of a metal screw to maintain the position of the femoral neck through the growth plate.
Physical therapy interventions for SCFE
Physical therapy interventions are dependent upon the surgeon’s protocol post-op and will gauge the progression of activities until return to full weight bearing.
Osgood-Schlatter disease
Common causes are repetitive movements, excessive growth during puberty, and participation in sports that require increased running and jumping. Age of onset is typically after age 12, during puberty. Confirmation of diagnosis is through physical examination and X-ray.
Symptoms
- Palpable swelling at the tibial tuberosity
- Pain at anterior knee
- Increased pain during running and jumping activities, with relief of pain during rest
Physical therapy interventions for Osgood-Schlatter disease
- Conservative care steps
- Activity modification: reduce or temporarily stop high-impact sports involving running and jumping until pain improves.
- Ice therapy: apply cold packs or ice massage to the affected area for 15 to 20 minutes several times a day, especially after activity.
- Pain relievers: use over-the-counter medications like ibuprofen, naproxen, or acetaminophen as directed to control discomfort.
- Strengthening of lower extremity muscles to create an even pull of muscles
- Dynamic balance activities to mimic times of exacerbation
- Postural re-education when performing running, jumping activities
Scoliosis
Most idiopathic cases are diagnosed during adolescence. Diagnosis is confirmed through physical examination and X-ray imaging. The severity of scoliosis is defined by the degree of curve — this also guides which interventions may be performed.
Cobb angle (severity of scoliosis)
- Mild scoliosis: Cobb angle less than 10 degrees
- No intervention or conservative management
- Moderate scoliosis: Cobb angle between 10 and 25 degrees
- Bracing and physical therapy may be indicated
- Severe scoliosis: Cobb angle greater than 25 degrees
- Surgical intervention to correct the curve, as a curve >25 degrees could compromise the respiratory system
Symptoms
- Uneven shoulders
- One shoulder blade that appears more prominent than the other
- Uneven waist
- One hip is higher than the other
- One side of the rib cage jutting forward
Physical therapy interventions for scoliosis
- Address muscle imbalances that may be present due to curvature
- Provide shoe inserts to correct leg length discrepancy
- Prescribe durable medical equipment as necessary
Autism spectrum disorder
Etiology is unknown, but it has been linked to genetic predisposition and/or diet. Diagnosis is made through observation, use of outcome measures, an interview with the parents and child, and diagnostic criteria. A reliable diagnosis can be made at age 2.
Symptoms
- Sensory integration dysfunction
- Hyposensitivity (sensory seeking) or hypersensitivity (sensory avoidant)
- Difficulty with verbal and non-verbal communication
- Impaired coordination
- Balance deficits
- Occasional strength and range of motion deficits
- Developmental delay
Physical therapy interventions for autism spectrum disorder
- Address developmental delay
- Improve strength
- Improve balance and coordination
- Sensory integration activities
- Be aware that new people and situations can cause either withdrawal behavior or increased aggression
Brachial plexus injuries
Common causes of brachial plexus injuries include breech birth (causing the use of assisted birth techniques such as forceps or vacuum), increased birth weight, multiple birth (twins or more), or gestational diabetes. Diagnosis is performed via physical examination (movement of the upper extremity and/or testing of primitive reflexes), x-ray, and MRI if needed.
Severity of brachial plexus injuries
- Traction
- Stretching of the nerve with spontaneous recovery
- Rupture
- Nerve is torn but remains attached to the spinal cord; may require surgical intervention
- Avulsion
- Nerve is completely torn from the spinal cord; permanent disability may result after surgical intervention
Common brachial plexus injuries
- Erb’s palsy
- Involves C5-C6 nerve roots — upper arm paralysis involving rhomboids, serratus anterior, levator scapula, deltoid, infraspinatus, supraspinatus, biceps
- Immobility of the shoulder girdle leading to subluxation of the shoulder
- Only use of hand muscles
- Involves C5-C6 nerve roots — upper arm paralysis involving rhomboids, serratus anterior, levator scapula, deltoid, infraspinatus, supraspinatus, biceps
- Klumpke’s palsy
- Involves C8-T1 nerve roots — lower arm paralysis involving intrinsic muscles of the hand, finger flexors, and finger extensors
- Contractures of the hand may result
- Functional use of the shoulder and elbow; deficits in the use of the wrist and hand
- Involves C8-T1 nerve roots — lower arm paralysis involving intrinsic muscles of the hand, finger flexors, and finger extensors
- Global palsy
- Involves C5-T1 — total arm paralysis
Physical therapy interventions for brachial plexus injuries
- Partial immobilization for 1-2 weeks of the injured extremity
- Constraint-induced therapy of the non-injured arm
- Range of motion to avoid contractures
- Age-appropriate movements to decrease the likelihood of developmental delay
- Parent education on positioning and handling of the infant
Torticollis
Torticollis can be caused by difficulties at birth, large infant weight, breech birth, or improper positioning after birth. Diagnosis is confirmed via physical examination.
Symptoms
- Persistent head tilt to one side
- Difficulty turning the head to the opposite side
- A lump or knot may be felt in the tight neck muscle
- Facial asymmetry may develop over time
- Flat head on the side of muscle tightness may present (plagiocephaly)
Physical therapy interventions for torticollis
- Stretching of the contracted sternocleidomastoid muscle
- Stretching involves lateral flexion away from the contracted side and opposite head rotations
- Positioning to allow for prolonged stretching
- Addressing any developmental delay issues