Article

Hip Range of Motion in Children

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Abstract

Abnormal range of motion (ROM) is a common sign of pathology in the pediatric hip, yet there are little data in the literature defining what the normal hip ROM is in children. The purpose of this study was to establish normative values for hip ROM in children of varying ages. We performed an Institutional Review Board approved, prospective study of otherwise healthy patients receiving fracture care at our institution. Inclusion criteria were boys and girls aged 2 to 17, who were being treated for an isolated upper extremity injury and who had no underlying musculoskeletal condition, history of lower extremity injury, or other systemic diagnosis. All patients were evaluated with a standard measurement technique using the same double-long-armed goniometer. Supine abduction, adduction, and hip flexion were measured with care taken to stabilize the pelvis. Internal and external rotation in flexion were assessed with both the hip and knee flexed to 90 degrees. In the prone position, hip extension was recorded as was internal and external rotation in extension. Left and right measurements were averaged to produce a single data point for each index. On the basis of a power analysis (to detect a minimal detectable difference of 6 degrees), 2 separate cohorts of 23 patients were randomly selected for the assessment of intraobserver and interobserver reliability. We measured 504 hips in 252 pediatric patients, including 163 boys and 89 girls. We found a decreasing trend in ROM for almost all indices with advancing age, although this decline was less apparent among girls. Intraobserver reliability demonstrated excellent agreement (intra class correlation coefficient>0.81) for all indices. Interobserver assessments revealed excellent agreement for abduction, external rotation in flexion, internal rotation in extension, and external rotation in extension. Substantial agreement (intra class correlation coefficient, 0.61 to 0.8) was found for adduction, flexion, extension, and internal rotation in flexion. Normative values for hip ROM in children of varying ages have been established with acceptable intraobserver and interobserver reliability. Level II (Diagnostic).

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... Previous research, notably by Staheli and associates in the 1980s and later investigations in the early 21st century, has examined these parameters [1]. Nevertheless, comprehensive data that integrates all 3 critical measures-joint range of motion, angular alignment, and rotational profiles-is still limited [2][3][4][5][6][7][8][9][10]. Moreover, demographic and anthropometric variables, including age, sex, laterality, weight, height, and body mass index (BMI), affect these parameters. ...
... For all ranges of motion, Mudge et al. (2014) [10] found similar ROM to our study for external hip rotation, knee extension, and ankle dorsiflexion on extended and flexed knees, but lower values for hip internal rotation and hip abduction in 17 volunteers (aged 8-11) and 16 volunteers (aged 12-16), whereas Lee et al. (2013) [3] found a greater annual change in ankle dorsiflexion (0.35° in our data vs. ~ 0.7° in Mudge et al.) [10]. Sankar et al. (2012) found similar values and changes concerning age for hip ROM for hip flexion, extension, abduction, and adduction [2]. ...
... For all ranges of motion, Mudge et al. (2014) [10] found similar ROM to our study for external hip rotation, knee extension, and ankle dorsiflexion on extended and flexed knees, but lower values for hip internal rotation and hip abduction in 17 volunteers (aged 8-11) and 16 volunteers (aged 12-16), whereas Lee et al. (2013) [3] found a greater annual change in ankle dorsiflexion (0.35° in our data vs. ~ 0.7° in Mudge et al.) [10]. Sankar et al. (2012) found similar values and changes concerning age for hip ROM for hip flexion, extension, abduction, and adduction [2]. ...
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Background and purpose We aimed to update reference intervals for anthropometric parameters for the passive joint range of motion (ROM), rotational profile, and angular alignment of the lower limb in typically developing children (TDC), to compare the association of the variables age, left–right sidedness, body mass index (BMI), and sex. Methods We conducted a cross-sectional study in a convenience sample of TDC from the 1st, 5th, and 9th grades (6–17 years) in a randomized selection of Danish primary schools. We examined the anthropometric parameters in a non-clinical setting. Descriptive statistics were used to characterize the data. To explore potential differences across the variables, we utilized Bonferroni-corrected Welch’s 2-sample t-tests, one-way analysis of means, and univariable linear regression. Results We analyzed the associations between the variables and the anthropometric parameters in 501 TDC, aged 6 to 17 years. We found a statistically significant, but not clinically meaningful decrease in ROM for the hip, knee, and ankle as well as decreased femoral anteversion and increased tibial torsion with increasing age, but no association with sex or sidedness. However, several associations between BMI and ROM measurements were statistically significant and potentially clinically meaningful, with ROM decreasing by approximately 0.4° to 1.2° per unit increase in BMI, particularly for hip, knee, and ankle flexion movements. Conclusion Anthropometric parameters remain clinically stable after 7 years of age and are affected only by the BMI but not sex or age. We found a statistically significant but not clinically relevant decrease in torsion and joint ROM with increasing age.
... Furthermore, Leon et al. [23] generated percentile curves for ankle dorsiflexion ROM in boys with DMD, showing negative ROM values (deficit to reach neutral) from the age of 8 years with the knee extended and from the age of 9 years with the knee flexed, indicating pathological shortening of the ankle plantar flexors. However, previous studies did not account for the typical reduction in ROM observed in TD children aged 2 to 17 years [29][30][31]. ...
... Since typical strength development and normal muscle growth are accounted for in this way, the use of z-scores facilitates the interpretation of pathological alterations during growth. Similarly, the TD reference values of Mudge et al. [29] and Sankar et al. [30] for three age groups can be used to calculate unit-less z-scores for ROM, allowing to correct for the typical reduction in ROM. Therefore, the aim of this study was to establish longitudinal trajectories for a comprehensive integrated set of muscle impairments, including muscle weakness, contractures, and muscle size alterations, while correcting for normal maturation, in growing boys with DMD through a longitudinal follow-up design. ...
... Contractures were assessed bilaterally, but only the values from the side selected for the strength assessment were included in further analyses to ensure consistency with the other measurements. During a standardized clinical examination, goniometry was used to measure the passive ROM of hip extension (modified Thomas test [29]), hip adduction (with an extended hip and knee on the assessed leg and 90° of hip and knee flexion on the contralateral leg [30]), knee extension [29], hamstrings (true popliteal angle [29]), and ankle dorsiflexion (with knee extended and knee flexed in 90° [29]) (A detailed description is provided in S2 Appendix). Previous studies reported acceptable intra-rater and inter-rater reliability of these measures [29]. ...
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Background Insights into the progression of muscle impairments in growing boys with Duchenne muscular dystrophy (DMD) remain incomplete due to the frequent oversight of normal maturation as a confounding factor, thereby restricting the delineation of sole pathological processes. Objective To establish longitudinal trajectories for a comprehensive integrated set of muscle impairments, including muscle weakness, contractures and muscle size alterations, while correcting for normal maturation, in DMD. Methods Thirty-three boys with DMD (aged 4.3–17 years) were included. Fixed dynamometry, goniometry, and 3D freehand ultrasound were used to repeatedly assess lower limb muscle strength, passive range of motion (ROM) and muscle size, resulting in 161, 178 and 64 assessments for the strength, ROM and ultrasound dataset, respectively. To account for natural strength development, ROM reduction, and muscle growth in growing children, muscle outcomes were converted to unit-less z-scores calculated in reference to typically developing (TD) peers. This allows the interpretation of the muscle outcomes as deficits or alterations with respect to TD. Mixed-effect models estimated the longitudinal change in muscle impairments. Results At 4.3–4.9 years of age, all muscle strength outcomes and several ROMs (i.e., dorsiflexion, hamstrings, and hip extension) showed deficits relative to TD, while m. medial gastrocnemius size was increased. Most muscle outcomes remained stable or slightly improved until the ages of 6.6–9.4 years (except knee flexion strength). After this period, muscle strength (−0.27 to −0.45 z-score/year; p < 0.0044), dorsiflexion ROM (−0.23 to −0.33 z-score/year; p < 0.0007), m. medial gastrocnemius size (−0.56 z-score/year; p = 0.0022), and m. rectus femoris size (−0.36 z-score/year; p = 0.0054) declined. Conclusions The current study established longitudinal trajectories of muscle impairments in boys with DMD. The results provided enriched history data and revealed promising outcome measures that could enhance the detection of the efficacy of novel therapeutic strategies. Future studies are necessary to validate these outcomes.
... Mean (standard deviation) passive range of motion is presented for the 15/17 participants with cerebral palsy assessed. Values were compared to the age-normative passive range of motion reported byMudge et al. (Mudge et al., 2014) (knee extension and ankle dorsiflexion) and Sankar et al.(Sankar et al., 2012) (hip extension). A contracture was reported if the range of motion was 6°, 4°, and 8° lower than the minimum normative value for the hip extension(Sankar et al., 2012), knee extension(Svensson et al., 2019) and ankle dorsiflexion, respectively. ...
... Values were compared to the age-normative passive range of motion reported byMudge et al. (Mudge et al., 2014) (knee extension and ankle dorsiflexion) and Sankar et al.(Sankar et al., 2012) (hip extension). A contracture was reported if the range of motion was 6°, 4°, and 8° lower than the minimum normative value for the hip extension(Sankar et al., 2012), knee extension(Svensson et al., 2019) and ankle dorsiflexion, respectively. A negative value represents flexion angle for the hip and knee extension, and plantarflexion angle for the ankle dorsiflexion. ...
... The author(s) declare no competing interests. and ankle dorsiflexion a) or age and sex (hip extension (Sankar et al., 2012)) of each participant. A negative value represents flexion angle for the hip and knee extension, and plantarflexion angle for the ankle dorsiflexion. ...
... 1 It is important to establish reference data so that abnormalities can be identified and quantified, progression monitored, and outcomes classified. 2 Studies have been published that provide the passive joint ROM in children and adults. [3][4][5][6][7][8][9][10][11] The methods of measurements, however, vary from different types of goniometers to camera-based systems. There are other limitations such as a small sample size, 6 a focus on only one or few joints [6][7][8][9][10] , or on a specific group of children. ...
... [3][4][5][6][7][8][9][10][11] The methods of measurements, however, vary from different types of goniometers to camera-based systems. There are other limitations such as a small sample size, 6 a focus on only one or few joints [6][7][8][9][10] , or on a specific group of children. 11 Macfarlane et al. 12 provide strength reference data for hip and knee in 6-to 8-year-old children using a handheld dynamometer. ...
... In this study, ROM was measured for six different joint motions. Sankar et al. 10 investigated ROM in the hip in typically developing children divided into three different age groups. The results of their study are in agreement with our study for hip abduction and adduction, as well as with the internal and external rotations in both positions. ...
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Background Joint range of motion based on the neutral null method, muscle strength based on manual muscle testing, and selective voluntary motor control based on selective control assessment of the lower extremity are standard parameters of a pediatric three-dimensional clinical gait analysis. Lower-limb reference data of children are necessary to identify and quantify abnormalities, but these are limited and when present restricted to specific joints or muscles. Methods This is the first study that encompasses the aforementioned parameters from a single group of 34 typically developing children aged 5–17 years. Left and right values were averaged for each participant, and then the mean and standard deviation calculated for the entire sample. The data set was tested for statistical significance ( p < 0.05). Results Joint angle reference values are mostly consistent with previously published standards, although there is a large variability in the existing literature. All muscle strength distributions, except for M. quadriceps femoris, differ significantly from the maximum value of 5. The mean number of repetitions of heel-rise test is 12 ± 5. Selective voluntary motor control shows that all distributions, except for M. quadriceps femoris, differ significantly from the maximum value of 2. Conclusion Since typically developing children do not match expectations and reference values from the available literature and clinical use, this study emphasizes the importance of normative data. Excessively high expectations lead to typically developing children being falsely underestimated and affected children being rated too low. This is of great relevance for therapists and clinicians. Level of evidence 3.
... The healthy side was used for planning the osteotomy. If both sides were affected, the planning was performed based on reference patients with the same age and weight in combination with information from literature [20,21]. The CT scan was segmented using the computer software D2P, 3D systems. ...
... Improvement in ROM of the hip was defined as the difference in the ROM, specifically flexion, internal rotation, external rotation and abduction of the hip, before and after surgery, and compared to normal values. We assumed the following normal values of the hip: Flexion Extension: 130-0-0; Internal External rotation: 45-0-45; Abduction Adduction: 40-0-40 [20,21]. ...
... Clinical results showing primary and secondary outcomes for the 21 participants. The ROM is the difference between post-operative ROM and the normal values[20,21] ...
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Background Accurate repositioning of the femoral head in patients with Slipped Capital Femoral Epiphysis (SCFE) undergoing Imhäuser osteotomy is very challenging. The objective of this study is to determine if preoperative 3D planning and a 3D-printed surgical guide improve the accuracy of the placement of the femoral head. Methods This retrospective study compared outcome parameters of patients who underwent a classic Imhäuser osteotomy from 2009 to 2013 with those who underwent an Imhäuser osteotomy using 3D preoperative planning and 3D-printed surgical guides from 2014 to 2021. The primary endpoint was improvement in Range of Motion (ROM) of the hip. Secondary outcomes were radiographic improvement (Southwick angle), patient-reported clinical outcomes regarding hip and psychosocial complaints assessed with two questionnaires and duration of surgery. Results In the 14 patients of the 3D group radiographic improvement was slightly greater and duration of surgery was slightly shorter than in the 7 patients of the classis Imhäuser group. No difference was found in the ROM, and patient reported clinical outcomes were slightly less favourable. Conclusions Surprisingly we didn’t find a significant difference between the two groups. Further research on the use of 3D planning an 3D-printed surgical guides is needed. Trial registration Approval for this study was obtained of the local ethics committees of both hospitals.
... 4 Table 5 illustrates mean ROM values for children obtained via universal goniometry from multiple studies using a variety of methods. 3,4,14,17 The data from the current study suggest that gender was a significant factor for hip flexion and abduction. In a study by Sankar et al. researchers found that older males (ages 11-17) had less ROM than older females in all directions aside from internal rotation (combined with hip flexion); however, they found no significant difference for gender with any motion in their youngest age group (ages 2-5), and no findings regarding gender differences were discussed for ages 6-10. ...
... In a study by Sankar et al. researchers found that older males (ages 11-17) had less ROM than older females in all directions aside from internal rotation (combined with hip flexion); however, they found no significant difference for gender with any motion in their youngest age group (ages 2-5), and no findings regarding gender differences were discussed for ages 6-10. 17 The current study produced similar findings where ROM was greater in females compared to males; however, these findings were seen in a younger age range (5-10 years old) than identified by Sankar et al. ...
... This is in contrast to previous studies, which suggest that range of motion tends to decline with increasing age. 4,14,17 An important note is that the age range in this study (5-10 years old) is narrower than in previous studies, which may explain this difference in findings. A gross comparison to the norms es-Reliability of the EasyAngle® for Assessing Hip Range of Motion in Healthy Children tablished in previous studies (Table 5) reveals that this study produced relatively similar averages across the age group studied here. ...
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Background The use of digital goniometry has emerged as a viable alternative to universal goniometry for assessing hip range of motion (ROM). However, few studies have assessed the use of digital goniometry in pediatric populations and there are a limited number of studies that investigate any one device. The EasyAngle® is a digital goniometer that may be beneficial for use in pediatric settings as it requires only one hand to operate the device. Purpose The purposes of this study were 1) to establish the intrarater and interrater reliability of the EasyAngle® digital goniometer in measuring hip joint ROM in healthy elementary school-aged children, and 2) to establish preliminary normative reference values for each year of age using the EasyAngle® for hip joint ROM in healthy elementary school-aged children. Study Design Descriptive Laboratory Study Methods Passive hip ROM (flexion, abduction, extension, internal rotation, external rotation) was measured on each leg of healthy participants using the EasyAngle®. A total of 40 hip joints were measured. Two blinded raters conducted three trials of each hip motion on both legs. Intrarater and interrater reliability of the recorded hip range of motion were calculated using intra-class correlation coefficients (ICC) (3,1). Results Twenty healthy children were measured (age 5-10, mean = 7.40 years old, SD = 1.37, 9 males, 11 females). Mean hip ROM was reported by age. Intrarater and interrater reliability were good to excellent for all hip ROM measurements (0.81-0.97 intra rater; 0.77- 0.91 interrater). Hip flexion had the strongest intrarater (0.96, 0.97) and interrater reliability (0.91). Intrarater reliability was lowest for hip abduction for Rater 1 and hip extension for Rater 2. Interrater reliability was lowest for hip external rotation (0.78) Conclusion The EasyAngle® is a reliable tool for assessing hip range of motion in healthy children ages 5-10. Normative hip ROM values using the EasyAngle® are available to clinicians. Level of Evidence Level 3- Reliability study
... Screening tests are also used to measure performance in athletes (Bishop, Read, McCubbine, & Turner, 2021), for progression during rehabilitation and for return to sport decisions (van Melick et al., 2020). Therefore, it is important as a researcher, clinician, or coach to have appropriate normative reference values for different defined populations (e.g., according to sex, age, or sport) to make it possible to assess and evaluate normal and abnormal values when screening athletes (Risberg et al., 2018;Sankar, Laird, & Baldwin, 2012). Normative values can also be used as a comparison tool for primary care physicians and other professions, to set rehabilitation goals, and for research. ...
... 2.3.1. ROM assessment ROM was measured for active trunk rotation (Asker, Wald en, K€ allberg, Holm, & Skillgate, 2017;Johnson, Kim, Yu, Saliba, & Grindstaff, 2012), passive hip flexion and abduction in supine position and passive hip extension, internal and external rotation in prone position (Prather et al., 2010;Sankar et al., 2012), and weightbearing ankle dorsiflexion (Konor, Morton, Eckerson, & Grindstaff, 2012). ...
... The clinical relevance of this finding is unclear because the minimum clinically important difference for external and internal hip rotation in youth baseball players has been reported previously to be 7.5 and 5.1 , respectively (Bullock, Beck, Collins, Filbay, & Nicholson, 2021). Normative data for ROM measurements have been reported previously for hip and ankle ROM in different cohorts (McKay et al., 2017;Onate et al., 2018;Sankar et al., 2012). The normative values reported in a general population of girls aged 11e17 years were almost identical to our reported data (Sankar et al., 2012). ...
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Objective To study normative values of range of motion (ROM), strength, and functional performance and investigate changes over 1 year in adolescent female football players. Design Cross-sectional. Participants 418 adolescent female football players aged 12–17 years. Main outcome measures The physical characteristic assessments included (1) ROM assessment of the trunk, hips, and ankles; (2) strength measures (maximal isometric and eccentric strength for the trunk, hips, and knees, and strength endurance for the neck, back, trunk and calves), and (3) functional performance (the one-leg long box jump test and the square hop test). Results Older players were stronger, but not when normalized to body weight. Only small differences in ROM regarding age were found. ROM increased over 1 year in most measurements with the largest change in hip external rotation, which increased by 6–7 degrees (Cohen's d = 0.83–0.87). Hip (d = 0.28–1.07) and knee (d = 0.38–0.53) muscle strength and the square hop test (d = 0.71–0.99) improved over 1 year. Conclusions Normative values for ROM and strength assessments of neck, back, trunk, hips, knees, calves and ankles are presented for adolescent female football players. Generally, fluctuations in ROM were small with little clinical meaning, whereas strength improved over 1 year.
... However, this association was more pronounced in the affected than in the nonaffected hip. Sankar et al. found an age-dependent range of motion of the hip, even in healthy children [14]. In our study no difference in the range of abduction was found between boys and girls, which is in line with the findings of Sankar et al. [14], who observed less range of abduction in boys than in girls only in the older age groups (11-17 years). ...
... Sankar et al. found an age-dependent range of motion of the hip, even in healthy children [14]. In our study no difference in the range of abduction was found between boys and girls, which is in line with the findings of Sankar et al. [14], who observed less range of abduction in boys than in girls only in the older age groups (11-17 years). Almost two thirds of the patients registered in the SPOQ received either instruction for Table 2 Linear regression analyses to identify the relationship of abduction at diagnosis and follow-up of the affected and nonaffected hip to age at diagnosis (adjusted for sex and abduction at diagnosis). ...
... However, instructions, how to measure abduction in a standardized technique are given in the SPOQ. In addition, Sankar et al. found excellent intraand interobserver agreement in abduction in a study of 504 hips examined by two observers [14]. An expert team of SPOQ which consists of the senior author and 2 additional pediatric orthopedic surgeons with special interest in LCPD validates the radiographic measurement annually by retrieving the radiographs of the different hospitals. ...
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Background Range of abduction often decreases during Legg-Calvé-Perthes Disease (LCPD) disease. However, a good range of abduction is required during the course of LCPD, especially when containment surgery should be performed. This study aimed to investigate how many patients registered in the Swedish Pediatric Orthopedic Quality register (SPOQ) with LCPD had reduced range of abduction at diagnosis in relation to sex or age at diagnosis or severity of disease (lateral pillar class at the time at diagnosis), if physiotherapy (PT) was prescribed and has a beneficial impact in maintaining (or increasing) abduction and if the range of abduction at diagnosis before fragmentation stage is predictive for the lateral pillar classification at fragmentation stage. Methods The national Swedish Pediatric Orthopedic Quality Register (SPOQ), established in 2015, is used to identify patients with LCPD. The patients are registered at three time points: at diagnosis, at potential surgery and 2 years after diagnosis. Range of abduction and information on PT are required to register at all registration sessions. One hundred ninety-nine hips from 192 children were registered in the SPOQ. Results Of all hips, the mean range of abduction at diagnosis was 39 degrees (range 0 to 90). One hundred twenty-six patients (63%) either received instructions for PT or were referred to a physiotherapist; two patients were treated additionally with an abduction brace. There was a trend that patients who received PT, compared to patients without PT, either maintained or increased their range of abduction at the 2-year follow-up. Older age at diagnosis correlated with decreased range of abduction at the 2-year follow-up (Estimate [Est]: − 3.1, 95% confidence interval [CI]: − 4.4 to − 1.7). The degree of abduction at diagnosis before fragmentation stage correlated with the lateral pillar group at the fragmentation stage (Est: -5.3, 95% CI: − 10.0 to − 1.1). Conclusion In all, 63% of the children with LCPD in SPOQ received either written instructions or were referred to PT or both. PT seems to have a favorable impact for maintaining the range of abduction in children with LCPD. Children with a lower range of abduction at diagnosis (before the fragmentation stage) developed a higher degree of lateral pillar involvement as measured by the lateral pillar classification.
... Passive range of motion (ROM) of hip extension (modified Thomas test [33]), hip adduction (with extended hip and knee of the assessed leg and hip and knee flexed in 90° of the contralateral leg), the hamstrings (true popliteal angle [33]), and ankle dorsiflexion (with knee extended and knee flexed in 90° [33]) was assessed using goniometry. The age-related normative values of Mudge et al. [33] and Sankar et al. [34] were used as the reference. Differences between the ROM measurements of the children with DMD and the reference ROM measurements of TD children with a similar age were calculated, reflecting ROM deficits. ...
... For the ROM measurements, we estimated the difference in fiber length at which the muscle starts to develop passive force between TD and DMD from the difference in joint angle at the end of ROM. The joint angle at the end of ROM of TD children was based on age-related reference data reported by Mudge et al. [33] and Sankar et al. [34]. To estimate the corresponding difference in fiber length, we multiplied the difference in measured joint angle at end ROM between TD and DMD (in radians) with the moment arm of the muscles in the anatomical position. ...
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Background Muscle weakness and contractures cause gait deficits in children with Duchenne muscular dystrophy (DMD) but their relative contributions are poorly understood and hence it is unclear whether contractures should be treated. Therefore, we aimed to differentiate the effect of muscle weakness in isolation from weakness and contractures combined on the gait patterns. Methods We used computer simulations that generate gait patterns based on a musculoskeletal model (without relying on experimental data) to establish the relationship between muscle impairments and gait deviations. We previously collected a longitudinal database of 137 repeated measurements in 30 boys with DMD and found that the data measured through 3D gait analysis could be clustered in three gait patterns. We estimated weakness based on data from fixed dynamometry, and contractures based on goniometry and clinical measures. Foot deformities were modeled by reducing the height of all foot segments and decreasing the strength of the intrinsic foot muscles. We created musculoskeletal models that either represented (1) the mean weakness; (2) the mean weakness and contractures; or (3) the mean weakness, contractures and foot deformities, in each gait pattern. Results Simulations based on models with both weakness and contractures captured most (but not all) experimentally observed gait deviations, demonstrating the validity of our approach. While muscle weakness was primarily responsible for gait deviations, muscle contractures and foot deformities further contributed to gait deviations. Interestingly, the simulations predict that the combination of increasing weakness and contractures rather than increasing weakness alone causes loss of ambulation for the most affected gait pattern. Conclusions Predictive simulations have the potential to elucidate causal relationships between muscle impairments and gait deviations in boys with DMD. In the future, they could be used to design targeted interventions (e.g. stretching, assistive devices) to prolong ambulation.
... The cable tension controller (Fig. 2b) includes a cable tension planner, tension compensation by cable speed, and PID controller with fuzzy gain scheduling, to reduce an excessively adducted hip joint angle of each participant compared with that of a healthy person [29], [30]. The cable tension planner computes desired cable tension with respect to the hip adduction angle measured in real-time. ...
... There is the upper limb of desired tension not to disturb the patient's intended walking, experimentally set for the participant who was applied the highest reference tension. Finally, in the outside of the outer range (−30 • to 15 • ) considering hip adduction ROM of children [30], we did not increase or decrease the target tension to avoid measurement error. Refer to the previous study about gait rehabilitation intervention using a cable-driven mechanism [19], we adopted a tension compensation algorithm to avoid a large overshoot of cable tension. ...
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Gait impairment represented by crouch gait is the main cause of decreases in the quality of lives of children with cerebral palsy. Various robotic rehabilitation interventions have been used to improve gait abnormalities in the sagittal plane of children with cerebral palsy, such as excessive flexion in the hip and knee joints, yet in few studies have postural improvements in the coronal plane been observed. The aim of this study was to design and validate a gait rehabilitation system using a new cable-driven mechanism applying assist in the coronal plane. We developed a mobile cable-tensioning platform that can control the magnitude and direction of the tension vector applied at the knee joints during treadmill walking, while minimizing the inertia of the worn part of the device for less obstructing the natural movement of the lower limbs. To validate the effectiveness of the proposed system, three different treadmill walking conditions were performed by four children with cerebral palsy. The experimental results showed that the system reduced hip adduction angle by an average of 4.57 ± 1.794.57~\pm ~1.79^{\circ } compared to unassisted walking. Importantly, we also observed improvements of hip joint kinematics in the sagittal plane, indicating that crouch gait can be improved by postural correction in the coronal plane. The device also improved anterior and lateral pelvic tilts during treadmill walking. The proposed cable-tensioning platform can be used as a rehabilitation system for crouch gait, and more specifically, for correcting gait posture with minimal disturbance to the voluntary movement.
... For male and female gymnasts, a number of significant differences were observed in all hip extension and hip abduction movements and for lumbar extension with all these values greater in female gymnasts which supports the finding of higher BS in female gymnasts. 54 reported that hip ROM decreased with age in male and female children aged 2 to 17 years and despite the potential for gymnastics to increase ROM this reduction was observed in the current study. ...
... Between female gymnasts ≥13 and male gymnasts <13 significant differences existed for all shoulder flexion movements and for lumbar extension was significantly greater in the <13 female gymnasts than ≥13 male gymnasts. Hypermobility decreases as age increases42,53 however, research comparing ROM in joints that do not form part of the BS is limited.Sankar et al (2012) ...
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Objectives: Hypermobility in gymnastics has both performance and injury implications. There is a paucity of studies that have reported joint hypermobility scores in young gymnasts and there is a need to consider joint hypermobility across different gender, age and performance levels. This study aimed to report the prevalence of joint hypermobility and range of motion values for the hip, shoulder, ankle and spine in male and female gymnasts. Methods: This study determined joint hypermobility via the Beighton score and range of motion for hip flexion, extension, abduction, shoulder flexion, ankle plantarflexion and lumbar extension in 25 male gymnasts (age:10.44±2.89 years, height:142.16±20.00cm, mass: 28.00±7.43kg and 25 female gymnasts (age:11.16±2.70 years,height: 141.55±22.34cm,mass: 32.33±7.99kg). Results: Joint hypermobility ranged from 56% (male gymnasts) to 68% (female gymnasts). The highest Beighton score was observed in female gymnasts (4.76±2.05), female gymnasts ≤13 years (4.93±1.87) and male national level gymnasts (5.67±1.15). No significant differences existed for Beighton scores between male and female gymnasts for gender (p=0.26) and age (p=0.095). Significant differences existed between male and female gymnasts for left hip extension (p=0.001), right hip extension (p=0.001), left hip abduction (p=0.001), right hip abduction (p=0.001) and lumbar extension (p=0.001) with all range of motion greater in females. For age and gender groups, significant differences existed between female gymnasts
... These measurements were compared with reported norms. 20 Hip adduction was assessed with Zhao 90-90 test. 21 Functional outcomes and scar satisfaction data were collected by an established set of questions asked verbally to the patient. ...
... *This table only includes data for patients with both preoperative and postoperative measurements. 20 This indicates that the surgery improves, but does not normalize ROM. However, all patients reported normal ability to walk, run, sit in a chair or bench, eat while sitting, use a pit-latrine style toilet, attend a full day of school, and perform physical education postoperatively. ...
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Background: Gluteal fibrosis (GF) is a fibrotic infiltration of the gluteal muscles resulting in functionally limiting contracture of the hips and is associated with injections of medications into the gluteal muscles. It has been reported in numerous countries throughout the world. This study assesses the 5-year postoperative range of motion (ROM) and functional outcomes for Ugandan children who underwent surgical release of GF. Methods: A retrospective cohort study of children who underwent release of GF in 2013 at Kumi Hospital in Eastern Uganda. Functional outcomes, hip ROM, and scar satisfaction data were collected for all patients residing within 40 km of the hospital. Results: One hundred eighteen children ages 4 to 16 at the time of surgery were treated with surgical release of GF in 2013 at Kumi Hospital. Of those 118, 89 were included in this study (79.5%). The remaining 29 were lost to follow-up or lived outside the study's radius. Detailed preoperative ROM and functional data were available for 53 of the 89 patients. In comparison with preoperative assessment, all patients postoperatively reported ability to run normally (P<0.001), sit upright in a chair (P<0.001), sit while eating (P<0.001), and attend the entire day of school (P<0.001). Passive hip flexion (P<0.001) improved when compared with preoperative measurements. In all, 85.2% (n=75) of patients reported satisfaction with scar appearance as "ok," "good," or "excellent" 29.2% (n=26) of patients reported back or hip complaints. Conclusions: Overall, the 5-year postoperative outcomes suggest that surgical release of GF improves ROM and functional quality of life with sustained effect. Level of evidence: Level IV-case series.
... In comparing our hip rotational ROM results with previous data from collegiate players, our youth cohort demonstrated more overall rotational ROM than older players [25], which is consistent with previous reports (see ▶table 3) [29,30]. Previous research has attributed increased hip ROM in younger athletes to be a product of immature development and the increased joint mobility and laxity common among younger athletes [28,29]. ...
... In comparing our hip rotational ROM results with previous data from collegiate players, our youth cohort demonstrated more overall rotational ROM than older players [25], which is consistent with previous reports (see ▶table 3) [29,30]. Previous research has attributed increased hip ROM in younger athletes to be a product of immature development and the increased joint mobility and laxity common among younger athletes [28,29]. Accordingly, our youth cohort did not show any side-to-side differences in rotational ROM, unlike older populations. ...
Article
The purpose of this study was to compare measures of bilateral shoulder and hip range of motion (ROM) between youth softball pitchers and position players. Fifty-two youth softball athletes (12.7±2.1 yrs.; 160.28±10.98 cm; 59.31±15.07 kg) participated. Bilateral hip and shoulder ROM were measured among pitchers (n=29) and position players (n=23). A 2 (pitcher/position player) × 2 (dominant/non-dominant) ANOVA was performed for both internal and external rotation ROM for the shoulder and hip. Paired sample t-tests were also conducted to examine side-to-side differences in total ROM. Data revealed a significant interaction between position and side dominance. Specifically, position players have significantly more non-dominant shoulder external rotation ROM (106.92°± 9.14°) than pitchers (100.12°± 11.21°). There were no significant differences between throwing and non-throwing sides. It is important that coaches and clinicians are aware of these adaptations between overhand and underhand throwing in order to properly develop conditioning and rehabilitation programs to alleviate injury susceptibility and cater to position-specific demands. Additionally, the current data suggest many of the functional adaptations seen within older populations are not fully developed until after youth.
... Therefore, information about joint ROM must be accurate [4]. Restriction or excessive joint ROM can be indicative of various disorders, such as osteoarthritis [5], joint deformities [6], or ligament injuries [7]. ...
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Telerehabilitation requires accurate joint range of motion (ROM) measurement methods. The aim of this study was to evaluate the reliability and validity of a computer vision (CV)‐based markerless human pose estimation (HPE) application measuring active hip and knee ROMs. For this study, the joint ROM of 30 healthy young adults (10 females, 20 males) aged 20–33 years (mean: 22.9 years) was measured, and test–retests were assessed for reliability. For validity evaluation, the CV‐based markerless HPE application used in this study was compared with an identical reference picture frame. The intraclass correlation coefficient (ICC) for the CV‐based markerless HPE application was 0.93 for active hip inner rotation, 0.83 for outer rotation, 0.82 for flexion, 0.82 for extension, and 0.74 for knee flexion. Correlations (r) of the two measurement methods were 0.99 for hip‐active inner rotation, 0.98 for outer rotation, 0.87 for flexion, 0.85 for extension, and 0.90 for knee flexion. This study highlights the potential of a CV‐based markerless HPE application as a reliable and valid tool for measuring hip and knee joint ROM. It could offer an accessible solution for telerehabilitation, enabling ROM monitoring.
... Internal rotation is evaluated by moving the legs away from midline, causing the hip to rotate internally, while external rotation involves allowing the legs to cross at midline. Normal values for internal and external rotation are 40-50° and around 45°, respectively; [28]. it is normal for internal rotation to decrease with age as femoral anteversion naturally decreases with growth. ...
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Purpose of Review Atraumatic hip pain in children is one of the most common orthopaedic complaints in this population. This review details the important elements of the pediatric hip physical exam and provides an overview of pertinent clinical exam findings in specific diagnoses of common pediatric hip pathology. Recent Findings A thorough physical exam is critical for the diagnosis of pediatric hip pathology, as many conditions have exam findings that are very commonly associated with the pathology, if not pathognomonic for the disorder. Additionally, pediatric hip pathology is strongly age-related, so an understanding of typical exam findings and common hip conditions by age can be invaluable in forming a correct diagnosis. Summary Inspection, palpation, range of motion, gait analysis, and provocative tests provide clues about potential diagnoses. Together with history and risk factors, pediatric clinicians can make appropriate diagnosis of pediatric hip disorders.
... The tests included mobility assessment of trunk rotation [2], hip flexion, abduction (in supine position), extension, internal rotation and external rotation (in prone position) [39], and weight-bearing ankle dorsiflexion [31]. Strength measures included isometric TA B L E 1 Description of the baseline tests. ...
Article
Purpose To investigate the association between common measures of trunk and lower extremity range of motion (ROM), strength, the results of one‐leg jump tests at baseline and the incidence of subsequent substantial knee injuries in adolescent female football players. Methods Players were assessed at baseline regarding (1) ROM of trunk, hip, and ankle; (2) trunk, hip, and knee strength; and (3) one‐leg jump tests. Players were prospectively monitored weekly for 1 year regarding knee injuries and the volume of matches and training. Hazard rate ratios (HRRs) and 95% confidence intervals (CIs) were calculated with Cox regression for the association between the baseline tests and the incidence of substantial knee injury (moderate/severe reduction in training volume or performance, or complete inability to participate in football). Exposures were categorized in tertiles (high, medium and low values). The highest tertile was used as reference. Results 376 players were included without substantial knee injury at baseline (mean age, 13.9 ± 1.1 years), and 71 (19%) reported at least one substantial knee injury during the follow‐up. Several associations were found; the strongest was that players in the lowest tertile of knee extension strength had a higher incidence of knee injuries than players in the highest tertile (HRR, 2.28; 95% CI, 1.20−4.38). Players in the lowest tertile of trunk rotation ROM in lunge position half‐kneeling (HRR, 0.50; 95% CI, 0.27−0.94) had lower incidence of knee injuries than players in the highest tertile. Conclusions Poor knee strength and high trunk ROM were associated with an increased incidence of substantial knee injury in adolescent female football players. Therefore, knee‐strengthening exercises during season may be recommended. Level of Evidence Level II.
... Sankar et al. demonstrated that goniometric evaluation should be > 6 degrees in order to observe clinically significant differences in joint mobility. Similarly, in our study, we determined that the difference in lower extremity asymmetry was clinically significant [33]. In previous studies decreased hip RoM and frontal pelvis asymmetry was reported in patient with IS compared to healthy individuals commonly used tests to demonstrate lumbopelvic stability and balance. ...
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Background Since scoliosis is a three-dimensional deformity, it causes some movement limitations in the spine and related joints. However, functional limitations associated with scoliosis-related hip joint involvement are the subject of research. Aims This study aims to investigate the physical characteristics and functional limitations associated with idiopathic scoliosis (IS), focusing on hip joint. Methods Demographic characteristics, scoliosis-specific assessments and hip joint active range of motion (RoM), lumbar mobility (Modified Schober test), lumbopelvic stability (Single leg squat test-SLS), hip joint position sense, lower extremity balance (Y-balance test) and lower extremity functionality (Lower extremity functional scale-LEFS) were evaluated. Results The study included 120 individuals, with 86 in the scoliosis group (mean age: 15.7 ± 3.4 years) and 34 in the control group (mean age: 16.1 ± 4.8 years). The scoliosis group exhibited limited RoM of the hip joint in flexion, extension, right abduction, adduction, internal rotation, and left external rotation compared to controls (p < 0.001). Lumbar mobility was decreased (p < 0.001). In the joint position sense test, the mean difference for right flexion was and for left flexion. Bilateral decreased SLS test performances (p < 0.001) and Y-balance test performance (p < 0.05) in individuals with IS. LEFS scores were statistically different but not clinically different between groups (p < 0.05). Conclusion Individuals with IS show decreased hip mobility, lumbopelvic stability, hip joint position sense, and balance compared to healthy peers; however, these limitations do not have a clinical impact on daily living activities.
... Second, measurement of hip abduction is examinerdependent, which could possibly affect the quality of input data. However, SPOQ provides detailed instructions, and previous studies show excellent agreement in hip abduction measurements [33]. Third, factors influencing the choice of surgical treatment, such as individual treatment preferences, surgeon experience, and socioeconomic factors, are not fully captured in the registry. ...
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Background and purpose: It is controversial as to which patients affected by Legg–Calvé–Perthes disease (LCPD) benefit from containment surgery. This population-based study based on data from a national quality registry aims to assess the incidence of LCPD and to explore which factors affect the decision for surgical intervention.Methods: This observational study involved 309 patients with unilateral LCPD reported between 2015 and 2023 to the Swedish Pediatric Orthopedic Quality Register (SPOQ). Descriptive statistics and logistic regression models were used for analysis.Results: In 2019, the assessed incidence of LCPD in the Swedish population of 2–12-year-olds was 4.2 per 105. 238 (77%) were boys with a mean age of 6 years. At diagnosis, 55 (30%) were overweight or obese, rising to 17 patients (39%) and 16 patients (40%) at 2-year follow-up for surgically and non-surgically treated groups, respectively. At diagnosis, affected hips had reduced abduction compared with healthy hips, and their abduction remained restricted at the 2-year follow-up. Surgically treated patients had inferior abduction compared with non-surgically treated ones at diagnosis. The adjusted risk for containment surgery increased with age and in the presence of a positive Trendelenburg sign but decreased with greater hip abduction.Conclusion: We found a lower national yearly incidence (4.2 per 105) than previously reported in Swedish studies. A higher proportion of overweight or obese patients compared with the general Swedish population of 4–9-year-olds was identified. Increasing age, positive Trendelenburg sign, and limited hip abduction at diagnosis correlated with increased surgical intervention likelihood.
... To ensure the symmetry of the model, bones from the left arm and leg were mirrored from the right corresponding segments and registered to their proper position. For each joint, the range of motion was set to values similar to currently available OpenSim models (models Gait 2392 and Pers_fbm_spine, available on SimTK.org), or retrieved from the literature for specific joints (Sankar et al. 2012;Epperson et al. 2024). Table 1 summarizes the modelled joints and their corresponding ranges of motion. ...
Article
Childbirth simulations lack realism due to an oversimplification of the foetal model, particularly as most models do not allow joint motion. Foetus-specific neuromusculoskeletal (NMS) model with a detailed articulated skeleton is still not available in the literature. The present work aims at proposing the first-ever foetus-specific NMS model and then simulating the foetal descent during a vaginal delivery by using in vivo medical resonance imaging (MRI) childbirth data. Moreover, the developed model is provided open source for the community. Our foetus-specific NMS model was developed using the geometries reconstructed from a foetal computed tomography (CT) scan (Female, mass = 2.35 kg, length = 50 cm). The model contains 22 joints (64 degrees of freedom) and 65 muscles with a particular attention to the cervical spine level to enable the simulation of the cardinal movements. Then, the skull-to-cervical-spine (S/CP) and cervical-spine-to-torso (CP/T) deflection angles were extracted from in vivo MRI data for motion simulation. The S/CP and CP/T deflexion angles range from 12 degrees of flexion to 2 degrees of extension and from 7 degrees of flexion to 22 degrees of extension respectively. The developed model opens new avenues in more biofidelic childbirth simulations with a complete foetal NMS model. Obtained outcomes with the in vivo MRI data enabled to perform a first simulation of the foetal descent kinematics using real childbirth data. Future works will focus on developing a novel muscle formulation of the foetus and combining such a NMS model with a deformable model to simulate childbirth and associated complication scenarios.
... 2 There are published normative values for the majority of joints, and these values have been established with acceptable intraobserver and interobserver reliability. 3 A common practical application of returning range of motion is for the patient to be at or above 85% of their range compared to the unaffected limb, or normative published values, prior to initiating a progressive resistance program. Figure 1 displays normative values for clinical reference. ...
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The purpose of this article is to identify gold standards of care for return to sport following athletic injury, investigate overlooked aspects of return to sport rehabilitation, and provide expert opinion regarding current practices. The article was written by performing a literature review, then providing editorial expert opinion regarding current standards of return to sport. We concluded, through literature review and expert consensus, that a three-pronged approach to return to sport is recommended for therapists. These three prongs are ROM, strength, and hop testing. Cardiovascular readiness and psychological readiness for return to sport must also be assessed.”
... The pre-menarche dancers are along their peak height velocity period, when bones grow faster than ligaments and tendons, and thus female dancers fail to increase their strength and power along with bone and soft tissue maturation (Quatman et al., 2006;Steinberg et al., 2011;Wild et al., 2012), whereas in post-menarche dancers a large proportion of total muscle tissue mass is gained along with endocrine system maturation (Day et al., 2015). Considering joint ROM with age and pubertal development, Sankar et al. (2012) assessed normative ROM values in children, and showed a decline in ROM with increased age and maturation. In dancers, joint ROM was found to decrease or to be preserved (but not to improve) with increasing age and maturation, in large sample of dancers (Steinberg et al., 2006(Steinberg et al., , 2016. ...
Article
Aiming to determine the association between joint range of motion (ROM) and muscle strength; and, the effect of age and menarche on those two factors; 132 pre-and post-menarche dancers, aged 12-14 years were assessed for joint ROM and for muscle strength at the hip, knee and ankle and foot joints. En-pointe ROM was significantly correlated with ankle plantar-flexors' (r = -.184) and with ankle dorsiflexors' muscle strength (r = -.221). Hip external rotation ROM was significantly correlated with knee extensors' strength (r = -.263). Pre-menarche dancers had higher joint ROM compared with post-menarche dancers; yet, dancers at post-menarche were stronger compared to dancers at pre-menarche. The slope coefficient was negative at the age of 12 in hip external rotation and in en-pointe (-0.80 and -0.52, respectively) and became steeper with age (age 13: -3.52 and -3.28, respectively; age 14: -6.31 and -4.42, respectively). Along maturation, dancers with high joints ROM showed reduced muscle strength. Pre-menarche dancers have higher joint ROM, yet reduced muscle strength, compared with post-menarche dancers. As the association between joint ROM and muscle strength might be involved with growth and development, young dancers should be screened along pubertal stages in order to decide the correct curricula and to prevent future injuries.
... In prone position, hip external rotations were lesser than internal rotations. This was in accordance with [2] but contrary to [3]and [4]. McKay et al reported a much higher ankle plantarflexion than our results [1]. ...
... In this study, the hip rotation was measured with the neutral position of the hip joint [18]. For children, the normative values of internal rotation were 40º-41º and external rotation were 44º-48º [35] and for adults 40º-45º internal rotation and 45º-50º external rotation [36]. Subjects from the GJH groups obtained an average of 16º-21º over the norm of internal rotation. ...
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Introduction: Generalized Joint Hypermobility (GJH) is defined as an increased range of motion in joints. There is no causal treatment of GJH, therefore the therapy should be based on the individual needs of patients after the comprehensive diagnostic of body posture. The occurrence of deformities of lower limbs in people with GJH should be an indication for the therapy. The aim of this study was the assessment of the impact of Generalized Joint Hypermobility on the lower limbs position. Materials and methods: The research was conducted on 30 children, aged 7-13 (10.1 ± 1.7), 51 adults aged 20-29 (23.2 ± 1.6). The study included the assessment of external and internal rotation of hips, tibial torsion, axis of lower limbs, longitudinal and transverse arch of the feet. Females with ≥5 and males with ≥4 scores in the Beighton test were included in the GJH groups. Results: Both children and adults with GJH presents higher internal rotation of hips in comparison to the control group (p = 0.03 for right and p = 0.00 for left side, and p = 0.00 for right and p = 0.00 for left side, for children and adults, respectively). Children with GJH obtained higher values of the Clarke angle for the right foot compared to the control group (p = 0.00). Conclusions: Regardless of age, subjects with Generalized Joint Hypermobility are characterized by higher internal rotation of the hip compared to healthy controls. Children with GJH present a higher longitudinal arch of the feet compared to peers, but the results fall within the normative ranges.
... Based on previously reported procedures 21 , we measured hip ROM in flexion and internal/external rotation with the hip flexed 90° and the participant in a supine position, and hip ROM in internal/external rotations of the extended hip with the participant in a prone position. The straight-leg raising angle was measured using a standard technique 22 , with the participant in a supine position. ...
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Asymptomatic elbow abnormalities are relatively common in young baseball players, but the factors responsible are unclear. To prospectively identify risk factors related to symptom manifestation in asymptomatic elbow abnormalities, we recruited 573 baseball players (age: 7–14 years) at a pre-participation medical/physical examination in the preseason who were right-handed and had asymptomatic medial elbow abnormalities on ultrasound (US). Baseline preseason and postseason participant characteristics were assessed. A “symptomatic” elbow was defined as an elbow with medial elbow joint problems that prevented ball throwing for ≥ 8 days. After exclusions, 82 players were enrolled, of whom 22 (26.8%) developed a symptomatic elbow. In univariate analyses, the external and internal rotation strengths of the dominant shoulder were significantly greater in the symptomatic group than in the asymptomatic group (P = 0.021). Multivariate logistic regression analysis showed that the internal rotation strength of the dominant shoulder was a significant independent risk factor (odds ratio = 1.091, P = 0.027) for developing a symptomatic elbow. In young asymptomatic baseball players with abnormalities in the medial elbow region of the dominant arm on US, stronger preseason internal rotation strength of the dominant shoulder was a significant independent risk factor for the development of a “symptomatic” elbow.
Article
Purpose Manual anthropometric evaluations of pediatric lower extremities are essential in orthopedic pediatric practice due to their noninvasive and time-feasible nature. Therefore, this study aims to assess the test–retest reliability of clinical measurements obtained on children to examine measurement stability over time. Methods In a test–retest design, data were collected from 50 Danish school children with 5–to 6 weeks between sessions. Measurements encompassed the joint range of motion (ROM), rotational profile, and angular alignment of lower extremities for a representative sample of school children. Reliability was assessed using intraclass correlations (ICC), and agreement was assessed using limits of agreement (LoA) and precision. Results Reliability analysis revealed excellent results for foot length (ICC > 0.9), good results for foot width (ICC < 0.9), and poor to moderate results for all other measurements (ICC < 0.5, ICC < 0.75). Agreement results for hallux valgus were acceptable (within established reference) and the remaining variables were not acceptable (outside established reference). Conclusions The majority of the manual assessment procedures were found to have poor reliability. This study highlights the need for reliable and time-efficient tools to assist clinicians in assessing manual clinical measurements and future research should explore this. Level of evidence Level III.
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Background Muscle weakness and contractures cause gait deficits in children with Duchenne muscular dystrophy (DMD) but their relative contributions are poorly understood and hence it is unclear whether contractures should be treated. Therefore, we aimed to differentiate the effect of muscle weakness in isolation from weakness and contractures combined on the gait patterns. Methods We used computer simulations that generate gait patterns based on a musculoskeletal model (without relying on experimental data) to establish the relationship between muscle impairments and gait deviations. We previously collected a longitudinal database of 137 repeated measurements in 30 boys with DMD and found that the data measured through 3D gait analysis could be clustered in three gait patterns. We estimated weakness based on data from fixed dynamometry, and contractures based on goniometry and clinical measures. Foot deformities were modeled by reducing the height of all foot segments and decreasing the strength of the intrinsic foot muscles. We created musculoskeletal models that either represented (1) the mean weakness, (2) the mean weakness and contractures, or (3) the mean weakness, contractures and foot deformities, in each gait pattern. Results Simulations based on models with both weakness and contractures captured most (but not all) experimentally observed gait deviations, demonstrating the validity of our approach. While muscle weakness was primarily responsible for gait deviations, muscle contractures and foot deformities further contributed to gait deviations. Interestingly, the simulations predict that the combination of increasing weakness and contractures rather than increasing weakness alone causes loss of ambulation for the most affected gait pattern. Conclusions Predictive simulations have the potential to elucidate causal relationships between muscle impairments and gait deviations in boys with DMD. In the future, they could be used to design targeted interventions (e.g. stretching, assistive devices) to prolong ambulation.
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Background Insights into the progression of muscle impairments in growing boys with Duchenne muscular dystrophy (DMD) remains incomplete due to the frequent oversight of normal maturation as confounding factor, thereby restricting the delineation of sole pathological processes. Objective To establish longitudinal trajectories for a comprehensive integrated set of muscle impairments, including muscle weakness, contractures and muscle size alterations, whilst correcting for normal maturation, in DMD. Methods Thirty-five boys with DMD (aged 4.3-17 years) were included. Fixed dynamometry, goniometry and 3D freehand ultrasound were used to repeatedly asses lower limb muscle strength, passive range of motion (ROM) and muscle size, resulting in 165, 182 and 67 assessments for the strength, ROM and ultrasound dataset, respectively. To account for natural strength development, ROM reduction and muscle growth in growing children, muscle impairments were converted to unit-less z-scores calculated in reference to typically developing (TD) peers. This allows the interpretation of the muscle impairments as deficits or alterations with respect to TD. Mixed-effect models estimated the longitudinal change in muscle impairments. Results The pathological trajectories of most muscle impairments with age followed a similar non-linear, piecewise pattern, characterized by an initial phase of improvement or stability lasting until 6.6-9.5 years, and a subsequent decline after these ages. The muscle strength outcomes and several ROMs showed already initial deficits at young ages. General muscle weakness and plantar flexion contractures exhibited the steepest declines, resulting in large deficits at older ages. The muscle size alterations with age were muscle-specific. Conclusions The established longitudinal trajectories of muscle impairments will serve as the basis to enhance understanding of their relationship with the progressive gait pathology in DMD. Our study provides outcome measures, which will be useful for future clinical trials that assess the efficacy of novel therapeutic strategies.
Article
b>Purposes: To report current status of normative values for upper and lower extremity joint motions in the pediatric population and effects of side of body, age, gender and ethnicity/race, and to summarize available joint motion measurement values to serve as a reference. Methods: PubMed searches were performed using combinations of the following terms: pediatric, children, normal range of motion, with upper extremity, shoulder, elbow, wrist, finger, and thumb; and with lower extremity, hip, knee, ankle, and foot. Inclusion criteria were 1-21 years of age, passive or active joint motion measured with goniometer, normal range of motion, and in English. Results: Seven upper extremity studies, 3 lifespan and 4 pediatrics only, and 11 lower extremity, 6 lifespan and 5 pediatrics only, were reviewed. Any left/right or dominant/non-dominant differences found were not statistically/clinically significant. For age-related comparisons: in lifespan studies, joint motion decreased as age increased; in pediatric only studies, variable findings were no relationship between amount of motion and age, motion decreased as age increased, and for a single motion (active), motion increased as age increased. Pediatric gender difference analyses produced mixed results of no differences, varying as a function of age and motion, and statistically significant differences. Ethnicity/race effect was addressed rarely. Discussion: Currently available upper and lower extremity joint motion normative values, which includes multiple measurements for some motions and few/none for others, were summarized. Lower extremity motions were examined to a greater extent than upper extremity motions. Further assessment is required to establish normative values for all passive motions and to clarify effects of side of body, age, gender, and ethnicity/race.
Article
Human intelligence and human consciousness emerge gradually during the process of cognitive development. Understanding this development is an essential aspect of understanding the human mind and may facilitate the construction of artificial minds with similar properties. Importantly, human cognitive development relies on embodied interactions with the physical and social environment, which is perceived via complementary sensory modalities. These interactions allow the developing mind to probe the causal structure of the world. This is in stark contrast to common machine learning approaches, e.g., for large language models, which are merely passively “digesting” large amounts of training data, but are not in control of their sensory inputs. However, computational modeling of the kind of self-determined embodied interactions that lead to human intelligence and consciousness is a formidable challenge. Here we present MIMo, an open-source multi-modal infant model for studying early cognitive development through computer simulations. MIMo’s body is modeled after an 18-month-old child with detailed five-fingered hands. MIMo perceives its surroundings via binocular vision, a vestibular system, proprioception, and touch perception through a full-body virtual skin, while two different actuation models allow control of his body.We describe the design and interfaces of MIMo and provide examples illustrating its use. All code is available at https://github.com/trieschlab/MIMo .
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Clinical gait analysis on uneven surfaces contributes to the ecological assessment of gait deviations of children with spastic cerebral palsy (CP). Walking on uneven surfaces requires specific motor strategies, which can be assessed by lower-limb kinematic and inter-joint coordination analyses. This study aimed to assess and compare kinematics and inter-joint coordination between children with CP and their typically developing (TD) peers when walking on even and two levels of uneven surfaces (medium and high). A total of 17 children with CP and 17 TD children (11.5 ± 3.5 and 10.4 ± 4.5 years old, respectively) were asked to complete 6–8 gait trials on a 4-m walkway of each surface (n = 3) in randomized blocks while fit with retro-reflective markers on their lower-limbs. Children with CP showed proximal gait adaptations (i.e., hip and knee) on uneven surfaces. Compared with the TD group, the CP group showed decreased hip extension during late stance (49–63%, d = 0.549, p < 0.001), and a more in-phase knee-hip coordination strategy during swing phase (75–84% of gait cycle, d = 1.035, p = 0.029 and 92–100%, d = 1.091, p = 0.030) when walking on an uneven (high), compared to even surface. This study provides a better understanding of kinematic strategies employed by children with spastic CP when facing typical daily life gait challenges. Further studies are needed to evaluate the benefits of integrating uneven surfaces in rehabilitation care.
Article
Childbirth is a complex physiological process in which a foetal neuromusculoskeletal model is of great importance to develop realistic delivery simulations and associated complication analyses. However, the estimation of hip joint centre (HJC) in foetuses remains a challenging issue. Thus, this paper aims to propose and evaluate a new approach to locate the HJC in foetuses. Hip CT-scans from 25 children (F = 11, age = 5.5 ± 2.6 years, height = 117 ± 21 cm, mass = 26 kg ± 9.5 kg) were used to propose and evaluate the novel acetabulum sphere fitting process to locate the HJC. This new approach using the acetabulum surface was applied to a population of 57 post-mortem foetal CT scans to locate the HJC as well as to determine associated regression equations using multiple linear regression. As results, the average distance between the HJC located using acetabulum sphere fitting and femoral head sphere fitting in children was 1.5 ± 0.7 mm. The average prediction error using our developed foetal HJC regression equations was 3.0 ± 1.5 mm, even though the equation for the x coordinate had a poor value of R2 (R2 for the x coordinate = 0.488). The present study suggests that the use of the acetabulum sphere fitting approach is a valid and accurate method to locate the HJC in children, and then can be extrapolated to get an estimation of the HJC in foetuses with incomplete bone ossification. Therefore, the present paper can be used as a guideline for foetus specific neuromusculoskeletal modelling.
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Background Accurate repositioning of the femoral head in patients with Slipped Capital Femoral Epiphysis (SCFE) undergoing Imhäuser osteotomy is very challenging. The objective of this study is to determine if preoperative 3D planning and a 3D-printed surgical guide improve the accuracy of the placement of the femoral head. Methods This retrospective study compared outcome parameters of patients who underwent a classic Imhäuser osteotomy from 2009 to 2013 with those who underwent an Imhäuser osteotomy using 3D preoperative planning and 3D-printed surgical guides from 2014 to 2021. The primary endpoint was improvement in Range of Motion (ROM) of the hip. Secondary outcomes were radiographic improvement (Southwick angle), patient-reported clinical outcomes regarding hip and psychosocial complaints assessed with two questionnaires and duration of surgery. Results In the 14 patients of the 3D group radiographic improvement was slightly greater and duration of surgery was slightly shorter than in the 7 patients of the classis Imhäuser group. No difference was found in the ROM, and patient reported clinical outcomes were slightly less favourable. Conclusions Surprisingly we didn’t find a significant difference between the two groups. Further research on the use of 3D planning an 3D-printed surgical guides is needed. Trial registration Approval for this study was obtained of the local ethics committees of both hospitals.
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Background In professional dance, a low body weight is of elementary importance. Therefore, there is already a high prevalence of underweight among female dance students. To date, it is unclear whether systematic associations exist between weight and other characteristics relevant to eligibility for training in professional dance. Therefore, the aim was to investigate selected relevant eligibility criteria (body weight, hormonal status, hip external rotation, rearfoot axis, current and previous injuries with missed training and mobility) considering weight status and age in female dance students (TS) aged between 5–19 years.Methods The basis was the evaluation of examination findings from check-up examinations (n = 391) of a German ballet education institution over a period of 20 years (1997–2017). The analysis was performed with SPSS 22 using mean and standard deviation and to test for differences using Fisher’s test or the Wilcoxon rank-sum test. All variables were compared within the previously defined age groups.ResultsLow body mass index (BMI) is largely independent of the other relevant eligibility criteria. Significant differences between weight status and other relevant characteristics between normal weight and underweight female dance students were only found for left hip external rotation in 11–13-year-olds and for rearfoot axis in 8–10-year-olds and 17–19-year-olds.Conclusion Underweight and normal weights hardly differ with respect to further criteria in their suitability for classical dance. Body weight should be considered largely independent of the other parameters. As underweight can often be combined with a deficit in energy availability, the focus here should be on ensuring that children and adolescents remain healthy in the long term. Consideration must be given to the various causes of underweight, existing comorbidities, and the special needs of this population.
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Background Normative values of lifestyle characteristics in adolescent female football players may be used by clinicians and coaches to take actions because the potential important for well-being, performance on the pitch, and risk of injury. The aim was to report descriptive characteristics of lifestyle factors in adolescent female football players and potential changes over 1 year. Methods We included 419 adolescent competitive female football players from 12 clubs and 27 teams (age 14 ± 1 years, range 12–17 years) and 286 were followed over 1 year. The players completed an extensive questionnaire regarding demographics, football-related factors, and lifestyle factors including tobacco consumption, alcohol use, medicine intake, eating and sleeping habits, well-being, stress, coping, and passion. Baseline data are presented for the total cohort and separately for 4 age groups (12, 13, 14, and 15–17 years). Results 12% skipped breakfast, 8% skipped lunch and 11% used protein supplements several days per week. 16% slept less than 8 h/night, 8% had impaired sleep with daytime consequences, and 22% stated that they were tired in daily activities several days per week. 32% experienced stress some or most days/week and 24% were classified as having psychological distress. Medicine intake (23% vs. 34%), skipping breakfast or lunch several days per week (10% vs. 47% and 20 vs. 33%), tiredness (20% vs. 27%), stress (26% vs. 40%), and psychological distress (27% vs. 37%) increased significantly (P = 0.031 to < 0.001) at the 1-year follow-up. Conclusion Many adolescent female football players skip breakfast and lunch, have insufficient sleep, experience stress and are classified as having psychological distress. These factors increased over 1 year.
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Developmental dysplasia of the hip (DDH) is an important cause of childhood disability: the spectrum of pathology ranges from acetabular dysplasia with enlocated, stable hips to complete dislocation. The precise definition of DDH is itself controversial and usually refers to an abnormality in development, such as in size, shape, or organization, of the femoral head, acetabulum, or both. These changes may lead to increased contact pressures on the joint and ultimately to hip arthritis. However, before the development of frank degenerative changes, many patients become symptomatic secondary to abnormal hip biomechanics, hip instability, impingement, or labral and chondral pathologies.Treatment depends upon the age of diagnosis. The primary aim of this treatment is to achieve a stable concentric reduction of the hip to enable normal joint development. When detected early, non-surgical treatment with a harness or cast is possible while, when non-surgical treatment fails, open reduction and cast should be considered. A complication of those treatment is avascular necrosis of the hip (AVN). When DDH is detected late, tenotomies, acetabular reorientation, or combined femoral and acetabular osteotomies should be considered. If DDH is not treated, it may lead to juvenile arthritis and lifelong gait problems, in those stages a total hip replacement should be considered.KeywordsOverview DDHDevelopmental hip dysplasiaHip dysplasiaAcetabular dysplasia
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A referral from accident and emergency for a child with hip pain is a scenario commonly faced by orthopaedic juniors on call. The list of differentials is vast and can make assessment and diagnosis challenging, with severe consequences if diagnosis is delayed or missed. Three common causes of paediatric hip pain are septic arthritis, transient synovitis and osteomyelitis. These can all present as a child with atraumatic hip pain, irritability, fever and refusal to weight bear. Differentiating between them can be challenging. A thorough history and examination, combined with appropriate investigations and imaging, is essential. Early diagnosis and prompt treatment are key to reducing irreversible secondary sequelae of joint destruction and long-term functional impairment.
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Context: Joint mobilizations have been studied extensively in the literature for the glenohumeral joint and talocrural joint (ankle). Consequently, joint mobilizations have been established as an effective means of improving range of motion (ROM) within these joints. However, there is a lack of extant research to suggest these effects may apply within another critical joint in the body, the hip. Objective: To examine the immediate effects of hip joint mobilizations on hip ROM and functional outcomes. Secondarily, this study sought to examine the efficacy of a novel hip mobilization protocol. Design: A prospective exploratory study. Setting: Two research labs. Patients or other participants: The study included 19 active male (n = 8) and female (n = 11) college students (20.56 [1.5] y, 171.70 [8.6] cm, 72.23 [12.9] kg). Interventions: Bilateral hip mobilizations were administered with the use of a mobilization belt. Each participant received hip joint mobilization treatments once during 3 weekly sessions followed immediately by preintervention and postintervention testing/measurements. Testing for each participant occurred once per week, at the same time of day, for 3 consecutive weeks. Hip ROM was the first week, followed by modified Star Excursion Balance Test the second week and agility T test during the third week. Main outcomes measures: Pretest and posttest measurements included hip ROM for hip flexion, extension, abduction, adduction, internal and external rotation, as well as scores on the modified Star Excursion Balance Test (anterior, posterolateral, and posteromedial directions) and agility T test. Results: A significant effect for time was found for hip adduction, internal and external rotation ROM, as well as the posterolateral and posteromedial directions of the modified Star Excursion Balance Test. A separate main effect for both limbs was found for adduction and internal rotation ROM. Conclusion: Isolated immediate changes in ROM and functional outcomes were evident. Further evaluation is needed.
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The hip is arguably the anatomic region of greatest concern in cerebral palsy. Tone, weakness, and spasticity about the hip can result in bony deformity such as increased femoral anteversion, coxa valga, and acetabular dysplasia. Muscular and tendinous pathology commonly includes hip flexion and adductor contractures. Bony and musculotendinous pathology can lead to pain, particularly when the hip is in advanced stages of subluxation or has dislocated. Functional problems are common, including difficulties with perineal care and seating, and in ambulatory children anterior pelvic tilt, pelvic obliquity, increased hip internal rotation, and scissoring may contribute to jump or crouch gait and in-toeing. Physical exam, x-rays, and selective use of gait analysis, MR, CT, and CT version studies are used to diagnose hip pathology, delineate how it is affecting gait, and develop a treatment protocol. Bracing and chemodenervation techniques to address hip pathology are addressed in more detail separately; surgical techniques to address hip pathology vary greatly with the most common techniques presented.
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SCFE is one of the most potentially damaging conditions of the adolescent hip. The onset may be associated with minor trauma but is often insidious and may present as vague thigh or knee pain. The lateral radiograph is the most sensitive view for detection of a low-grade slip. The contralateral hip must be examined carefully as there may be bilateral disease with the pain and disability of the presenting side masking the symptoms of less involved hip. SCFE is occasionally associated with other metabolic and endocrinologic disease, and these should be screened for in the history and physical examination. Once a slip begins, the hip remains at jeopardy for acute progression until the physeal plate closes. We recommend immediate surgical stabilization and prefer a cannulated screw system. Proper technique is critical to safe and reliable surgery. The most common complications, AVN and chondrolysis, are often related to technical errors and should be minimized with attention to detail.
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Femoroacetabular impingement (FAI) is a recently recognized hip disorder resulting from an abnormal morphology of the proximal femur and acetabulum. This morphology results in increased hip contact forces with hip motion, specifically flexion. This may lead to labral-cartilage injury and pain. The purpose of this study is to describe the clinical presentation and diagnosis of FAI as a cause of hip pain in adolescents.Thirty-five patients with FAI as the etiology of chronic hip pain from one institution were reviewed. The common symptoms, physical examination, and radiographic findings were analyzed.The age range was 13 to 18 years. There were 30 girls and 5 boys. All patients complained of anterior groin pain. All patients performed a sport/activity that contributed to the symptoms such as dancing. Patients had decreased flexion and limited internal rotation on physical examination. All patients had a positive impingement test. Fifteen patients (43%) had primarily pincer impingement with a crossover sign or acetabular retroversion. Cam impingement was the primary type in 2 patients (6%). There were findings of cam and pincer in 18 patients (51%). Sixteen of 28 patients had a positive labral tear on magnetic resonance imaging (57%). Femoroacetabular impingement is a cause of hip pain in the adolescent population. The diagnosis can be derived from reproducible history, physical examination, and radiographic findings. It is more common in female adolescents, and pincer type is more prevalent.
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With a clinical goniometer, we measured the arcs of active motion of the shoulder, elbow, forearm, wrist, hip, knee, ankle, and foot in 109 normal male subjects ranging in age from eighteen months to fifty-four years old. The normal limits were determined for subjects who were one to nineteen years old and for those who were twenty to fifty-four years old. Significant differences were found between the two age groups for most motions. The data were compared with estimations in the handbook of The American Academy of Orthopaedic Surgeons as the standard reference. The data constitute a more detailed set of measurements, based on a sample described according to height and age, than has been available hitherto.
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This study determined the intratester and intertester variability and reliability of goniometric measurements taken by four physical therapists on upper and lower extremity motions of normal male subjects. The same subjects were measured once weekly for four weeks by testers with varied experience in goniometry. Data were analyzed by analyses of variance with repeated measures. Intratester variation for all measurements was less than intertester variation. Further, intertester variation was less for the three upper extremity motions than for those of the lower extremity. These findings indicate the necessity for using the same tester when effects of treatment are evaluated. When the same tester measures the same movement, increases in joint motion of at least three to four degrees determine improvement for either the upper or lower extremity. When more than one tester, however, measures the same movement, increases in joint motion should exceed five degrees for the upper extremity and six degrees for the lower extremity to determine improvement.
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This paper presents a general statistical methodology for the analysis of multivariate categorical data arising from observer reliability studies. The procedure essentially involves the construction of functions of the observed proportions which are directed at the extent to which the observers agree among themselves and the construction of test statistics for hypotheses involving these functions. Tests for interobserver bias are presented in terms of first-order marginal homogeneity and measures of interobserver agreement are developed as generalized kappa-type statistics. These procedures are illustrated with a clinical diagnosis example from the epidemiological literature.
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Flexion contracture, internal rotation and external rotation of the hip were reported in 40 infants at 6 weeks and 3 months and in an independent sample of 40 infants at 6 months of age. Population means and normal ranges of motion were determined for use in the evaluation of hip problems and their treatment. A mean hip flexion contracture of 19 degrees was present at 6 weeks of age, decreasing to 7 degrees by three months, but still persisting at 6 months suggesting that forceful extension of the hip in infants may be contraindicated. Hip flexion contracture decreased in every child from 6 weeks to three months. In all cases, external rotation was greater than internal rotation. Internal rotation greater than external rotation before the age of 6 months appears contrary to normal development. There was a significant correlation between the changes in hip flexion contracture and internal rotation from 6 weeks to 3 months. An interesting extension of this study would be a longitudinal follow-up of infants beyond 6 months of age to further define these developmental trends.
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SCFE is one of the most potentially damaging conditions of the adolescent hip. The onset may be associated with minor trauma but is often insidious and may present as vague thigh or knee pain. The lateral radiograph is the most sensitive view for detection of a low-grade slip. The contralateral hip must be examined carefully as there may be bilateral disease with the pain and disability of the presenting side masking the symptoms of less involved hip. SCFE is occasionally associated with other metabolic and endocrinologic disease, and these should be screened for in the history and physical examination. Once a slip begins, the hip remains at jeopardy for acute progression until the physeal plate closes. We recommend immediate surgical stabilization and prefer a cannulated screw system. Proper technique is critical to safe and reliable surgery. The most common complications, AVN and chondrolysis, are often related to technical errors and should be minimized with attention to detail.
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We studied 1,000 normal lower extremities of children and adults in order to establish normal values for the rotational profile. The intrauterine position of the fetus molds the femur by rotating it laterally and molds the tibia by rotating it medially. These molding effects usually resolve spontaneously during infancy, and then genetically determined individual differences are unmasked. Rotational problems should be clinically evaluated and the findings compared with the normal values provided by this study. Out-toeing in infants, medial tibial torsion in toddlers, and medial femoral torsion in young children are extremes of a normal developmental pattern. In the vast majority, these rotational variations fall within the broad range of normal and require no treatment.
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200 white and 200 black normal term infants were clinically evaluated for range of motion of hip joints. Normal ranges and means were established clinically. Flexion contracture proved most constant (standard deviation 8°) and external rotation most variable (standard deviation 14°). When subjected to T-test for statistical significance, no significant differences were found between blacks and whites or males and females. Variability in the range of hip motion in the newborn does not correlate with known differences in incidence and severity of various childhood and adult hip maladies according to race and/or sex. An interesting extension of this study would be the longterm followup of these infants to determine if the subsequent development of hip problems in this group was related to early range of motion.
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Slipped capital femoral epiphysis (SCFE) is a common adolescent hip disorder. The etiology of SCFE includes biomechanical and biochemical factors. SCFEs are classified as stable and unstable and are more common in boys than girls and in certain racial groups; most children with SCFEs are obese. Bilateral SCFEs may have a simultaneous or sequential presentation. Imaging studies show a posterior slip of the epiphysis relative to the metaphysis, seen early on lateral radiographs. The most common and effective initial treatment for stable SCFEs is in situ central single-screw fixation; other options include epiphysiodesis, and osteotomy with or without surgical dislocation of the hip. Later reconstruction options, typically reserved for the child with functional abnormalities, include proximal femoral osteotomy, or surgical dislocation of the hip with removal of metaphyseal prominent bone to remove the source of femoroacetabular impingement. Unstable SCFEs have an increased risk of osteonecrosis; the role of reduction, methods of fixation, and decompression are controversial. The natural history of untreated SCFEs is associated with the risk of progression and later degenerative joint disease. Based on treatment methods of 30 to 40 years ago, in situ fixation provided the best long-term function with the lowest risk of complications and the most effective delay of degenerative arthritis regardless of the severity of the SCFE. Newer technologies and techniques are allowing the reevaluation of the role of either acute or later reconstructive osteotomy. It has not yet been determined if these improved techniques will result in better outcomes than in the past. Surgical dislocation of the hip with epiphyseal orientation is a considered treatment option for those technically adept at the procedure; however, the long-term outcome compared with in situ fixation is still unknown.
Interpretation of changes in health-related quality of life: the remarkable universality of half a standard deviation.
  • Norman