APTA Intro to Identity. The Movement System The Kinesiopathologic Model Movement System Impairment Syndromes of the Knee THE HUMAN MOVEMENT SYSTEM

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1 The Movement System The Kinesiopathologic Model Movement System Impairment Syndromes of the Knee Shirley Sahrmann, PT, PhD, FAPTA Professor Emerita Statement of Privacy To protect the privacy of the subjects or patients that are depicted in this presentation and based on copyright laws, this information should not be shared in any manner. We do NOT allow any photographing or videotaping during any part of this presentation. Thank you. Missing Figures Any missing figures were intentionally omitted due to copyright laws in the United States. THE HUMAN MOVEMENT SYSTEM The Body System for which Physical Therapists are Responsible. The System of our Expertise Our Identity APTA 2013 The Movement System Movement is an essential function of life at all levels of living organisms. From ions moving through membranes to moving your limbs to moving in your environment The human movement system is a system of physiological organ systems that interact to produce movement of the body and its parts. umanmovementsystem.aspx APTA Intro to Identity Profession will define and promote The movement system as the foundation for optimizing movement. The recognition and validation of the movement system is essential to fully understand the physiological function and potential of the human body. The profession will be responsible for monitoring an individual s movement system across the lifespan in order to promote optimal development, diagnose dysfunction, and provide interventions targeted at preventing or ameliorating restrictions to activity and participation. The movement system will form the basis of practice, education and research of the profession. 1

2 Proposed Definition of Movement System The human movement system comprises the anatomic structures and physiologic functions that interact to move the body or its component parts. APTA work group MDT Movement System Diagnoses Musculoskeletal Neurological Cardiopulmonary Treatment Based Diagnoses O Sullivan Class Tissue Impairments (Pathoanatomic) Powers syndromes MSI syndromes (Neuromuscular) MSI syndromes (Neuromusculoskeletal) Movement System Dysfunctions Pathokinesiologic Pathology in component system induces movement disorder CVA Rheumatoid arthritis Fracture Kinesiopathologic Movement induces pathology Low back pain Hip pain Knee pain Carpal tunnel syndrome The Kinesiopathologic Model Movement inducing pathology A Theoretical Construct of Movement System Impairment Syndromes Movements & Alignments Repeated movements Prolonged alignments of Everyday activities induce tissue adaptations of movement system components Tibiofemoral Rotation Trauma versus Repetitive Injury 2

3 Movement Becomes Impaired Induced adaptive changes in movement system components Result in the joint (knee/patella) moving too readily in a specific direction(s) Becomes the path of least resistance The adaptive changes and impaired joint movement vary because of intrinsic and extrinsic factors Kinesiopathologic model Kinesiopathologic Model of Movement System Musculoskeletal Repeated movements INDUCERS Prolonged postures Relative Stiffness of muscle & connective tissue Relative Flexibility Intra-joint + Inter-joint Motor Performance Learning Nervous Biomechanics Tissue Adaptations Micro Joint Accessory Hypermobility Personal Characteristics intrinsic Activity Demands - extrinsic Macro trauma Cardio-Pulmon - endocrine Path of Least Resistance Result of Adaptive Tissue Changes Path of least resistance for motion Relative Flexibility Intra-joint; intrinsic accessory motion mobility e.g excessive tibiofemoral rot Inter-joint; physiological motion, e.g knee vs ankle Relative Stiffness Passive tension of muscle & connective tissue Change in tension /unit change in length Highly correlated with muscle size e.g Biceps femoris vs medial hamstrings Results in joint (micro-instability) hypermobility causes the pain What moves is what hurts Cause versus Source Operational Definitions Cause the mechanical factor (movement) that results in tissue irritation e.g. femoral anterior glide, tibiofemoral rotation syndromes, Patellar lateral glide cause Source the tissue or pathoanatomical structure that is symptomatic e.g. iliopsoas tendin(itis, osis, opathy); patellarfemoral dysfunction Tibiofemoral Rotation Syndrome Knee pain associated with impaired rotation of the tibiofemoral joint in transverse or frontal plane. Salsich GB, Perman WH JOSPT 2007 Salsich GB, Perman WH J Science and Medicine in Sport 2013 Patellar lateral glide with femoral med rot Anterior knee pain Eckhoff DG et al Jones RB et al Patellofemoral pain Hefzy MS et al Lee TQ et al. 2001, Powers CM et al Li G et al Salsich GB et al Tibiofemoral Rotation Syndrome Subcategories VALGUS Pronated foot or abnormal pronation during gait Weak hip abductors, external rotators Poor dynamic knee joint stability/medial collapse At risk for ACL injuries Hewett et al Ford KR et al McLean et al VARUS Supinated Foot Often with hyperextension May demonstrate a varus thrust May have increased risk for OA Chang et al

4 MSI Exam movement Standing Alignment: Swayback; Pelvic Tilt; Iliac crest height; pelvic rotation; Knee alignment hyperextended, flexed, valgus, varus Foot: pronated, supinated Forward bending Single-leg standing Squat Step down and up Supine Hip extension-knee flexed (two joint hip flexor test) Hip abduction Hip-knee flexion & extension Valgus Varus Tibial Torsion structural (in joint vs in shaft) Tibial Torsion Structural vs Acquired Structural impairments Tibial Torsion in Knee Joint Swayback Knee Hyperextension 4

5 Single Leg Stance Note Position of patella Video Kendall Muscles Testing & Function 1993 Squat Test Preferred - Corrected Step Up Test Impaired knee alignment Corrected knee alignment Symptoms decrease with correction Step Up Test TF Rotation with Valgus Alignment and Movement - Inconsistent 5

6 Test: Hip Extension with Knee Flexion TFL-ITB causing tibial rotation Ballet Dancer with tibiofemoral rotation associated with femoral anteversion Femoral Anteversion Ballet Dancer MSI Exam continued Medial Rotation Lateral Rotation Craig s test 27 deg Side-lying Hip abduction-lateral rotation Hip abduction adduction Prone Knee flexion Hip rotation Hip extension Quadruped Rocking backward Sitting Knee extension Sit to stand Gait Exam: Hip Abd/Lateral Rotation Hip Abduction Dominance of hip lateral rotators vs hip abductors Gluteus Medius performance Exam: Knee flexion & Hip Extension & Hip Rotation Knee Flexion Assess tibial rotation Hip Rotation ROM - version Hip Extension Knee extended timing Glut max performance 6

7 Femoral Posterior Glide Affect on Knee Exam: Hip Rotators & Iliopsoas Treatment Treatment Functional activities Sit to Stand Corrective specific exercises The tests failed become the exercises Correction of basic mobility activities - Most Important Sit to stand Stairs Squatting Gait Running when indicated Correction of sports performance patterns Recommend appropriate programs of physical activity Lots of evidence of the health value of exercise Treatment Activity is Good Is Monitoring Necessary? Correction during sporting activities Knees Optimal?? 7

8 How Many Are Doing The Exercises Correctly? Exercising But Need Monitoring None of these children are correctly flexed in the hips Movement System Practitioners Should be lifespan practitioners Should provide yearly exams of the movement system and recommend appropriate programs of correction for Alignment Movement patterns Strength assessments Aerobic assessments Diagnose dysfunctions of movement Develop treatment programs Never discharge a patient but end an episode of care 8