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Limping in a child is a concern. Limping in a child is never normal. It can be caused by many things, sometimes by something minor, like a blister or cut. The most common cause of a limp in young children is a fracture. Sometimes it is caused by a serious infection. Although rare, it can also be caused by a tumor.

This guide will help you understand:

• what can cause this condition
• what the symptoms are
• how your health care professional will diagnose the condition
• what treatment options are available
• what First Choice Physical Therapy’s approach to rehabilitation is

What parts of the body can be involved?

Reasons for limping can involve many parts of the body. The hip, knee, shin bone, ankle, and foot are common parts that can cause limping. Limping can also be caused by problems in the back or pelvis.

The hip is a ball-and-socket joint. A tough lining called the synovium covers it. The ball of the joint is the end of the thigh bone, called the femur. Like other ends of bones in children, the ball has an area called a growth plate. A growth plate has cells that produce new bone. The growth plate is weaker than other parts of the bone. This makes this area more likely to fracture.

The socket part of the hip joint is called the acetabulum. It is actually part of the pelvis. The acetabulum forms a cup where the ball of the femur sits. It is covered with articular cartilage. Articular cartilage is the material that covers the ends of the bone of any joint. It’s a rubbery, slippery substance that allows the surfaces to slide against one another without damage to either surface.

The knee joint is made up of the other end of the femur and the end of the shin bone. The knee cap, or patella, is also part of the knee joint.

The lower leg is made up of two main bones. The larger bone is the shin bone, called the tibia. The smaller bone runs along the outside of the tibia it’s called the fibula. These bones, along with a saddle shaped bone at the top of the foot called the talus form the ankle.

The foot has many bones. There are seven short bones below the ankle called the tarsals. The big square bone on the outside of the middle of the foot is called the cuboid. The long bones of the foot from the arch to the joints of the toes are called the metatarsals.

Tarsals

What are some common causes of pain that can cause a limp in children?

The most common cause of a limp in small children is a fracture. Toddler’s fractures involve buckling or bowing of the tibia (shin bone). This usually happens when a child trips or falls up stairs.

Bunk-bed fractures are caused by jumping. The cuboid bone and first metatarsal in the foot are the bones that are usually broken in this type of injury.

In children from two to ten years old, the most common cause of hip pain is transient synovitis (TS). This involves swelling or inflammation of the synovium of the hip. The synovium is a tough covering of the joint. Often, the child will have had a cold or viral infection just before the hip pain started. Transient synovitis usually lasts ten days. It generally gets better with minimal treatment.

Joint infection of the hip causes a more sudden onset of pain. Children will usually not walk at all when the joint is infected.

Osteomyelitis is an infection of the bone. It usually happens near the ends of the bones, close to the growth plate.

Overuse syndromes are common in active adolescents. Stress fractures of the foot, patellofemoral joint problems, and Osgood-Schlatter’s disease are examples of overuse syndromes.

Osgood-Schlatter’s Disease

Legg-Calvé-Perthes disease typically affects boys between the ages of five and ten. It is also called osteonecrosis and avascular necrosis of the hip. It literally means death of bone. The ball of the hip dies because the blood supply has been cut off. When this happens, the femoral head and acetabulum will change their shapes over one to three years. The ball of the femur will flatten out. This problem with the hip is often missed at first. It is frequently misdiagnosed as synovitis of the hip.

Slipped Capital Femoral Epiphysis

is the slipping of the growth plate of the ball of the hip joint. It usually happens in obese, older children.

Tumors in bone are rare in children however they can occur. Ewing’s sarcoma is a cancerous tumor that starts in the bone. More often, a tumor found in the bone is from cancer somewhere else in the body. Neuroblastoma and leukemia are both known to cause destruction of bones.

Rheumatoid arthritis is an auto-immune disease. It can affect children. When it does it is called juvenile onset rheumatoid arthritis. When left untreated it can destroy the synovium of joints, causing deformity, pain, and loss of mobility.

Neuromuscular disease such as muscular dystrophy or other genetic problems may also cause limping.

Back problems, appendicitis, or other problems in the abdomen or pelvis can cause limping, usually in older children.

In addition to limping due to pain, or not walking at all, other symptoms may occur.

Swelling or redness near a joint often means infection or inflammation. Fever or chills can also mean infection. Tenderness of a specific area could be suspicious for a fracture.

As mentioned above, transient synovitis often happens after having a cold or viral infection.

Diagnosis

How does a health care professional diagnose the condition?

Making a diagnosis can be difficult. At First Choice Physical Therapy your Physical Therapist will initially take a thorough history of when and how the limping started. It is important to determine if there has been an accident or fall and also important to discern whether or not the limping started suddenly or gradually. Repetitive or strenuous activity may also initiate an injury that causes limping so we may inquire about your child’s activity level. We may also ask you about any other related symptoms such as swelling and redness, or may inquire about whether your child has had a recent illness or cold. Your Physical Therapist may ask to watch your child walk to assess the limp during the gait cycle. In addition your Physical Therapist will observe your child in standing and possibly sitting or lying to look for any bone alignment problems that may be contributing to their limp.

Next your Physical Therapist will then palpate around any areas of pain. As referred pain can cause symptoms in unrelated areas to the actual problem, they may also palpate areas that are not notably painful such as the low back or anywhere along the lower limb. Commonly, for example, problems in the hip will cause symptoms in the knee of a child therefore thorough examination is necessary.

Following palpation your Physical Therapist will assess the range of motion of your child’s joints and compare them to the other side. They will also check the strength of the muscles on both sides and may check for the integrity of the ligaments around the joints.

If it is clearly determined from the history and physical examination that your child’s limping is the result of an orthopaedic origin that can be treated by Physical Therapy, your  Physical Therapist will explain the cause of the limp and then discuss the treatment options. If, however, a definitive origin of the pain cannot be determined your Physical Therapist will recommend that your child is reviewed by a doctor for further examination and investigative tests to more clearly discern the cause of the limp.

Your child’s doctor will also take a thorough history and will want to look at your child’s skin and joints. He/She is looking for things such as cuts, blisters, rash, insect bites, joint swelling and deformity of bones which can be gateways to infections into the joints.

In many cases, laboratory testing and imaging tests (x-rays) are needed to make the right diagnosis.

Since fractures are the most common cause of limping in children, x-rays are done in most cases. In young children, x-rays of the pelvis, hips, and lower legs are recommended.

Magnetic resonance imaging (MRI) allows your doctor to look at slices of the area in question. The MRI machine uses magnetic waves, not x-rays, to show the soft tissues of the body. It is best at evaluating soft-tissue injury and tumors. The test may require the use of dye in an IV. Children may need to have sedation or anesthesia in order to lie still for the test.

Computed tomography (CT) scan may be ordered. It is best for evaluating problems with bones. It is usually tolerated by children; however, it exposes them to radiation.

Bone scans, also called nuclear scans can be used to detect fractures, osteomyelitis, and Legg-Calvé-Perthes disease. A radioactive tracer, Technetium, is injected into your child’s vein. Where there is an increase in metabolic activity, such as in the case with inflammation, fracture, infection, or tumor, the Technetium will be more concentrated.

Ultrasound is another form of imaging that may be used. It uses sound waves to create a picture. Ultrasound of the hip can show osteomyelitis, septic arthritis, transient synovitis, and Legg-Calvé-Perthes disease.

Laboratory studies may also help your child’s doctor make a diagnosis. Most common is a complete blood count (CBC). This checks the white blood cell count which can increase during an infection. When inflammation and infection are present, your erythrocyte sedimentation rate (ESR) and C-reactive protein increase so these lab tests may also be done. Other lab tests may be done, such as rheumatoid factor, sickle cell tests, and lyme disease tests.

If joint or bone infection is suspected, blood cultures can be helpful. Your child’s doctor will likely want the joint aspirated. The bone may need to have a biopsy. A needle is placed in the joint or bone, and some of the fluid is removed and tested. In the case of infection, the bacteria causing the infection can be determined and an appropriate antibiotic treatment can then be chosen.

Your child’s doctor will want to follow up periodically. Sometimes this requires repeat blood work and/or imaging studies.

What treatment options are available?

Nonsurgical Treatment

Transient synovitis usually responds to anti-inflammatory medication and rest. Symptoms generally improve after 10 days, with an eventual return to activity.

In the case of infection, six weeks of intravenous (IV) antibiotics is usually required. Sometimes antibiotics taken by mouth can be effective instead of such a long period of IV antibiotics. Your child may need to be in the hospital for a few days at first. Sometimes surgery is necessary to drain the area that is infected.

Referral to a doctor who specializes in arthritis will be necessary if your child is diagnosed with rheumatoid arthritis.

Although tumors are rare in children, they do occur. Some tumors may respond to chemotherapy or radiation. Sometimes the tumor has to be surgically removed.

In toddler’s fractures and bunk-bed fractures, sometimes casts must be used. Limiting weight bearing when walking may mean your child will have to use crutches, or be in a wheelchair for awhile. Your Physical Therapist will teach your child how to properly walk with crutches and how to safely manage them on stairs.

Stress fractures and Osgood-Schlatter’s usually respond well to a discontinuation of the activity that caused them while continuing exercises like swimming and stationary biking to maintain conditioning. Your Physical Therapist can provide advice on how to best maintain fitness and can design an individualized program for your child to follow while their injury heals.

Patellofemoral joint problems and overuse syndromes usually respond well to Physical Therapy treatment. Physical Therapy may even be recommended when the cause of the limp has been determined to be infectious or other in nature (once the initial problem has been cleared up) as limping, even for short periods, can cause your child to lose strength or range of motion in their limb. Your Physical Therapist can address these problems to ensure they do not have lasting effects.

In general, most of the causes of limping can be treated without surgery. The majority of children respond well to therapy and resume walking normally without any long-term problems.

Nonsurgical Rehabilitation

Once the cause of your child’s limping has been clearly determined through examination and investigations, your Physical Therapist will determine if Physical Therapy treatment is required and if so, will decide on the best therapy for your child.

Initially your First Choice Physical Therapy’s Physical Therapist may use modalities such as heat, ice, ultrasound, or electrical current to assist with decreasing any pain associated with the cause of the limp. If necessary we may also suggest the use of a brace or use taping to assist with the pain. Your Physical Therapist will address your child’s walking pattern and assist your child in gait retraining to ensure they are walking as normal as possible as the problem resolves. If your child continues to find it difficult to walk without limping, your Physical Therapist will suggest the use of one or two crutches to normalize their gait and prevent compensatory problems in other areas of the body.

The next part of our treatment will focus on normalizing any deficits that may have developed in the range of motion and strength of the lower limb joints. Your Physical Therapist may assist in stretching your child’s limb or lower back while in the clinic and, if necessary, will ‘mobilize’ the joints of your child. This hands-on technique encourages the stiff joints to move gradually into their normal range of motion. In addition to the hands-on treatment in the clinic we will also prescribe a series of stretching exercises that we will encourage your child to do as part of a home exercise program. Generally these exercises will be simple activities that you can incorporate into the everyday activities of your child. For example, if your child is young, your Physical Therapist may show you some stretching positions that you can encourage your child to sit or lie in while they play to improve range of motion. If your child is of an adolescent age, formal stretches will be taught and encouraged throughout the day.

Similarly to the range of motion deficits, strength deficits will also be addressed. Again, for young children, your Physical Therapist will show you how to incorporate strengthening exercises into your child’s normal activities such as walking or stair climbing, whereas older children will be prescribed a more traditional strength building set of exercises. For all children we may incorporate items such as Theraband into the exercises to provide additional resistance for the limb.

The final part of our First Choice Physical Therapy treatment will be ensuring that your child’s coordination and balance have returned to normal after their injury. Again, after even a short period of not walking or walking with a limp, your child’s normal balance, coordination, and proprioception (the ability to know where your body is without looking at it) can decline in function. Exercises, which may include balancing on one foot, jumping, and quick agility movements, will be encouraged.

Fortunately, gaining lost range of motion, strength, and coordination due to limping goes quickly once the initial cause of the limping has been addressed. You will notice improvements in your child’s function and gait even after just a few treatments with your Physical Therapist.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

Surgical treatment is specific to the cause of the problem.

In the case of slipped capital femoral epiphysis, surgery is often required. The femur can be pinned through the skin (percutaneous pinning). The surgeon may need to open the joint to place pins in it. Sometimes the hip that is not affected is also pinned because it is also likely to slip.

Legg-Calve-Perthes often requires surgery to shape the hip joint.

Tumors are rare in children but they do occur. Your child will probably be referred to a specialist to determine the best method of treatment for the type of tumor discovered. Some tumors respond to chemotherapy or radiation. Surgical excision (removal) may be necessary.

Osteomyelitis sometimes requires a surgeon to open the area. This allows drainage of the infectious fluid and removal of damaged tissue and bone if needed.

Rehabilitation post-surgically can begin once your child’s surgeon indicates that it is safe to do so. Each particular type of surgical procedure performed will have rehabilitation guidelines specific to that surgery. Your  Physical Therapist at First Choice Physical Therapy will liaise with your surgeon regarding the specific restrictions that he or she requires for your child and will discuss with you what to expect during your child’s individual rehabilitation process.

The goals of Physical Therapy post-surgically are similar to the goals of Physical Therapy discussed above under nonsurgical rehabilitation. Thus, once your child’s surgeon indicates that  Physical Therapy can begin, your  Physical Therapist will work to reduce associated pain, retrain your child’s gait, and address any deficits in range of motion, strength, coordination, balance, and proprioception.

If your child’s pain continues longer than it should or Physical Therapy is not progressing as your Physical Therapist would expect, we will ask you to follow-up with your child’s surgeon to confirm that there are no post-surgical complications that may be impeding your child’s recovery. Generally, however, children who have required surgery to correct the problem causing their limp respond very well to the post-surgical Physical Therapy we provide at First Choice Physical Therapy. Under the supervision of one of our Physical Therapists your child should be back to the daily activities they enjoy in no time.

Bowlegs, also known as tibia varum (singular) or tibia vara (plural) are common in toddlers and young children. The condition is called physiologic tibia varum when it’s within a normal variation and the child will grow out of it. Most toddlers have bowlegs from their positioning in utero (in the uterus). This curvature remains until the muscles of the lower back and legs are strong enough to support them in the upright position.

In some cases abnormal growth of the bone causes the bowing to get worse instead of better over time. This condition is called Blount’s disease or pathologic tibia varum.
Blount’s disease becomes obvious between the ages of two and four as the bowing gets worse. Overweight adolescents or teenagers can also develop Blount’s disease.

This guide will help you understand:

• what part of the leg is involved
• what causes the condition
• how health care professionals identify this problem
• what treatment options are available
• what First Choice Physical Therapy’s approach to rehabilitation is

What part of the leg is involved?

The tibia (lower leg bone) or more commonly called the shin is affected by Blount’s disease. Infantile (less than three years old) Blount’s is usually bilateral which means both legs are affected at the same time. The bones start to form an angle and rotate inwardly. Adolescent (11 years of age and older) Blount’s is more likely to be unilateral affecting just one leg.

In the growing child, there are special structures at the end of most bones called growth plates. The growth plate is sandwiched between two special areas of the bone called the epiphysis and the metaphysis. The growth plate is made of a special type of cartilage that builds bone on top of the end of the metaphysis and lengthens the bone as we grow.

In Blount’s disease the epiphysis and metaphysis both are involved. Only the medial or inside edge of the bone is affected. The metaphysis is the wider part of the tibial bone shaft. In the early stages of Blount’s disease, the medial metaphysis breaks down and growth stops. In the child who is still growing, the metaphysis containing the growth zone consists of spongy bone that has not yet hardened.

What causes this condition?

There are three types of tibia varum based on the age it begins: 1) infantile (less than three years old), 2) juvenile (occurs between four and 10 years), and 3) adolescent (11 years of age and older).

Physiologic tibia varum occurs between the ages of 15 months to three years. There’s no need for treatment for this normal stage of development however it is not always clear at this age if the tibia varum is physiologic (normal variation) or pathologic (Blount’s disease).
Blount’s disease is caused by a growth disorder of the upper part of the tibial bone.

Toddlers and children who are large or overweight for their age and who walk early are most often affected. As the child walks, the repeated stress and compression of extra weight suppresses (slows) or stops growth of the developing bone. When only one side of the tibia stops growing, there are abnormal changes in bone alignment resulting in this curvature or bowing of the bone.

There can be other causes of bowed legs in toddlers or young children. Metabolic disorders such as a deficiency of vitamin D causing rickets is more common in other countries. In the first world countries many foods are fortified with vitamin D to prevent this problem. In a small number of children, vitamin D deficiency occurs as a result of a genetic abnormality where the child cannot absorb or metabolize vitamin D.

Juvenile or adolescent Blount’s disease is usually caused by obesity (being overweight) but can be the result of an infection or trauma that disrupts the medial growth plate.

What does this condition feel like?

The young child may not feel any symptoms. However patients with adolescent tibia varum usually complain of pain along the medial side of the knee. The bowed appearance of the lower legs may be the first obvious sign. The child may have trouble walking without tripping. The way the child walks may not look normal. He or she thrusts the leg out away from the other leg when walking on the affected leg.

How do health care professionals identify this condition?

Visual observation is the first method of diagnosis. The family or health care professional sees the problem when looking at the child or while watching him or her walk. The distance between the knees is measured with the child standing with the feet together. If the space between the knees is more than five centimeters (1 1/4 inches) further testing is needed.

Bowing of the bones can be seen more clearly on X-rays. There are six stages of tibia varum seen on X-ray and named after the physician (Dr. Langenskiold) who first described them. The radiologist will see a sharp varus angle and other changes in the metaphysis. Often there is widening of the growth plate. The top of the tibia looks like it has grown a beak just on the medial side.

What treatment options are available?

Treatment depends on the age of the child and the stage of the disease. Between ages birth and two, careful observation or a trial of bracing (also called orthotics) may be done. If the child doesn’t receive treatment, Blount’s disease will gradually get worse with more and more bowlegged deformity. Surgery may be needed to correct the problem. For the obese child, weight loss is helpful but often difficult.

Nonsurgical Treatment

Most of the time infantile bowlegs or genu varum resolves on its own with time and growth. No specific treatment is needed unless the problem persists after age two.
In the case of Blount’s disease aggressive treatment is needed. Severe bowing before the age of three is braced with a hip-knee-ankle-foot orthotic (HKAFO) or knee-ankle-foot orthotic (KAFO). Bracing is used 23 hours a day. As the bone straightens out with bracing, the orthotic is changed every two months or so to correct the bowlegged position.

What should I expect from treatment?

Your Physical Therapist at First Choice Physical Therapy will work with you and your child to teach you how to put on and take off the orthotic. Inspection and care of the skin is very important and will be included in the instructions given. You should watch for any blisters that develop or ‘hot spots’ which are areas of redness that indicate the brace is rubbing.

If your child is using any assistive devices, such as a walker or crutches, your Physical Therapist will teach your child how to properly use them and ensure they are using the most appropriate walking aid for their needs.

Your  Physical Therapist at First Choice Physical Therapy is skilled in biomechanical assessment and gait analysis so the next part of your child’s treatment will include an analysis of their alignment and walking pattern in the brace. Adjustments to the brace may be needed. Due to muscle imbalances occurring from abnormal alignment, your Physical Therapist may need to prescribe some strengthening and stretching exercises to address these imbalances and encourage normal gait. If your child is young, your Physical Therapist will show you how to incorporate activities into your child’s daily play or normal routine that help to develop their strength and addresses imbalances.  For example, we may encourage you to assist your child in stepping up and down high steps in order to gain access to a toy.  This improves overall lower limb strength. You may also be encouraged to do range of motion or strengthening exercises when the brace is off, despite this time being very short. Older children will be given a more formal exercise program to address any deficits that are present.

In-toeing is often associated with Blount’s disease and this alone frequently causes children to trip and fall when walking.  The combination of the orthotic and exercises will work to combat this position of the foot and improve the overall alignment of the limb. Activities that target the hip and core area will also be encouraged as these areas are the main controllers of the position of the lower extremity.  Poor endurance or activation of muscles in these regions can significantly contribute to the progression of the knee deformity. Balance and coordination exercises will be combined into the activities that your Physical Therapist prescribes. Proprioception (the ability to know where your joints are without thinking about it) combines balance and coordination and is important in gaining maximum control over one’s joints and preventing future injuries. Exercises may include such things as encouraging your child to stand on a couch cushion while they play, or step over obstacles in order to get somewhere.

Improved strength and range of motion alone will not cure Blount’s disease, but it will make physical activity easier and may help to prevent further progression of the deformity or secondary compensation problems in the ankles, hips or low back.

If Blount’s disease in your child has been attributed to excess body weight in relation to your child’s age, your Physical Therapist at First Choice Physical Therapy will discuss strategies for weight loss including tips to encourage your child to be more active despite the limitations that the deformity causes. Non-weight bearing exercises that do not put excess strain on the injured joints such as swimming and cycling can be useful. If necessary, we will refer you on to a nutritionist so you can discuss a modification in caloric intake in addition to an increased physical activity regime.

Failure to correct the tibia vara deformity early often results in permanent damage to the growth plate and growing bone. Later, joint degeneration may occur. It is therefore imperative that the deformity is addressed early, and that surgical intervention is considered as a treatment option in the early stages if gradual correction does not occur.

Surgical correction may be needed especially for the younger child with advanced stages of tibia varum or the older child who has not improved with orthotics. Surgery isn’t usually done on children under the age of two because at this young age, it’s still difficult to tell if the child has Blount’s disease or just excessive tibial bowing. Brace treatment for adolescent Blount’s is not effective so it generally requires surgery to correct the problem.

A tibial osteotomy is done before permanent damage occurs. In an osteotomy, a wedge-shaped piece of bone is removed from the medial side of the femur (thigh bone). It’s then inserted into the tibia to replace the broken down inner edge of the bone. Hardware such as pins and screws may be used to hold everything in place. If the fixation is used inside the leg, it’s called internal fixation osteotomy. External fixation osteotomy describes a special circular wire frame on the outside of the leg with pins to hold the device in place.

Unfortunately, in some patients with adolescent Blount’s disease, the bowed leg is shorter than the normal or unaffected side. A simple surgery to correct the angle of the deformity isn’t always possible. In such cases an external fixation device is used to provide traction to lengthen the leg while gradually correcting the deformity. This operation is called a distraction osteogenesis. The frame gives the patient stability and allows for weight bearing right away.

Parents or guardians should be advised that Blount’s disease might not be cured with surgery. Results are usually good with infantile tibia varum. When treated at a young age and at an early stage, the problem usually doesn’t come back. Older patients with advanced deformity have a much higher risk of recurrence of the deformity. Patients must be followed carefully throughout their growth and development. Unilateral bowing can result in that leg being shorter than the other leg. This is called a leg length discrepancy and may need additional treatment.

Osteotomy with internal fixation usually heals in six to eight weeks. The cast is removed five to six weeks after the operation if there’s enough bone build-up to prevent change or loss of position. A second cast is applied that keeps the knee straight but the foot and ankle are free to put weight through the leg.

When the child has surgery with external fixators and distraction osteogenesis, gradual correction of the deformity takes place over the next three weeks. After the tibia is straightened, extra rods are used to stabilize the external frame. The frame is taken off about 12 weeks postoperatively.

Following surgery for Blount’s disease Physical Therapy treatment at First Choice Physical Therapy is very useful in returning your child to a normal activity level as quickly as possible. Physical Therapy can also assist in avoiding future compensatory problems in the back or lower limbs.

Rehabilitation at First Choice Physical Therapy can begin as soon as your child’s surgeon recommends it. Each surgeon will set his or her own specific restrictions based on the child’s individual severity of deformity, the exact surgical procedure used, personal experience, and whether there is evidence that the bones are healing as expected.

The first part of our treatment will be to assist with any lingering pain there may be from the surgical procedure. Your Physical Therapist may use modalities such as heat, ice, ultrasound, or electrical current to aid in pain relief.

If your child is still using a walking aid such as crutches or a walking frame, your Physical Therapist will ensure your child is using them safely and appropriately and that they are abiding by the weight bearing restrictions set by their surgeon. We generally recommend that until it is possible to walk without a significant limp, a walking aid continue to be used. Improper gait can lead to a host of other pains in the knee, hip and back so it is prudent to continue using the aid until near normal walking can be achieved. It is expected that with young children, it is generally not possible to continue the use of the walking aid even if they would be better with it, as they will discard it as soon as they can freely move around without it.

The next part of our treatment at First Choice Physical Therapy will focus on regaining the range of motion and strength of your child’s lower limbs, and to encourage proper alignment now that the deformity has been surgically repaired. Your Physical Therapist may assist in stretching your child’s limbs while at the clinic and, if necessary, will ‘mobilize’ your child’s knees. This hands-on technique encourages the joints to move gradually into their normal range of motion. In addition to the hands-on treatment in the clinic we will also prescribe a series of range of motion exercises that we will encourage you to do with your child as part of their daily activity at home. Older children, as mentioned above, will be instructed to do some simple independent exercises.

Similarly to the range of motion deficits, strength deficits will also be addressed. A similar strengthening regime as that mentioned above under non-surgical rehabilitation will be used. It is pertinent to again address muscle weaknesses that have developed in the hips, core area, as well as those muscles directly around the knee.  Now that a ‘new normal’ alignment has been surgically achieved, the muscles will need to be strengthened to assist in maintaining this alignment.

The final part of our First Choice Physical Therapy treatment will be ensuring that your child’s coordination and balance have returned to normal after their surgery. Following even a short period of walking with crutches and due to the surgical changes to the joint, your child’s normal balance, coordination, and proprioception can decline in function. Exercises, which may include balancing on one foot, or walking on a line or on their tippy toes, will be encouraged. More advanced exercises such as jumping, and quick agility movements will be encouraged at an appropriate time in line with the surgeon’s restrictions.

Fortunately, gaining lost range of motion, strength, and coordination after surgery for Blount’s disease goes quickly. You will notice improvements in your child’s function and gait even after just a few treatments with your Physical Therapist at First Choice Physical Therapy. If, however, your child’s post-surgical therapy is not progressing as your Physical Therapist would expect, we will ask you to follow-up with your surgeon to confirm that the knees are tolerating the rehabilitation well and ensure that there are no post-surgical complications that may be impeding your child’s recovery.

Perthes disease is a condition that affects the hip in children between the ages of four and eight. The condition is also referred to as Legg-Calve-Perthes disease in honor of the three physicians who each separately described the disease. In this condition, the blood supply to the growth center of the hip (the capital femoral epiphysis) is disturbed, causing the bone in this area to die. The blood supply eventually returns, and the bone heals. How the bone heals determines what problems the condition will cause in later life. Perthes disease may affect both hips. In fact, 10 to 12 percent of the time the condition is bilateral (meaning that it affects both hips). This condition can lead to serious problems in the hip joint later in life.

This guide will help you understand:

• what part of the hip is involved
• what causes the condition
• what treatment options are available
• what First Choice Physical Therapy’s approach to rehabilitation is

What part of the hip is affected?

The hip joint is where the thighbone (femur) connects to the pelvis. The joint is made up of two parts. The upper end of the femur is shaped like a ball. It is called the femoral head. The femoral head fits into a socket in the pelvis called the acetabulum. This ball and socket joint is what allows us to move our leg in many directions in relation to our body.

In the growing child, there are special structures at the end of most bones called growth plates. The growth plate is sandwiched between two special areas of the bone called the epiphysis and the metaphysis. The growth plate is made of a special type of cartilage that builds bone on top of the end of the metaphysis and lengthens the bone as we grow. In the hip joint, the femoral head is one of the epiphyses of the femur.

The capital femoral epiphysis is somewhat unique. It is one of the few epiphyses in the body that is inside the joint capsule. (The joint capsule is the tissue that surrounds the joint.) The blood vessels that go to the epiphysis run along the side of the femoral neck and are in danger of being torn or pinched off if something happens to the growth plate. This can result in a loss of the blood supply to the epiphysis.

How does this problem develop?

Perthes disease results when the blood supply to the capital femoral epiphysis is blocked. There are many theories about what causes this problem with the blood supply, yet none have been proven. There appears to be some relationship to nutrition as children who are malnourished are more likely to develop this condition.

Children who have abnormal blood clotting (a condition called thrombophilia) may also have a higher risk of developing Perthes disease. These children have blood that clots easier and quicker than normal. This may lead to blood clotting that blocks the small arteries going to the femoral head. As a result of new evidence, the certainty of thrombophilia as a cause of Perthes is now under debate. This will remain an area of study until scientists clear up the significance of thrombophilia as a possible cause of Perthes.

There is some new evidence that Perthes disease may be genetic as a result of a mutation (abnormal change) in the type II collagen (fibers that make up soft tissue structures). Previously there was no known increase in risk for children whose parent had Perthes disease as a child, but this belief may no longer be accurate.

Studies among Asian families who have many family members with this disease have been found with this mutation in the type II collagen gene. Scientists think that the mutation results in weakening of the hip joint cartilage that also affects the blood vessels within the cartilage.

Whatever the true cause of ischemia (lack of blood to the area), the result is bone death (called necrosis) of the femoral head. Without a normal blood supply, the bone loses its strength and shape. The loss of bone density and softening of the head result in a femoral head that is misshaped. With the hip supporting the weight of the body, tiny microfractures in the soft, necrotic bone fail to heal. This is another reason why normal wear and tear results in a deformity.

What does this problem feel like?

Most children with Perthes disease develop discomfort in the hip and walk with a limp. Children will not usually complain of pain unless specifically asked. The most common way that the disease is discovered is when someone, usually a parent, notices the limp and consults a physician.

When the doctor examines the hip, the motion of the hip is abnormal and restricted. Turning the leg inward produces pain. This usually indicates that the hip is inflamed and may have inflammatory fluid (called an effusion) present in the hip joint.

Interestingly, problems in the hip sometimes do not cause pain in the hip itself. The knee is where the pain is felt. This can be confusing both to patients and physicians. In general, a child with knee pain (who has no clear-cut reason to have knee pain), or an abnormal gait, should be examined for possible Perthes disease. This usually includes X-rays of the hips to make sure that Perthes disease is not missed.

The main problem with Perthes disease is that it changes the structure of the hip joint. How much it affects the way the hip joint works depends on how much the hip joint is deformed. Muscle weakness and atrophy affecting the thigh and calf muscles may develop over time. The affected leg can shorten as a result of the changes in the hip. The result may be a significant leg length difference. Problems later in life are more likely the greater the deformity after the condition has healed.

In general, the most common problem later in life is the development of arthritis in the hip joint. The type of arthritis that develops in the hip is osteoarthritis (also known as wear and tear arthritis). Just like a machine that is out of balance, the hip joint wears out and becomes painful.

How do health care professionals identify the problem?

The history and physical examination are usually enough to make your health care professional highly suspicious about the diagnosis of Perthes disease. X-rays are usually necessary to confirm the diagnosis. It is usually not necessary to get an MRI scan to make the diagnosis, however, this test may be useful to determine whether the other hip is involved in the disease. A special MRI using a dye called gadolinium may help show changes in blood supply before anything shows up on an X-ray.

In planning treatment another test, called an arthrogram, may be required. In this test, dye is injected into the hip joint to outline the cartilage surface of the joint. Much of the child’s hip joint is made up of cartilage. Cartilage does not usually show up on X-rays. The dye is necessary to see what the hip will actually look like when the cartilage turns to bone.

What treatment options are available?

The primary goal of treatment for Perthes disease is to help the femoral head recover and grow to a normal shape. The closer to normal the femoral head is when growth stops, the better the hip will function in later life. The way that surgeons achieve this goal is using a concept called containment.

Containment is a simple concept. The femoral head can be molded as it heals. This is very similar to molding plastic. Plastic is poured into a mold and held there as it cools. It then holds the shape of the mold. The hip socket, or acetabulum, is not affected when the femoral head loses its blood supply. It can be used as a mold to shape the femoral head as it heals. The trick is that the femoral head must be held in the joint socket (acetabulum) as much as possible, however, it is better if the hip is allowed to move and is not held completely still in the joint socket. Joint motion is necessary for nutrition of the cartilage and for healthy growth of the joint.

All treatment options for Perthes disease try to position and hold the hip in the acetabulum as much as possible. This healing process can take several years.
Many children who are diagnosed with Perthes disease do not require any treatment except careful watching. When the condition is mild, the results of not doing anything are often as good as aggressive treatment. The majority of children who are treated for Perthes disease these days require only a program for maintaining a near-normal range of motion. This may include nighttime splinting, home traction, and Physical Therapy (see below.) The surgeon will determine treatment based on the classification of the severity of the disease. The classification is determined by the X-ray findings.

Nonsurgical Treatment

Maintaining or regaining hip motion to as near to normal as possible, is critical to the successful treatment of Perthes disease. The disease causes inflammation in the joint. This leads to loss of motion and contracture (tightening) of the muscles surrounding the hip joint. Treating these problems to restore normal motion is necessary.

When lack of motion has become a problem, the child may be admitted to the hospital and placed in traction. Traction is used to give the joint some space and therefore quiet the inflammation. The rest for the joint while in traction also helps to settle the inflammation. Settling the inflammation usually takes about a week. Home traction may also be an option.

Anti-inflammatory medications may also be prescribed. In addition, antiresorptive agents may also be prescribed. These medications help to slow or block the resorption of bone and help decrease deformity. Studies are being done to fully test the effect of these medications in children with Perthes.

Physical Therapy while in the hospital is used to restore the hip motion as the inflammation comes under control. A Physical Therapist will visit your child in their room and assist them with some gentle hip rotation and abduction exercises (taking the leg out to the side.) These exercises will maintain and improve range of motion but will also assist in moving the fluid inside the hip joint, which assists with joint nutrition and is crucial to healing. They will also show you and your child how to continue the exercises independently once your child leaves the hospital if you will be using a home traction unit, and may prescribe further simple exercises that your child should do once they are no longer in traction. Your Physical Therapist may even recommend that your child do some exercises in the pool to take advantage of the hydrostatic properties of the water to gain range of motion with less weight bearing impact.

In the past, surgeons have tried to hold the hip in the best position where the femoral head was molded by the acetabulum using many different casts and braces. The most common way of doing this today is the Scottish Rite Orthosis. This brace fits around the waist and thighs and has hinges at the hip joints. The brace allows the child to walk and play while it holds the hip joint in the best position for containment. Your doctor may prescribe this for your child once they leave the hospital. Your Physical Therapist will help your child learn to safely use crutches or a walker/frame if they are needed while in the brace.

Sometimes, adequate motion cannot be regained with traction and Physical Therapy alone, therefore in some cases, surgery will be required to obtain adequate containment.  If the condition is longstanding, the muscles may have contracted or shrunk and cannot be stretched back out. To help restore motion, the surgeon may recommend a tenotomy of the contracted muscles. When a tenotomy is performed, the tendon of the muscle that is overly tight is cut and lengthened. This is a simple procedure that requires only a small incision. The tendon eventually scars down in the lengthened position, and no functional loss is noticeable.

Surgical treatment for containment may be best in older children who are not compliant with brace treatment or where the psychological effects of wearing braces may outweigh the benefits. Surgical containment does not require long-term braces or casts. Once the procedure has been performed and the bones have healed, the child can pursue normal activities as tolerated.

Surgical treatment for containment usually consists of procedures that realign the femur (thighbone), the acetabulum (hip socket), or both.

Realignment of the femur is called a femoral osteotomy. This procedure changes the angle of the femoral neck so that the femoral head points more towards the socket. To perform this procedure, an incision is made in the side of the thigh. The bone of the femur is cut and realigned in a new position. A large metal plate and screws are then inserted to hold the bones in the new position until the bone has healed. The plate and screws may need to be removed once the bone has healed.

Realignment of the acetabulum is called a pelvic osteotomy. This procedure changes the angle of the acetabulum (socket) so that it better covers, or contains, the femoral head. To perform this procedure, an incision is made in the side of the buttock. The bone of the pelvis is cut and realigned in a new position. Large metal pins or screws are then inserted to hold the bones in the new position until the bone has healed. The pins usually must be removed once the bone has healed.

If there is a serious structural change in the anatomy of the hip, there may need to be further surgery to restore the alignment closer to normal. This is usually not considered until growth stops. As a child grows, there will be some remodeling that occurs in the hip joint. This may improve the situation such that further surgery is unnecessary.

In severe cases, both femoral osteotomy and pelvic osteotomy may be combined to obtain even more containment.

Osteotomy Types

What should I expect from treatment?

Following surgery for Perthes disease, Physical Therapy treatment at First Choice Physical Therapy is very useful in returning your child to their pre-injury activity level as quickly as possible. Physical Therapy can also assist in avoiding other compensatory problems in the back or lower limb in the future as well as to restore and regain any strength and range of motion deficits that have developed as a result of the disease up to this point.
Rehabilitation at First Choice Physical Therapy can begin as soon as your child’s surgeon recommends it. Each surgeon will set his or her own specific restrictions based on the child’s individual severity of injury, the surgical procedure used, personal experience, and whether the hip is healing as expected.

If your child is still suffering from any residual pain from the surgical procedure when they come to First Choice Physical Therapy for their initial appointment, your Physical Therapist may use modalities such as heat, ice, ultrasound, or electrical current to assist with decreasing the pain. If your child is walking with a walker/frame or crutches, your Physical Therapist will ensure your child is using the crutches safely and appropriately and that they are abiding by any weight bearing restrictions set by their surgeon. Your Physical Therapist will also ensure that your child can safely use the crutches on stairs.

We generally recommend that until it is possible to walk without a significant limp, either a walker or one or two crutches continue to be used. Improper gait can lead to a host of other pains in the knee, hip and back so it is prudent to continue on crutches until near normal walking can be achieved. Your Physical Therapist will give advice regarding the appropriate time for your child to be walking without any support at all, although with young children, the ongoing use of a walking aid, even if recommended, can be difficult as they tend to discard them once they can get around without them.  Once your child is no longer using any walking aid your Physical Therapist will assist with normal gait re-education.

The next part of our treatment at First Choice Physical Therapy will focus on normalizing any deficits that may have developed in the range of motion and strength of your child’s lower limbs. Your Physical Therapist may assist in stretching your child’s limb or lower back while at the clinic and, if necessary, will ‘mobilize’ the joints of your child. This hands-on technique encourages the stiff joints to move gradually into their normal range of motion. In addition to the hands-on treatment in the clinic we will also prescribe a series of stretching exercises that we will encourage your child to do as part of a regular home exercise program. We will especially focus on maintaining or gaining range of motion in the surgical hip.

Similarly to the range of motion deficits, strength deficits will also be addressed. Strength building exercises particularly for the hip will be taught in the clinic and added to your child’s home program. For older children we may incorporate items such as Theraband or light weights into the exercises to provide additional resistance for the limb.  If your child is still young your Physical Therapist will explicitly explain how you can work with your child to complete the stretching and strengthening exercises. We will provide ideas for ways that you can incorporate the exercises into your child’s daily play routine.

The final part of our Physical Therapy treatment at First Choice Physical Therapy will be ensuring that your child’s coordination and balance have returned to normal after their surgery. Following even a short period of walking with crutches or a period where your child is walking abnormally due to pain, your child’s normal balance, coordination, and proprioception (the ability to know where your body is without looking at it) can decline in function. Exercises, which may include balancing on one foot, jumping, and quick agility movements will be encouraged at an appropriate time in line with the surgeon’s restrictions.

Fortunately, gaining lost range of motion, strength, and coordination after surgery for Perthes disease happens quickly. You will notice improvements in your child’s function and gait even after just a few treatments with your Physical Therapist at First Choice Physical Therapy. If, however, your child’s post-surgical therapy is not progressing as your Physical Therapist would expect, we will ask you to follow-up with your surgeon to confirm that the hip is tolerating the rehabilitation well and ensure that there are no post-surgical complications that may be impeding your child’s recovery. Generally your child’s surgeon will follow-up quite regularly anyways to monitor symptoms, check on hip mobility, and to make sure that the condition is not deteriorating, so appropriate progression of rehabilitation is easily monitored as well. The surgeon will also take X-rays during their follow-up visits to determine the healing of the femoral head.

Despite optimal surgical and post-surgical care, patients with Perthes disease are always at higher risk of developing osteoarthritis of the hip. The end result is that most patients with Perthes disease will require an artificial hip at some point in the future. Most patients do not develop problems for 40 years or more. How soon patients have problems with their hip is directly related to how much deformity remains once the condition heals. In general, the more round the femoral hip is at that time of complete healing, the longer the hip will stay free of pain.

When a child or adolescent complains of pain and tenderness near the bottom of the kneecap, the problem might be from jumper’s knee. Kids in sports that require a lot of kicking, jumping, or running are affected most. Repeating these actions over and over can lead to pain in the tendon that stretches over the front of the kneecap (the patellar tendon.)

Sometimes the bone growth center at the bottom tip of the kneecap is affected instead of the patellar tendon itself. This condition is known as Sinding-Larsen-Johansson disorder. It is mostly likely to occur during growth spurts. Disruption within the developing bone in the bottom tip of the kneecap also produces pain and tenderness in the front of the knee.

Fortunately, this condition is not serious. It is usually only temporary and will improve with age.

This guide will help you understand:

• what part of the knee is involved
• what causes the condition
• what the condition feels like
• how health care professionals identify the problem
• what treatment options are available
• what First Choice Physical Therapy’s approach to rehabilitation is

What part of the knee is involved?

Jumper’s knee affects the patellar tendon. The patellar tendon connects the large and powerful quadriceps muscle in the front of the thigh to the tibia (shinbone). The patellar tendon wraps over the front of the patella (kneecap). The upper end of the patellar tendon connects to the bottom tip of the patella. This area is called the inferior pole of the patella. The lower end of the patellar tendon connects to a small bump of bone on the front surface of the tibia. This bump is called the tibial tuberosity.

How does this problem develop?

Jumper’s knee is usually caused by overuse of the patellar tendon. Kids who play sports with a lot of squatting and jumping are most at risk. In order to squat and to land softly from a jump, the quadriceps muscle must work extra hard to slow the body down and protect the knee. It does this by lengthening as it works, which is called an eccentric contraction. This muscle action places very high tension on the patellar tendon. When squatting and jumping are performed over and over, the repetitive stress on the tendon causes injury to the individual fibers of the tendon. The tendon becomes inflamed and painful. This is the condition called jumper’s knee.

In addition to overuse of the tendon causing the patellar tendon pain, abnormal alignment of the lower limbs can play a major part in the development of jumper’s knee. Kids who are knock-kneed or flat-footed seem to be more prone to the condition. These altered postures cause a sharper angle between the quadriceps muscle and the patellar tendon. This angle is called the Q-angle. Having a large Q-angle puts more tension on the patellar tendon and the risk of developing jumper’s knee is thus higher.

A large Q-angle also places abnormal tension on the bone growth plate of the inferior pole of the patella, also increasing the risk for Sinding-Larsen-Johansson disorder. A high-riding patella, called patella alta, is also thought to contribute to development of jumper’s knee in children and adolescents.

Pain around the patellar tendon pain can start simply from a growth spurt in an active child whose bones are not done growing. Increased tension in the tendon starts during the growth spurt. The patellar tendon is unable to keep up with the growth of the lower leg. As a result, the tendon is too short. This causes the tendon to pull on the bottom tip of the kneecap. Heavy or repetitive sports activity during this time stresses this area even more. Eventually the increased tension disrupts normal growth of the bottom tip of the patella. Again, this is known as Sinding-Larsen-Johansson disorder.

Sinding-Larsen-Johansson disorder is part of a category of bone development disorders known as the osteochondroses. (Osteo means bone, and chondro means cartilage.) In normal development, specialized areas called growth plates change over time from cartilage to bone. The growth plates expand and unite. This is how bones grow in length and width. Bone growth centers are located throughout the body.

Children with bone development disorders in one part of their body are likely to develop similar problems elsewhere. For example, children who have Sinding-Larsen-Johansson disorder also have a small chance of bone growth problems where the lower end of the patellar tendon attaches to the tibial tuberosity. This is known as Osgood Schlatter’s disease.

What does this problem feel like?

Jumper’s knee commonly produces pain and tenderness directly over the patellar tendon, just below the kneecap. Sometimes there is a small amount of swelling. Kneeling on the sore knee usually hurts. Activities where the quadriceps muscle works eccentrically, such as squatting, jumping, and going down stairs, are often painful.

Kids with Sinding-Larsen-Johansson disorder may feel similar symptoms right along the bottom of the kneecap, where the patella meets the patellar tendon. Sometimes they feel tightness in this area, especially when they try to fully bend the knee.

How do health care professionals identify the problem?

The history and physical examination are often enough to suspect a diagnosis of jumper’s knee. Your Physical Therapist at First Choice Physical Therapy will ask many questions and will want information about your child’s age and activity level. They will also ask about where precisely the pain is, when the pain began, what your child was doing when the pain started, and what movements aggravate or ease the pain.  Jumper’s knee generally begins insidiously, but on occasion it can be instigated by a trauma to the knee such as a fall or hard knock to the knee.

Next your Physical Therapist will do a physical examination of the knee and entire lower extremities. They will palpate, or touch, around the knee and particularly along the patella and patellar tendon to determine the exact location of pain. Your Physical Therapist will look for factors such as bony alignment (Q-angle,) muscle flexibility, mobility of the patella, and joint laxity that may be contributing to your child’s knee pain. They may want to look at how your child stands, their foot position, or watch them walk, squat, or jump. Your Physical Therapist will also check the strength and lengths of the muscles surrounding and affecting the knee joint such as the quadriceps, hamstrings, calves, hip flexors and buttocks muscles. All of these muscles, if weak or tight, can contribute to the forces applied to the knee joint and contribute to the development of jumper’s knee. They may also assess your child’s core stability (specific lumbar and abdominal muscles) as poor functioning of the core can also contribute to the development of knee problems.

Lastly, resistance while your child straightens their knee will be checked to see if it elicits pain.  This action generally reproduces the pain associated with jumper’s knee because it puts tension on the patellar tendon.

If Sinding-Larsen-Johansson disorder is suspected, it is wise to have an X-ray. The X-ray is taken from the side of the knee. This view may show small fragments of bone where tension in the patellar tendon has disrupted the growth plate in the bottom tip of the patella. The X-ray may also show calcification or roughness around the bottom of the patella.

If a trauma to the knee instigated the pain then an X-ray is also required to rule out a patellar fracture.

An ultrasound may also be suggested as a way to directly view any damage to the patellar tendon itself, but it is not frequently needed to confirm the diagnosis.

Occasionally, a magnetic resonance imaging (MRI) scan will be ordered in addition to an X-ray as it may show more detail. The MRI can give a better view of any calcification in the patellar tendon where it attaches on the bottom tip of the kneecap. The MRI can also detect swelling, which is not seen well on X-ray. It can also show if injury or inflammation is present within the patellar tendon itself.

What treatment options are available?

Nonsurgical Rehabilitation and Treatment

In the case of Sinding-Larsen-Johansson disorder, the disease is often self-limiting, which means that with a certain passing of time, the pain will entirely go away. This time frame coincides with the bone growth plates that form the inferior pole of the patella growing together to form one solid bone. This generally takes one to two years. Once the bones have grown together, the pain and symptoms usually go away completely. Physical Therapy treatment at First Choice Physical Therapy during this time, while the bones are still growing together, can be very useful to manage the injury by decreasing pain and inflammation, as well as to monitor the appropriate level of physical activity that your child partakes in. For true jumper’s knee, where the patellar tendon itself if affected and not the growth plate, Physical Therapy is also very useful for the same reasons.

In some cases of jumper’s knee, your child may need to stop sports activities for a short period. This allows the pain and inflammation to settle. Usually patients don’t need to avoid sports for a long time. ‘Relative rest’ may be suggested rather than a complete cessation of physical activity. ‘Relative rest’ is a term used to describe a process of rest-to-recovery based on the severity of symptoms. If your child is experiencing pain while doing nothing (resting) it means the injury is more severe and your Physical Therapist will advise a period of strict cessation of activity. If, however, your child’s pain is not severe and only occurs intermittently with certain activities or after activity, then your child may be able to continue to partake in a moderate amount of activity (relative rest) while being treated for jumper’s knee. Your Physical Therapist will provide advice on the appropriate activity level that your child can safely partake in while dealing with their jumper’s knee.

The initial treatment for jumper’s knee at First Choice Physical Therapy will aim to decrease the inflammation and pain in the knee. Simply icing the knee can often assist with the inflammation and relieve a great deal of the pain. In cases of chronic pain (lasting longer than 3 months), heat may be more useful in decreasing pain. Your Physical Therapist may also use electrical modalities such as ultrasound or interferential current to decrease the pain and inflammation. Massage, particularly for the quadriceps muscle, may also be helpful.

Medication to ease the pain or inflammation can often be very beneficial in the overall treatment of jumper’s knee. Your Physical Therapist may suggest you see your doctor to discuss the use of anti-inflammatories or pain-relieving medications in conjunction with your Physical Therapy treatment. Your Physical Therapist may even liaise directly with your doctor to obtain their advice on the use of medication in your individual case, and suggest you see them if they feel it would be beneficial.

Cortisone injections performed by a doctor are commonly used to control pain and inflammation in other types of injuries involving the patellar tendon, however, a cortisone injection is usually not appropriate for this condition. Cortisone injections haven’t shown consistently good results for jumper’s knee and there is also a high risk that the cortisone will cause the patellar tendon to rupture.

Once the initial pain and inflammation has calmed down, your Physical Therapist will focus on improving the flexibility, strength, and alignment around the knee joint and entire lower extremity. Static stretches for the muscles and tissues around the knee (particularly the quadriceps and iliotibial band on the outside of the knee) will be prescribed by your Physical Therapist early on in your treatment to improve flexibility.

Again, any tightness in the muscles or tissues around the knee can increase the pull on the patellar tendon or affect alignment during walking, running or jumping so it is important to address this immediately. Dynamic stretching (rapid motions that stretch the tissues quickly, similar to that of an eccentric contraction,) will also be taught and will be incorporated into your child’s rehabilitation exercise routine as part of their warm-up when doing more physical activity. Dynamic stretches more effectively prepare the tissues for rapid and repetitive activity than static stretches, which focus more on gaining overall flexibility.

Strength imbalances will also affect the alignment of the knee and can cause muscles to tighten which puts more pressure on the knee and can contribute to the cause of jumper’s knee. Your Physical Therapist will determine which muscles in your child’s individual case require the most strengthening. Strength in both the knee and the hip (which controls the knee position) are very important.  When bending the knee, as stated above, the patellar tendon is placed under load while it is stretching (eccentric load.) This load can be tremendous especially when jumping and landing. In order to prepare the healing tendon to take this load once your child returns to activity your Physical Therapist will prescribe ‘eccentric’ muscle strengthening. Bending the knee quickly into a squatting position and then stopping rapidly (drop squats) encourages the patellar tendon (and entire knee joint) to adapt to the force that will eventually be needed to return to physical activity. When appropriate, weights can be added to simulate the increased body weight that the knee endures during running and jumping.

Your Physical Therapist may ask your child to do this exercise on a board slanting downwards (approximately 25 degrees) which has been shown to also increase the force through the tendon. In addition, an electrical muscle stimulator may be used on the quadriceps muscle during the activity which encourages improved recruitment of the muscle, particularly the medial quadriceps portion which has a considerable effect on the position of the patella and pull on the patellar tendon. All exercises should be completed with minimal or no pain and advancing the exercises should be done at the discretion of your Physical Therapist as not to flare up the healing tendon. Once these exercise are mastered, your Physical Therapist may add even more advanced exercises such as jumping and landing from a height or on different surfaces.

As part of your treatment your Physical Therapist may choose to use a hands-on technique to mobilize your kneecap and improve its flexibility.  In cases where the patella does not move well, improved movement can change the overall pull on the patellar tendon and therefore assist in decreasing overall pain.

Bracing or taping the knee or kneecap may also help your child do exercises and activities with less pain. Your Physical Therapist can educate you on which brace would be most appropriate for your child but an initial trial of taping is an easy and cost-effective way to determine if a brace will in fact decrease your child’s pain before actually investing in one.  Your Physical Therapist may even teach your child how to tape their own knee or show you how to do it for them. Taping over a longer time frame will cause irritation to the skin and can be cumbersome, therefore if the taping helps, a brace, which performs a similar function, may be suggested. Braces used for jumper’s knee are made of soft fabric, such as cloth or neoprene. There are different types of braces that may help.  The braces work by one of two mechanisms. They either work to encourage proper alignment of the patella as it glides down the knee, and therefore decreases the abnormal pull on the patellar tendon, or the brace presses into the patellar tendon itself and distributes the force of the load through a greater region of the patellar tendon. Patients commonly report less pain and improved function with both taping and bracing.

As mentioned above, proper alignment of your child’s entire lower extremity is paramount to decreasing the overall stress that is placed on the patellar tendon. In addition to strengthening, stretching, hands-on treatment, and taping, foot orthotics may be useful to assist with alignment.  Foot orthotics can correct a flat foot position, which in turn then encourages proper alignment up the lower extremity chain. Your Physical Therapist can advise you on whether orthotics would be useful for your child, and also on where to purchase them.

A critical part of our treatment for jumpers knee at First Choice Physical Therapy includes specific education on returning to full physical activity. Bending and straightening the knee occurs often in everyday activities such as walking or stair climbing so a patellar tendon that is recovering from injury can easily be aggravated.  Returning your child back to normal physical activity at a graduated pace is crucial to avoid repetitive pain or a chronic injury. Your Physical Therapist will advise you on the acceptable level of activity at each stage of your child’s rehabilitation process and assist your child in returning to his or her activities as quickly and as safely as possible.

With a well-planned rehabilitation program and adherence to suggested levels of rest and activity modification, most children and adolescents dealing with jumper’s knee or Sinding-Larsen-Johansson disorder eventually recover fully without recurring symptoms. By following the rehabilitation plan, most children are also able to partake in a level of activity that suits them while recovering.

Surgery is rarely needed for jumper’s knee. Surgery may be considered if the problem involves only the tendon (not the growth plate) and if symptoms have not gone away with other forms of treatment. In these cases, the surgeon may do an operation to strip away (debride) inflamed and damaged tissue on the surface of the patellar tendon.
In this procedure, a small incision is made down the front of the knee, below the patella.

The skin is opened to expose the patellar tendon. Next, the surgeon carefully peels damaged tissue off the surface of the tendon. Three to five thin lengths of the tendon are removed. In some cases, small drill holes are made in the bottom tip of the patella. This drilling causes a small amount of bleeding, which signals the body to begin to heal the area. The surgeon also removes any damaged tissue nearby the area before completing the operation by stitching up the skin and wrapping the area with a bandage.

Surgery is not generally used when symptoms are caused by Sinding-Larsen-Johansson disorder, unless bone growth is complete and symptoms have not gone away with nonsurgical treatment. Even then, surgery for Sinding-Larsen-Johansson disorder is unusual.

The surgeon may recommend wearing a hinged knee brace for a few weeks after surgery. The brace lets the knee bend, but it doesn’t let the quadriceps muscle fully straighten the knee. This decreases the amount of force put through the healing tendon. Crutches may be needed for a few days after the operation, until the patient can bear weight without pain or problems, and walk without a limp.

Patients will follow up with their surgeon 10 to 14 days after surgery. Stitches will be taken out at this time, and patients are encouraged to begin actively bending and straightening the knee. Post-surgical rehabilitation at First Choice Physical Therapy can begin at this time.

Post-surgical rehabilitation at First Choice Physical Therapy will initially focus on minimizing the pain and swelling from the surgery. Similar to non-surgical rehabilitation, your Physical Therapist may use modalities such as ice, ultrasound, or interferential current to accomplish this. They may also use gentle massage around the muscles of your child’s surgical knee. If your child is still using crutches when we initially see them, your Physical Therapist will ensure your child knows how to use them properly on level ground as well as stairs, and they will advise your child when it is safe to go without using the crutches at all.

One of the first exercises your Physical Therapist will prescribe will be some gentle range of motion exercises for your knee to gradually regain full movement. This should be done within a pain free range of motion, however, movement will be encouraged even if it causes a slight bit of discomfort as the movement itself can greatly assist with dispersing any inflammation as well as improving the overall level of pain. A stationary bicycle can be very useful in the initial stages of gaining range of motion in the knee, so if able, you will be encouraged to use one.  Even if you are unable to fully rotate the pedals, the back and forth motion on the bike is an excellent method of slowly encouraging the knee to regain its full range of motion.

Once the pain and swelling is under control your child’s rehabilitation will follow a similar pattern to that described above under non-surgical rehabilitation. Your Physical Therapist will prescribe a series of exercises that address the strength, endurance, and flexibility of the muscles of the knee and hip joints. They will also address the overall alignment of the entire lower limb during both the rehabilitation exercises as well during everyday activities and sporting endeavors. Eccentric exercises are an important part of post-surgical rehabilitation and will be introduced as soon as your Physical Therapist feels it is appropriate.

Daily activities will be resumed fairly quickly but vigorous activities and exercise should be avoided for at least six weeks after surgery to give adequate rest to the healing tendon. High-level athletes, unfortunately, may be restricted in their sporting activities for up to six months to allow the tendon to heal and to ensure there is not a recurrence of the injury.

Recovery from surgery for jumper’s knee in adolescents or children generally progresses very well with rehabilitation at First Choice Physical Therapy. If however, your child’s pain lasts longer than it should or their rehabilitation is not progressing as quickly as your Physical Therapist feels it should be, they will ask you to follow up again with your child’s surgeon to ensure there are no complicating factors impeding the recovery.

Until more recently, a complaint of back pain in a child or adolescent was considered uncommon. It was usually associated with a certain condition such as curvature of the spine, a broken spinal bone, inflammation, a tumor, or infection.

More recently, however, reports of back pain among children are much more common.  It is not clear why but may be due to children carrying heavier backpacks or sitting longer due to increased computer use.  By the age of fifteen, 20-70 percent of children will report back pain but it is seldom associated with a serious condition, particularly as age increases. There are still a few cases, however, in which the pain is due to a serious condition so symptoms must be heeded.

This guide will give you a general overview of back pain in children. It will help you understand:

• What parts make up the spine
• What causes back pain in children
• How the diagnosis is made
• What First Choice Physical Therapy’s approach to treatment is

What parts make up the spine?

The spine is made up of a column of bones.  A round block of bone, called a vertebral body, forms the biggest portion of each segment, or vertebrae. A bony ring attaches to the back of the vertebral body, forming a canal for the spinal cord. 
Facet joints are small joints on either side of the spine that allow motion. As the bones of the spine interlock, a facet joint is formed. Each vertebra will form two facet joints, on either side. There is a pair at the top and a pair at the bottom of each vertebra. The area of the vertebra that connects the large body of the vertebra to the facet joints is called the pars articularis or pedicle. 
 The part between the two sets of facet joints is the lamina.

Intervertebral discs form a cushion between the round blocks of bone making up the vertebral body. The area where the disc attaches to the vertebral body is called an end plate.  Discs are a collection of tough tissue similar to a ligament. They are filled with fluid when healthy. 
There are three general portions of the spinal column:  The cervical or neck portion, the thoracic portion making up the mid-back, and the lumbar or lower portion. The lumbar portion connects with the pelvis at the sacrum.

There are specific curves associated with each region of the spine. When looking from the side, the cervical spine has an inward curve called a lordosis. The thoracic spine curves outward and is called a kyphosis, and the lumbar spine normally curves into the opposite way, creating a lordosis again. These three curves maintain balance of the spine in a forward and backward plane. 

When there is a sideways curve in the spine (most exaggerated in the thoracic spine) it is called a scoliosis.

What causes back pain in children?


There are several red flag warning signs that may suggest a specific cause for back pain: night pain, constant pain, or pain that spreads into the buttocks or legs are some of them. Leg weakness or bowel and bladder problems (particularly incontinence) are also red flags that can indicate nerve or spinal cord problems.
  Conditions that can cause back pain are grouped into nonspecific causes, meaning the cause is unknown, and specific causes/back pain, meaning there is an identified cause for the pain.

With nonspecific back pain there is no specific anatomical structural reason or cause for the back pain that can be found. Approximately 60 to 75 percent of children reporting back pain will have non-specific pain. Their physical exam and X-rays will be normal. It is usually considered a muscle strain or a result of a general strain on the spine from poor posture. 
In some cases, non-specific back pain may be related to mood problems such as depression or anxiety. It is even sometimes related to problems at school or with peers.

Specific back pain means a structural cause for the pain is identifiable.  Approximately 25 to 40 percent of children will have specific back pain and will show changes on imaging studies (such as X-ray or magnetic resonance images) that indicate a pathological reason (meaning one caused by disease) for their back pain. These causes include the following:

Spondylolysis is a fracture of the pars interarticularis or pedicle(s), usually of the L5 or last lumbar vertebrae. This injury is most likely caused by a traumatic event but it may also be caused by repetitive activity (in this case it is called a stress fracture.) 
Spondylolysis is a common cause for back pain in children, especially for those who are intensely active or competitive in sport, particularly at a younger age.  The motions that most likely cause spondylolysis include extension (bending backwards) and rotation. Sports that put athletes at higher risk include ballet, gymnastics, football, high jumping, diving, rowing, and weight lifting but other sports can certainly cause this type of fracture as well.  Spondylolysis is three times more common in boys than girls. Growth spurts and involvement in contact sports may explain the difference between boys and girls. 
In the early stage of the injury an X-ray may not show a fracture. Special imaging tests such as magnetic resonance imaging (MRI), computed tomography scans (CT), or a bone scan may show signs of a stress fracture. Spondylolysis may cause pain in a particular spot in the low back and spasm of the muscles along the spine. Often it will cause pain into the buttocks or thighs. Spondylolysis will often heal with the appropriate rest, a change in activity levels, and by avoiding hyperextension and rotation of the spine. Bracing may be helpful if symptoms do not get better.

Spondylolisthesis is the slippage of one vertebrae on another. A spondylolisthesis can occur when spondylolysis worsens or does not heal, although a fracture does not always need to have occurred for a spondylolisthesis to be present.  A spondylolisthesis can also occur as a result of a malformation of the spine at birth.  Despite being present from birth, however, sometimes this slippage is not picked up until later in life when an incident of back pain is being investigated.

A spondylolisthesis slippage is generally graded from I through IV, one being mild, and IV being the most severe, which often causes neurological symptoms.

Scoliosis or sideways curvature of the spine may be the source of back pain in some children. Most cases of scoliosis only require monitoring for worsening symptoms, along with Physical Therapy to improve muscle strength and flexibility.  More severe cases, however, may need bracing or even surgery. In some rare cases a scoliosis is caused by a tumor or infection of the spine.

Scheuermann’s kyphosis is a thoracic spine deformity where there is wedging of three or more vertebrae in a row.  Wedging means that the vertebra is wider towards the back, and narrower towards the front. The vertebra has lost its usual rectangular shape. This wedging causes increased curvature or forward bending of the spine, which is called kyphosis.  The cause of the wedging is unknown.  The curve from a sideways view can be 50 degrees or more. If the curvature is greater than 75 degrees, surgery to straighten the spine may be necessary.

There may also be narrowing of the disc spaces between the vertebrae. Most of the time there are also Schmorl’s nodes seen in the vertebral body, which are areas of disc material that bulge into the end plate. On imaging studies these look like small hollowed areas.

Discitis and vertebral osteomyelitis are rare in children. When a disc becomes inflamed and possibly infected, the condition is called discitis. If the vertebral bone becomes infected, the condition is called vertebral osteomyelitis.  
Common symptoms of these conditions include refusal to crawl, sit, or walk and complaints of back pain. A limp and forward bending while placing the hands on the thighs for support are also common signs. 
With discitis, the disc will appear narrowed on an X-ray or an MRI.  Discitis usually occurs in children less than five years old.

Vertebral osteomyelitis tends to affect older children and adolescents.  The vertebral bone and surrounding tissue including the disc can become infected. On X-ray or MRI the bone and/or tissue can show destruction.  Fever of 102 degrees Fahrenheit or 39 degrees Celsius or greater is common in vertebral osteomyelitis.
  Both discitis and vertebral osteomyelitis are treated with rest, as well as oral and IV antibiotics. A brace to support the spine may be suggested.  With osteomyelitis surgery may be necessary to clean out the infection and/or to stabilize the spine.

Tumors are another rare cause of back pain in children. A tumor of the spine is an abnormal growth of tissue in or around the spinal column. There are many different types of spinal tumors. They can be benign or malignant. Benign means that the tumor does not spread to other parts of the body. It can still cause destruction of vertebral bone or spinal tissue. Some benign tumors can grow back after they have been removed. Benign tumors include osteoid osteoma, osteoblastoma, and aneurysmal bone cysts. Malignant tumors are tumors that can spread to other parts of the body. These include sarcoma, leukemia, and lymphoma.

Depending on the age of the child, they may or may not be able to tell you about their symptoms. 
 In a younger child, refusal to crawl, sit, or walk may indicate back pain.
  In older children, verbal symptoms (and objective signs) may include:

• Pain involving the spine
• Spasm of the nearby muscles
• Decreased range of motion or stiffness in the back
• Stiffness and pain after prolonged sitting or standing
• Pain with loading the spine as when lifting and carrying
• Pain referred to areas away from the spine itself such as into the buttocks or legs
• Leg weakness or bowel and bladder problems, which can indicate nerve or spinal cord problems
• Difficulty walking
• Fever

How is this condition diagnosed?


On initial assessment at First Choice Physical Therapy your Physical Therapist will perform an examination that will start with your child’s history. They will ask questions about when your child’s pain began, when and where precisely the pain occurs, your child’s activity levels, whether there have been any previous spinal injuries, whether there are any problems with urination or bowel movements, whether there are any muscle weaknesses, and what makes your child’s pain better or worse.  They will also want to know if your child complains of pain in any other areas of their body such as their hips or knees. They may also ask questions about school and sport activities, activities at home, your child’s moods, and whether or not they have had a fever associated with their pain.

A physical examination will be done once the history is complete.  Your Physical Therapist will examine your child’s back to evaluate the curves of the spine, spasm of the muscles, overall posturing and alignment of the back and lower extremities, and for unusual markings on the skin or soft tissues along the spine.  They will palpate, or touch along the spine and over the muscles to determine if any particular areas are painful or tight.  They may push on the spine, or manually move the spine to get a general idea of how much motion is available at each segment.

Your Physical Therapist will also examine your child’s hips, knees, and ankles to determine if these joints and the muscles that are involved with them might be contributing to the pain your child feels in their back.  The length (flexibility) and strength of the muscles of the buttocks, the front of the hip, as well as the thigh (quadriceps and hamstrings muscles) are particularly important areas that your therapist will assess.  These muscles can pull on the back if they are too tight, or not support the back well enough if they are too weak.  Both tightness and/or weakness can lead to back pain.  The hip joints themselves, if restricted in motion, can lead to back pain so their motion will be thoroughly assessed.  The hips are designed to be mobile enough so that your trunk can turn and move freely especially when twisting or extending the spine. If the hip joints become restricted or tight there is less motion available in the joint.  The decreased motion found in the hips is then often made up for by increased movement occurring in the back instead, which can lead to pain.

Your Physical Therapist will also want to examine your child’s ability to bend their back forwards, backwards, sideways, as well as rotate it and to get into positions involving a combination of these motions.  Your Physical Therapist will also look at your child’s posture and alignment while they are standing and sitting, and may also want to watch your child during different activities such as walking, squatting, jumping, lifting one leg, or kneeling on their hands and knees.  The ability for your child’s trunk to be supported by the deep muscles of the abdominal area and back will be determined by your therapist as they observe your child performing these activities.

A neurological examination may need to be done which will include checking your child’s reflexes, sensation, and muscle strength.

Imaging studies

X-rays are recommended for most children complaining of back pain due to the fragile nature of their developing spine. Views of the spine from the front, the side, and part way in between (oblique) should be taken. X-rays will allow examination of bone as well as the disc spaces.

An MRI may be required if further examination of the spine is needed. An MRI machine uses magnetic waves, not X-rays, to show the soft tissues of the body. These tissues include the spinal cord, nerves, and discs. It can also evaluate spinal bones. An MRI allows your healthcare professional to look at slices of the area in question. The test may require the use of dye in an IV. Sedation or anesthesia may be needed to help your child lie still for this test.

A computed tomography (CT) scan may also be ordered. This test is best for evaluating problems with the vertebral bones. Children usually tolerate this test well, however, this test exposes them to radiation, which is significantly higher than during plain x-rays. Sometimes this test may require dye in the spinal canal fluid for easier identification of the spinal cord and nerve root anatomy. When dye is injected for this purpose, the technique is called a myelogram.

Bone scans, also called nuclear scans, can be used to detect fractures, bone infections, or tumors. A radioactive tracer, Technetium, is injected into your child’s vein and any area where there is an increase in metabolic activity the Technetium will show up as being more concentrated.  Increased metabolic activity occurs when there is inflammation, a fracture, an infection, or a tumor. Some tumors in the spine can spread to other parts of the body, or come from cancer somewhere else in the body. A scan can be helpful to see if there are other areas in the body where the cancer may be.

SPECT imaging is often added after a bone scan to provide information that is not available on routine bone scan images. SPECT stands for Single Photon Emission Computed Tomography. It provides three-dimensional (3-D) views of the area examined. Following a bone scan your child will remain on the exam table and the camera will rotate around the table while it takes pictures. SPECT imaging adds 30 to 60 minutes to the time of the nuclear scan. Sedation may be needed.
  A biopsy of the spine may be required if an infection or tumor is found. In some cases tissue samples can be taken with a needle but in other cases a minor surgery is needed to obtain the tissue biopsy as this allows the doctor a better view of the area he or she needs to biopsy. The tissue is then looked at under a microscope.

Laboratory Studies

Blood tests may be requested to evaluate the blood for specific bacteria causing an infection. A complete blood count (CBC), especially in children under the age of 10, is important as the chance that back pain is from leukemia is greater in children younger than 10. If there is an infection, the CBC may show an increase in the infection-fighting white blood cells. A C-reactive protein (C-RP) and erythrocyte sedimentation rate (ESR) may also show an increase when an infection is present. A blood culture may be necessary to help determine which bacteria are causing the infection in discitis or vertebral osteomyelitis.
  In some cases a biopsy may be required to determine which bacteria is the culprit.  Knowing which bacteria is present will help your doctor choose the right antibiotic to treat the infection.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

What treatments are available?

Non-surgical  

Most treatment for back pain in children is non-surgical and involves a combination of medical treatment and close follow-up by your child’s doctor, as well as consulting with a Physical Therapist at First Choice Physical Therapy. Periodic follow-up with your child’s physician is required as repeated or different imaging studies may be necessary, particularly if symptoms do not improve. Any laboratory tests done initially may also need to be repeated. Short-term use of over-the-counter medications such as Ibuprofen may be beneficial. Weight loss may be recommended if this is deemed to be a causative factor of the back pain.  Antibiotics either by IV and/or by mouth are necessary for the treatment of discitis and vertebral osteomyelitis.

Treatment of non-specific back pain may include involving the school counselor or a psychologist as children may complain of back pain when they are depressed or anxious about problems at home, in school, or with peers.

What should I expect during treatment?


Non-surgical Rehabilitation


If your child has non-specific back pain an exact anatomical cause for your child’s back pain may not be able to be determined, however, that does not exclude the need for Physical Therapy treatment.  The symptoms present can be assisted by Physical Therapy.  Any muscle weaknesses, tightness, or imbalances can also be identified and treated in order to help decrease the pain but also to avoid the back pain from re-occurring.

If your child is old enough then one of the first things your therapist will do is to discuss your child’s posture and alignment.  Poor posture can contribute heavily to ongoing back pain.  Your Physical Therapist will explain to your child about maintaining good posture and will give advice on sitting and standing postures.  They will also discuss your child’s current activities and activity levels.  A short period of complete rest from aggravating activities, or a period where activities are at least decreased may be needed to allow the back pain to ease.  Your child’s Physical Therapist will discuss which activities are safe to continue participating in as well as those which your child may require a break from.  Safe lifting techniques will also be discussed if your child is of an appropriate age to grasp the concept.

During the first few appointments at First Choice Physical Therapy treatment will focus on relieving your child’s pain.  Your Physical Therapist may use modalities such as heat or ice to assist with decreasing any pain or swelling in your child’s back.  In some cases ultrasound, or electrical current may be used.  Your therapist may also use hands-on techniques such as massage, mobilizations, or manual stretching to improve motion and relieve discomfort.

Next your Physical Therapist will prescribe stretching and strengthening exercises that address any tight or weak muscles noted on the physical examination.  In particular your Physical Therapist will ensure that your child’s hips and the joints of their back are moving well, as these areas work closely together.  As mentioned above, if the hips are stiff, often the back takes up the slack and is required to move more, which can cause back pain.  If the joints of the back themselves are stiff this will put strain on the joints and also cause discomfort.  In addition, if the buttocks muscles (gluteals), which support the hips and back, are weak the back again endures extra stress.  For this reason the gluteals will be focused on in regards to strengthening.  All exercises prescribed will be done both in the clinic but also as part of a home exercise program.

Your Physical Therapist will next teach your child how to use their core stabilizing muscles in order to support their back.  Activating the deep core muscles assists greatly in supporting the back and decreasing back pain.  Your child will be asked to do specific exercises for their core muscles but will also be asked to try to gently activate these muscles during everyday activities such as sitting, walking, running, or sporting activities.

Carrying backpacks may sometimes be to blame for non-specific back pain.  Your Physical Therapist will discuss this with your child and may ask to see the backpack that your child regularly uses.  Many children these days carry extremely heavy backpacks and use backpacks that are poorly designed ergonomically.  It is suggested that children wear their backpack using both shoulder straps and that if there is a waist or chest strap, that these straps also be used.  When purchasing a backpack, ensure the shoulder straps are wide, padded, and adjustable so that the weight can be evenly distributed.  As a general rule backpacks should not be heavier than 10% of your child’s body weight.  Making more frequent trips to the locker can decrease the weight of the backpack, and packing the backpack so the weight is distributed evenly can also decrease the strain on the back.  Using a wheeled backpack may be an option and should be considered if your child suffers from frequent back pain, or is recovering from an injury.

Bracing may also be useful to assist in treating some conditions and your Physical Therapist will discuss if this may be helpful in your child’s case.  Taping can provide similar short term benefits as a brace and may be trialed by your child’s therapist to determine if it assists with decreasing pain or improves the ability of your child to move their back.  Tape can be used before investing in a brace, or in some cases instead of purchasing a brace.

Fortunately most back pain in children does very well with the rehabilitation we provide at First Choice Physical Therapy.  If, however, your child’s pain continues longer than it should or therapy is not progressing as your Physical Therapist at First Choice Physical Therapy would expect, we will liaise with your child’s doctor regarding the lack of progress and will ask you to follow-up with your child’s doctor as well to possibly do further investigations.

Physical Therapy in Lynn Haven and Panama City Beach for Pediatric Issues


Surgical treatment for back pain in children is rare.  
If a tumor has been discovered as the source of your child’s back pain, the treatment options will vary depending on the type of tumor found.
 Some tumors are evaluated periodically on a watch-and-see basis. Surgery to remove the tumor is often recommended. If radiation or chemotherapy is required, your child will be referred to an oncologist (cancer specialist). In the case of a tumor, radiation may begin as early as one to two weeks following surgery.  Radiation usually lasts only 15 to 20 minutes per day for two to six weeks. Treatment options and the prognosis for many tumors have improved greatly in the past few years.  The spine may need to be stabilized due to scoliosis or kyphosis, or from the removal of a tumor or infection. Metal hardware such as screws, rods, plates, or cages may need to be used. The bone may also be supported by bone graft or bone cement.

Periodic follow-up visits with your child’s surgeon after surgery will be required. Repeated or different imaging studies may be necessary and any laboratory tests done may need to be repeated. Follow up may need to be on a long-term basis and is done to watch for the development of spinal deformity or recurrence of a tumor.


The amount of time your child is hospitalized depends on the type of surgery required.  If your child’s surgeon recommends it a Physical Therapist may visit your child in the hospital to start assisting them with gentle back strengthening and range of motion exercises immediately after surgery. Activities such as sitting, crawling, or walking are usually allowed immediately after surgery as well as activities that do not require stretching or straining of the spine, but these restrictions depend on what was done during surgery as well as the surgeon’s preferences in regards to rehabilitation.  Some surgeons may recommend a short period of complete rest where minimal or no activity is done immediately following the surgery.  Lifting is also generally limited during the initial recovery period.

Your child will likely be required to use a brace or corset after their surgery to help with stability of the spine. 
Your child’s surgeon will determine how long the brace is required, but generally once the muscles have regained the strength to support the spine, the brace can be discarded.

Your child may begin Physical Therapy at First Choice Physical Therapy as soon as their surgeon recommends it.

During the first few appointments at First Choice Physical Therapy treatment will focus initially on relieving any residual pain that may be lingering from the surgery.  Your child’s therapist may use modalities such as heat or ice to assist with decreasing any pain or swelling in your child’s back.  In some cases ultrasound, or electrical current may be used, depending partly on the age of your child.  Your therapist may also use hands-on techniques such as massage or mobilizations to improve motion and relieve discomfort.

Next your child’s therapist will begin with range of motion exercises for your child’s back as well as their hips to ensure they regain maximum movement of these areas and can get back to normal motion of the spine as quickly as is safely possible.  Any movement restrictions implicated by your child’s surgeon will be strictly abided by.  If movement for your child is difficult or continues to be restricted by pain, your therapist may suggest that your child does their therapy exercises in a Physical Therapy pool where the warmth of the water and the hydrostatic properties can assist with decreasing pain and make motion easier.  Your therapist will discuss this with you if they feel it is appropriate.

Core strengthening after spinal surgery is particularly important so will begin as soon as possible.  Your therapist will teach your child how to use their core muscles, and will prescribe specific exercises for your child to improve their core strength.  They will also encourage your child to use their core muscles during everyday activities such as sitting, or getting out of bed.  As they progress in their rehabilitation they will also be asked to incorporate core strengthening into more advanced activities such as playing and running.  While learning to activate these muscles, your child’s therapist may use taping techniques to help provide feedback for your child and, if needed, to provide ongoing support for the back as your child moves towards doing their normal activities.

Other stretches and strengthening exercises that target your child’s individual muscular deficits will also be incorporated into your child’s rehabilitation program and will be done both in the clinic but will also be required to be done as part of a home exercise program.  These exercises will address any tight, weak, or overactive muscles identified in your child that may restrict your child’s back from moving optimally or may contribute to back pain in the future.

Finally, if your child is of an appropriate age your therapist will discuss proper posture and alignment with your child.  Maintaining good posture as often as possible can help to prevent back pain in the future or can at least decrease the incidences or severity of back pain that may arise.

Slowly your Physical Therapist will assist your child in returning to their normal activities.  Generally rehabilitation after spinal surgery in a child progresses very well with the treatment we provide at First Choice Physical Therapy.  If, however, your child’s pain continues longer than it should or therapy is not progressing as your Physical Therapist would expect, we will ask you to follow-up with your child’s surgeon to ensure their back is tolerating the rehabilitation well and to ensure there are no hardware issues that may be impeding recovery.

Clubfoot is a congenital condition that affects newborn infants. The medical term for clubfoot is Congenital Talipes Equinovarus. This condition has been described in medical literature since the ancient Egyptians. Congenital means that the condition is present at birth and occurred during fetal development. The condition is not rare and the incidence varies widely among different races. In the Caucasian population, about one in a thousand infants are born with a clubfoot. In Japan, the numbers are one in two thousand and in some races in the South Pacific it can be as high as seven infants in one thousand who are born with a clubfoot. The condition affects both feet in about half of the infants born with clubfoot. Clubfoot affects twice as many males as females.

This guide will help you understand:

• what part of the foot is involved
• what causes the condition
• what treatment options are available
• what First Choice Physical Therapy’s approach to rehabilitation is

What part of the foot is affected?

The tarsal bones are the seven bones that make up the heel and the midfoot. The metatarsals and the phalanges are connected to the tarsals and form the forefoot. Clubfoot primarily affects three bones: the calcaneus, talus and navicular.  The deformity can affect the growth of the entire foot to some degree so other bones may be involved as well.

The clubfoot is unmistakable. The foot is turned under and towards the other foot. The medical terminology for this position is equinus and varus. Equinus means that the toes are pointed down and the ankle flexed forward (sort of like the position of the foot when a ballet dancer is on her toes). Varus means tilted inward. The ankle is in varus position when you try to put the soles of your feet together.

This twisted position of the foot causes several problems in the foot. The ligaments, which are the connecting tissue between the bones, are contracted, or shortened and the joints between the tarsal bones do not move, as they should. The bones themselves are deformed. This results in a very tight stiff foot that cannot be placed flat on the ground for walking. To walk, the child must walk on the outside edge of the foot rather than on the sole of the foot.

One interesting finding is that the calf muscles on the leg with the clubfoot are smaller than normal. If the clubfoot only affects one foot, the calf muscles on this leg will always remain smaller than the opposite side.

How does this problem develop?

During the nine months of pregnancy, the fetus undergoes remarkable changes. In the skeleton, these changes include the separation of each individual bone in the body from one mass of bone material. In some cases, this process is flawed. A clubfoot occurs when this failure of separation occurs in the tarsal bones of the foot.

Until recently, most experts believed that the clubfoot deformity was due to the foot being stuck in the wrong position in the womb. As development progressed, the foot could not grow normally because it was turned under and held in that position. Today, most information suggests that clubfoot is hereditary, meaning that it runs in families. It is not clear what genetic defect causes the problem. It is not known yet whether the defect affects the development of the muscles, blood vessels, or bones of the foot.

The foot is an incredibly complex structure. For the foot to grow and develop correctly, all of the bones of the foot must move normally in relationship to each other. If the movement between two bones is abnormal, or non-existent, that changes how the bones grow after birth. If untreated, over time this leads to further deformity in the foot.

What does this problem feel like?

The condition in itself is not painful to the child. The primary problem of a clubfoot is that the foot cannot be placed flat on the ground so that the child can walk on the sole of the foot. In developing countries where there is sometimes no treatment for conditions such as this, adults with a clubfoot walk on the side of their foot. They do not walk normally and this may cause pain. Due to this abnormal force on the side of the foot the foot is extremely deformed with calluses where it contacts the ground. Footwear is very difficult to fit and usually must be custom-made, as normal shoes will not fit. Eventually the abnormality can lead to wear and tear arthritis in the joints of the foot, pain, and decreased ability to walk.

How do doctors identify the problem?

The history and physical examination make the diagnosis of clubfoot. The appearance alone is usually enough to determine that a clubfoot is present.  A complete examination of the newborn with a clubfoot is critical since there are other genetic conditions that are associated with clubfeet. Your pediatrician will perform a complete evaluation to make sure there are no other congenital conditions to be concerned with.

A clubfoot can be diagnosed before birth using ultrasound. Many women have routine ultrasound tests to assess the status of the pregnancy. There is currently no treatment available before birth if a clubfoot should be found. Being that clubfoot is associated with other serious congenital and genetic abnormalities, the obstetrician may recommend amniocentesis to look for genetic problems in the fetus if a clubfoot is present. An amniocentesis is a test where a needle is inserted into the uterus and a small amount of fluid removed. This fluid is sent to the lab for analysis. If evidence for serious genetic or congenital anomalies is found, then the option of terminating the pregnancy exists.
X-rays are helpful in determining the severity of the condition. This information may become important later in trying to decide what treatment is best to recommend. Usually, no other imaging studies are needed.

What treatment options are available?

Treatment for clubfoot usually begins at birth. Treatment in the majority of infants will require both non-surgical treatment and surgery. The foot will never be normal, but treatment can provide a very functional foot that can be used for walking without pain.

Nonsurgical Treatment

The most commonly used non-surgical treatment in the newborn and infant is manipulation and casting. This is started as soon as possible. The foot is manipulated to stretch and loosen the tight structures. The foot is then placed in a cast to hold it in a corrected position. This is repeated every one or two weeks until the deformity is corrected or surgery is performed.

As any parent knows, the newborn grows rapidly after birth. The technique of manipulation and casting the foot is used to guide the growth of the foot towards the normal alignment. Without this guidance, the foot will remain deformed and may actually get worse. The greatest chance for correction of deformity occurs early in life when there is so much growth occurring.

There have been many different techniques proposed for the way the foot is manipulated and the way the casts are applied. Treatment of the infant with clubfoot is definitely one of the arts of medicine. Successful treatment requires patience and attention to detail.
The success of treatment of clubfoot by manipulation and casting alone varies greatly. The majority of infants will eventually require surgery but the manipulation and casting begins the process of guiding the foot towards a more normal form. In the infant that eventually needs surgery, the manipulation and casting are still required to obtain as much correction as possible prior to the surgery.

When it is clear that manipulation and casting alone will not result in success, your surgeon will recommend surgery. The main question is when to perform the surgery. The earlier the surgery is performed, the more growth that remains in the foot. The more growth remaining, the more the deformity can be corrected. The downside is that a smaller foot is much harder to effectively operate on and the risk of damage to the nerves, blood vessels, and bones is much higher.

Most surgeons recommend waiting until the foot is about eight centimeters (three inches) long. This usually occurs when the infant is about nine months old. Most surgeons agree that it is ideal to have the surgery over and healed before the infant starts to try and walk. Surgery performed at nine months will usually accomplish this goal.

The surgical procedure to correct clubfoot is tedious and complex, but the goals are always the same. Your surgeon will find and cut all the ligaments that are too tight. When they are cut, they eventually heal back with scar tissue. In the growing infant, this scar tissue will grow back to form new ligaments that are not so tight.

Once the ligaments have been loosened, your surgeon can align the bones of the foot as normal as possible. Metal pins are commonly used to hold the bones in the proper alignment. These metals pins stick out through the skin and are removed three to six weeks after the surgery is completed.

After surgery for clubfoot, a large bandage is applied to the foot. Some type of cast or brace may also be used. The child will probably need to wear some type of brace for several months, and maybe even years after the surgery, but ideally, the treatment should not interfere with the normal developmental milestones. Once the surgery is over, Mother Nature takes over. Weight bearing will help guide the growth in the foot towards a more functional orientation where the sole of the foot can be placed flat on the floor.  Physical Therapy at First Choice Physical Therapy can be very helpful as well in improving the functional use of the foot.

What should be expected from treatment?

Physiotherapy at First Choice Physical Therapy after surgery for a clubfoot can begin as soon as your child’s surgeon recommends it.  All treatment, either surgical or non-surgical including Physical Therapy, is designed to give the child a foot that can be placed flat on the floor. Another goal of therapy at First Choice Physical Therapy is to assist your child’s walking biomechanics in order to encourage your child to walk as efficiently as possible. Lastly, our goals also include relieving any pain if present, preventing pain in the future, maintaining the flexibility of your child’s muscles and tissues, and preventing any weaknesses around the lower extremities and core from developing.

During your first appointment at First Choice Physical Therapy your Physical Therapist will discuss your child’s foot brace with you and ensure that you are confident putting it on and taking it off.  Your doctor will set the specifications of the brace according to your child’s needs. Your doctor will inform you which activities are safe while in the brace and which ones should be avoided. Your child must learn that he/she can kick and swing the legs simultaneously with the brace on.  If your child is still young, your Physical Therapist can help you learn how to hold and handle your child with their brace on.  If your child is old enough, they should be encouraged to be part of the routine of putting the brace on and taking it off.  General bracing advice, such as the best types of socks and clothing garments to wear with the brace as well as proper strapping or lacing of the brace will also be discussed.

Your Physical Therapist will also inspect your child’s bare feet and note any areas of the brace that may be irritating your child. Generally your child will need to build up a tolerance to wearing the brace and for this reason some areas where pressure is noted by redness may be considered normal. Any areas of redness, however, should be closely monitored and padded for extra comfort and to disperse the pressure if necessary.

Creams or lotions should not be applied to areas where the skin is red (and unbroken) as this can make the friction worse. Areas that have developed blisters will need to be protected to avoid them getting worse or breaking open.  Any broken or fragile skin can become a more serious problem and prevent the braces from being worn for a prolonged period of time, which can result in a relapse of the clubfoot position.  In some cases a return visit to your doctor or Orthotist for an early adjustment of the brace may be necessary.

The schedule of how long your child will have to wear the brace each day will be set by your child’s surgeon.  At first the time with the brace on will likely need to be most of the day and night. Generally the wearing time is gradually decreased over time so that your child has some awake time without the brace on. In most cases children will need to wear the brace during all sleep times until eventually sleep time is the only time the child is required to wear the brace. Depending on the age of your child, once the brace is discarded during the day, your Physical Therapist may incorporate taping techniques of the foot to provide gentle foot positioning guidance.

Your Physical Therapist may address any pain issues that your child may be experiencing from the surgical procedure or the deformity itself, depending on the age of your child. Your Physical Therapist may use modalities such as ice, heat or massage to try to relieve any pain. In some cases they may even use ultrasound, again depending on your child’s age and the location of their pain.

Maintaining the length of the tissues in your child’s foot is the main goal of any stretching exercises we do with your child or ask you to do with them.  Your child’s age at the time of surgery will largely influence how formal the stretches and strengthening exercises for your child will be. If they are old enough to understand and follow along, your Physical Therapist may encourage specific stretches for the back of the calf and Achilles tendon, as well as for the bottom of the foot.  Often, however, children who have had surgery for clubfoot are too young to effectively engage in formal stretches therefore play activities that encourage these types of stretches will be taught.  Ensuring that your child spends time squatting, standing with feet flat, standing on their toes, standing on their heels, walking without the brace, and practicing jumping are ways to encourage proper foot movement. Your Physical Therapist will guide you through which of the activities are most important for your child at which time, the proper technique for these activities, and how long they should be performing each activity.  While at First Choice Physical Therapy you will be taught by your therapist how to apply pressure properly to your child’s foot or leg during these activities in order to encourage normal foot alignment.  If your child is too young to walk or do the higher level activities then your Physical Therapist will teach you age-appropriate play activities that encourage the proper positioning of your child’s foot and lower leg.  Range of movement exercises that encourage motion of the foot in all directions away from the clubfoot position will be important.  Of particular importance are passive Achilles tendon stretches, which will be taught to you and will be encouraged frequently.  The Achilles tendon is the thick tendon at the back of the ankle.

Maintaining the length of the Achilles tendon after casting and surgery to lengthen it prepares the foot and ankle to take the body’s weight for activities such as walking, squatting, and jumping.  It should be noted how important it is to maximize use of the time that your child spends outside of the brace by doing the specified activities that your Physical Therapist prescribes as this will train the muscles to hold your child’s new foot position and give the other tissues as much active stretching as possible.

Formal strengthening exercises for older children will be taught which encourage ankle, calf, hip, and core strengthening as well strengthening for the muscles that pull the foot into a position where the sole of the foot is turned up and out (opposite to the clubbed foot position.) As previously mentioned often the child who has had surgery for clubfeet is too young to perform any formal exercises. Playing is once again the best method to encourage strength development in your child’s feet, legs and core area.

Your Physical Therapist will encourage fun play activities and games such as assisted frog jumps or hops on one leg in order to strengthen the appropriate muscles.  Even helping the young child mimic these types of activities can be very useful to strengthen the legs and feet and encourage proper foot position. Any activity they enjoy which encourages the proper motion is useful! Often singing while doing activities or making a game of the exercises is the best method of incorporating rehabilitation into your young child’s world.

For those children that are old enough to ambulate, gait retraining when the brace is off is a crucial part of our rehabilitation at First Choice Physical Therapy after surgery for clubfeet. By using hands on techniques your therapist will encourage the appropriate motions for your child while they walk and they will teach you how to do the same for when you do the exercises at home. Your Physical Therapist will also work on your child’s foot and ankle proprioception (knowing where their foot is in space without them having to look at it) by having them stand or walk on different surfaces such as a soft mat or foam, as well as on different angles.  Activities such as hopping or climbing on apparatus will also help to improve their proprioception.  Climbing up onto things such as stairs or gym equipment simultaneously helps to build the needed strength in the hip area, which is an important area that assists in controlling the knee and foot position. For children who are not yet walking, holding them in the standing position (with proper foot alignment) on different surfaces as well as on different angles will accomplish the same thing. Most importantly, for all exercises, the goal is to get the foot into a proper weight bearing position and keep it out of the clubbed foot position.

Your therapist will be a useful resource for discussing footwear modifications for your child if needed.  They may consult with a Podiatrist to ensure that the most appropriate footwear is prescribed for you child.

As your child grows, rehabilitation will need to be continued but the frequency of sessions should decrease as long as early intervention has started your child on the right path to correcting the alignment of your child’s foot, ankle, and lower limb, and as long as you are actively doing the home rehabilitation program. As your child grows and becomes more mature, Physical Therapy at First Choice Physical Therapy will include more formal types of exercises to encourage proper foot alignment.  It is expected that your child will eventually be able to partake in all physical activities that other children their age partake in.

Generally children who have had surgery for clubfeet do extremely well with the Physical Therapy we provide at First Choice Physical Therapy.  Over the course of your child’s therapy your therapist will liaise closely with your child’s doctor, surgeon, Orthotist, and Podiatrist as well as any other health care professionals that are involved in their care to ensure your child is recovering as quickly and normally as possible.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

What can go wrong?

As with any treatment, complications can result from both conservative and surgical treatment of clubfoot. Failure of manipulation and casting to result in a successful outcome is not a complication. The majority of patients will not be treated successfully with non-surgical treatment alone.

Several complications are possible both during and after surgery. Wound problems may occur after surgery due to abnormal swelling or pressure from the cast. When the foot is markedly deformed, correction of the deformity may stretch the skin so tight that the blood supply is compromised. This may result in a small section of the skin actually dying. This normally heals with time and only rarely does this require a skin graft.

Infection can occur following any type of surgery. A wound infection can occur after clubfoot surgery. This may require additional surgery to drain the infection and antibiotics to treat the infection.

The infant foot is very small. The structures are very difficult to see even using magnifying glasses. Blood vessels and nerves may be damaged or cut during the operation. The bones of the infant foot are mostly made of cartilage. This material can be damaged, resulting in deformities of these bones. This damage usually corrects itself with growth.

Up to half of all patients undergoing clubfoot surgery will require at least one additional surgical procedure later in life.

Osteoporosis is a very common disorder affecting the skeleton. In a patient with osteoporosis, the bones begin losing their minerals and support capabilities, leaving the skeleton brittle and prone to fractures.

Osteoporosis affects an estimated 75 million people in Europe, USA and Japan.

Bone fractures caused by osteoporosis have become very costly. Half of all bone fractures are related to osteoporosis. A person with a hip fracture has a 20 percent chance of dying within six months as a result of the fracture. Many people who have a fracture related to osteoporosis spend considerable time in the hospital and in rehabilitation. Often, they need to spend some time in a nursing home.

This guide will help you understand:

• what happens to your bones when you have osteoporosis
• how health care professionals diagnose the condition
• what you can do to slow or stop bone loss
• First Choice Physical Therapy’s approach to rehabilitation

What happens to bones with osteoporosis?

Most people think of their bones as completely solid and unchanging. This is not true. Your bones are constantly changing as they respond to the way you use your body. As muscles get stronger, the bones underneath them also get stronger. As muscles lose strength, the bones underneath them weaken. Changes in hormone levels or the immune system can also change the way the bones degenerate and rebuild themselves.

As a child, your bones are constantly growing and getting denser. At about age 25, you hit your peak bone mass. As an adult, you can help maintain this peak bone mass by staying active and eating a diet with enough calories, calcium, and vitamin D.  Maintaining this bone mass, unfortunately, gets more difficult as we get older. Age alone makes building bone mass more difficult. In women, the loss of estrogen at menopause can cause the bones to lose density very rapidly.

The bone cells responsible for building new bone are called osteoblasts. Stimulating the creation of osteoblasts helps your body build bone and improve bone density. The bone cells involved in degeneration of the bones are called osteoclasts. Interfering with the action of the osteoclasts can speed up bone loss.

In high-turnover osteoporosis, the osteoclasts reabsorb bone cells very quickly. The osteoblasts can’t produce bone cells fast enough to keep up with the osteoclasts. The result is a loss of bone mass, particularly trabecular bone, which is the spongy bone inside vertebral bones and at the end of long bones. Postmenopausal women tend to have high-turnover osteoporosis (also known as primary type one osteoporosis). This relates to their sudden decrease in production of estrogen after menopause. Bones weakened by this type of osteoporosis are most prone to spine and wrist fractures.

In low-turnover osteoporosis, osteoclasts are working at their normal rate, but the osteoblasts aren’t forming enough new bone. Aging adults tend to have low-turnover osteoporosis (also known as primary type two osteoporosis). Hip fractures are most common in people with this type of osteoporosis.

Secondary osteoporosis describes bone loss that is caused by, or secondary to, another medical problem. These other problems interfere with cell function of osteoblasts and cause over-activity of osteoclasts. Examples include imbalances in hormones, certain bone diseases and cancers, and medical conditions that result in inactivity. Some medications, especially long term use of corticosteroids, are known to cause secondary osteoporosis due to their impact on bone turnover.

Osteoporosis basically creates weak bones. When these weak bones are stressed or injured, they often fracture. Fractures most often occur in the hip or the bones of the spine (the vertebrae). They can also occur in the upper arm, wrist, knee, and ankle.

What causes osteoporosis?

Aging is one of the main risk factors for osteoporosis and osteoporotic fractures. If you are lucky enough to live a long life, you are much more likely to develop weakened bones from osteoporosis. In women, the loss of estrogen at menopause causes bone loss of up to two percent per year. Caucasian women over age 50 have a lifetime risk of fracture of about 50 percent. This figure increases with increasing age.

A number of factors contribute to or put you at risk of developing osteoporosis:

• advanced age
• female gender
• low body weight or a thin and slender build
• recent weight loss
• history of fractures
• family history of fractures
• tobacco use
• alcohol abuse
• lack of exercise
• extended use of certain medications (e.g., corticosteroids, anticonvulsants, and thyroid medicine)
• eating disorders such as anorexia or bulimia
• Asian or Caucasian race

These risk factors are just as relevant as a bone mass measurement in determining how likely you are to have a fracture. People with low bone mass but no additional risk factors often don’t develop fractures. People with small amounts of bone loss but many risk factors are more likely to eventually develop fractures.

What does osteoporosis feel like?

Fractures caused by osteoporosis are often painful. Osteoporosis itself, however, has no symptoms. It is often called the ‘silent disease’ or ‘silent thief’ as many people don’t recognize they have it until a fracture occurs.  For this reason it is especially important to get tested if you are a woman past menopause and have any of the above risk factors. Women over 65 should be tested whether or not they have other risk factors. People with other bone problems or who take drugs that weaken the bones should also be tested. An initial screening for osteoporosis is painless and easy.

How do health care professionals diagnose osteoporosis?

Free osteoporosis screenings that estimate your bone density measure (BDM) are available in many drug stores and malls. Most of these screenings use a machine that scans the bone in the heel of your foot. It is a fast and simple way to get an idea of your bone density. However, this test is not entirely accurate. Due to the heel bone bearing a lot of weight in normal activity, the test may show normal bone in the heel, even though the hipbones or spine may have low bone density. If however the foot scan shows a low bone mass, you should talk to your doctor. If the scan is negative however, and you suspect you may have osteoporosis or have some of the risk factors for developing the disease that are listed above, it is still recommended that you consult with your doctor.

When visiting your doctor he or she will take a detailed medical history to help weigh your risk factors for osteoporosis. If osteoporosis is suspected or you are at risk of developing it, your doctor may also recommend more precise testing. A bone density test, or in medical terms a dual-energy X-ray absorptiometry (DEXA) test is the most common method of measuring bone mass. A DEXA test is painless and uses special X-rays of the bones of your hip and spine to show your bone mass in these areas. The bone mass is then compared to that of a healthy thirty-year-old, called a T score. If you are within one standard deviation (SD) for bone density, you have normal bone. (SD is a statistic to measure variations in how a group is distributed.) If you are between one and 2.5 SDs below ideal levels, you are considered to be osteopenic. This means you have a mild form of osteoporosis. If the bone mass is more than 2.5 SDs below ideal levels, you have osteoporosis.

Unfortunately a single DEXA scan cannot show your doctor whether your bone mass is stable, increasing, or decreasing. Your doctor may have you take certain medications that create markers in the blood or urine to show what is happening in your bones. These tests will tell your doctor if you have high-turnover or low-turnover osteoporosis.

Be aware also that DEXA scans are not perfect. Different equipment or different technicians can get somewhat different readings. If you need to have more precise data, your doctor may recommend additional types of scans or tests.
Although a DEXA scan is the most common method of measuring bone density, other tests such as ultrasound, quantitative computed tomography (CT) scans, or single-photon absorptiometry may also be used instead of or in addition to the DEXA scan to confirm the diagnosis of osteoporosis.

If bone density tests show that you have weakened bones, your doctor will need to rule out other causes for this other than osteoporosis. In some cases, problems with bone marrow or hormone levels can cause bone loss. Blood tests can show these conditions.
In other cases the bone weakening is actually from a condition called osteomalacia.

Osteomalacia involves a softening of the bones caused by a lack of vitamin D. Vitamin D in your body comes from food and sunlight. Due to a lack of sunlight, almost 10 percent of people with hip fractures in the northern parts of the world have osteomalacia rather than osteoporosis. Urine and blood tests can help rule out osteomalacia.

In some cases, your primary care physician may refer you to a doctor who specializes in osteoporosis. For instance, if you are on medication to prevent bone reasbsorption and still have significant bone loss you may need to see a specialist. Referral is also advised for patients who have recurring fractures during therapy or repeated, unexplained fractures. Your doctor will help you find the right specialist for your situation.

What can be done for osteoporosis?

The goal of your treatment plan will be to prevent fractures. This is especially important if you’ve already suffered a fracture from osteoporosis. To prevent fractures, you need to increase your bone mass. If you have high-turnover osteoporosis, you also need to prevent rapid bone reabsorption.

You need to take several steps to increase your bone mass:

• If you smoke, quit immediately.
• If you drink alcohol, do so moderately.
• Make sure you get enough calcium and vitamin D. (Vitamin D helps your body absorb calcium.) Researchers think that increased calcium intake alone could reduce the number of fractures by 10 percent. Many people don’t get enough calcium or vitamin D, especially as we age. It is difficult to get recommended levels from the food we eat, so supplements are probably necessary. Talk to your doctor about what kind of supplements to buy. Calcium comes in many forms, for example, calcium carbonate, calcium citrate, calcium phosphate, and calcium from bone meal. Some forms of calcium can be taken with any type of food, and others need to be taken with certain types of food. Taking extra calcium and vitamin D improves the effectiveness of all other treatments for osteoporosis.
• Eat enough calories to maintain a healthy weight. Being too thin increases your risk of osteoporotic fractures. Weight loss can be a cause of bone loss.
• Exercise. Your bones are constantly adjusting to the demands you put on them. Even low levels of exercise can help you maintain better bone mass. Low-impact exercises, muscle-strengthening exercises and balance training are all recommended (see section below.)

Patients with osteoporosis or those at risk of developing osteoporosis will benefit from working with a Physical Therapist at First Choice Physical Therapy.

The goals of our Physical Therapy treatment is to educate you on proper posture, teach you safe ways of moving and lifting, and to provide you with exercises you can do at home to help prevent a decline in bone mass and prevent fractures. The exercises we prescribe will particularly focus on activities that help to increase the strength in your bones, as well as exercises that help to maintain or improve your balance. Optimum balance helps to decrease your risk of falling, which can easily fracture an osteoporotic bone. We will also suggest exercises for your flexibility to help decrease the stress placed on the bones by tight muscles as well as improve your overall mobility. If you have experienced a fracture from osteoporosis, Physical Therapy at First Choice Physical Therapy can also help with controlling your pain and gradually returning you back to your regular activities.

Maintaining good posture is of utmost importance if you have osteoporosis. A stooped upper spine posture, called kyphosis, is common in osteoporosis due to the wedge-like fracturing of the thoracic spine that often occurs (the front part of the vertebrae collapses leaving the posterior portion higher and the overall vertebrae appearing wedge-like.)  Losing height as a result of these fractures is a common occurrence in osteoporosis. For this reason accurately measuring and recording your body height is a key part of our Physical Therapy evaluation. A height measurement gives your Physical Therapist an idea of how osteoporosis is affecting your bones and posture, and by comparing the recordings over a period of time it can help us track your success with treatments.

With posture exercises, the goal is to get your body lined up from head to toe, with weight going through your hips. In a healthy spine posture, the head is balanced on top of the spine rather than jutted forward which is common in osteoporosis. In people with advanced osteoporosis, the upper body is also commonly bent forward at the hips. This prevents the hip bones from getting the right amount of stress and weight through them. As a result, the bones weaken and become more prone to fracture.  It is therefore important at all times to try to “be tall” which can both prevent a loss of height as well as help you regain height lost from an already fractured osteoporotic spine.
Your Physical Therapist will explain ways you can put good posture into practice. This is called body mechanics, which is the way you align your body when you do your daily activities. Remember that a healthy posture is balanced with the body aligned from the head to toes. The same posture should be used when you bend forward to pick things up. Instead of rounding out your shoulders and upper back, keep the back in its healthy alignment as you bend forward at the hip joint. This keeps your back in a safe position. When bones are weakened from osteoporosis, rounding the spine forward when bending and lifting pinches the front section of the vertebrae and increases the risk of a spine fracture. This pinching is exacerbated when any weight at all is lifted in this position. Even the weight of a purse or shopping bag can add detrimental stress to an osteoporotic spine leading to a fracture. Along with maintaining proper posture, gently tightening the muscles around your core area can also help to protect the back during activities such as lifting.  Your Physical Therapist will educate you on how to use your core muscles to protect your spine.  Rapid bending forward of the osteoporotic spine, such as that experienced when one sneezes or coughs, can be enough to cause a fracture of the osteoporotic spine. For this reason, your Physical Therapist will educate you on consciously extending rather than flexing your spine during these activities.
Another motion particularly stressful for the osteoporotic spine is a twisting motion. The normal structure of bone is not designed to withstand twisting very well so combined with the weakened bone state of osteoporosis, the motion of a twist can easily cause a fracture. Although difficult to eliminate from every day life, twisting should be avoided whenever possible especially in combination with higher velocity motions such as a golf swing, tennis swing or bowling action.

Strengthening exercises for your bones are of utmost importance in maintaining the health of osteoporotic bones. As mentioned above, as your muscles get stronger, the bones underneath them also get stronger as they react to the added stress placed on them. In this way, strength training and weight-bearing activities force the bones to build mass. Your Physical Therapist will prescribe some gentle weighted exercises, using either elastics or weights, for your upper and lower extremities. Using an appropriate weight is of utmost importance and your Physical Therapist can educate you on how much resistance is appropriate for you. If using free weights, handling the weights is just as important as doing the exercises themselves. Never lift weights in the flexed forward posture described above, and be careful to gradually increase the resistance you use as weights that are too heavy will naturally cause your body to slip into the flexed forward posturing that is detrimental to people with osteoporosis. Performing exercises while your upper back is supported in good alignment is also recommended to avoid added stress on the thoracic spine. Exercises that incorporate flexing of the spine, such as toe touches, abdominal crunches, and dead lifts should strictly be avoided. Strengthening exercises for your upper back, however, will be encouraged by your Physical Therapist in order to counteract the stooped forward posturing.

Weight bearing cardiovascular exercises such as walking outdoors or on a treadmill, gentle non-pounding forms of dance, and stair climbing are useful activities to put weight through the bones and encourage an upright posture while also improving cardiovascular health. Cycling is not a recommended activity as it does not provide the benefits of weight bearing and it also encourages the detrimental flexed forward posturing of the spine. Pool exercises are not weight bearing either so are not recommended unless severe pain from osteoporosis limits physical activity on the land in which case exercising in the pool would be acceptable and recommended. High impact activities such as running, jumping, and pounding forms of dance should be strictly avoided. Your Physical Therapist at First Choice Physical Therapy can educate you on safe cardiovascular activities specific to your interests and your physical needs.

The next part of our treatment will focus on your balance. As stated above, poor balance can lead to a fall which can easily fracture an osteoporotic bone. In some cases a fracture from a fall can be a potentially life-threatening situation. Exercises to improve your balance can be as simple as standing with your feet close together, standing on one foot, or standing with one foot in front of the other. Closing your eyes can make any of these activities even more difficult. By challenging your balance, your reaction time to unexpected situations such as tripping will improve and your likelihood of falling will decrease. The most important aspect of working your balance is ensuring that you are doing it in a safe environment. Your Physical Therapist will provide you with exercises that are specific and challenging to your current level of balance.  As your balance gets better, more challenging exercises will be provided. Tai chi, which is an exercise form originating in China, is another great way to improve one’s balance, and many patients benefit from practicing this on a regular basis.

The final component to our treatment at First Choice Physical Therapy will be to provide you with some flexibility exercises. By improving and maintaining your flexibility, the stress put on your bones by tight muscles will decrease and the ability to practice good posture and body mechanics will be improved. Good flexibility also improves your mobility, which in turn improves you balance and decreases your risk of falls. Stretches for your upper back and chest in particular will be prescribed to decrease the likelihood of developing a stooped posture. Stretches for your hips, calves, and neck are also important if you have osteoporosis and will be included in your stretching regime.

Your Physical Therapist will continue to compare your test results of body height, posture, strength, balance, and flexibility to see how well you are improving and to encourage you in continuing with your exercise program.  Once you can safely and proficiently perform your home exercise program, regular visits to First Choice Physical Therapy will not be required, however, we will continue to be a resource for any further questions you may have or problems you may encounter.
If you are seeing one of our Physical Therapists at First Choice Physical Therapy because you have recently had a fracture related to osteoporosis, our treatment will start with a  focus on decreasing your pain. We may use hands on treatment as well as modalities such as ice, heat, ultrasound, or electrical current to assist in managing your pain. We will liaise with your doctor to determine the most appropriate time for you to begin the more advanced exercises involving strengthening, balance, and flexibility as outlined above, and will proceed with them as appropriate in order to allow you to return to your normal activities as quickly as possible.

Depending on your situation, your doctor may prescribe medications to slow down your body’s reabsorption of bone.

Many drugs are now available for the prevention and/or treatment of osteoporosis. Finding the right drug for each patient takes into consideration the benefits and risks of the drug. These are matched against specific patient characteristics and risk factors. Ultimately, the best drug is the one most likely to be taken consistently and/or correctly by the patient.

If you are past menopause, hormone replacement therapy can be very effective. Bisphosphonates and calcitonin can also slow your body’s reabsorption of bone.
Studies have shown that 80 percent of women actually build bone mass up to two percent per year while on estrogen replacement therapy. Estrogen has been shown to decrease the occurrence of fractures in the vertebrae by 50 percent and fractures in the hip by 25 percent. Fortunately studies have also shown that hormone replacement therapy can also lower rates of coronary artery disease, relieve some symptoms of menopause, and maybe even prevent or postpone Alzheimer’s disease.

Hormone replacement therapy, however, worries many women. Studies have shown that it may increase the risk of breast cancer. For women with a family history of breast cancer or who have had a stroke or thrombophlebitis (blood clots), hormone replacement therapy is probably not appropriate. Other women however, should at least consider taking estrogen as its effects on osteoporosis are dramatic. Researchers estimate that, if estrogen were widely used, it could reduce all osteoporotic fractures by 50 to 75 percent.

Hormone replacement therapy must be continued to be effective, however. When a woman stops taking estrogen, she’ll start to lose bone at a very fast rate again. Within seven years, her bone density will be as low as that of a woman who never took estrogen.

Doctors often prescribe calcitonin to patients with fractures. Calcitonin is a non-sex, non-steroid hormone. Calcitonin binds to osteoclasts (the bone cells that reabsorb bone) and decreases their numbers and activity levels. Calcitonin used to be given only by injection, but now it is available in a nasal spray and a rectal suppository. Nasal calcitonin is used most often for women with osteoporosis who are five years or more past menopause and unable to take other approved agents. For unknown reasons, calcitonin also seems to relieve pain.

You and your doctor need to work together to monitor the effects of calcitonin. It is a new drug, and its long-term effects and benefits are still not fully known. More than 20 percent of patients develop a resistance to calcitonin over time, and it stops working for them.

Bisphosphonates also slow reabsorption by affecting the osteoclasts. Some common bisphosphonates are Alendronate (Fosamax), Risedronate (Actonel), or Ibandronate (Boniva).

Some bisphosphonates are taken orally (pill form) on a daily basis. Others are available in weekly or monthly doses. A new injectable bisphosphonate (Zoledronate) can be given annually (once a year). Boniva comes in pill form and can also be injected once every three months. The injectable forms of this drug are used in the management of postmenopausal osteoporosis.

Studies have shown that bisphosphonates increase bone mass and prevent fractures. No one is sure how well bisphosphonates work when used for a long time however stopping the drug doesn’t seem to cause the rapid bone loss that occurs when a patient stops taking estrogen. Due to the potential of side effects with these medications, you need to liaise closely with your doctor if you take them.

Some new drugs that may be used to treat osteoporosis are currently being researched. Some of these drugs, such as sodium fluoride, can be helpful in low-turnover osteoporosis. These drugs affect your osteoblasts in ways that cause them to create more bone. Sodium fluoride may be available in the near future. Another drug used for the treatment of osteoporosis is Raloxifene (Evista) which is an anti-estrogen.

Anti-estrogens are also called selective estrogen-receptor modifiers (SERMs). SERMs improve bone density and prevent fractures similar to estrogen, but without increasing the chances of hormone-related cancers. Their main benefit over hormone replacement therapy is that they do not increase the risk of breast cancer.

Raloxifene is used most often for postmenopausal women younger than 65. They must not be at risk for blood clots or have cardiovascular disease. Men may be prescribed the only anabolic agent (Teriparatide/Forteo) approved for the management of osteoporosis. Anabolic usually refers to hormones that build up muscle or bone mass. Forteo is a form of parathyroid hormone used for patients at high risk of fracture. An agent with antiresorptive effects, such as a bisphosphonate, usually follows it.

Lifestyle changes, hormone replacement therapy, exercise prescription, and recent advances in drug therapy can help you take control of your osteoporosis. You and your doctor should be able to find ways to help you prevent the debilitating fractures of osteoporosis.

Muscles make up over half of the weight of a human body and they are required to make even the smallest of movements such as nodding your head or tapping your toe.  If too much stretch is put through one of your muscles you may end up with a painful muscle strain.  If the similar type of injury occurred to one of the ligaments in your body, it is termed a sprain.

This guide will help you understand:

• the anatomy of a muscle
• what a muscle strain is and why it occurs
• how muscle strains are classified
• the symptoms of a muscle strain
• how your health care professional diagnoses a muscle strain
• what First Choice Physical Therapy’s approach to rehabilitation is

What parts of the body are involved?

Muscles are composed of many fibers bundled together; the bigger, more frequently used muscles have more fibers than the smaller, lesser-used ones. Among the muscles are voluntary and involuntary muscles. Voluntary, or striated muscles, are those that we move by choice (for example, the muscles in your arms and legs). Involuntary muscles, or smooth muscles, are the ones that move on their own (for example, the muscles that control your diaphragm and help you breathe). The muscles in your heart are called involuntary cardiac muscles.

Voluntary muscles are attached to bones by tendons, a sinewy type of tissue.  The area where the muscle attaches to the tendon is called the musculotendinous junction.

What causes a muscle strain?

A muscle strain, or a muscle pull occurs when a muscle in your body is overstretched or overworked.  Even if the injury from overstretching or overworking occurs more to the attaching tendon it can also be classified under the term muscle strain. A muscle strain can occur in any of your voluntary muscles (or tendons which attach to the muscle), but they are most common in the low back, the calves, the front and back of the thighs, the pectoral muscles, and the muscles of the neck and the shoulder. Muscle strains occur more often in muscles that cross two joints (such as the thigh or calf muscles) and often occur when the muscles are working eccentrically (working while under a stretch).  Most often a strain occurs at the musculotendinous junction but can occur anywhere along the muscle.

A muscle strain can occur due to a one-time overstretching or overworking of a muscle (acute injury) or can occur from repetitive use of a muscle over time (overuse injury).

How are muscle strains classified?

There are several classification systems developed and in use regarding muscle strains but the most commonly used system includes three grades. All muscle strains include tearing of some muscle fibers:

Grade I (mild): Very few muscle fibers have been injured. Pain may not be felt until the following day after the instigating activity. Strength and range of motion of the muscle remains full but pain can be felt when engaging the muscle often when it is at its end range of stretching. No swelling or bruising is noted.

Grade II (moderate): A large category including all strains between a grade I and grade III.  Being that this category is so large, it is sometimes further divided into having a mild, moderate or severe grade II strain. With this category many muscle fibers are torn which results in a decrease in strength and often a limited range of motion.  Some muscle fibers remain uninjured and intact. Pain is present both when stretching the muscle and on muscle strength testing. Swelling and bruising may be noted.

Grade III (severe): All fibers of the muscle are completely torn. This means that the muscle is completely torn into two parts or the muscle belly has torn from its attachment to the tendon.  Severe swelling, pain, and bruising accompany a grade III strain.  There is generally limited ability to generate any force on strength testing of the muscle due to the tear (however other muscles may compensate to initiate some strength) and the range of motion is either severely limited due to pain, or the range of motion testing may show excessive range due to the torn muscle not providing any limitation as it is stretched.

What does a muscle strain feel like?

Several symptoms can indicate that you have incurred a muscle strain but the symptoms you feel will depend on the grade of strain you have incurred:

• sudden onset of pain, or pain/soreness that comes on the next day related to a specific event
• pain on touching the injured area
• mild, moderate, or severely limited range of movement, or an extreme abnormal range of motion
• decreased strength in the injured muscle
• bruising or discoloration in the area or at a distal location to the strain
• swelling
• a “knotted up” feeling
• a local divot or bump in the affected area due to the torn muscle fibers
• muscle spasm in the area
• stiffness in the area

How do health care professionals diagnose the problem?

Your Physical Therapist at First Choice Physical Therapy will ask a number of questions to determine if you have strained your muscle and to determine how severe the damage is.  They will want to know exactly when you injured yourself and if you injured the muscle from one specific event or if a repetitive injury caused your pain. They will want to know what you felt immediately after the injury and whether or not you feel that you have lost any strength or range of motion. Your therapist will also want to know if there has been any swelling or bruising around the area or anywhere down one of your limbs.  They will also want to know what sort of things are aggravating your pain or if you have been able to do anything to make your pain feel better.  They will inquire about any medications you are taking and whether or not you have ever injured this muscle in the past.

After a thorough history your Physical Therapist will do a physical examination.  Firstly they will observe how you are holding your affected limb or your neck or back, if this is the area in question.  Next they will examine the area to determine if there is any swelling or bruising present.  They will palpate (feel) your muscle to find out which area is most sore.  They will also check to see if there are any divots or unusual bumps in the area, which would be the result of a section of torn muscle fibers; this would indicate a more severe strain. Finally, they will ask you to move your muscle in order to determine how much you can move it and whether or not moving it causes you pain.  In order to help determine the severity of the strain your Physical Therapist will also assess how much they can passively stretch your injured muscle, and will check how much strength against resistance you can generate with your muscle.  If you are able to they may ask you to push, pull, bend, stand, sit, or jump in order to help assess your strain.  Lastly, they will check the integrity of the joints that are closest to your injured muscle to ensure that you haven’t also injured them.

After a thorough history and physical examination your Physical Therapist will determine the grade of your muscle strain.  If they determine that your strain is severe (severe grade II or a grade III) they may send you to your physician for a review as further investigations are possibly required, and medication may be needed to control some of your symptoms.  If you have a severe strain to one of your lower extremity muscles you may require the use of crutches in order to get around; your Physical Therapist can teach you how to use them. The general rule regarding when to use crutches is such that if you are limping when walking without crutches you should use crutches until your strain heals enough so that you are able to walk without limping when not using crutches.

Physician Review

What will my doctor do when I see them?

In the case of a severe strain (severe grade II or a grade III), a physician’s review may be necessary. When you see your physician, they may prescribe anti-inflammatory or pain medications to help control the swelling and assist with the pain.

Your physician will determine if a diagnostic investigation is required to further assess your muscle strain.  In most cases an X-ray is not necessary unless your physician is concerned that you may have also fractured the bone, in which they will order an X-ray to rule this out. Diagnostic ultrasound is a timely way to image muscle groups to determine strain severity. In cases of severe strains, a magnetic imaging resonance (MRI) test may be ordered to confirm the muscle that has been injured, and to determine the exact amount of damage to the muscle, particularly if it looks severe enough to warrant surgical consideration.  An MRI has the benefit of confirming the exact severity of the muscle strain.  Grade I or grade II strains that are mild to moderate do not generally require any investigative reviews but may benefit from the use of pain or anti-inflammatory medications.

The initial approach to Physical Therapy of your muscle strain will depend on how long after your injury that you seek treatment.  The immediate line of defense straight after a muscle strain should be the application of ice and compression, followed by rest and elevation for the affected muscle.   Recent research on the benefits of applying ice immediately after an injury are beginning to be questioned, but the general consensus is still to apply ice.  The importance of applying compression initially as a line of first defense (generally done by wrapping the affected area) is becoming more evident.

The initial aim of treatment for acute strains at First Choice Physical Therapy is to manage the inflammation and pain in the area.  The initial aim of treatment for acute muscle strains at First Choice Physical Therapy is to decrease the pain as well as any secondary inflammation in the area.  Some initial inflammation is actually required to start the healing process, but a large inflammatory response can also lead to secondary inflammation and secondary cell injury, which affects tissues that were not directly related to the initial insult.  Ice and compression can greatly assist in decreasing this detrimental secondary tissue injury.

In cases where it is not an acute strain heat may be more useful in decreasing pain.  Your Physical Therapist can advise you whether it is best to use ice or heat at your stage of healing. Your therapist may also use electrical modalities such as ultrasound or interferential current to help decrease the pain and control the amount of inflammation. It should be noted, however, that some mild inflammation is actually needed in order for the muscle to heal; all anti-inflammatory attempts are aimed at controlling too much inflammation from occurring, rather than completely eliminating it.  Massage of the injured area or the tissues surrounding the area may also be helpful.  Depending on the severity of the strain and the time that has elapsed since the injury, massage directly over the torn area can slow the healing process and may lead to other muscle complications so be sure to let your Physical Therapist determine whether or not this is something you should be doing on your own.

As indicated above, medication to ease the pain or inflammation can often be very beneficial in the overall treatment of a muscle strain. Depending on the degree of your strain your Physical Therapist may suggest you see your doctor to discuss the use of anti-inflammatories or pain-relieving medications in conjunction with your Physical Therapy treatment.  Your Physical Therapist may even liaise directly with your doctor to obtain their advice on the use of medication in your individual case.

Once the initial pain and inflammation has calmed down, your Physical Therapist will focus on improving the flexibility and strength of the involved muscle. Static stretches to increase the flexibility of the muscle will be prescribed by your Physical Therapist early on in your treatment as these types of stretches encourage the healing tissues to withstand stretch and they ensure that you do not lose any range of motion overall.  As your range of motion improves, more aggressive stretches will be added, however stretching should be limited such that it never causes pain.  Feeling a gentle stretch at the end of the range of motion should be the limit otherwise further damage could occur to the muscle.  As the muscle nears the end of its healing, dynamic stretching (rapid motions that stretch the tissues quickly) will also be taught and will be incorporated into your rehabilitation exercise routine in order to prepare your muscle to return to more taxing movements such as those involved in normal everyday activity or sport. Dynamic stretches are used to prepare the tissues for activity whereas static stretches focus more on gaining flexibility.

Rest is also an important part of your Physical Therapy treatment.  ‘Relative rest’ is a term used to describe a scale of resting compared to the normal activity you would be doing. If you are experiencing pain while doing nothing at all it means the injury is more severe and your Physical Therapist may advise a period of complete rest where you do either no activity, or very little activity such as a few gentle stretches.  As your pain improves then the rest to activity balance will swing the other way such that you will still require more rest for the muscle than usual but there will also be a gradual increase in activity including more aggressive stretches along with strengthening so long as there is no return in symptoms.

Along with stretching exercises, your Physical Therapist will also prescribe strengthening exercises in order to get your strained muscle back in top shape.  Initially your therapist may suggest that you only do isometric contractions of your muscle, which means that you tighten the affected muscle without actually moving the associated joints. An example of this type of contraction occurs when people are asked to flex their biceps muscle, and they tighten the muscle fibers of the upper arm in place, without bending the elbow or moving the shoulder. This type of contraction is an effective way to begin strengthening an injured muscle. As the muscle continues to heal, more aggressive strengthening will be prescribed where you are moving your limb and using the weight of your body to provide resistance.  When appropriate your therapist will prescribe strengthening exercises with free weights, elastic bands or tubing, weight machines, or cardiovascular machines such as stationary bicycles or a treadmill in order to continue to increase the strength and endurance in your injured muscle.  As your strained muscle is more fully healed, your therapist will add eccentric type strengthening to your rehabilitation program. Eccentric exercises are ones that put load through your muscle as it is lengthening.

These types of exercises are necessary as part of your rehabilitation program in order to prepare the strained muscle for the return to normal everyday activity and sport. Quite often it is an eccentric contraction of the muscle that has caused the strain in the first place, so training the muscle to withstand this type of force when the time is right is crucial to ensuring it won’t be re-injured.

In addition to stretching and strengthening the muscle, taping or wrapping the affected muscle with an elastic bandage may be done by your Physical Therapist in order to assist initial swelling, and to provide support to the muscle as you rehabilitate it.  They may even teach you how to tape or wrap your own muscle so you can do it on your own.

If your muscle strain is in the lower part of your body, your therapist may prescribe a specific type of strengthening called plyometrics. Plyometrics is a form of power strengthening that is a particularly important part of the end stage of your rehabilitation for any of your power muscles in your legs such as your quads, hamstrings, and calves, especially if you are involved in sport.  Plyometrics involves repetitive jumping which forces your muscles to engage in force as they repetitively shorten and lengthen. This type of training maximally loads the lower extremity muscles and prepares them to take the high stress load involved with activity such as sport or daily activities such as running across the street.

A critical part of our treatment for a muscle strain at First Choice Physical Therapy includes advice on finally returning to your normal physical activity level. Strained muscles can easily be aggravated if too much stress is put through them at an inappropriate time.  Returning to your normal physical activity at a graduated pace is crucial to avoiding repetitive muscle strains of the same muscle or a chronic injury. Advice from your Physical Therapist on the acceptable level of activity at each stage of your rehabilitation process will be invaluable, and will assist you in returning to your activities as quickly but as safely as possible.

*New research is emerging examining the use of ice in acute injury and suggests that ice may slow down the inflammatory response necessary to initiate healing.  As the body of literature grows and practice changes we will be sure to update our recommendations.

What kinds of complications can occur from a muscle strain?

The healing of a muscle strain may result in a complication, which is more common when dealing with a severe than mild strain.  Factors that may affect the risk of developing a complication include stretching the muscle too aggressively and too early on, not having an appropriate time to heal before returning to activity, or massaging directly over the strain too aggressively.

The most common complication with a muscle strain is a re-injury which most often results from returning to activity too soon before the tear is healed.  In order to ensure you don’t do too much too soon, strictly follow the advice of your Physical Therapist in regards to your stretching, strengthening, and return to everyday and sporting activity.

In more severe strains, hematomas (blood clots) can develop as a complication within the healing muscle.  The hematoma is felt as a hard lump in the muscle fairly early on in the recovery process. The development of a hematoma can delay recovery time, but the hematoma, in most cases, will eventually be reabsorbed back into the tissue, and a full recovery will be made.

In some cases of muscle strains myositis ossificans (MO) may develop. This condition occurs most commonly in strains of the quadriceps muscle but can occur in any strained muscle. In this condition damaged muscle fibers turn into small bone fragments (ossify) but the exact mechanism of this conversion remains unclear.  MO will also cause a lump in the healing tissue, similar to a hematoma, but the calcification of the muscle will not be felt or show up on X-ray usually any earlier than approximately 4 weeks after the injury, which distinguishes it from a hematoma.  Being too aggressive in early rehabilitation or returning to activity too early may be related to developing MO. See First Choice Physical Therapy’s Guide to Myositis Ossificans.

Another complication of severe muscle strains can be a compartment syndrome.  When a severe strain occurs there is a lot of local swelling and blood in the area, which has nowhere to escape to.  The force of the extra fluid in the area can put pressure on the other local muscles and arteries and can cause severe damage or death to the muscles by cutting off their blood supply.  Symptoms of a compartment syndrome can include a sudden, new and excessive pain or ache in the injured area, pins and needles or tingling, difficulty moving the body part, and tightness on palpation of the area.  An acute compartment syndrome requires immediate medical attention in order to decompress the compartment, restore blood supply to the tissues, and ensure no muscle death occurs in the affected area.

A severe muscle strain may also result in a much less common, but serious, complication call rhabdomyolysis. In this condition muscle fibers rapidly die off and muscle protein and enzymes are then released into the blood stream and out in the urine. Due to the muscle protein and enzymes traveling in the blood stream, rhabdomyolysis can cause symptoms related to not just the local muscle, but also the entire functioning of the body including kidney problems.  The condition of rhabdomyolysis can also be caused by other injuries than a muscle strain.  Rhabdomyolysis may be difficult to diagnose but can cause symptoms such as ongoing muscle pain, weakness and stiffness, as well as darkened urine. Rhabdomyolysis itself can be the cause of a compartment syndrome in the area.  If rhabdomyolysis is suspected, a blood and urine test will be required to confirm the diagnosis. Treatment of rhabdomyolysis can be complicated and will depend on the severity of the condition as well as the initial cause of it.

Muscle strains involve a tear to the fibers of a muscle and vary in healing time depending on how severe the strain is. If you experience a muscle strain, let the expert Physical Therapists at First Choice Physical Therapy assist you in determining the severity of your strain as well as help get you back to your everyday activity or sport by guiding you through the appropriate rehabilitation program.