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Sylvia Czuppon, PT, DPT, OCS
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Diagnosis & Treatment of Common Hip and Knee Musculoskeletal
Conditions: Movement System Impairment
Syndromes (MSI) Approach Shirley Sahrmann, PhD, PT, FAPTA and Associates
Presented by: Sylvia Czuppon, PT, DPT, OCS
Associate Professor
Physical Therapy and Orthopaedic Surgery
Twitter: @czuppons
Program in Physical Therapy
Associates – Washington University School of Medicine Faculty Clinical Emphasis Nancy Bloom, PT, DPT, MSOT Cheryl Caldwell, PT, DPT, CHT Suzy Cornbleet, PT, DPT Sylvia Czuppon, PT, DPT, OCS Ryan DeGeeter, PT, DPT, SCS, CSCS Judy Gelber, PT, DPT, OCS, CSCS Greg Holtzman, PT, DPT, SCS Renee Ivens, PT, DPT Lynnette Khoo-Summers, PT, DPT Caitlin Kothe, PT, DPT, MS Vanessa Lanier, PT, DPT, OCS Jennifer Miller, PT, DPT,WCS, CLT Debbie Fleming McDonnell, PT, DPT Mary Kate McDonnell, PT, DPT, OCS Patty McGee, PT, DPT, PCS Tracy Spitznagle, PT, DPT, WCS Stacy Tylka, PT, DPT, WCS, CLT
Research Emphasis Linda Van Dillen, PT, PhD Barbara Norton, PT, PhD, FAPTA Sara Gombatto, PT, PhD Cara Lewis, PT, PhD Sara Scholtes, DPT, PhD Marcie Harris-Hayes, PT, DPT, MSCI Mary Hastings, PT, DPT, MSCI, ATC
Program in Physical Therapy
Mosby 2001 Elsevier 2010
Website: https://pt.wustl.edu/Education/ContinuingEducation/Pages/ContinuingEducation.aspx
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About Me
• 2002: MS, PT – Washington University
• 2010: OCS
• 2011: DPT – Washington University
• Current position: Associate Professor, Physical Therapy and Orthopaedic Surgery, Washington University School of Medicine
• Have been teaching in the entry-level WU DPT program and MSI continuing education courses since 2003.
Program in Physical Therapy
Objectives
• Describe the MSI approach to evaluation and treatment of neuromusculoskeletal pain conditions.
• Describe the normal alignment and movement patterns of the hip, knee, ankle during selected movements.
• Discuss principles to guide treatment.
• Recognize the importance of individualizing exercise programs for each patient.
Program in Physical Therapy
Pain Models:
• Pathokinesiologic Model: Pathology is source of pain
Hislop HJ, Phys Ther, 1975; 19:1069-1080 Sahrmann SA, 2002
• Kinesiopathologic Model: Imprecision of movement results in pathology
Sylvia Czuppon, PT, DPT, OCS
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Program in Physical Therapy
What is MSI? (Movement System Impairment Syndromes)
• Utilizes the kinesiopathologic model to drive evaluation and treatment of neuromusculoskeletal pain conditions
• Deviations in alignment and the precision of joint motion (movement impairment) create microtrauma that can lead to macrotrauma
• In cases of trauma, alterations of normal movement or alignment will perpetuate the pain
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Why Does Movement Become Impaired?
• Repeated movements and prolonged postures associated with everyday activities induce adaptive changes in movement system components.
• The adaptive changes vary because of intrinsic (genetics, sex, age) and extrinsic (fitness, work activity) factors.
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Why Does Movement Become Impaired?
• The body follows the law of physics and follows the path of least resistance for motion which contributes to subtle hypermobility.
• The way everyday activities are performed reinforces this hypermobility and the movement pattern.
• Muscle performance is determined by the pattern of movement. Altered movement patterns impair proper muscle performance.
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Working Theory • Musculoskeletal pain is:
1. Related to lifestyle similar to many other health conditions
2. A progressive condition
• Starting with acute pain – first indication of tissue damage
• High recurrence rate - leading to chronic problem
3. The result of tissue changes associated with
• Aging-related degeneration and
• Activity-induced tissue injury from impaired joint movement
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The Challenge: Keeping the Acute Problem From Becoming Chronic
• Acute symptoms subside
• With time
• With variety of interventions addressing symptoms
• However recurrence is common!
• Pathoanatomic structures are traditionally considered the cause.
• Unfortunately, the impaired movement is not considered as cause.
• Therefore has not been identified & addressed.
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The Challenge: Keeping the Acute Problem From Becoming Chronic
• To minimize recurrence, must identify the movement cause & contributing factors
• Develop a treatment program that includes:
• Patient specific exercises
• Correction of performance of basic daily activities
• Correction of performance of work, recreation, fitness, & sports activities
Sylvia Czuppon, PT, DPT, OCS
Not to be reproduced without permission 3
Program in Physical Therapy
MSI Approach
• PT expertise = Human Movement System • http://www.apta.org/MovementSystem/
• Knowledge of normal alignment and movement pattern is the basis of our practice
pt.wustl.edu
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MSI Approach
• Systematic examination used to evaluate, diagnose and treat neuromusculoskeletal pain problems
• Based on anatomy and kinesiology
• Exam is based on symptom alleviation, not just provocation
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MSI Approach
• Emphasis is on the CAUSE (movement) vs. SOURCE (pathoanatomy) of symptoms
• Identification of the pathoanatomical structure that is the source of symptoms may be useful for prognosis/staging but does not necessarily direct treatment.
• Often > 1 pathoanatomical source
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Movement Exam • To date, whether the movement
impairment is the cause or result of the pain is unknown.
• But if during the exam, correcting the movement impairment immediately alleviates the symptoms, then treatment may be most effectively directed by a movement diagnosis (Ludewig PM
2009, Kibler WB 2013)
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Movement Exam Diagnosis
• PTs must establish a diagnosis of the condition they are treating to ensure most effective treatment (APTA House of Delegates 1994, 1995)
• Diagnosis named according to the impairment(s) observed
• Frequency
• Magnitude
• Production of symptoms
• Response to modification of movement
• Diagnosis directs treatment
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Movement Examination
• Consists of:
• Alignment tests
• Movement tests performed in a variety of positions (standing, supine, prone, quadruped, sitting)
• Analysis of functional activities
Sylvia Czuppon, PT, DPT, OCS
Not to be reproduced without permission 4
Program in Physical Therapy
Movement Examination
• During the examination, the patient’s preferred alignment and movements are analyzed to determine their precision and effect on symptoms.
• The preferred pattern is followed immediately by a secondary test modifying the movement to determine the effect on symptoms.
• Goal: Determine the pattern of movement which most consistently elicits symptoms and when corrected, decreases symptoms
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HIP MOVEMENT IMPAIRMENTS
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2 Categories of MSI Syndromes of the Hip
Femoral Syndromes
Accessory motion impairments
• Joint related symptoms
• Ex. Femoral Anterior Glide – groin pain, impingement
• Ex. Femoral Posterior Glide – buttock pain, sciatica
Hip Syndromes
Physiological motion impairments
• Contractile tissue symptoms
• Ex. Hip Adduction – lateral hip pain, trochanteric bursitis, gluteus medius tendinopathy
• Ex. Hip Extension with Knee Extension – buttock pain, hamstring strain
Not to be reproduced without permission Program in Physical Therapy
Femoral MSI Syndromes
• Anterior Glide • with medial rotation
• with lateral rotation
• Posterior Glide • with medial rotation
• Multidirectional Accessory Hypermobility • With knee movement
• Hypomobility with Superior Glide
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Physiological Hip MSI Syndromes
• Adduction • With medial rotation
• Extension with Knee Extension • With medial rotation
• Lateral Rotation
• Hip Flexion
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Early evidence for movement pattern impairments with pre-arthritic hip disease
• Van Houcke, J Clin Biomech, 2013
• Kumar D, PM&R, 2014
• Harris-Hayes M, JOSPT, 2016 • Preliminary study
Case Reports:
• Austin AA, JOSPT, 2008
• Khoo-Summers L, Man Ther, 2015
• Lewis, C, Man Ther, 2015
Sylvia Czuppon, PT, DPT, OCS
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LATERAL HIP PAIN (BURSITIS, GM TENDINOPATHY)
Hip Movement Impairments
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Hip Adduction with Med Rotation
• Symptoms:
• posterior lateral hip pain
• sciatica (lengthened piriformis)
• lateral thigh pain (ITB)
• pain in WB activities in standing or prolonged sitting
• Common Referring Diagnoses: • sciatica
• hamstring strain
• ischiogluteal bursitis
• ITB fasciitis
• gluteus medius strain/tendinopathy
• trochanteric bursitis
• snapping hip syndrome
• other
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Hip Add with MR
• Treatment
• Reduce stress -tape or cane may be needed
• Education:
• Out of chair every 30 min (sciatica), symmetrical sit/stand, sleep, avoid excessive stretching
• Avoid crossing legs
• Strengthen PGM and LRs
Anteversi
on
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ANTERIOR HIP PAIN (IMPINGEMENT, LABRAL PATHOLOGY)
Hip Movement Impairments
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Symptoms
• Pain in anterior groin, anterolateral hip particularly with sitting, walking, sleeping
• Painful hip flexion
• Possibly mechanical complaints of clicking, “popping”, locking, giving way
• May or may not have radiographic diagnosis of FAI
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Without abnormalities
FEMOROACETABULAR IMPINGEMENT (Bony overgrowth) • Deep acetabulum • Large femoral neck
Sylvia Czuppon, PT, DPT, OCS
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JBJS-JOSPT Special Report: It Takes a Team March 2013
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Diagnosis
• Focus has been on pathoanatomy and bony abnormalities
• No consensus on one method for determining a movement system diagnosis
Not to be reproduced without permission
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Patients (and you) may ask . . .
• “If it’s a structural problem, how can it get better without
surgery?”
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Non-operative Care First
• PT*
• Activity modification*
• Medication
• Injections
• Rumored not to work
* Wall PD, PM&R, 2013 (Review)
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References Supporting Non-operative Care
• Emara K, J Orthop Surg, 2011
• Yazbek PM, JOSPT, 2011
• Hunt D, PM&R, 2012 • 44% of patients with pre-arthritic intra-articular hip disorders
improved with non-operative care alone (not all FAI)
• 35% of those with a dx of FAI responded to non-operative care
• Wall PD, PM&R, 2013 (Review) • Very limited experimental data
• Non-operative treatment regimens, particularly PT, need to be evaluated more extensively and rigorously
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Femoral Anterior Glide
• Excessive flexibility of anterior hip joint structures as result of maintained hip extension creates a path of least resistance to anterior glide
• Most common diagnosis with FAI patients
Sylvia Czuppon, PT, DPT, OCS
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Femoral Anterior Glide
• Imprecise spinning of femoral head during hip flexion
Normal
Not to be reproduced without permission Program in Physical Therapy
Weak or painful iliopsoas
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Femoral Anterior Glide: Focus of Treatment
• Correct alignment and gait • Restore precise hip flexion
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Femoral Anterior Glide: Focus of Treatment
• Increase iliopsoas muscle performance
• Progression – Passive
– Passive/hold end range
– Active assistive
– Active
– Active/resist end range
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Femoral Anterior Glide: Focus of Treatment
• Improve performance of posterior hip muscles
• Improve timing of gluteus max versus hamstrings during active hip extension
• If excessive femoral medial rotation noted, also will need to address strength of deep hip LRs
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KNEE MOVEMENT IMPAIRMENTS
Sylvia Czuppon, PT, DPT, OCS
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Movement System Diagnoses for the Knee
• Tibiofemoral Rotation
• With Valgus
• With Varus
• Tibiofemoral Hypomobility
• Knee Extension (with or without Superior Glide)
• Knee Hyperextension
• Tibiofemoral Accessory Hypermobility
• Patellar Lateral Glide
• Knee Impairment
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Is the knee a “victim”?
• Consider effect of hip on the knee • Alignment of hip joint (structural impairments)
• Strength of hip muscles
• Length of hip muscles
• Consider effect of ankle/foot on the knee • Pronated ankle/foot
• Rigid foot
• Stiff ankle – limited DF
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Structural & Alignment Impairments
Femoral Version (ante or retro)
Hip Medial Rotation
Genu Valgum
Genu Varum
Tibial Varum
Tibial Torsion
Genu Recurvatum
Ankle Pronation/Supination
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Hip Medial Rotation
Preferred Alignment Corrected Alignment
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Genu Varus
Not to be reproduced without permission
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Kendall Muscles Testing & Function 1993
Effects of Prolonged Genu Recurvatum
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Tibial Torsion vs. Tibial Lateral Rotation ???
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Patellofemoral Pain Syndrome – “Anterior Knee Pain”
• Pain along anterior, medial > lateral knee especially with squatting, stairs, prolonged sitting, running
• Regarded as more common in women than men
• Not related to Q angle
• May or may not be related to quadriceps activation
3rd annual PFP Consensus Statement, Witvrouw et al BJSM 2013
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Patellofemoral Pain Syndrome – “Anterior Knee Pain”
• Muscle performance
• Weaker hip extensors
• Delayed/shortened gluteus medius activation
• Poor proximal mechanics (trunk and hip)
Anterior knee pain
Eckhoff DG et al 1997
Jones RB et al 1995
Patellofemoral pain
Hefzy MS et al 1991 Lee TQ et al 2001 Powers CM et al 2003 Li G et al 2004 Salsich GB et al 2007 Noehren B et al 2012
3rd annual PFP Consensus Statement, Witvrouw et al BJSM 2013
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Patellar vs. Femoral Movement
Open Chain
(Non-weightbearing)
Closed Chain
(Weight-bearing)
Modified from Powers CM et al 2003
Left knee
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• Little movements mean a lot! A small movement impairment can be detrimental to joint
Liao TC et al, Med Sci Sport Exer, 2015
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• Knee pain associated with impaired rotation of the tibiofemoral joint in transverse or frontal plane
• Excessive femoral MR relative to tibia
AND/OR
• Excessive tibial LR relative to femur
Movement System Diagnosis: Tibiofemoral Rotation
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Excessive flexibility at knee compensating for
lack of hip lateral rotation
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Short/stiff TFL-ITB
Example of Relative Stiffness/Flexibility
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Focus of Treatment
• Alignment
• Must account/accommodate for structural impairments
• Functional activities
• Sleeping, sit to stand, stairs, gait
• Therapeutic exercises focused on strengthening posterolateral hip muscles
• Stretching
• TFL/ITB, gastroc/soleus
• Monitoring relative flexibility of TFJ
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MSI TREATMENT GUIDELINES: SUMMARY
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“Muscle performance is determined by the pattern of movement. Correction of faulty patterns is best achieved by
training the correct pattern and not by isolated ‘strengthening’ of a muscle.
…
The critical issue is how an activity is performed not just performing the activity.”
(MSI Syndromes of the Extremities, 2011)
Sylvia Czuppon, PT, DPT, OCS
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Program in Physical Therapy
General Treatment Goals
• Redistribute movement to appropriate joints
• Correct the movement pattern that is causing the tissue to become painful rather than direct treatment to the affected tissue.
• Training proper movement patterns will induce appropriate muscular (strength, length) and biomechanical adaptations that will reinforce the development of optimal neuromuscular action
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Treatment
• Movement Diagnosis directs treatment
• Correct alignment and movement during functional activities
• Prescribe corrective exercise program:
• Emphasizes precise motion
• Individualized to the patient
• Practice performing movements using the corrected or modified strategy
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Treatment
• Because treatment is addressing cause of symptoms, pain reduces as tissue stresses are reduced
• Recurrence less likely if cause of pain is addressed
• Source of pain indirectly addressed
Mueller and Maluf 2002
= Pain
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Treatment of Relative Flexibility
Incorporate the following principles into functional activities and exercises as often as possible
• Prevent repeated stretching of flexible site
• Improve performance of stabilizing muscles
• Active contraction at desired length
• Stiffen and shorten long muscles
• Stretch short/stiff muscles
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Educate patient about how daily habits and preferred alignments contribute to
movement patterns
Harris-Hayes et al JOSPT 2008
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Treatment: Fitness activities
Sylvia Czuppon, PT, DPT, OCS
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Take Home Messages
• The body follows the path of least resistance for motion which contributes to subtle hypermobility.
• The way everyday activities are performed reinforces this hypermobility and the movement pattern.
• Muscle performance is determined by the pattern of movement. Altered movement patterns impair proper muscle performance.
Program in Physical Therapy
Take Home Messages
• During exam, when a movement does not appear ideal or causes symptoms, try to modify movement.
• Doing this repeatedly during the exam helps confirm diagnosis
• Think “big picture” – how do the findings of the exam relate to one another?
• Diagnosing is based on pattern recognition
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Take Home Messages
• Treatment:
1) Correct the pattern of motion to restore more precise joint motion
2) Correct functional activity performance
3) Individualized to each patient
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Questions?
