The Movement System Statement of Privacy

The Kinesiopathologic Model

• To protect the privacy of the subjects or patients
Movement System Impairment that are depicted in this presentation and based
Syndromes of the Knee on copyright laws, this information should not be
shared in any manner. We do NOT allow any
Shirley Sahrmann, PT, PhD, FAPTA photographing or videotaping during any part of
Professor Emerita this presentation.
• Thank you.
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Missing Figures THE HUMAN MOVEMENT

• Any missing figures were intentionally SYSTEM
omitted due to copyright laws in the
United States.
The Body System for which Physical
Therapists are Responsible.
The System of our Expertise
Our Identity – APTA 2013

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The Movement System APTA Intro to Identity

• Profession will define and promote
• Movement is an • The movement system as the foundation for optimizing
essential function of movement.
• The recognition and validation of the movement system
life at all levels of is essential to fully understand the physiological function
living organisms. and potential of the human body.
• From ions moving through • The profession will be responsible for monitoring an
membranes to moving your individual’s movement system across the lifespan in
limbs to moving in your order to
environment • promote optimal development, diagnose dysfunction, and
• provide interventions targeted at preventing or ameliorating
The human movement system is a system restrictions to activity and participation.
of physiological organ systems that interact • The movement system will form the basis of practice,
to produce movement of the body and its education and research of the profession.”
parts.
http://pt.wusm.wustl.edu/AboutUs/Pages/H
umanMovementSystem.aspx
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Proposed Definition of Movement Movement System Diagnoses
System
• The human movement system
comprises the anatomic Musculoskeletal Neurological Cardiopulmonary

structures and physiologic O’Sullivan Class

Tissue

functions that interact to move Impairments

(Pathoanatomic)
MSI syndromes
the body or its component parts.
MDT
Powers syndromes (Neuromuscular)
• APTA work group
Treatment Based Diagnoses

MSI syndromes
(Neuromusculoskeletal)

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Movement System Dysfunctions

Pathokinesiologic Kinesiopathologic The Kinesiopathologic Model
• Pathology in • Movement induces Movement inducing pathology
component system pathology
induces movement • Low back pain
A Theoretical Construct of Movement
disorder • Hip pain
• CVA • Knee pain
System Impairment Syndromes
• Rheumatoid • Carpal tunnel
arthritis syndrome
• Fracture

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Movements & Alignments Tibiofemoral Rotation

• Repeated movements • Trauma versus Repetitive
• Prolonged alignments Injury
of
• Everyday activities
induce tissue
adaptations of
movement system
components

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 Kinesiopathologic Model of Movement System
Movement Becomes Impaired
Cardio-Pulmon -
Musculoskeletal Nervous
• Induced adaptive changes in movement endocrine

system components Biomechanics

• Result in the joint (knee/patella) moving too Repeated movements Personal Characteristics – intrinsic
INDUCERS
readily in a specific direction(s) Prolonged postures Activity Demands - extrinsic
Relative Stiffness of
• Becomes the path of least resistance muscle & Tissue Adaptations
connective tissue Path of Least
• The adaptive changes and impaired joint Relative Flexibility
Resistance
movement vary because of intrinsic and Intra-joint + Inter-joint
Joint Accessory
Motor Performance Hypermobility
extrinsic factors Learning

• Kinesiopathologic model Micro Macro trauma

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Result of Adaptive Tissue Changes Cause versus Source

Operational Definitions
Path of least resistance for motion
• Relative Flexibility Source
• Intra-joint; intrinsic accessory motion mobility Cause
e.g excessive tibiofemoral rot
• Inter-joint; physiological motion, e.g knee vs • the mechanical • the tissue or
ankle
factor (movement) pathoanatomical
• Relative Stiffness that results in tissue structure that is
• Passive tension of muscle & connective
tissue irritation symptomatic
• Change in tension /unit change in length
• Highly correlated with muscle size • e.g. femoral anterior • e.g. iliopsoas
e.g Biceps femoris vs medial hamstrings
glide, tibiofemoral cause tendin(itis, osis,
Results in joint (micro-instability) rotation syndromes, opathy); patellar-
hypermobility causes the pain
• What moves is what hurts Patellar lateral glide femoral dysfunction

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Tibiofemoral Rotation Syndrome Tibiofemoral Rotation Syndrome

• Knee pain associated with impaired rotation of Subcategories
the tibiofemoral joint in transverse or frontal VALGUS VARUS
• Pronated foot or abnormal
plane. pronation during gait
• Supinated Foot
• Salsich GB, Perman WH JOSPT 2007 • Weak hip abductors, external • Often with hyperextension
• Salsich GB, Perman WH J Science and Medicine in Sport rotators • May demonstrate a varus
2013 • Poor dynamic knee joint thrust
stability/Medial collapse
• Patellar lateral glide with femoral med rot • At risk for ACL injuries
• May have increased risk
for OA
Anterior knee pain Patellofemoral pain
Eckhoff DG et al. 1997 Hefzy MS et al. 1991 Hewett et al. 2005 Chang et al. 2004
Lee TQ et al. 2001, Powers CM Ford KR et al. 2003
Jones RB et al. 1995
et al. 2003 McLean et al. 2005
Li G et al. 2004
Salsich GB et al. 2007

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 MSI Exam – movement Valgus Varus
• Standing
• Alignment: Swayback; Pelvic Tilt; Iliac crest height; pelvic rotation;
• Knee alignment – hyperextended, flexed, valgus, varus
• Foot: pronated, supinated
• Forward bending
• Single-leg standing
• Squat
• Step down and up
• Supine
• Hip extension-knee flexed (two joint hip flexor test)
• Hip abduction
• Hip-knee flexion & extension

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Tibial Torsion – structural

(in joint vs in shaft) Tibial Torsion Structural vs Acquired

Structural
impairments

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Tibial Torsion in Knee Joint Swayback – Knee Hyperextension

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 Single Leg Stance
Note Position
of patella

Video

Kendall Muscles Testing & Function 1993

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Squat Test – Preferred - Corrected Step Up Test

Corrected knee
Impaired knee
alignment
alignment

Symptoms decrease with correction

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Step Up Test – TF Rotation with Valgus

Alignment and Movement - Inconsistent

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 Test: Hip Extension with Knee Flexion

TFL-ITB causing tibial rotation Ballet Dancer with tibiofemoral rotation associated with femoral anteversion

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Femoral Anteversion – Ballet Dancer MSI Exam continued

• Side-lying
• Hip abduction-lateral rotation
• Hip abduction – adduction
• Prone
• Knee flexion
• Hip rotation
• Hip extension
• Quadruped
• Rocking backward
• Sitting
• Knee extension
• Sit to stand
Medial Rotation • Gait
Lateral Rotation Craig’s test – 27 deg

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Exam: Hip Abd/Lateral Rotation Exam: Knee flexion & Hip

Hip Abduction Extension & Hip Rotation
• Dominance of hip Knee Flexion
lateral rotators vs Assess tibial rotation
hip abductors
Hip Rotation
• Gluteus Medius
ROM - version
performance
Hip Extension
Knee extended –
timing
Glut max performance

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 Exam: Hip Rotators & Iliopsoas
Femoral Posterior Glide – Affect on Knee

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Treatment – Functional activities Sit to

Treatment Stand
• Corrective specific exercises
• The tests failed become the exercises
• Correction of basic mobility activities - Most Important
• Sit to stand
• Stairs
• Squatting
• Gait
• Running when indicated
• Correction of sports performance patterns
• Recommend appropriate programs of physical activity
• Lots of evidence of the health value of exercise

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Activity is Good – Is Monitoring Necessary?

Treatment
• Correction during sporting activities

Knees
Optimal??

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How Many Are Doing The Exercises
Correctly? Exercising But Need Monitoring

None of these children are correctly flexed in the hips

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Movement System Practitioners

• Should be lifespan practitioners
• Should provide yearly exams of the movement system and
recommend appropriate programs of correction for
• Alignment
• Movement patterns
• Strength assessments
• Aerobic assessments
• Diagnose dysfunctions of movement
• Develop treatment programs
• Never discharge a patient but end an episode of care

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