Embed Size (px)
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General NOTES
bull More emotional impact with lecturing
bull NO CATCH yet hellip SUCCESS -gt what is my story here Emotion question bull Christian VandeVelde -gt struggling to find power with one leg
bull Anchor points you are informing your practice with evidence -gt Harkening back to some of the phrases that I used earlierDx that we are coming to understand coming to know what to do and we can inform our practice Bulley here is the hip and the victim can be anywhere keep coming back to the language that I was already usinghellip Slide in names dates research where I can
Curtis Cramblett PT CFMT CSCS Coach
- Physical Therapist 20 years physio educator
- PT and fitter for Garmin rsquo09-rsquo11 multiple Olympians and triathletes
- Fit Certified RETUL FIST SICI Bike PT
- Chair Med of Cycling Bike fit Task force
- Cyclist Racer 25 years
- Cycling and Strength Conditioning Coach
Unpacking Lower Extremity
Cycling Disorders
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO A WELLNESS TEAM
FROM KNEE TO BODY
bull Why might an elite athlete getting lots of
care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen
the stars are alignedrsquo
Bent Up
PART 1If we are to understand what is keeping our
cyclist Legs from feeling and performing betterhellip
We must explore the interconnectedness
of the bodies systems
Understand the
Myo-FASCIAL chain
in a closed kinetic system
Trauma experienced thru a SYSTEM
Anatomy of a Chain
Thomas Meyers Anatomy Trains
Tensegrity
Tensional Integrity
Buckminster Fuller
Tensegrity
Buckminster Fuller US Paten lsquo62
Tensegrity
Bikefitcom
Regional
Interdependence
ldquo A musculoskeletal examination model whorsquos time has comerdquo Josh Cleland PT JOBST lsquo95
BULLY
Thoracic spine
Victim
Pressure on
saddle
Feel it yourself
bull Standing feel the foot drop
Be an Inspector to find underlying diagnosis
Or BE THE PLUMMER
STEP 2 FIND IT
Making wise clinical decisions
ldquoThe greater the ignorance the greater the
dogmatismrdquo
Sir William Osler MD
Wise Diagnoses Treatments
Evidence Based
Practice
2005 ASHAs Coordinating Committee on EBP
Best ObjectiveData Research
Clinical Experience
ClientValues - Goals
Wise Clinical Decision
Evidence Informed
Practice
Subjective
Clinical Scientists
Subjective Objective
Develop Hypothesis
Intervention
Id RelevantData
Change Bike Treat Exercise
IT Band aggravated by Seat ht
Knee angle 20 deg PF 120 degPositive Ober Test Current knee discomfort
GOAL Eliminate Lateral Knee Pain currently feeling knee on trainer
Recheck
ldquoThe practice of medicine is an art based on
sciencerdquo
Sir William Osler MD
Be the Detective FIND
Diagnostic Clues
Interview
bull Agg eases
bull Changes since onset of symptoms
bull Trauma Surgeries
Be the Detective FIND the
Relevant Signs
Objective Evaluation
bull Observation
bull ROM
bull Palpation
bull NRM Control Strength
bull Special Tests
Are you sure about your Dx hypothesis
bull You rely on more than
one variable
bull Clustering ndash Rule of 3rsquos
Measuring Certainty
Fagan TJ Nomogram fro Bayes Theorem N Engl J Med 1975
Pattern Recognition
ldquoWhen you hear hoof beats think horses hellip not zebrasrdquo
Theodore Woodard MD
Zebra Medicine
STEP 3
Evaluation and
Treatment of common
LE disorders
PT
MD
Fit
CoachOtheran Integrated Approach
Explore 3 Dx of LE
1) FAI (Femoral Acetabular Impingement)
2) Met Head Pain Metatarsilgia
3) PFPS (Patella Femoral Pain Syndrome)
Visual Animation FAI
In The Headlines
Alex Rodriguez
Barton SilvermanThe New York Times
Hip ndash FAI
Diagnosis FAI
Ortho Exam
bull Subj Anterior hip pain with flexion
activities
bull Somara ldquoCrdquo Sign
bull Hip Outcome Score
Clohisy MD lsquo89
Diagnosis FAI
bull Ortho Exam
ndash Obj Scour FABER Flex Add IR
ndash Strength Weakness around the hip w dec EMG TFL
bull Diff Dx
ndash Labral Tears Hip OA Tendinopathies of Psoas
bull RO Femoral Stress Fractures
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Curtis Cramblett PT CFMT CSCS Coach
- Physical Therapist 20 years physio educator
- PT and fitter for Garmin rsquo09-rsquo11 multiple Olympians and triathletes
- Fit Certified RETUL FIST SICI Bike PT
- Chair Med of Cycling Bike fit Task force
- Cyclist Racer 25 years
- Cycling and Strength Conditioning Coach
Unpacking Lower Extremity
Cycling Disorders
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO A WELLNESS TEAM
FROM KNEE TO BODY
bull Why might an elite athlete getting lots of
care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen
the stars are alignedrsquo
Bent Up
PART 1If we are to understand what is keeping our
cyclist Legs from feeling and performing betterhellip
We must explore the interconnectedness
of the bodies systems
Understand the
Myo-FASCIAL chain
in a closed kinetic system
Trauma experienced thru a SYSTEM
Anatomy of a Chain
Thomas Meyers Anatomy Trains
Tensegrity
Tensional Integrity
Buckminster Fuller
Tensegrity
Buckminster Fuller US Paten lsquo62
Tensegrity
Bikefitcom
Regional
Interdependence
ldquo A musculoskeletal examination model whorsquos time has comerdquo Josh Cleland PT JOBST lsquo95
BULLY
Thoracic spine
Victim
Pressure on
saddle
Feel it yourself
bull Standing feel the foot drop
Be an Inspector to find underlying diagnosis
Or BE THE PLUMMER
STEP 2 FIND IT
Making wise clinical decisions
ldquoThe greater the ignorance the greater the
dogmatismrdquo
Sir William Osler MD
Wise Diagnoses Treatments
Evidence Based
Practice
2005 ASHAs Coordinating Committee on EBP
Best ObjectiveData Research
Clinical Experience
ClientValues - Goals
Wise Clinical Decision
Evidence Informed
Practice
Subjective
Clinical Scientists
Subjective Objective
Develop Hypothesis
Intervention
Id RelevantData
Change Bike Treat Exercise
IT Band aggravated by Seat ht
Knee angle 20 deg PF 120 degPositive Ober Test Current knee discomfort
GOAL Eliminate Lateral Knee Pain currently feeling knee on trainer
Recheck
ldquoThe practice of medicine is an art based on
sciencerdquo
Sir William Osler MD
Be the Detective FIND
Diagnostic Clues
Interview
bull Agg eases
bull Changes since onset of symptoms
bull Trauma Surgeries
Be the Detective FIND the
Relevant Signs
Objective Evaluation
bull Observation
bull ROM
bull Palpation
bull NRM Control Strength
bull Special Tests
Are you sure about your Dx hypothesis
bull You rely on more than
one variable
bull Clustering ndash Rule of 3rsquos
Measuring Certainty
Fagan TJ Nomogram fro Bayes Theorem N Engl J Med 1975
Pattern Recognition
ldquoWhen you hear hoof beats think horses hellip not zebrasrdquo
Theodore Woodard MD
Zebra Medicine
STEP 3
Evaluation and
Treatment of common
LE disorders
PT
MD
Fit
CoachOtheran Integrated Approach
Explore 3 Dx of LE
1) FAI (Femoral Acetabular Impingement)
2) Met Head Pain Metatarsilgia
3) PFPS (Patella Femoral Pain Syndrome)
Visual Animation FAI
In The Headlines
Alex Rodriguez
Barton SilvermanThe New York Times
Hip ndash FAI
Diagnosis FAI
Ortho Exam
bull Subj Anterior hip pain with flexion
activities
bull Somara ldquoCrdquo Sign
bull Hip Outcome Score
Clohisy MD lsquo89
Diagnosis FAI
bull Ortho Exam
ndash Obj Scour FABER Flex Add IR
ndash Strength Weakness around the hip w dec EMG TFL
bull Diff Dx
ndash Labral Tears Hip OA Tendinopathies of Psoas
bull RO Femoral Stress Fractures
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO A WELLNESS TEAM
FROM KNEE TO BODY
bull Why might an elite athlete getting lots of
care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen
the stars are alignedrsquo
Bent Up
PART 1If we are to understand what is keeping our
cyclist Legs from feeling and performing betterhellip
We must explore the interconnectedness
of the bodies systems
Understand the
Myo-FASCIAL chain
in a closed kinetic system
Trauma experienced thru a SYSTEM
Anatomy of a Chain
Thomas Meyers Anatomy Trains
Tensegrity
Tensional Integrity
Buckminster Fuller
Tensegrity
Buckminster Fuller US Paten lsquo62
Tensegrity
Bikefitcom
Regional
Interdependence
ldquo A musculoskeletal examination model whorsquos time has comerdquo Josh Cleland PT JOBST lsquo95
BULLY
Thoracic spine
Victim
Pressure on
saddle
Feel it yourself
bull Standing feel the foot drop
Be an Inspector to find underlying diagnosis
Or BE THE PLUMMER
STEP 2 FIND IT
Making wise clinical decisions
ldquoThe greater the ignorance the greater the
dogmatismrdquo
Sir William Osler MD
Wise Diagnoses Treatments
Evidence Based
Practice
2005 ASHAs Coordinating Committee on EBP
Best ObjectiveData Research
Clinical Experience
ClientValues - Goals
Wise Clinical Decision
Evidence Informed
Practice
Subjective
Clinical Scientists
Subjective Objective
Develop Hypothesis
Intervention
Id RelevantData
Change Bike Treat Exercise
IT Band aggravated by Seat ht
Knee angle 20 deg PF 120 degPositive Ober Test Current knee discomfort
GOAL Eliminate Lateral Knee Pain currently feeling knee on trainer
Recheck
ldquoThe practice of medicine is an art based on
sciencerdquo
Sir William Osler MD
Be the Detective FIND
Diagnostic Clues
Interview
bull Agg eases
bull Changes since onset of symptoms
bull Trauma Surgeries
Be the Detective FIND the
Relevant Signs
Objective Evaluation
bull Observation
bull ROM
bull Palpation
bull NRM Control Strength
bull Special Tests
Are you sure about your Dx hypothesis
bull You rely on more than
one variable
bull Clustering ndash Rule of 3rsquos
Measuring Certainty
Fagan TJ Nomogram fro Bayes Theorem N Engl J Med 1975
Pattern Recognition
ldquoWhen you hear hoof beats think horses hellip not zebrasrdquo
Theodore Woodard MD
Zebra Medicine
STEP 3
Evaluation and
Treatment of common
LE disorders
PT
MD
Fit
CoachOtheran Integrated Approach
Explore 3 Dx of LE
1) FAI (Femoral Acetabular Impingement)
2) Met Head Pain Metatarsilgia
3) PFPS (Patella Femoral Pain Syndrome)
Visual Animation FAI
In The Headlines
Alex Rodriguez
Barton SilvermanThe New York Times
Hip ndash FAI
Diagnosis FAI
Ortho Exam
bull Subj Anterior hip pain with flexion
activities
bull Somara ldquoCrdquo Sign
bull Hip Outcome Score
Clohisy MD lsquo89
Diagnosis FAI
bull Ortho Exam
ndash Obj Scour FABER Flex Add IR
ndash Strength Weakness around the hip w dec EMG TFL
bull Diff Dx
ndash Labral Tears Hip OA Tendinopathies of Psoas
bull RO Femoral Stress Fractures
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
bull Why might an elite athlete getting lots of
care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen
the stars are alignedrsquo
Bent Up
PART 1If we are to understand what is keeping our
cyclist Legs from feeling and performing betterhellip
We must explore the interconnectedness
of the bodies systems
Understand the
Myo-FASCIAL chain
in a closed kinetic system
Trauma experienced thru a SYSTEM
Anatomy of a Chain
Thomas Meyers Anatomy Trains
Tensegrity
Tensional Integrity
Buckminster Fuller
Tensegrity
Buckminster Fuller US Paten lsquo62
Tensegrity
Bikefitcom
Regional
Interdependence
ldquo A musculoskeletal examination model whorsquos time has comerdquo Josh Cleland PT JOBST lsquo95
BULLY
Thoracic spine
Victim
Pressure on
saddle
Feel it yourself
bull Standing feel the foot drop
Be an Inspector to find underlying diagnosis
Or BE THE PLUMMER
STEP 2 FIND IT
Making wise clinical decisions
ldquoThe greater the ignorance the greater the
dogmatismrdquo
Sir William Osler MD
Wise Diagnoses Treatments
Evidence Based
Practice
2005 ASHAs Coordinating Committee on EBP
Best ObjectiveData Research
Clinical Experience
ClientValues - Goals
Wise Clinical Decision
Evidence Informed
Practice
Subjective
Clinical Scientists
Subjective Objective
Develop Hypothesis
Intervention
Id RelevantData
Change Bike Treat Exercise
IT Band aggravated by Seat ht
Knee angle 20 deg PF 120 degPositive Ober Test Current knee discomfort
GOAL Eliminate Lateral Knee Pain currently feeling knee on trainer
Recheck
ldquoThe practice of medicine is an art based on
sciencerdquo
Sir William Osler MD
Be the Detective FIND
Diagnostic Clues
Interview
bull Agg eases
bull Changes since onset of symptoms
bull Trauma Surgeries
Be the Detective FIND the
Relevant Signs
Objective Evaluation
bull Observation
bull ROM
bull Palpation
bull NRM Control Strength
bull Special Tests
Are you sure about your Dx hypothesis
bull You rely on more than
one variable
bull Clustering ndash Rule of 3rsquos
Measuring Certainty
Fagan TJ Nomogram fro Bayes Theorem N Engl J Med 1975
Pattern Recognition
ldquoWhen you hear hoof beats think horses hellip not zebrasrdquo
Theodore Woodard MD
Zebra Medicine
STEP 3
Evaluation and
Treatment of common
LE disorders
PT
MD
Fit
CoachOtheran Integrated Approach
Explore 3 Dx of LE
1) FAI (Femoral Acetabular Impingement)
2) Met Head Pain Metatarsilgia
3) PFPS (Patella Femoral Pain Syndrome)
Visual Animation FAI
In The Headlines
Alex Rodriguez
Barton SilvermanThe New York Times
Hip ndash FAI
Diagnosis FAI
Ortho Exam
bull Subj Anterior hip pain with flexion
activities
bull Somara ldquoCrdquo Sign
bull Hip Outcome Score
Clohisy MD lsquo89
Diagnosis FAI
bull Ortho Exam
ndash Obj Scour FABER Flex Add IR
ndash Strength Weakness around the hip w dec EMG TFL
bull Diff Dx
ndash Labral Tears Hip OA Tendinopathies of Psoas
bull RO Femoral Stress Fractures
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
PART 1If we are to understand what is keeping our
cyclist Legs from feeling and performing betterhellip
We must explore the interconnectedness
of the bodies systems
Understand the
Myo-FASCIAL chain
in a closed kinetic system
Trauma experienced thru a SYSTEM
Anatomy of a Chain
Thomas Meyers Anatomy Trains
Tensegrity
Tensional Integrity
Buckminster Fuller
Tensegrity
Buckminster Fuller US Paten lsquo62
Tensegrity
Bikefitcom
Regional
Interdependence
ldquo A musculoskeletal examination model whorsquos time has comerdquo Josh Cleland PT JOBST lsquo95
BULLY
Thoracic spine
Victim
Pressure on
saddle
Feel it yourself
bull Standing feel the foot drop
Be an Inspector to find underlying diagnosis
Or BE THE PLUMMER
STEP 2 FIND IT
Making wise clinical decisions
ldquoThe greater the ignorance the greater the
dogmatismrdquo
Sir William Osler MD
Wise Diagnoses Treatments
Evidence Based
Practice
2005 ASHAs Coordinating Committee on EBP
Best ObjectiveData Research
Clinical Experience
ClientValues - Goals
Wise Clinical Decision
Evidence Informed
Practice
Subjective
Clinical Scientists
Subjective Objective
Develop Hypothesis
Intervention
Id RelevantData
Change Bike Treat Exercise
IT Band aggravated by Seat ht
Knee angle 20 deg PF 120 degPositive Ober Test Current knee discomfort
GOAL Eliminate Lateral Knee Pain currently feeling knee on trainer
Recheck
ldquoThe practice of medicine is an art based on
sciencerdquo
Sir William Osler MD
Be the Detective FIND
Diagnostic Clues
Interview
bull Agg eases
bull Changes since onset of symptoms
bull Trauma Surgeries
Be the Detective FIND the
Relevant Signs
Objective Evaluation
bull Observation
bull ROM
bull Palpation
bull NRM Control Strength
bull Special Tests
Are you sure about your Dx hypothesis
bull You rely on more than
one variable
bull Clustering ndash Rule of 3rsquos
Measuring Certainty
Fagan TJ Nomogram fro Bayes Theorem N Engl J Med 1975
Pattern Recognition
ldquoWhen you hear hoof beats think horses hellip not zebrasrdquo
Theodore Woodard MD
Zebra Medicine
STEP 3
Evaluation and
Treatment of common
LE disorders
PT
MD
Fit
CoachOtheran Integrated Approach
Explore 3 Dx of LE
1) FAI (Femoral Acetabular Impingement)
2) Met Head Pain Metatarsilgia
3) PFPS (Patella Femoral Pain Syndrome)
Visual Animation FAI
In The Headlines
Alex Rodriguez
Barton SilvermanThe New York Times
Hip ndash FAI
Diagnosis FAI
Ortho Exam
bull Subj Anterior hip pain with flexion
activities
bull Somara ldquoCrdquo Sign
bull Hip Outcome Score
Clohisy MD lsquo89
Diagnosis FAI
bull Ortho Exam
ndash Obj Scour FABER Flex Add IR
ndash Strength Weakness around the hip w dec EMG TFL
bull Diff Dx
ndash Labral Tears Hip OA Tendinopathies of Psoas
bull RO Femoral Stress Fractures
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Understand the
Myo-FASCIAL chain
in a closed kinetic system
Trauma experienced thru a SYSTEM
Anatomy of a Chain
Thomas Meyers Anatomy Trains
Tensegrity
Tensional Integrity
Buckminster Fuller
Tensegrity
Buckminster Fuller US Paten lsquo62
Tensegrity
Bikefitcom
Regional
Interdependence
ldquo A musculoskeletal examination model whorsquos time has comerdquo Josh Cleland PT JOBST lsquo95
BULLY
Thoracic spine
Victim
Pressure on
saddle
Feel it yourself
bull Standing feel the foot drop
Be an Inspector to find underlying diagnosis
Or BE THE PLUMMER
STEP 2 FIND IT
Making wise clinical decisions
ldquoThe greater the ignorance the greater the
dogmatismrdquo
Sir William Osler MD
Wise Diagnoses Treatments
Evidence Based
Practice
2005 ASHAs Coordinating Committee on EBP
Best ObjectiveData Research
Clinical Experience
ClientValues - Goals
Wise Clinical Decision
Evidence Informed
Practice
Subjective
Clinical Scientists
Subjective Objective
Develop Hypothesis
Intervention
Id RelevantData
Change Bike Treat Exercise
IT Band aggravated by Seat ht
Knee angle 20 deg PF 120 degPositive Ober Test Current knee discomfort
GOAL Eliminate Lateral Knee Pain currently feeling knee on trainer
Recheck
ldquoThe practice of medicine is an art based on
sciencerdquo
Sir William Osler MD
Be the Detective FIND
Diagnostic Clues
Interview
bull Agg eases
bull Changes since onset of symptoms
bull Trauma Surgeries
Be the Detective FIND the
Relevant Signs
Objective Evaluation
bull Observation
bull ROM
bull Palpation
bull NRM Control Strength
bull Special Tests
Are you sure about your Dx hypothesis
bull You rely on more than
one variable
bull Clustering ndash Rule of 3rsquos
Measuring Certainty
Fagan TJ Nomogram fro Bayes Theorem N Engl J Med 1975
Pattern Recognition
ldquoWhen you hear hoof beats think horses hellip not zebrasrdquo
Theodore Woodard MD
Zebra Medicine
STEP 3
Evaluation and
Treatment of common
LE disorders
PT
MD
Fit
CoachOtheran Integrated Approach
Explore 3 Dx of LE
1) FAI (Femoral Acetabular Impingement)
2) Met Head Pain Metatarsilgia
3) PFPS (Patella Femoral Pain Syndrome)
Visual Animation FAI
In The Headlines
Alex Rodriguez
Barton SilvermanThe New York Times
Hip ndash FAI
Diagnosis FAI
Ortho Exam
bull Subj Anterior hip pain with flexion
activities
bull Somara ldquoCrdquo Sign
bull Hip Outcome Score
Clohisy MD lsquo89
Diagnosis FAI
bull Ortho Exam
ndash Obj Scour FABER Flex Add IR
ndash Strength Weakness around the hip w dec EMG TFL
bull Diff Dx
ndash Labral Tears Hip OA Tendinopathies of Psoas
bull RO Femoral Stress Fractures
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Trauma experienced thru a SYSTEM
Anatomy of a Chain
Thomas Meyers Anatomy Trains
Tensegrity
Tensional Integrity
Buckminster Fuller
Tensegrity
Buckminster Fuller US Paten lsquo62
Tensegrity
Bikefitcom
Regional
Interdependence
ldquo A musculoskeletal examination model whorsquos time has comerdquo Josh Cleland PT JOBST lsquo95
BULLY
Thoracic spine
Victim
Pressure on
saddle
Feel it yourself
bull Standing feel the foot drop
Be an Inspector to find underlying diagnosis
Or BE THE PLUMMER
STEP 2 FIND IT
Making wise clinical decisions
ldquoThe greater the ignorance the greater the
dogmatismrdquo
Sir William Osler MD
Wise Diagnoses Treatments
Evidence Based
Practice
2005 ASHAs Coordinating Committee on EBP
Best ObjectiveData Research
Clinical Experience
ClientValues - Goals
Wise Clinical Decision
Evidence Informed
Practice
Subjective
Clinical Scientists
Subjective Objective
Develop Hypothesis
Intervention
Id RelevantData
Change Bike Treat Exercise
IT Band aggravated by Seat ht
Knee angle 20 deg PF 120 degPositive Ober Test Current knee discomfort
GOAL Eliminate Lateral Knee Pain currently feeling knee on trainer
Recheck
ldquoThe practice of medicine is an art based on
sciencerdquo
Sir William Osler MD
Be the Detective FIND
Diagnostic Clues
Interview
bull Agg eases
bull Changes since onset of symptoms
bull Trauma Surgeries
Be the Detective FIND the
Relevant Signs
Objective Evaluation
bull Observation
bull ROM
bull Palpation
bull NRM Control Strength
bull Special Tests
Are you sure about your Dx hypothesis
bull You rely on more than
one variable
bull Clustering ndash Rule of 3rsquos
Measuring Certainty
Fagan TJ Nomogram fro Bayes Theorem N Engl J Med 1975
Pattern Recognition
ldquoWhen you hear hoof beats think horses hellip not zebrasrdquo
Theodore Woodard MD
Zebra Medicine
STEP 3
Evaluation and
Treatment of common
LE disorders
PT
MD
Fit
CoachOtheran Integrated Approach
Explore 3 Dx of LE
1) FAI (Femoral Acetabular Impingement)
2) Met Head Pain Metatarsilgia
3) PFPS (Patella Femoral Pain Syndrome)
Visual Animation FAI
In The Headlines
Alex Rodriguez
Barton SilvermanThe New York Times
Hip ndash FAI
Diagnosis FAI
Ortho Exam
bull Subj Anterior hip pain with flexion
activities
bull Somara ldquoCrdquo Sign
bull Hip Outcome Score
Clohisy MD lsquo89
Diagnosis FAI
bull Ortho Exam
ndash Obj Scour FABER Flex Add IR
ndash Strength Weakness around the hip w dec EMG TFL
bull Diff Dx
ndash Labral Tears Hip OA Tendinopathies of Psoas
bull RO Femoral Stress Fractures
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Anatomy of a Chain
Thomas Meyers Anatomy Trains
Tensegrity
Tensional Integrity
Buckminster Fuller
Tensegrity
Buckminster Fuller US Paten lsquo62
Tensegrity
Bikefitcom
Regional
Interdependence
ldquo A musculoskeletal examination model whorsquos time has comerdquo Josh Cleland PT JOBST lsquo95
BULLY
Thoracic spine
Victim
Pressure on
saddle
Feel it yourself
bull Standing feel the foot drop
Be an Inspector to find underlying diagnosis
Or BE THE PLUMMER
STEP 2 FIND IT
Making wise clinical decisions
ldquoThe greater the ignorance the greater the
dogmatismrdquo
Sir William Osler MD
Wise Diagnoses Treatments
Evidence Based
Practice
2005 ASHAs Coordinating Committee on EBP
Best ObjectiveData Research
Clinical Experience
ClientValues - Goals
Wise Clinical Decision
Evidence Informed
Practice
Subjective
Clinical Scientists
Subjective Objective
Develop Hypothesis
Intervention
Id RelevantData
Change Bike Treat Exercise
IT Band aggravated by Seat ht
Knee angle 20 deg PF 120 degPositive Ober Test Current knee discomfort
GOAL Eliminate Lateral Knee Pain currently feeling knee on trainer
Recheck
ldquoThe practice of medicine is an art based on
sciencerdquo
Sir William Osler MD
Be the Detective FIND
Diagnostic Clues
Interview
bull Agg eases
bull Changes since onset of symptoms
bull Trauma Surgeries
Be the Detective FIND the
Relevant Signs
Objective Evaluation
bull Observation
bull ROM
bull Palpation
bull NRM Control Strength
bull Special Tests
Are you sure about your Dx hypothesis
bull You rely on more than
one variable
bull Clustering ndash Rule of 3rsquos
Measuring Certainty
Fagan TJ Nomogram fro Bayes Theorem N Engl J Med 1975
Pattern Recognition
ldquoWhen you hear hoof beats think horses hellip not zebrasrdquo
Theodore Woodard MD
Zebra Medicine
STEP 3
Evaluation and
Treatment of common
LE disorders
PT
MD
Fit
CoachOtheran Integrated Approach
Explore 3 Dx of LE
1) FAI (Femoral Acetabular Impingement)
2) Met Head Pain Metatarsilgia
3) PFPS (Patella Femoral Pain Syndrome)
Visual Animation FAI
In The Headlines
Alex Rodriguez
Barton SilvermanThe New York Times
Hip ndash FAI
Diagnosis FAI
Ortho Exam
bull Subj Anterior hip pain with flexion
activities
bull Somara ldquoCrdquo Sign
bull Hip Outcome Score
Clohisy MD lsquo89
Diagnosis FAI
bull Ortho Exam
ndash Obj Scour FABER Flex Add IR
ndash Strength Weakness around the hip w dec EMG TFL
bull Diff Dx
ndash Labral Tears Hip OA Tendinopathies of Psoas
bull RO Femoral Stress Fractures
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Tensegrity
Tensional Integrity
Buckminster Fuller
Tensegrity
Buckminster Fuller US Paten lsquo62
Tensegrity
Bikefitcom
Regional
Interdependence
ldquo A musculoskeletal examination model whorsquos time has comerdquo Josh Cleland PT JOBST lsquo95
BULLY
Thoracic spine
Victim
Pressure on
saddle
Feel it yourself
bull Standing feel the foot drop
Be an Inspector to find underlying diagnosis
Or BE THE PLUMMER
STEP 2 FIND IT
Making wise clinical decisions
ldquoThe greater the ignorance the greater the
dogmatismrdquo
Sir William Osler MD
Wise Diagnoses Treatments
Evidence Based
Practice
2005 ASHAs Coordinating Committee on EBP
Best ObjectiveData Research
Clinical Experience
ClientValues - Goals
Wise Clinical Decision
Evidence Informed
Practice
Subjective
Clinical Scientists
Subjective Objective
Develop Hypothesis
Intervention
Id RelevantData
Change Bike Treat Exercise
IT Band aggravated by Seat ht
Knee angle 20 deg PF 120 degPositive Ober Test Current knee discomfort
GOAL Eliminate Lateral Knee Pain currently feeling knee on trainer
Recheck
ldquoThe practice of medicine is an art based on
sciencerdquo
Sir William Osler MD
Be the Detective FIND
Diagnostic Clues
Interview
bull Agg eases
bull Changes since onset of symptoms
bull Trauma Surgeries
Be the Detective FIND the
Relevant Signs
Objective Evaluation
bull Observation
bull ROM
bull Palpation
bull NRM Control Strength
bull Special Tests
Are you sure about your Dx hypothesis
bull You rely on more than
one variable
bull Clustering ndash Rule of 3rsquos
Measuring Certainty
Fagan TJ Nomogram fro Bayes Theorem N Engl J Med 1975
Pattern Recognition
ldquoWhen you hear hoof beats think horses hellip not zebrasrdquo
Theodore Woodard MD
Zebra Medicine
STEP 3
Evaluation and
Treatment of common
LE disorders
PT
MD
Fit
CoachOtheran Integrated Approach
Explore 3 Dx of LE
1) FAI (Femoral Acetabular Impingement)
2) Met Head Pain Metatarsilgia
3) PFPS (Patella Femoral Pain Syndrome)
Visual Animation FAI
In The Headlines
Alex Rodriguez
Barton SilvermanThe New York Times
Hip ndash FAI
Diagnosis FAI
Ortho Exam
bull Subj Anterior hip pain with flexion
activities
bull Somara ldquoCrdquo Sign
bull Hip Outcome Score
Clohisy MD lsquo89
Diagnosis FAI
bull Ortho Exam
ndash Obj Scour FABER Flex Add IR
ndash Strength Weakness around the hip w dec EMG TFL
bull Diff Dx
ndash Labral Tears Hip OA Tendinopathies of Psoas
bull RO Femoral Stress Fractures
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Tensegrity
Buckminster Fuller US Paten lsquo62
Tensegrity
Bikefitcom
Regional
Interdependence
ldquo A musculoskeletal examination model whorsquos time has comerdquo Josh Cleland PT JOBST lsquo95
BULLY
Thoracic spine
Victim
Pressure on
saddle
Feel it yourself
bull Standing feel the foot drop
Be an Inspector to find underlying diagnosis
Or BE THE PLUMMER
STEP 2 FIND IT
Making wise clinical decisions
ldquoThe greater the ignorance the greater the
dogmatismrdquo
Sir William Osler MD
Wise Diagnoses Treatments
Evidence Based
Practice
2005 ASHAs Coordinating Committee on EBP
Best ObjectiveData Research
Clinical Experience
ClientValues - Goals
Wise Clinical Decision
Evidence Informed
Practice
Subjective
Clinical Scientists
Subjective Objective
Develop Hypothesis
Intervention
Id RelevantData
Change Bike Treat Exercise
IT Band aggravated by Seat ht
Knee angle 20 deg PF 120 degPositive Ober Test Current knee discomfort
GOAL Eliminate Lateral Knee Pain currently feeling knee on trainer
Recheck
ldquoThe practice of medicine is an art based on
sciencerdquo
Sir William Osler MD
Be the Detective FIND
Diagnostic Clues
Interview
bull Agg eases
bull Changes since onset of symptoms
bull Trauma Surgeries
Be the Detective FIND the
Relevant Signs
Objective Evaluation
bull Observation
bull ROM
bull Palpation
bull NRM Control Strength
bull Special Tests
Are you sure about your Dx hypothesis
bull You rely on more than
one variable
bull Clustering ndash Rule of 3rsquos
Measuring Certainty
Fagan TJ Nomogram fro Bayes Theorem N Engl J Med 1975
Pattern Recognition
ldquoWhen you hear hoof beats think horses hellip not zebrasrdquo
Theodore Woodard MD
Zebra Medicine
STEP 3
Evaluation and
Treatment of common
LE disorders
PT
MD
Fit
CoachOtheran Integrated Approach
Explore 3 Dx of LE
1) FAI (Femoral Acetabular Impingement)
2) Met Head Pain Metatarsilgia
3) PFPS (Patella Femoral Pain Syndrome)
Visual Animation FAI
In The Headlines
Alex Rodriguez
Barton SilvermanThe New York Times
Hip ndash FAI
Diagnosis FAI
Ortho Exam
bull Subj Anterior hip pain with flexion
activities
bull Somara ldquoCrdquo Sign
bull Hip Outcome Score
Clohisy MD lsquo89
Diagnosis FAI
bull Ortho Exam
ndash Obj Scour FABER Flex Add IR
ndash Strength Weakness around the hip w dec EMG TFL
bull Diff Dx
ndash Labral Tears Hip OA Tendinopathies of Psoas
bull RO Femoral Stress Fractures
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Tensegrity
Bikefitcom
Regional
Interdependence
ldquo A musculoskeletal examination model whorsquos time has comerdquo Josh Cleland PT JOBST lsquo95
BULLY
Thoracic spine
Victim
Pressure on
saddle
Feel it yourself
bull Standing feel the foot drop
Be an Inspector to find underlying diagnosis
Or BE THE PLUMMER
STEP 2 FIND IT
Making wise clinical decisions
ldquoThe greater the ignorance the greater the
dogmatismrdquo
Sir William Osler MD
Wise Diagnoses Treatments
Evidence Based
Practice
2005 ASHAs Coordinating Committee on EBP
Best ObjectiveData Research
Clinical Experience
ClientValues - Goals
Wise Clinical Decision
Evidence Informed
Practice
Subjective
Clinical Scientists
Subjective Objective
Develop Hypothesis
Intervention
Id RelevantData
Change Bike Treat Exercise
IT Band aggravated by Seat ht
Knee angle 20 deg PF 120 degPositive Ober Test Current knee discomfort
GOAL Eliminate Lateral Knee Pain currently feeling knee on trainer
Recheck
ldquoThe practice of medicine is an art based on
sciencerdquo
Sir William Osler MD
Be the Detective FIND
Diagnostic Clues
Interview
bull Agg eases
bull Changes since onset of symptoms
bull Trauma Surgeries
Be the Detective FIND the
Relevant Signs
Objective Evaluation
bull Observation
bull ROM
bull Palpation
bull NRM Control Strength
bull Special Tests
Are you sure about your Dx hypothesis
bull You rely on more than
one variable
bull Clustering ndash Rule of 3rsquos
Measuring Certainty
Fagan TJ Nomogram fro Bayes Theorem N Engl J Med 1975
Pattern Recognition
ldquoWhen you hear hoof beats think horses hellip not zebrasrdquo
Theodore Woodard MD
Zebra Medicine
STEP 3
Evaluation and
Treatment of common
LE disorders
PT
MD
Fit
CoachOtheran Integrated Approach
Explore 3 Dx of LE
1) FAI (Femoral Acetabular Impingement)
2) Met Head Pain Metatarsilgia
3) PFPS (Patella Femoral Pain Syndrome)
Visual Animation FAI
In The Headlines
Alex Rodriguez
Barton SilvermanThe New York Times
Hip ndash FAI
Diagnosis FAI
Ortho Exam
bull Subj Anterior hip pain with flexion
activities
bull Somara ldquoCrdquo Sign
bull Hip Outcome Score
Clohisy MD lsquo89
Diagnosis FAI
bull Ortho Exam
ndash Obj Scour FABER Flex Add IR
ndash Strength Weakness around the hip w dec EMG TFL
bull Diff Dx
ndash Labral Tears Hip OA Tendinopathies of Psoas
bull RO Femoral Stress Fractures
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Regional
Interdependence
ldquo A musculoskeletal examination model whorsquos time has comerdquo Josh Cleland PT JOBST lsquo95
BULLY
Thoracic spine
Victim
Pressure on
saddle
Feel it yourself
bull Standing feel the foot drop
Be an Inspector to find underlying diagnosis
Or BE THE PLUMMER
STEP 2 FIND IT
Making wise clinical decisions
ldquoThe greater the ignorance the greater the
dogmatismrdquo
Sir William Osler MD
Wise Diagnoses Treatments
Evidence Based
Practice
2005 ASHAs Coordinating Committee on EBP
Best ObjectiveData Research
Clinical Experience
ClientValues - Goals
Wise Clinical Decision
Evidence Informed
Practice
Subjective
Clinical Scientists
Subjective Objective
Develop Hypothesis
Intervention
Id RelevantData
Change Bike Treat Exercise
IT Band aggravated by Seat ht
Knee angle 20 deg PF 120 degPositive Ober Test Current knee discomfort
GOAL Eliminate Lateral Knee Pain currently feeling knee on trainer
Recheck
ldquoThe practice of medicine is an art based on
sciencerdquo
Sir William Osler MD
Be the Detective FIND
Diagnostic Clues
Interview
bull Agg eases
bull Changes since onset of symptoms
bull Trauma Surgeries
Be the Detective FIND the
Relevant Signs
Objective Evaluation
bull Observation
bull ROM
bull Palpation
bull NRM Control Strength
bull Special Tests
Are you sure about your Dx hypothesis
bull You rely on more than
one variable
bull Clustering ndash Rule of 3rsquos
Measuring Certainty
Fagan TJ Nomogram fro Bayes Theorem N Engl J Med 1975
Pattern Recognition
ldquoWhen you hear hoof beats think horses hellip not zebrasrdquo
Theodore Woodard MD
Zebra Medicine
STEP 3
Evaluation and
Treatment of common
LE disorders
PT
MD
Fit
CoachOtheran Integrated Approach
Explore 3 Dx of LE
1) FAI (Femoral Acetabular Impingement)
2) Met Head Pain Metatarsilgia
3) PFPS (Patella Femoral Pain Syndrome)
Visual Animation FAI
In The Headlines
Alex Rodriguez
Barton SilvermanThe New York Times
Hip ndash FAI
Diagnosis FAI
Ortho Exam
bull Subj Anterior hip pain with flexion
activities
bull Somara ldquoCrdquo Sign
bull Hip Outcome Score
Clohisy MD lsquo89
Diagnosis FAI
bull Ortho Exam
ndash Obj Scour FABER Flex Add IR
ndash Strength Weakness around the hip w dec EMG TFL
bull Diff Dx
ndash Labral Tears Hip OA Tendinopathies of Psoas
bull RO Femoral Stress Fractures
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
BULLY
Thoracic spine
Victim
Pressure on
saddle
Feel it yourself
bull Standing feel the foot drop
Be an Inspector to find underlying diagnosis
Or BE THE PLUMMER
STEP 2 FIND IT
Making wise clinical decisions
ldquoThe greater the ignorance the greater the
dogmatismrdquo
Sir William Osler MD
Wise Diagnoses Treatments
Evidence Based
Practice
2005 ASHAs Coordinating Committee on EBP
Best ObjectiveData Research
Clinical Experience
ClientValues - Goals
Wise Clinical Decision
Evidence Informed
Practice
Subjective
Clinical Scientists
Subjective Objective
Develop Hypothesis
Intervention
Id RelevantData
Change Bike Treat Exercise
IT Band aggravated by Seat ht
Knee angle 20 deg PF 120 degPositive Ober Test Current knee discomfort
GOAL Eliminate Lateral Knee Pain currently feeling knee on trainer
Recheck
ldquoThe practice of medicine is an art based on
sciencerdquo
Sir William Osler MD
Be the Detective FIND
Diagnostic Clues
Interview
bull Agg eases
bull Changes since onset of symptoms
bull Trauma Surgeries
Be the Detective FIND the
Relevant Signs
Objective Evaluation
bull Observation
bull ROM
bull Palpation
bull NRM Control Strength
bull Special Tests
Are you sure about your Dx hypothesis
bull You rely on more than
one variable
bull Clustering ndash Rule of 3rsquos
Measuring Certainty
Fagan TJ Nomogram fro Bayes Theorem N Engl J Med 1975
Pattern Recognition
ldquoWhen you hear hoof beats think horses hellip not zebrasrdquo
Theodore Woodard MD
Zebra Medicine
STEP 3
Evaluation and
Treatment of common
LE disorders
PT
MD
Fit
CoachOtheran Integrated Approach
Explore 3 Dx of LE
1) FAI (Femoral Acetabular Impingement)
2) Met Head Pain Metatarsilgia
3) PFPS (Patella Femoral Pain Syndrome)
Visual Animation FAI
In The Headlines
Alex Rodriguez
Barton SilvermanThe New York Times
Hip ndash FAI
Diagnosis FAI
Ortho Exam
bull Subj Anterior hip pain with flexion
activities
bull Somara ldquoCrdquo Sign
bull Hip Outcome Score
Clohisy MD lsquo89
Diagnosis FAI
bull Ortho Exam
ndash Obj Scour FABER Flex Add IR
ndash Strength Weakness around the hip w dec EMG TFL
bull Diff Dx
ndash Labral Tears Hip OA Tendinopathies of Psoas
bull RO Femoral Stress Fractures
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Feel it yourself
bull Standing feel the foot drop
Be an Inspector to find underlying diagnosis
Or BE THE PLUMMER
STEP 2 FIND IT
Making wise clinical decisions
ldquoThe greater the ignorance the greater the
dogmatismrdquo
Sir William Osler MD
Wise Diagnoses Treatments
Evidence Based
Practice
2005 ASHAs Coordinating Committee on EBP
Best ObjectiveData Research
Clinical Experience
ClientValues - Goals
Wise Clinical Decision
Evidence Informed
Practice
Subjective
Clinical Scientists
Subjective Objective
Develop Hypothesis
Intervention
Id RelevantData
Change Bike Treat Exercise
IT Band aggravated by Seat ht
Knee angle 20 deg PF 120 degPositive Ober Test Current knee discomfort
GOAL Eliminate Lateral Knee Pain currently feeling knee on trainer
Recheck
ldquoThe practice of medicine is an art based on
sciencerdquo
Sir William Osler MD
Be the Detective FIND
Diagnostic Clues
Interview
bull Agg eases
bull Changes since onset of symptoms
bull Trauma Surgeries
Be the Detective FIND the
Relevant Signs
Objective Evaluation
bull Observation
bull ROM
bull Palpation
bull NRM Control Strength
bull Special Tests
Are you sure about your Dx hypothesis
bull You rely on more than
one variable
bull Clustering ndash Rule of 3rsquos
Measuring Certainty
Fagan TJ Nomogram fro Bayes Theorem N Engl J Med 1975
Pattern Recognition
ldquoWhen you hear hoof beats think horses hellip not zebrasrdquo
Theodore Woodard MD
Zebra Medicine
STEP 3
Evaluation and
Treatment of common
LE disorders
PT
MD
Fit
CoachOtheran Integrated Approach
Explore 3 Dx of LE
1) FAI (Femoral Acetabular Impingement)
2) Met Head Pain Metatarsilgia
3) PFPS (Patella Femoral Pain Syndrome)
Visual Animation FAI
In The Headlines
Alex Rodriguez
Barton SilvermanThe New York Times
Hip ndash FAI
Diagnosis FAI
Ortho Exam
bull Subj Anterior hip pain with flexion
activities
bull Somara ldquoCrdquo Sign
bull Hip Outcome Score
Clohisy MD lsquo89
Diagnosis FAI
bull Ortho Exam
ndash Obj Scour FABER Flex Add IR
ndash Strength Weakness around the hip w dec EMG TFL
bull Diff Dx
ndash Labral Tears Hip OA Tendinopathies of Psoas
bull RO Femoral Stress Fractures
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Be an Inspector to find underlying diagnosis
Or BE THE PLUMMER
STEP 2 FIND IT
Making wise clinical decisions
ldquoThe greater the ignorance the greater the
dogmatismrdquo
Sir William Osler MD
Wise Diagnoses Treatments
Evidence Based
Practice
2005 ASHAs Coordinating Committee on EBP
Best ObjectiveData Research
Clinical Experience
ClientValues - Goals
Wise Clinical Decision
Evidence Informed
Practice
Subjective
Clinical Scientists
Subjective Objective
Develop Hypothesis
Intervention
Id RelevantData
Change Bike Treat Exercise
IT Band aggravated by Seat ht
Knee angle 20 deg PF 120 degPositive Ober Test Current knee discomfort
GOAL Eliminate Lateral Knee Pain currently feeling knee on trainer
Recheck
ldquoThe practice of medicine is an art based on
sciencerdquo
Sir William Osler MD
Be the Detective FIND
Diagnostic Clues
Interview
bull Agg eases
bull Changes since onset of symptoms
bull Trauma Surgeries
Be the Detective FIND the
Relevant Signs
Objective Evaluation
bull Observation
bull ROM
bull Palpation
bull NRM Control Strength
bull Special Tests
Are you sure about your Dx hypothesis
bull You rely on more than
one variable
bull Clustering ndash Rule of 3rsquos
Measuring Certainty
Fagan TJ Nomogram fro Bayes Theorem N Engl J Med 1975
Pattern Recognition
ldquoWhen you hear hoof beats think horses hellip not zebrasrdquo
Theodore Woodard MD
Zebra Medicine
STEP 3
Evaluation and
Treatment of common
LE disorders
PT
MD
Fit
CoachOtheran Integrated Approach
Explore 3 Dx of LE
1) FAI (Femoral Acetabular Impingement)
2) Met Head Pain Metatarsilgia
3) PFPS (Patella Femoral Pain Syndrome)
Visual Animation FAI
In The Headlines
Alex Rodriguez
Barton SilvermanThe New York Times
Hip ndash FAI
Diagnosis FAI
Ortho Exam
bull Subj Anterior hip pain with flexion
activities
bull Somara ldquoCrdquo Sign
bull Hip Outcome Score
Clohisy MD lsquo89
Diagnosis FAI
bull Ortho Exam
ndash Obj Scour FABER Flex Add IR
ndash Strength Weakness around the hip w dec EMG TFL
bull Diff Dx
ndash Labral Tears Hip OA Tendinopathies of Psoas
bull RO Femoral Stress Fractures
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
STEP 2 FIND IT
Making wise clinical decisions
ldquoThe greater the ignorance the greater the
dogmatismrdquo
Sir William Osler MD
Wise Diagnoses Treatments
Evidence Based
Practice
2005 ASHAs Coordinating Committee on EBP
Best ObjectiveData Research
Clinical Experience
ClientValues - Goals
Wise Clinical Decision
Evidence Informed
Practice
Subjective
Clinical Scientists
Subjective Objective
Develop Hypothesis
Intervention
Id RelevantData
Change Bike Treat Exercise
IT Band aggravated by Seat ht
Knee angle 20 deg PF 120 degPositive Ober Test Current knee discomfort
GOAL Eliminate Lateral Knee Pain currently feeling knee on trainer
Recheck
ldquoThe practice of medicine is an art based on
sciencerdquo
Sir William Osler MD
Be the Detective FIND
Diagnostic Clues
Interview
bull Agg eases
bull Changes since onset of symptoms
bull Trauma Surgeries
Be the Detective FIND the
Relevant Signs
Objective Evaluation
bull Observation
bull ROM
bull Palpation
bull NRM Control Strength
bull Special Tests
Are you sure about your Dx hypothesis
bull You rely on more than
one variable
bull Clustering ndash Rule of 3rsquos
Measuring Certainty
Fagan TJ Nomogram fro Bayes Theorem N Engl J Med 1975
Pattern Recognition
ldquoWhen you hear hoof beats think horses hellip not zebrasrdquo
Theodore Woodard MD
Zebra Medicine
STEP 3
Evaluation and
Treatment of common
LE disorders
PT
MD
Fit
CoachOtheran Integrated Approach
Explore 3 Dx of LE
1) FAI (Femoral Acetabular Impingement)
2) Met Head Pain Metatarsilgia
3) PFPS (Patella Femoral Pain Syndrome)
Visual Animation FAI
In The Headlines
Alex Rodriguez
Barton SilvermanThe New York Times
Hip ndash FAI
Diagnosis FAI
Ortho Exam
bull Subj Anterior hip pain with flexion
activities
bull Somara ldquoCrdquo Sign
bull Hip Outcome Score
Clohisy MD lsquo89
Diagnosis FAI
bull Ortho Exam
ndash Obj Scour FABER Flex Add IR
ndash Strength Weakness around the hip w dec EMG TFL
bull Diff Dx
ndash Labral Tears Hip OA Tendinopathies of Psoas
bull RO Femoral Stress Fractures
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
ldquoThe greater the ignorance the greater the
dogmatismrdquo
Sir William Osler MD
Wise Diagnoses Treatments
Evidence Based
Practice
2005 ASHAs Coordinating Committee on EBP
Best ObjectiveData Research
Clinical Experience
ClientValues - Goals
Wise Clinical Decision
Evidence Informed
Practice
Subjective
Clinical Scientists
Subjective Objective
Develop Hypothesis
Intervention
Id RelevantData
Change Bike Treat Exercise
IT Band aggravated by Seat ht
Knee angle 20 deg PF 120 degPositive Ober Test Current knee discomfort
GOAL Eliminate Lateral Knee Pain currently feeling knee on trainer
Recheck
ldquoThe practice of medicine is an art based on
sciencerdquo
Sir William Osler MD
Be the Detective FIND
Diagnostic Clues
Interview
bull Agg eases
bull Changes since onset of symptoms
bull Trauma Surgeries
Be the Detective FIND the
Relevant Signs
Objective Evaluation
bull Observation
bull ROM
bull Palpation
bull NRM Control Strength
bull Special Tests
Are you sure about your Dx hypothesis
bull You rely on more than
one variable
bull Clustering ndash Rule of 3rsquos
Measuring Certainty
Fagan TJ Nomogram fro Bayes Theorem N Engl J Med 1975
Pattern Recognition
ldquoWhen you hear hoof beats think horses hellip not zebrasrdquo
Theodore Woodard MD
Zebra Medicine
STEP 3
Evaluation and
Treatment of common
LE disorders
PT
MD
Fit
CoachOtheran Integrated Approach
Explore 3 Dx of LE
1) FAI (Femoral Acetabular Impingement)
2) Met Head Pain Metatarsilgia
3) PFPS (Patella Femoral Pain Syndrome)
Visual Animation FAI
In The Headlines
Alex Rodriguez
Barton SilvermanThe New York Times
Hip ndash FAI
Diagnosis FAI
Ortho Exam
bull Subj Anterior hip pain with flexion
activities
bull Somara ldquoCrdquo Sign
bull Hip Outcome Score
Clohisy MD lsquo89
Diagnosis FAI
bull Ortho Exam
ndash Obj Scour FABER Flex Add IR
ndash Strength Weakness around the hip w dec EMG TFL
bull Diff Dx
ndash Labral Tears Hip OA Tendinopathies of Psoas
bull RO Femoral Stress Fractures
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Wise Diagnoses Treatments
Evidence Based
Practice
2005 ASHAs Coordinating Committee on EBP
Best ObjectiveData Research
Clinical Experience
ClientValues - Goals
Wise Clinical Decision
Evidence Informed
Practice
Subjective
Clinical Scientists
Subjective Objective
Develop Hypothesis
Intervention
Id RelevantData
Change Bike Treat Exercise
IT Band aggravated by Seat ht
Knee angle 20 deg PF 120 degPositive Ober Test Current knee discomfort
GOAL Eliminate Lateral Knee Pain currently feeling knee on trainer
Recheck
ldquoThe practice of medicine is an art based on
sciencerdquo
Sir William Osler MD
Be the Detective FIND
Diagnostic Clues
Interview
bull Agg eases
bull Changes since onset of symptoms
bull Trauma Surgeries
Be the Detective FIND the
Relevant Signs
Objective Evaluation
bull Observation
bull ROM
bull Palpation
bull NRM Control Strength
bull Special Tests
Are you sure about your Dx hypothesis
bull You rely on more than
one variable
bull Clustering ndash Rule of 3rsquos
Measuring Certainty
Fagan TJ Nomogram fro Bayes Theorem N Engl J Med 1975
Pattern Recognition
ldquoWhen you hear hoof beats think horses hellip not zebrasrdquo
Theodore Woodard MD
Zebra Medicine
STEP 3
Evaluation and
Treatment of common
LE disorders
PT
MD
Fit
CoachOtheran Integrated Approach
Explore 3 Dx of LE
1) FAI (Femoral Acetabular Impingement)
2) Met Head Pain Metatarsilgia
3) PFPS (Patella Femoral Pain Syndrome)
Visual Animation FAI
In The Headlines
Alex Rodriguez
Barton SilvermanThe New York Times
Hip ndash FAI
Diagnosis FAI
Ortho Exam
bull Subj Anterior hip pain with flexion
activities
bull Somara ldquoCrdquo Sign
bull Hip Outcome Score
Clohisy MD lsquo89
Diagnosis FAI
bull Ortho Exam
ndash Obj Scour FABER Flex Add IR
ndash Strength Weakness around the hip w dec EMG TFL
bull Diff Dx
ndash Labral Tears Hip OA Tendinopathies of Psoas
bull RO Femoral Stress Fractures
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Subjective
Clinical Scientists
Subjective Objective
Develop Hypothesis
Intervention
Id RelevantData
Change Bike Treat Exercise
IT Band aggravated by Seat ht
Knee angle 20 deg PF 120 degPositive Ober Test Current knee discomfort
GOAL Eliminate Lateral Knee Pain currently feeling knee on trainer
Recheck
ldquoThe practice of medicine is an art based on
sciencerdquo
Sir William Osler MD
Be the Detective FIND
Diagnostic Clues
Interview
bull Agg eases
bull Changes since onset of symptoms
bull Trauma Surgeries
Be the Detective FIND the
Relevant Signs
Objective Evaluation
bull Observation
bull ROM
bull Palpation
bull NRM Control Strength
bull Special Tests
Are you sure about your Dx hypothesis
bull You rely on more than
one variable
bull Clustering ndash Rule of 3rsquos
Measuring Certainty
Fagan TJ Nomogram fro Bayes Theorem N Engl J Med 1975
Pattern Recognition
ldquoWhen you hear hoof beats think horses hellip not zebrasrdquo
Theodore Woodard MD
Zebra Medicine
STEP 3
Evaluation and
Treatment of common
LE disorders
PT
MD
Fit
CoachOtheran Integrated Approach
Explore 3 Dx of LE
1) FAI (Femoral Acetabular Impingement)
2) Met Head Pain Metatarsilgia
3) PFPS (Patella Femoral Pain Syndrome)
Visual Animation FAI
In The Headlines
Alex Rodriguez
Barton SilvermanThe New York Times
Hip ndash FAI
Diagnosis FAI
Ortho Exam
bull Subj Anterior hip pain with flexion
activities
bull Somara ldquoCrdquo Sign
bull Hip Outcome Score
Clohisy MD lsquo89
Diagnosis FAI
bull Ortho Exam
ndash Obj Scour FABER Flex Add IR
ndash Strength Weakness around the hip w dec EMG TFL
bull Diff Dx
ndash Labral Tears Hip OA Tendinopathies of Psoas
bull RO Femoral Stress Fractures
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
ldquoThe practice of medicine is an art based on
sciencerdquo
Sir William Osler MD
Be the Detective FIND
Diagnostic Clues
Interview
bull Agg eases
bull Changes since onset of symptoms
bull Trauma Surgeries
Be the Detective FIND the
Relevant Signs
Objective Evaluation
bull Observation
bull ROM
bull Palpation
bull NRM Control Strength
bull Special Tests
Are you sure about your Dx hypothesis
bull You rely on more than
one variable
bull Clustering ndash Rule of 3rsquos
Measuring Certainty
Fagan TJ Nomogram fro Bayes Theorem N Engl J Med 1975
Pattern Recognition
ldquoWhen you hear hoof beats think horses hellip not zebrasrdquo
Theodore Woodard MD
Zebra Medicine
STEP 3
Evaluation and
Treatment of common
LE disorders
PT
MD
Fit
CoachOtheran Integrated Approach
Explore 3 Dx of LE
1) FAI (Femoral Acetabular Impingement)
2) Met Head Pain Metatarsilgia
3) PFPS (Patella Femoral Pain Syndrome)
Visual Animation FAI
In The Headlines
Alex Rodriguez
Barton SilvermanThe New York Times
Hip ndash FAI
Diagnosis FAI
Ortho Exam
bull Subj Anterior hip pain with flexion
activities
bull Somara ldquoCrdquo Sign
bull Hip Outcome Score
Clohisy MD lsquo89
Diagnosis FAI
bull Ortho Exam
ndash Obj Scour FABER Flex Add IR
ndash Strength Weakness around the hip w dec EMG TFL
bull Diff Dx
ndash Labral Tears Hip OA Tendinopathies of Psoas
bull RO Femoral Stress Fractures
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Be the Detective FIND
Diagnostic Clues
Interview
bull Agg eases
bull Changes since onset of symptoms
bull Trauma Surgeries
Be the Detective FIND the
Relevant Signs
Objective Evaluation
bull Observation
bull ROM
bull Palpation
bull NRM Control Strength
bull Special Tests
Are you sure about your Dx hypothesis
bull You rely on more than
one variable
bull Clustering ndash Rule of 3rsquos
Measuring Certainty
Fagan TJ Nomogram fro Bayes Theorem N Engl J Med 1975
Pattern Recognition
ldquoWhen you hear hoof beats think horses hellip not zebrasrdquo
Theodore Woodard MD
Zebra Medicine
STEP 3
Evaluation and
Treatment of common
LE disorders
PT
MD
Fit
CoachOtheran Integrated Approach
Explore 3 Dx of LE
1) FAI (Femoral Acetabular Impingement)
2) Met Head Pain Metatarsilgia
3) PFPS (Patella Femoral Pain Syndrome)
Visual Animation FAI
In The Headlines
Alex Rodriguez
Barton SilvermanThe New York Times
Hip ndash FAI
Diagnosis FAI
Ortho Exam
bull Subj Anterior hip pain with flexion
activities
bull Somara ldquoCrdquo Sign
bull Hip Outcome Score
Clohisy MD lsquo89
Diagnosis FAI
bull Ortho Exam
ndash Obj Scour FABER Flex Add IR
ndash Strength Weakness around the hip w dec EMG TFL
bull Diff Dx
ndash Labral Tears Hip OA Tendinopathies of Psoas
bull RO Femoral Stress Fractures
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Be the Detective FIND the
Relevant Signs
Objective Evaluation
bull Observation
bull ROM
bull Palpation
bull NRM Control Strength
bull Special Tests
Are you sure about your Dx hypothesis
bull You rely on more than
one variable
bull Clustering ndash Rule of 3rsquos
Measuring Certainty
Fagan TJ Nomogram fro Bayes Theorem N Engl J Med 1975
Pattern Recognition
ldquoWhen you hear hoof beats think horses hellip not zebrasrdquo
Theodore Woodard MD
Zebra Medicine
STEP 3
Evaluation and
Treatment of common
LE disorders
PT
MD
Fit
CoachOtheran Integrated Approach
Explore 3 Dx of LE
1) FAI (Femoral Acetabular Impingement)
2) Met Head Pain Metatarsilgia
3) PFPS (Patella Femoral Pain Syndrome)
Visual Animation FAI
In The Headlines
Alex Rodriguez
Barton SilvermanThe New York Times
Hip ndash FAI
Diagnosis FAI
Ortho Exam
bull Subj Anterior hip pain with flexion
activities
bull Somara ldquoCrdquo Sign
bull Hip Outcome Score
Clohisy MD lsquo89
Diagnosis FAI
bull Ortho Exam
ndash Obj Scour FABER Flex Add IR
ndash Strength Weakness around the hip w dec EMG TFL
bull Diff Dx
ndash Labral Tears Hip OA Tendinopathies of Psoas
bull RO Femoral Stress Fractures
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Are you sure about your Dx hypothesis
bull You rely on more than
one variable
bull Clustering ndash Rule of 3rsquos
Measuring Certainty
Fagan TJ Nomogram fro Bayes Theorem N Engl J Med 1975
Pattern Recognition
ldquoWhen you hear hoof beats think horses hellip not zebrasrdquo
Theodore Woodard MD
Zebra Medicine
STEP 3
Evaluation and
Treatment of common
LE disorders
PT
MD
Fit
CoachOtheran Integrated Approach
Explore 3 Dx of LE
1) FAI (Femoral Acetabular Impingement)
2) Met Head Pain Metatarsilgia
3) PFPS (Patella Femoral Pain Syndrome)
Visual Animation FAI
In The Headlines
Alex Rodriguez
Barton SilvermanThe New York Times
Hip ndash FAI
Diagnosis FAI
Ortho Exam
bull Subj Anterior hip pain with flexion
activities
bull Somara ldquoCrdquo Sign
bull Hip Outcome Score
Clohisy MD lsquo89
Diagnosis FAI
bull Ortho Exam
ndash Obj Scour FABER Flex Add IR
ndash Strength Weakness around the hip w dec EMG TFL
bull Diff Dx
ndash Labral Tears Hip OA Tendinopathies of Psoas
bull RO Femoral Stress Fractures
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Pattern Recognition
ldquoWhen you hear hoof beats think horses hellip not zebrasrdquo
Theodore Woodard MD
Zebra Medicine
STEP 3
Evaluation and
Treatment of common
LE disorders
PT
MD
Fit
CoachOtheran Integrated Approach
Explore 3 Dx of LE
1) FAI (Femoral Acetabular Impingement)
2) Met Head Pain Metatarsilgia
3) PFPS (Patella Femoral Pain Syndrome)
Visual Animation FAI
In The Headlines
Alex Rodriguez
Barton SilvermanThe New York Times
Hip ndash FAI
Diagnosis FAI
Ortho Exam
bull Subj Anterior hip pain with flexion
activities
bull Somara ldquoCrdquo Sign
bull Hip Outcome Score
Clohisy MD lsquo89
Diagnosis FAI
bull Ortho Exam
ndash Obj Scour FABER Flex Add IR
ndash Strength Weakness around the hip w dec EMG TFL
bull Diff Dx
ndash Labral Tears Hip OA Tendinopathies of Psoas
bull RO Femoral Stress Fractures
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
STEP 3
Evaluation and
Treatment of common
LE disorders
PT
MD
Fit
CoachOtheran Integrated Approach
Explore 3 Dx of LE
1) FAI (Femoral Acetabular Impingement)
2) Met Head Pain Metatarsilgia
3) PFPS (Patella Femoral Pain Syndrome)
Visual Animation FAI
In The Headlines
Alex Rodriguez
Barton SilvermanThe New York Times
Hip ndash FAI
Diagnosis FAI
Ortho Exam
bull Subj Anterior hip pain with flexion
activities
bull Somara ldquoCrdquo Sign
bull Hip Outcome Score
Clohisy MD lsquo89
Diagnosis FAI
bull Ortho Exam
ndash Obj Scour FABER Flex Add IR
ndash Strength Weakness around the hip w dec EMG TFL
bull Diff Dx
ndash Labral Tears Hip OA Tendinopathies of Psoas
bull RO Femoral Stress Fractures
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Explore 3 Dx of LE
1) FAI (Femoral Acetabular Impingement)
2) Met Head Pain Metatarsilgia
3) PFPS (Patella Femoral Pain Syndrome)
Visual Animation FAI
In The Headlines
Alex Rodriguez
Barton SilvermanThe New York Times
Hip ndash FAI
Diagnosis FAI
Ortho Exam
bull Subj Anterior hip pain with flexion
activities
bull Somara ldquoCrdquo Sign
bull Hip Outcome Score
Clohisy MD lsquo89
Diagnosis FAI
bull Ortho Exam
ndash Obj Scour FABER Flex Add IR
ndash Strength Weakness around the hip w dec EMG TFL
bull Diff Dx
ndash Labral Tears Hip OA Tendinopathies of Psoas
bull RO Femoral Stress Fractures
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Visual Animation FAI
In The Headlines
Alex Rodriguez
Barton SilvermanThe New York Times
Hip ndash FAI
Diagnosis FAI
Ortho Exam
bull Subj Anterior hip pain with flexion
activities
bull Somara ldquoCrdquo Sign
bull Hip Outcome Score
Clohisy MD lsquo89
Diagnosis FAI
bull Ortho Exam
ndash Obj Scour FABER Flex Add IR
ndash Strength Weakness around the hip w dec EMG TFL
bull Diff Dx
ndash Labral Tears Hip OA Tendinopathies of Psoas
bull RO Femoral Stress Fractures
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
In The Headlines
Alex Rodriguez
Barton SilvermanThe New York Times
Hip ndash FAI
Diagnosis FAI
Ortho Exam
bull Subj Anterior hip pain with flexion
activities
bull Somara ldquoCrdquo Sign
bull Hip Outcome Score
Clohisy MD lsquo89
Diagnosis FAI
bull Ortho Exam
ndash Obj Scour FABER Flex Add IR
ndash Strength Weakness around the hip w dec EMG TFL
bull Diff Dx
ndash Labral Tears Hip OA Tendinopathies of Psoas
bull RO Femoral Stress Fractures
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Hip ndash FAI
Diagnosis FAI
Ortho Exam
bull Subj Anterior hip pain with flexion
activities
bull Somara ldquoCrdquo Sign
bull Hip Outcome Score
Clohisy MD lsquo89
Diagnosis FAI
bull Ortho Exam
ndash Obj Scour FABER Flex Add IR
ndash Strength Weakness around the hip w dec EMG TFL
bull Diff Dx
ndash Labral Tears Hip OA Tendinopathies of Psoas
bull RO Femoral Stress Fractures
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Diagnosis FAI
Ortho Exam
bull Subj Anterior hip pain with flexion
activities
bull Somara ldquoCrdquo Sign
bull Hip Outcome Score
Clohisy MD lsquo89
Diagnosis FAI
bull Ortho Exam
ndash Obj Scour FABER Flex Add IR
ndash Strength Weakness around the hip w dec EMG TFL
bull Diff Dx
ndash Labral Tears Hip OA Tendinopathies of Psoas
bull RO Femoral Stress Fractures
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Diagnosis FAI
bull Ortho Exam
ndash Obj Scour FABER Flex Add IR
ndash Strength Weakness around the hip w dec EMG TFL
bull Diff Dx
ndash Labral Tears Hip OA Tendinopathies of Psoas
bull RO Femoral Stress Fractures
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Special Tests
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Special Tests
MR Arthrography
MR Arthrogram
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
FAI Conservative Care
Nonoperative treatment for femoroacetabular impingement a
systematic review of the literature
bull Review of 48 articles published 2013 PM R Wall PD et al
bull SYNTHESIS (65 of articles indicated a trial of conservative
care was appropriate)
bull CONCLUSION Although the available literature with
experimental data is limited there is a suggestion that physical
therapy and activity modification confer some benefit to patients
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Integrated Treatment
bull Fit Open hip - handle bars crank arm length
seat position
bull PT Balanced hip pelvic mobility strength
gluteals stability core
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Integrated Treatment
bull Coach
ndash Pedaling style to much pull up
ndash Time in drops
ndash Modification of intensity duration
bull MD NSAIDs Injections Surgical Intervention
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
From the hip to the foot
A Regional Interdependence Model
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Metatarsalgia
bull Collection of Dx
bull Diff Dx
ndash Arterial stress Fx
bursitis fat pad hellip
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Diagnosis
bull Ortho Exam
ndash Palpation (Mulders click) Heel Raises
immediately vs after multiples fx vs msk eval
bull Special Tests
ndash Ultra sound Diagnostic injections
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Integrated Treatment
PT
MD
Fit
CoachOther
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Integrated Treatment
Bike fit Shoe Fit
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Itrsquos Been Done
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Integrated Treatmentbull Fit Shoes
Oscar Freire
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Integrated Treatment
bull Fit Shoes
ndash Width
ndash Length
ndash Volume
Shoe test inser
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Integrated Treatment
bull Fit
ndash foot bed Orthotics (12)
ndash size of pedal cleat
ndash cleat placement
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Integrated Treatment
bull PT
ndash Foot and Calf mobility
ndash foot intrinsic NRM Strength
bull Coach
ndash training load
ndash cadence pedaling mechanics
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Integrated Treatment
bull MD NSAIDSs injections immobilization
unweighting
bull Surgical depends on pain generator
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Sometimes you have zebras
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Knee
Patella Femoral Pain Syndrome
Perpetrator
Stiff Hip Weak Foot
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Diagnosis
bull Ortho Exam crepitis pain w resisted knee ext step down
bull Special Tests Xray ndash
ndash Merchant XRAY PIC pat positioning abnormal pat positioning
ndash MR for Chondromalacia
bull Diff dx
ndash Pat tendonitis intra articular (sub chondral bone) itb (bursa)
plica retinaculum
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Integrated Treatment
bull Fit
ndash Seat ht (13)
ndash Crank Arms
ndash fore ndash aft (14)
ndash seat choice
American A of Pediatrics
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Integrated Treatment
bull PT (15)
ndash Mobility esp Patellar NRM esp Quad and hip -
gt Str strong NRM connected hip and foot
Symposium on PFPS -gt proximal disorders to
distal pain
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Treatment
bull MD
ndash NSAIDS injections
ndash Surgical lateral release
Surgical Technique Lateral
Retinaculum Release in Knee
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Knee Pain Case
Dx
- PFPS
- Patellar Tendonitis
J Orthop Sports Phys Ther 2008
Isolated knee pain a case report
highlighting regional interdependence
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Relevant
Signs and Symptoms
Symptoms
Speed
(power aero)
Other
Currently
Measurable
Observable
Questionable
Client Goals Relevant SS
Jeff Maitland PT FAAOMPT
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Relevant Signs Pedaling Mechanics
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Relevant Signs Symptoms
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Integrated Treatment Approach
bull Physical Therapy
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Foot Nrm and Strength
bull Foot intrinsics Tibialis Post Peroneus longus
ndash Clinic hands on facilitation (PNF) for initiation cold
ndash Home Therapeutic Exercises including neutralheel raises taught him how to tape
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Able to push thru pedal
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Effects of the foot intervention
Pedaling Mechanics
Lunge Mechanics
Power Pressure
Relevant SS
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Left Hip Mobility Loss
Hip flexion 120 left 143 deg right
bull Clinic
ndash Joint Mobilization soft tissue mobilization at hip
bull Home
ndash Foam Roller and Ball in Gluteal area
ndash Active stretching ndash hip flexion with self joint mobs
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Integrated Treatment Approach
Coach
ndash Cadence Gears (Force)
ndash Training load (hours) intensity (power)
ndash Pedaling Style Pressure on the pedals
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Integrated Treatment Approach
bull Accommodated Bicycle Fit
bull DPM PT
ndash External Support Orthotics Shoes Tape
bull MD Referral as needed
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
In Summary
PTMD
Fit
CoachOther
Think Regional Interdependence
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
bull Why might an elite athlete getting lots of care still feel this is neutral
bull Sit on the bike twisted
bull And only be able to use his left leg lsquowhen the stars are alignedrsquo
Integrated Approach
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
CHANGE
Doing the SAME thing and expecting DIFFERENT Results
If you Always DO
What you have Always DONE
Then you will Always GET
What you have Always GOT
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
MOVING FROM ISOLATION TO
INTEGRATION
FROM PRACTITIONER TO TEAM
Unpacking Lower ExtremityCycling Disorders
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
Biblio
1 (slide 18) Sir William Oslers Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean MD[3]
2 (slide 17) A regional interdependence model of musculoskeletal dysfunction research mechanisms and clinical implications Derrick G Sueki etal Journal of Manual and Manipulative Therapy
3 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
4 Evidence-Based Practice Opportunities and Challenges for Continuing Education Providers By Robert Mullen
5 Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement John C Clohisy MD rsquo09
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
7 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
8 Nonoperative treatment for femoroacetabular impingement a systematic review of the literature Review published 2013
9 Clohissy et al (lsquo09) Clinical presentation of patients with symptomatic anterior hip impingement Clinical Ortho and Related Research
10 J Bone Joint Surg Br 2002 May84(4)556-60 The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement Noumltzli HP1
11 Osteoarthritis Cartilage 2011 Jul19(7)816-21 doi 101016jjoca201104001 Epub 2011 Apr 12 Hip muscle weakness in patients with symptomatic femoroacetabular impingement Casartelli NC
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
12 Metatarsalgia Differential diagnosis and therapeutic algorithm] Fuhrmann RA1 Roth A Venbrocks RA
13 Sports Med 2011 Jun 141(6)463-76 Effects of bicycle saddle height on knee injury risk and cycling performance Bini R1
14 Phys Ther Sport 2013 Feb14(1)23-7 doi 101016jptsp201202003 Epub 2012 Apr 28Effects of moving forward or backward on the saddle on knee joint forces during cycling Bini RR1
15 Am J Sports Med 2002 Nov-Dec30(6)857-65 Physical therapy for patellofemoral pain a randomized double-blinded placebo-controlled trial Crossley K1
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
16 Foot Ankle Int 1981 1 229 Pierce E Scranton Jr Metatarsalgia A Clinical Review of Diagnosis and Management
17 J Knee Surg 2006 Oct19(4)278-84 Lateral retinacular release for anterior knee pain a systematic review of the literature Lattermann C1
18 Acta Radiol 2008 May49(4)436-41 The prevalence of cam-type deformity of the hip joint a survey of 4151 subjects of the Copenhagen Osteoarthritis Study
19 Clinical Practice Guidelines Linked to the International Classifiationof Functioning Disability and Health From the Orthopaedic Section of the American Physical Therapy Association 2014
