MUSCLE SORENESS v. JOINT PAIN

Many of our patients come into the clinic after a few sessions complaining that their joint pain has increased since their initial evaluation. This is not meant to whitewash those concerns, as an increase in joint pain due to a specific exercise is fairly common. However, typically the significant increases in joint pain will only come while performing that specific exercise, and subside significantly, if not entirely, a short time after. 

An increase in pain for longer periods of time, like 1-2 days, is more indicative of muscle soreness - not joint pain. While muscle soreness can be just as, if not more, debilitating compared to joint pain, muscle soreness is a good sign. 

Most of the time when patients come in with joint pain, they'll have been limiting activity that could increase that joint pain. For example: a patient comes in, chief complaint is knee pain, they'll likely have been avoiding stairs, bending down or squatting to pick something up or participate in hobbies, such as gardening, and moving slowly and cautiously. In physical therapy, to first lessen the pressure on the inflamed joint, we'll need to strengthen the muscles around the joint. To do so, patients will complete a number of exercises that don't necessarily aggravate those painful symptoms at the time, but can lead to soreness later. The soreness occurs because the muscles surrounding the joints are likely very out of practice - as your natural instinct to avoid an increase in pain is to minimize all causes of the pain. In turn, the muscle soreness will increase as they adapt to the newly added activities. 

Fortunately, muscle soreness doesn't last forever. It lasts a few days, maximum, and will decrease thereafter - usually leaving patients in less pain than they started. Patients need not worry that they'll reproduce that soreness each time, as each time they complete their Home Exercise Program, the muscles will continue to strengthen and therefore, adapt faster. Most of the time, patients will not be sore after a few visits to the clinic - given that they're doing their exercises as prescribed. Soreness from that point on will only increase as the intensity or difficulty of the exercises increase, but increases in difficulty means progression. 

Differences in joint pain versus muscle soreness include:

- Joint pain is sharp, stabbing, debilitating, while muscle soreness is dull, burning, achey

- Muscle soreness leads to problems you may not be used to: say your knee pain was below the kneecap, but now is above and on the sides of the kneecap

- Joint pain will increase during a specific movement, and decrease after the movement, whereas muscle soreness will decrease or become more manageable the more the movement is performed

- Muscle soreness only lasts 1-3 days, whereas joint pain will continue to hurt each time you do specific movements for an undefined amount of time, and can possibly even get worse

Still think it's joint pain? There are tests we can do here at CHAMPION Performance and Physical Therapy that can help us as professionals determine where the pain is stemming. It's our job as therapists to educate you on the circumstances of your pain.  Keep in mind, every patient is unique and your pain may continue to stem from the joint as we progress - and that's a bridge we'll cross when we get there. Our goal is to improve your quality of life back to functionality status at the very least, or in other words, give you the ability to do the things you love. 

THE FEMALE ATHLETE TRIAD

The "female athlete triad" is a term used to describe three distinct but interrelated conditions, including, low energy availability, menstrual dysfunction and low bone mineral density. Low energy availability is a term that is used to describe the condition that occurs if a female has low stored energy (low body weight for height), and/or low energy intake (insufficient calorie intake) and/or high levels of energy expenditure (lots of physical activity and/or exercise). The state of low energy availability can result in disruption of the normal menstrual cycle or delay the onset of a female’s first menstrual period. This is referred to as delayed menarche. Delayed menarche is defined as not having had your first menstrual period by age 15. In those females who have had their first period, but have low energy availability, their periods may get farther apart, or they may go away completely. Periods that occur every 35-90 days are referred to as “oligomenorrhea”. Periods that are farther than 90 days apart, or completely absent, are referred to as “amenorrhea”.

Low energy availability may occur unintentionally as a result of inadequate dietary intake relative to very high levels of exercise training. More often, it occurs as a result of intentional dietary restriction in the setting of disordered eating or an eating disorder such as anorexia nervosa or bulimia nervosa. A number of health problems can occur as a result of low energy availability leading to disrupted menstrual function. Infrequent or absent menstrual periods can result in low estrogen levels in the blood, which in turn leads to lower than expected bone mineral density. Amongst athletes, especially those that perform a weight bearing and/or impact sport like long distance running or basketball, the combination of these activities and low bone mineral density increases the likelihood of getting bone stress fractures. Stress fractures are serious injuries and can be a season ending and in some, a career ending injury.

Any female athlete is at risk for the female athlete triad. However, athletes who participate in aesthetic sports like gymnastics, figure skating, diving and dance, or in sports where leanness confers a competitive advantage like long distance running, are more likely to be affected by any component of the triad. We recommend that female athletes in high school and college undergo yearly preparticipation screening with a team physician or sports medicine physician who screens for the triad with the questions listed in Table 1.

Table 1: Female Athlete Triad Preparticipation Physical Evaluation Questions

• Have you ever had a menstrual period?
• How old were you when you had your “first menstrual period ?"
• When was your most recent menstrual period?
• How many periods have you had in the past 12 months?
• Are you presently taking any female hormones (estrogen, progesterone, birth control pills)?
• Do you worry about your weight?
• Are you trying to or has anyone recommended that you gain or lose weight?
• Are you on a special diet or do you avoid certain types of foods or food groups?
• Have you ever had an eating disorder?
• Have you ever had a stress fracture?
• Have you ever been told you have low bone density (osteopenia or osteoporosis)?

Athletes identified as having any one component of the triad, should be carefully screened for the other aspects. While disruption of the menstrual cycle is a relatively common consequence of low energy availability, it’s important to make sure that other conditions are not resulting in menstrual disruption, specifically pregnancy and thyroid disease. Similarly, there are other conditions that can result in lower than expected bone mineral density. These conditions should be considered by a healthcare provider when evaluating an athlete with low bone mineral density.

Comprehensive evaluation of the athlete affected by the triad includes a physical and laboratory evaluation by a healthcare provider. Usually, an evaluation of dietary intake by a registered sports dietitian, and oftentimes an evaluation by a mental health professional, is done, especially if there is evidence of disordered eating or an eating disorder. Bone mineral density is often assessed using a tool called a dual-energy x-ray absorptiometry (DEXA)scan. The DEXA scan provides a number of scores. In the high school, college and young adult female, the “Z-Score” is used to make clinical decisions and NOT the “T-Score”. A Z-Score greater than 0 is normal. A Z-Score between -1 and 0 is still considered normal, but in the setting CONTINUED FROM PAGE 1 of the Triad should prompt discussion about the relationship between low energy availability, menstrual function and bone health – this is especially true if a prior DEXA is available for comparison and was previously greater than 0. A Z-Score between -1 and -2 in a weight bearing athlete is concerning and would indicate that bone health has been negatively affected. A Z-Score less than -2 indicates significant bone loss. Treatment of the triad should be focused on establishing adequate energy availability to meet energy demands of exercise, activities of daily living and in the younger athlete, growth. Although every person’s energy (or calorie) needs are different, research has found that achieving energy availability of 45 kilocalories per kilogram of fat free mass per day is associated with regular menstrual cycles. Fat free mass can be calculated (by measuring body fat percentage) or estimated. An example of this is provided in Figure 1.

Figure 1 : Calculating Energy Availability to Achieve Menstrual Regulation

18 years old
120 lb female
120 lb ÷ 2.2 = 54.5 kg
18% body fat
Fat Mass = 54.5 X 0.18 = 9.8 kg
Fat Free Mass = 54.5 – 9.8 = 44.7 kg
45 kcal X 44.7 kg = 2011 kcal/day

In this example of a 120-lb 18-year-old female, she would require 2011 kcal per day to support healthy reproductive function. A recent paper (2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad) written by members of the Female Athlete Triad Coalition, and published in the British Journal of Sports Medicine, Clinical Journal of Sports Medicine and Current Sports Medicine Reports, and endorsed by several medical professional societies also outlines the use of medications that may be considered in the treatment of women and girls who are affected by the Triad. However, it bears repeating that the primary treatment efforts should be focused on achieving adequate energy intake and adequate stored energy relative to energy expenditure. Medications such as birth control pills to initiate or regulate menstrual function should be used in those cases as outlined in the consensus statement.

The consensus statement also provides physicians with guidance regarding clearance and return to play for athletes affected by the triad. The paper developed a “Magnitude of Risk” tool that includes known risk factors that can be identified and scored leading to Risk Stratification and Recommendations. The risk factors included in this tool include: 1) presence or history of an eating disorder or disordered eating; 2) Current body mass index (BMI); 3) Age of first menstrual period; 4) Number of menstrual periods in the past 12 months; 5) Bone mineral density as measured by DXA scan; 6) History of bone stress fractures or stress reactions. Using the Magnitude of Risk and Risk Stratification tools, a physician can then inform the athlete where she lies on the continuum, and develop a plan to achieve health and guide safe participation in sports or exercise. In conclusion, exercise and sport participation improve health and quality of life for females of all ages.

The female athlete triad can be a consequence of participation, the same way that knee injuries can be a part of football participation. We should not discourage females from participating in sport, instead we should screen for risk factors and the conditions that make up the triad, and treat it appropriately.

IT BAND SYNDROME

What is it?
The iliotibial band (“IT band”) is a thick band of fascia (a kind of hard flesh) that extends down the outside of the upper thigh. It begins on the pelvis, crosses the hip and knee, and attaches just below the knee. Pain is a result of friction or rubbing of the iliotibial band against the bone on the outside of the knee, which results in irritation of the band. It is one of the most common knee injuries (second only to patellofemoral pain syndrome) and has been reported in as many as 12 percent of runners. Athletes involved in cycling, weightlifting, football, soccer and tennis may also experience pain from the IT band. 

Symptoms

• Pain on the outer part of the knee with sporting activities
• Popping or rubbing sensation on the outer knee
• Pain after sitting for long periods of time with the knee bent
• Pain typically worsening with activities

Sports Medicine Evaluation and Treatment
A sports medicine physician will ask an athlete questions about potential risk factors for ITBS, including running mileage, change in mileage, uphill and downhill running routines, and track workouts. Running the same direction around a track for a long time may worsen ITBS symptoms. A sports medicine physician will perform a thorough physical exam of the athlete’s knee and leg. The provider may look at muscle imbalances, flexibility, leg length, hip and knee alignment, running gait, foot arches and footwear.

For ITBS, imaging is not usually necessary, unless the physician suspects that other causes within the knee may be causing the pain. Treatment of ITBS includes rest, ice and anti-inflammatory medications. Athletes may also have to alter training routines during the recovery period to avoid activities that cause pain. Stretching is an important component to the treatment of ITBS, as well as identifying and correcting strength imbalances. Other treatment options include steroid injections, foot orthotics and very rarely, surgical referral.

Injury Prevention
Athletes should maintain appropriate flexibility and strength, and ensure a proper warm-up prior to activity. 

Return to Play
Athletes may expect to return to activity once the symptoms have improved. Cross training is often a useful tool to use to aid in recovery. Once symptoms are improved, the athlete can gradually return to activity, generally over a period of about four to six weeks.

Authors: AMSSM Members Raul Raudales, MD, and David Berkoff, MD

ARE YOUR HIPS SNAPPING MORE THAN YOUR FINGERS?

What is Snapping Hip Syndrome?

Snapping hip occurs when a muscle, tendon, or ligament rolls over a bony prominence in the hip. Snapping hip can occur in different areas of the hip:

• Front. Snapping at the front of the hip can involve the hip flexor muscle rolling over the front of the hip bone, or the hip ligaments rolling over the thigh bone or tissues of the hip joint.
• Side. This condition involves the ITB (iliotibial band) rolling over the outer thigh bone or the big muscle on the back of the hip (gluteus maximus) sliding over the outer thigh bone.
• Back. This condition involves one of the hamstring muscles rolling over the bottom of the hip bone.

Snapping hip can occur when the hip muscles are excessively used and become fatigued, tight, and/or swollen.

Athletic activities like track and field, soccer, horseback riding, cycling, gymnastics, and dance can trigger the condition. It can also occur during everyday activities that require repeated forceful movement of the legs.

How Does it Feel?

Snapping hip causes a snapping sensation and sound that can be felt in the front, the side, or the back of the hip. Often, the snapping can be pain-free. If it causes pain, the pain usually ceases when the leg movement causing the snapping is stopped. In athletes and dancers, the snapping can be accompanied by weakness and may diminish performance.

The snapping is most commonly felt when kicking the leg forward or to the side, when bringing the leg behind the body, when rising from a chair, or when rotating the body or the leg.

Often, walking and running in a straight line are snap-free and pain-free, although in some people these activities are limited by the pain of the structure that is snapping.

Signs and Symptoms

With snapping hip, you may have:

• Snapping or popping in the front, side, or back of hip when lifting, lowering, or swinging the leg
• Weakness in the leg when trying to lift it forward or sideways
• Tightness in the front or back of the hip
• Swelling in the front or side of the hip
• Difficulty performing daily activities such as rising from a chair and walking

How Is It Diagnosed?

If you see your physical therapist first, the therapist will conduct a thorough evaluation that includes taking your health history. Your therapist will ask you:

• How you injured your hip and if you heard a pop when you suffered the injury
• If you feel snapping, popping, or pain
• Where you feel the snapping or pain
• If you experienced a direct hit to the leg
• If you saw swelling in the first 2 to 3 hours following the injury
• If you experience pain when lifting your leg forward or backward, walking, changing directions while walking or running, or when lifting the knee
• If you participate in any repetitive, forceful, or plyometric (quick explosive jumping) sport activities.

Your physical therapist also will perform special tests to help determine whether you have a snapping hip, such as:

• Asking you to lift your leg quickly
• Asking you to push against the physical therapist’s hand when he or she tries to push your leg outward, backward, and forward (muscle strength test)
• Gently feeling the muscle to determine the specific location of the injury (palpation)

Your therapist may use additional tests to assess possible damage to other parts of your body, such as your hip joint or lower back.

To provide a definitive diagnosis, your therapist may collaborate with a physician or other health care provider. The physician may order further tests—such as an x-ray or magnetic resonance imaging (MRI)—to confirm the diagnosis and also to rule out other potential damage. However, these tests are not commonly needed for snapping hip syndrome.

How Can a Physical Therapist Help?

Your physical therapist will design a specific treatment program to speed your recovery, including exercises and treatments you should perform at home. This program will help you return to your normal life and activities and reach your recovery goals.

The First 24-48 Hours

Your physical therapist may advise you to:

• Rest the injured hip by avoiding walking or any activity that causes pain. In rare cases, crutches may be recommended to reduce further strain on the muscles when walking.
• Apply ice packs to the affected area for 15 to 20 minutes every 2 hours.
• Consult with another health care provider for further services such as medication or diagnostic tests.

Reduce Pain

Your physical therapist can use different types of treatments and technologies to control and reduce your pain, including ice, heat, ultrasound, electricity, taping, exercises, and special hands-on techniques that move muscles and joints (manual therapy).

Improve Motion

Your physical therapist will choose specific activities and treatments to help restore normal movement in the leg and hip. These might start with movements of the leg and hip joint that the therapist gently performs, and progress to active exercises and stretches. Treatment for snapping hip often involves manual therapy techniques called trigger point release and soft tissue mobilization, as well as specific stretches to muscles that might be abnormally tight.

Improve Strength

Certain exercises will benefit your injury at each stage of recovery, and your physical therapist will choose and teach you the appropriate exercises that will restore your strength, power, and agility. These may be performed using free weights, stretchy bands, weight-lifting equipment, and cardio exercise machines such as treadmills and stationary bicycles. For snapping hip syndrome, muscles of the hip and core are often targeted by the strength exercises.

Speed Recovery Time

Your physical therapist is trained and experienced in choosing the treatments and exercises to help you heal, get back to your normal life, and reach your goals faster than you might be able to on your own.

Return to Activities

Your physical therapist will collaborate with you to decide on your recovery goals, including return to work and sport, as well as design your plan of care to help you reach those goals in the safest, fastest, and most effective way possible. Your physical therapist will use hands-on therapy and teach you exercises and work retraining activities. Athletes will be taught sport-specific techniques and drills to help achieve sport-specific goals.

Prevent Future Re-injury

Your physical therapist can recommend a home exercise program to strengthen and stretch the muscles around your hip, upper leg, and core (abdomen) to help prevent future injury. These may include strength and flexibility exercises for the hip, thigh, and core muscles.

If Surgery Is Necessary

Surgery is rarely necessary in the case of snapping hip syndrome. If it is required, your physical therapist will help you minimize pain, restore motion and strength, and return to normal activities in the speediest manner possible after surgery.

Can this Injury or Condition be Prevented?

Snapping hip syndrome can be prevented by:

• Warming up before starting a sport or heavy physical activity. Your warm-up should include stretches taught to you by your physical therapist, including those for the muscles on the front, side, and back of the hip.
• Gradually increasing the intensity of an activity or sport. Avoid pushing too hard, too fast, too soon.
• Following a consistent strength and flexibility exercise program to maintain good physical conditioning, even in a sport’s off-season.
• Wearing shoes that are in good condition and fit well.

PREPARING FOR YOUR PT VISIT

Physical therapists are highly educated, licensed health care professionals who help patients improve or restore mobility, and in many cases helping patients reduce pain, and avoid the need for surgery and the long-term use of prescription medications and their side effects.

Physical therapists examine, evaluate, and treat patients whose conditions limit their ability to move and function in daily life. Your physical therapist's overall goal is to maintain, restore, or improve your mobility and help reduce your pain.

In most states, you can make an appointment with a physical therapist without a physician referral. Whether this is your first visit or you've been treated by a physical therapist in the past, there are things you can do to make your visit as successful as possible.

Before Your Visit:

Make a list of any questions that you have, to make the best use of your time with your physical therapist.

Write down any symptoms you've been having and for how long. If you have more than one symptom, begin with the one that is the most bothersome to you. For example, is your pain or symptom:

• Better or worse with certain activities or movements or with certain positions, such as sitting or standing?
• More noticeable at certain times of day?
• Relieved or made worse by resting?

Write down key information about your medical history, even if it seems unrelated to the condition for which you are seeing the physical therapist. For example:

• Make a list of all prescription and over-the-counter medications, vitamins, and supplements that you are taking.
• Make a note of any important personal information, including any recent stressful events, injuries, incidents, or environmental factors that you believe might have contributed to your condition.
• Make a list of any medical conditions of your parents or siblings.
• Consider taking a family member or trusted friend along to help you remember details from your own health history and to take notes about what is discussed during your visit. Make sure you can see and hear as well as possible. If you wear glasses, take them with you. If you use a hearing aid, make certain that it is working well, and wear it. Tell your physical therapist and clinic staff if you have a hard time seeing or hearing. If available, bring any lab, diagnostic, or medical reports from other health care professionals that may be related to your medical history or who have treated you for your current condition.
• Bring a list of the names of your physician and other health care professionals that you would like your physical therapist to contact regarding your evaluation and your progress.

When you call to make your appointment, ask whether you should wear or bring a certain type of clothing when you come for your first visit. You may want to avoid tight or formal clothes, in case the therapist wants you to engage in activities during the first session.

Financial Considerations

• Carefully review the clinic's financial policy prior to starting care. Be sure to ask questions if anything is unclear. If the financial policy is not presented at the time of your initial appointment, request it be provided and explained prior to the initiation of treatment.
• The physical therapy clinic will ask you to sign the financial agreement. Review the agreement carefully and ask questions if anything is unclear.
• Applicable deductibles and copayments will be requested prior to or upon completion of each appointment. It is important to pay the proper amounts at the time of service. This will help you to better manage your health care costs and avoid a large bill at the end of care.
• If the frequency of visits needs to be adjusted for financial reasons, discuss this directly with your physical therapist. In partnership with your therapist, you can explore alternatives and develop a workable plan.
• If you change insurance plans or lose insurance coverage for any reason, be sure to inform your therapist as well as the clinic’s front office staff.

What to Expect During Your First Visit:

Your physical therapist will begin by asking you lots of questions about your health and about the specific condition for which you are seeing the physical therapist. Detailed information about you and your condition will help the physical therapist determine whether you are likely to benefit from physical therapy and which treatments are most likely to help you.

Your physical therapist will perform a detailed examination. Depending on your symptoms and condition, the physical therapist might evaluate your strength, flexibility, balance, coordination, posture, blood pressure, and heart and respiration rates. Your physical therapist might use his or her hands to examine or "palpate" the affected area or to perform a detailed examination of the mobility of your joints, muscles, and other tissues.

Your physical therapist also might evaluate:

• How you walk (your "gait")
• How you get up from a lying position or get in and out of a chair ("functional activities")
• How you use your body for certain activities, such as bending and lifting ("body mechanics")

Your physical therapist might ask you specific questions about your home or work environment, your health habits and activity level, and your leisure and recreational interests so that the therapist can help you become as active and independent as possible.

Your physical therapist will work with you to determine your goals for physical therapy and will begin to develop a plan for your treatment. In many cases, the physical therapist will make a diagnosis and begin treatment almost immediately.

One of the main goals of treatment is almost always to improve or maintain your ability to do your daily tasks and activities. To reach this goal, the physical therapist may need to focus on pain, swelling, weakness, or limited motion. Your physical therapist will constantly assess your response to each treatment and will make adjustments as needed.

In most cases, an important aspect of your physical therapy treatment will be education. Your physical therapist might teach you special exercises to do at home. You might learn new and different ways to perform your activities at work and home. These new techniques can help minimize pain, lessen strain, avoid reinjury, and speed your recovery.

Your physical therapist will evaluate your need for special equipment, such as special footwear, splints, or crutches. If the evaluation indicates that you are at risk for falling, your physical therapist might recommend simple equipment to help make your home a safer place for you. The therapist will know what equipment you need and can either get it for you or tell you where you can find it. If you do need special equipment, your physical therapist can show you how to use it properly.

Your physical therapist will communicate the important information from your examination to your physician and to other health care professionals at your request.

Your physical therapist will continually recheck your progress and work with you to plan for your discharge from physical therapy when you are ready. Make sure you talk with your physical therapist about what you should do after discharge if you have questions, or if your symptoms or condition worsen.

Keeping Your Appointments

• Arrive for treatment sessions at the scheduled time or a few minutes early so you are prepared. Late arrival may affect not only your 1-on-1 time with the therapist, but that of other patients in the clinic.
• Actively participate in the discussion to determine visit frequency and work in partnership with the physical therapist to achieve your treatment goals.
• Show up for appointments. Failure to show for an appointment and not calling to cancel the visit may result in a fee and is disruptive to the physical therapist’s schedule. If an emergency prevents you from attending, try to provide adequate notice. It is important to review the facility’s financial and cancellation policy prior to the start of treatment.
• If you plan to discontinue therapy or change the frequency of treatment because of personal or financial considerations, discuss this with your physical therapist.

You will get out of therapy what you put into it. Sufficient effort, as agreed between you and the physical therapist, is necessary to maximize benefit from each treatment session.

Observe all precautions as instructed by your physical therapist. This may include modifying an activity, reducing weight on 1 limb while walking, avoiding certain movements, or restricting use of a specific body part. Lack of compliance with treatment precautions may cause injury and result in delayed recovery.

If special devices such as splints, walkers, canes, or braces are provided for home use, follow the physical therapist’s exact instructions. Be sure to ask questions if you are unclear, as incorrect use may be harmful.

The therapist may advise physical modifications in your home such as removing throw rugs, rearranging furniture, and installing safety rails. For your safety, it's essential to comply with these recommendations.

Follow the home program as instructed by the physical therapist. Your ongoing performance and commitment to the home program is essential to your recovery.

If the instructions are unclear, ask for clarification. Only perform exercises at the therapist-specified repetition, frequency, and resistance (such as weight or resistance band color). More is not always better and may cause injury!

After your physical therapy care is completed, continue to follow the after-care instructions provided by the physical therapist.

Changing the Rehabilitation Setting

Physical therapy can occur in a variety of settings including hospitals, skilled nursing facilities, rehabilitation facilities, at home or in an outpatient clinic. Depending on your condition and recovery, your medical team may recommend your transfer from one setting to another. For example, if you are discharged from the hospital, physical therapy treatment may be continued in an inpatient rehabilitation facility, your home, or an outpatient clinic depending on the level of care you need.

It is important that your rehabilitation be disrupted as little as possible during the change in setting. Case managers are available in most hospitals and rehabilitation centers to help ensure a smooth transition.

If you are returning home from another facility, ask the physical therapist what special equipment or family support is needed prior to the transfer.

GENU VALGUM IN YOUTH AND ADOLESCENCE

What is Genu Valgum? 

Valgum, more commonly referred to via medical terminology as "valgus" or "knock-knee" is a condition in which the knees angle inward toward each other, or the midline of the body, when the legs are fully straight.  The opposite occurrence is genu varum, otherwise known as "bowleggedness". 

Flexibility in the joints during childhood is completely normal, and is the reason why your children can sit cross-legged, or any other position you wonder how you were ever able to do.

Cases vary from slight to extreme, and are developed under a multitude of circumstances, including passively due to activity levels, hereditary, or retained as a result of a genetic disorder. Children who are "pigeon-toed" have an increased variability of retaining valgus into adulthood. According to , the average child has most prominent increase in valgus around age 4 at average 8 degrees, lessening each year with valgus averaging <6 degrees by age 11. Children in this study who's valgus was deemed within normal limits ranged from anywhere up to 12 degrees for ages 2-11. 

What does that mean?

Valgum is extremely common, more common in fact than it's counterpart in genu varum. During youth, it's nothing to be extremely concerned about. Often, as children age and become engaged in more strenuous physical activities ( ex: running while playing soccer), the musculature in the lower extremities will naturally reduce the angle of varum. In other words - many a times, valgum is corrected on it's own. 

What if it doesn't?

In most cases, physical therapy is an option to increase the strength on the lateral (outsides) aspect of the lower extremities, which will help to reduce the angle in a controlled environment. Teaching proper body mechanics through movement will increase the ability of the child to improve his/her valgum without the trained eye of a physical therapist, or the watchful eyes of their parents around. 

If the angle is more severe, other options can be provided and discussed with an orthopedic specialist and a primary care physician to determine the best course of action. 

Why should we correct it?

Genu valgum is not considered an emergency situation - nor should it be. It's a natural aspect of growing - simply something to be monitored. However, allowing valgum to stabilize and continue on into adulthood will create problems for the child later on in his/her lifetime. Multiple studies have shown that the presence of untreated valgum has an extremely high correlation with osteoarthritis of the knee and hip, misalignments of the pelvis and sacrum, which increase the risk of low back pain, leg length discrepancies, musculoskeletal issues, to name a few. 

If that doesn't convince your young adult to improve their valgum condition, it may help to remind them that valgum is also correlated with an increase in non-contact ligamentous/soft tissue tears in the knee joint - those will end a season fairly quickly, and will increase their risk to tear a ligament simply performing a daily activity, such as jumping down off of a small ledge, or stepping off of a curb. 

Knowledge is power!