The Whole is more than the sum of the parts popularquotessy.tk Shelly Post, PA-C Seattle Children's Hospital Department of Orthopedics Seattle, Washington michelle.post@seattlechildrens.org

Anterior Knee Pain/Patellofemoral syndrome Typical history/PE No trauma, vague achy anterior knee pain, worse with activity No effusion, may not have any tenderness, ligaments stable, tight quads and hamstrings X-Rays normal Functional exam: popliteal angles/Ely’s test, squat, jump and land single leg hop

Make the Patient show you! **Increases force between patella and femur fthefreshman15.com283 www.mikereinold.com290 Functionaltrainingcoach.com **Increases stress on medial side of knee

Anterior Knee Pain/Patellofemoral syndrome Red Flags: trauma, effusion, painful popping, locking, giving way, night pain, worsening pain or not improving with rest, fever Look for another cause Take home: tight hamstrings means quads work harder, poor mechanics increase force on anterior knee and between patellofemoral joint, strong core and hips protect the knee Make your case stronger by showing patient and family the mechanics

Functional/Non-specific Back Pain Functional Back pain Typical history/PE: usually teenager, chronic pain, diffuse, pain with flexion, complain of pain with activity but doesn’t prevent activity X-Rays normal Red flags: trauma  must rule out fracture increased pain with extension  rule out spondylolysis or Bertolotti’s positive straight leg raise/numbness/weakness/asymmetric reflexes concern for herniated disc or intrathecal pathology stiffness, night pain, one finger sign  keep looking for another cause Fitseats.com I have 15 out of 10 pain all day, every day.

Functional/Non-specific Back Pain Benign Back pain Functional exam: feel ropey paraspinals, posture, bird dog, single leg squat, slump test Bird dog: Look for exaggerated lordosis, tipping of pelvis, uncoordinated movement www.quotezine.com380 munfitnessblog.com290 www.youtube.com480

Functional/Non-specific Back Pain Take home: Poor posture/weak core  paraspinal muscles get overworked Tight hamstrings often contribute Make patient demonstrate mechanics Refer if red flags are present or the diagnosis is in question Screening (labs, bone scan, MRI) may be necessary to rule out other pathology if not responding to rest, PT, NSAIDS www.thegorillapitmembers.com433 **Ear in line with shoulder, shoulder in line with hip

Shoulder Pain/Glenohumeral Dysfunction Shoulder pain/Glenohumeral Dyskinesia Typical history/PE: no trauma, gradual onset, often dominant side in a throwing/overhead athlete, vague anterior or posterior pain, some impingement, X-Rays normal Red flags: trauma, apprehension or feelings of instability, numbness or weakness, night pain Upper trapezius is overpowering, weak rhomboids and lower trapezius, poor scapular control impingement and pain eastbayhittinginstruction.com www.flexibilityrx.com

Shoulder Pain/Glenohumeral Dysfunction Functional exam: watch flexion and abduction from behind the patient, watch for elevation superiorly and also elevation off the thorax, watch for asymmetric glide thesportsphysio.wordpress.com Mikereinold.com

“The whole is more than the sum of the parts.” Summary Common theme: All are considered rather benign diagnoses that cause much pain and complaining. Patients/families will continue to look for more answers unless the cause is clearly demonstrated. “The whole is more than the sum of the parts.” When to worry: Night pain, swelling, mechanical symptoms (locking, painful popping, instability), neuro symptoms, fevers, persistent or worsening symptoms especially after rest, pain out of proportion to injury Refer if red flags are present or the diagnosis is in question