Soft Tissue Release Research Articles

Outcomes of Triceps Surae Lengthening Surgery in Children With Charcot-Marie-Tooth Disease: A Multisite Investigation.

Orthopaedic surgical intervention in children with Charcot-Marie-Tooth (CMT) often includes triceps surae lengthening (TSL) and foot procedures to address instability and pain due to equinus and cavovarus deformities. These surgeries may unmask underlying weakness in this progressive disease causing increased calcaneal pitch and excessive dorsiflexion in terminal stance leading to crouch. The purpose of this study was to evaluate changes in ankle function during gait following TSL surgery in children with CMT. Nineteen participants (11 male; age 12.8, SD 3.6y) with CMT underwent gait analysis and clinical examination preoperatively and postoperatively to determine the outcomes of (1) triceps surae lengthening (TSL) and (2) plantar fascia release with bony foot surgery with or without TSL. TSL was performed in limbs with limited passive dorsiflexion range of motion (ROM) and decreased peak dorsiflexion in terminal stance, with gastrocnemius recession (GR) being preferred over tendo-Achilles lengthening (TAL) in cases with smaller dorsiflexion deficits. Passive dorsiflexion ROM, gait kinematics and kinetics, and foot posture index (FPI) were examined within and across surgical groups using linear mixed models. Dorsiflexion ROM, peak dorsiflexion in terminal stance and mid-swing, and peak nondimensional plantar flexor moment improved significantly after both GR (n=8 limbs) and TAL (n=11 limbs) (P≤0.02). After plantar fascia release with bony foot surgery (n=20 limbs), FPI changed significantly, indicating reduced cavovarus regardless of whether TSL was done (P<0.05). Passive and dynamic dorsiflexion and ankle kinetics (moment and power) increased only when concomitant TSL was done (P≤0.04). In patients with increased equinus due to reduced passive dorsiflexion range of motion, TSL is an effective surgery for reducing excessive equinus in terminal stance and mid-swing, decreasing toe-walking, and improving swing phase clearance. It can be combined with extensive foot surgery to correct cavovarus deformity without leading to excessive dorsiflexion in terminal stance and crouch gait. Clinical gait analysis is an important tool to help identify appropriate candidates for TSL based on the key indicator of peak dorsiflexion in terminal stance. Level IV.

Effect Of Self Myofascial Release on Flexibility in Athletes: A Systematic Review

Effect Of Self Myofascial Release on Flexibility in Athletes: A Systematic Review

Functional alignment is a feasible alignment strategy in robotic assisted total knee arthroplasty for knee osteoarthritis with extra-articular deformity - A case series.

Extraarticular deformity (EAD) with knee arthritis is a complex condition involving tri-planar bone deformity with pathological malalignment and chronic soft tissue contracture or laxity in the knee joint. Intraarticular correction by TKA, which was previously performed with conventional manual jig by mechanical alignment technique, had its limits and difficulties especially extensive soft tissue release and risk of jeopardizing the collateral ligaments. Robotic technology allows for reproducible and precise execution of surgical plan and allows adjustment to various new personalised alignment philosophy including functional alignment (FA). FA technique involves the adjustment of components positioning that least compromise the soft tissue envelope while restoring the limb alignment and joint obliquity to create a balanced knee. The aim is to study the outcome of intra-articular correction by robotic assisted TKA using Functional Alignment (FA) technique. This is a single surgeon series of 8 patients with extraarticular deformity who underwent robotic assisted total knee arthroplasty (TKA) with FA technique. Soft tissue release was gradually released and followed by adjustments of implant positioning in order to achieve a balanced medio-lateral gap. Postoperatively, the lower limb alignment of all patients were restored within 6° (mean 4.54°) based on functional alignment boundaries. Knee phenotype and joint line obliquity (JLO) were restored in comparison to contralateral lower limb. There were 6 varus and 2 valgus malalignment. 7 patients were implanted with posterior stabilized implants while 1 was implanted with cruciate retaining implant. Arc of knee flexion and extension improved (P=0.002). There was a large postoperative improvement in the Knee Society Score (KSS) (P<0.001). Intraarticular correction by TKA for EAD with knee arthritis is technically reliable with robotic technology. It allows intraoperative adjustment following functional alignment philosophy, thereby, restoring pre-arthritic alignment, knee phenotype and joint line obliquity.

Effectiveness of Myofascial Release Along with Conventional Physiotherapy for Chronic Neck Pain Patients: A Randomized Controlled Trial

Background: Chronic neck pain ranks as the fourth most common cause of disability globally. However, the treatment for this condition is expensive and lacks substantial proof of its efficacy. Objectives: The study aimed to identify the effectiveness of myofascial release (MFR) on the upper trapezius and scalene muscles for chronic neck pain. Methods and Materials: The study was a double-blind, randomized controlled trial. A total of 40 individuals with persistent neck pain were allocated randomly to an experimental and a control group. The trial group provided MFR along with conventional physiotherapy. The control group got just conventional physiotherapy. The total number of therapy sessions was nine, with a frequency of three sessions per week for duration of three weeks. The visual analogue scale (VAS) was used to measure pain, universal goniometer to measure range of motion (ROM), and the neck disability index (NDI) to measure neck function and disability. Results: The experimental group revealed significant differences (p &lt;0.05) and had a positive correlation between the pre- and post-NDI scores. Statistically significant changes (p&lt;0.05) were seen in pain intensity and ROM. The results also showed that paired t-test within group analysis for NDI has positive effects on both groups. Patients' pain intensity and NDI scores improved considerably compared to the control group. Conclusion: Myofascial release therapy has shown to be beneficial in lowering pain intensity and increasing ROM in different directions for individuals with chronic neck pain.

EXPLORING THE MYOKINETIC AND ANATOMICAL MERIDIAN TRAINS IMPLICATIONS FOR MOVEMENT PATTERNS AND MERIDIAN-BASED THERAPY PROTOCOL FOR REHABILITATION IN PHYSIOTHERAPY

In recent years, the understanding of movement patterns and musculoskeletal dysfunctions has expanded significantly through the lens of fascial and myofascial systems. Myokinetic and anatomical meridian trains, introduced by Thomas W. Myers, provide a comprehensive model of myofascial connections that link distant regions of the body, influencing postural stability, movement efficiency, and rehabilitation strategies. This paper explores the primary anatomy trains, including the Superficial Front Line, Superficial Back Line, Lateral Line, Spiral Line, and Deep Front Line, among others. We discuss their relevance in understanding movement patterns, postural imbalances, and their implications for rehabilitation in physiotherapy.

COMPARATIVE EFFECTS OF DIAPHRAGMATIC MYOFASCIAL RELEASE VERSUS DIAPHRAGMATIC BREATHING IN POST-OPERATIVE PATIENTS DIAGNOSED WITH GASTRO ESOPHAGEAL REFLUX DISEASE (GERD)

Background: GERD is a short form of “Gastro esophageal Reflux Disease”. It is a condition characterized by backflow of food particles from stomach to food pipe and associated symptoms. Objective: To determine the comparative effects of Diaphragmatic breathing exercises and diaphragm atic myofascial release in post-operative patients diagnosed with GERD. Methodology: We distributed participants through clinical trial. Postoperative patients diagnosed with GERD were studied. Sample size was 28. Patients were allocated to two treatment groups A and B by lottery method. Group A was treated with diaphragmatic myofascial release and Group B was treated with diaphragmatic breathing exercise. Reflux disease questionnaire (RDQ) was used as primary outcome measure for GERD. The secondary outcome measure was gastrointestinal symptom rating scale (GSRS) Result: A cross group analysis revealed that there was statistical significant difference in post treatment values of GSRS and RDQ, with p values of 0.001and 0.001 respectively. Conclusion: Diaphragmatic myofascial release is more effective than diaphragmatic breathing exercises in reducing the severity of GERD symptoms and improving quality of life in postoperative patients diagnosed with GERD.

Elucidation of The Effect of Flossing on Improving Joint Range of Motion

Flossing has been hypothesized to improve joint range of motion (flexibility), potentially through enhanced fascial gliding, although this mechanism remains speculative. This study aimed to clarify the effect of flossing, a new type of myofascial release, on joint range of motion by focusing on tissue gliding properties. This study involved 14 healthy participants (aged 18-25 years) who performed two types of active exercises with floss bands wrapped around their lower legs. As a control, the participants performed the same active exercises on different days without floss bands. Measurements taken before and after the intervention included ankle dorsiflexion range of motion, ankle plantar flexion maximum voluntary contraction, medial head of the gastrocnemius muscle thickness using ultrasound, and fascial hardness at five locations according to depth. Lower leg flossing significantly increased ankle dorsiflexion range of motion by 28.3 ± 19.9% (control: 14.6 ± 12.4%, P = 0.04, d = 0.83). No significant changes were observed in maximum voluntary plantar flexion contraction or overall muscle and fascial hardness. However, the rate of change in hardness showed a trend toward reduction in the superficial fascia and the upper and middle gastrocnemius muscles, with the upper gastrocnemius muscle exhibiting a statistically significant decrease in hardness (P = 0.05). Flossing showed trends toward reducing superficial muscle and fascial hardness, particularly in the superficial fascia and the upper gastrocnemius muscle, although not all changes were statistically significant. This suggests that potential improvements in intertissue gliding around the fascia could contribute to an increased range of motion.

Efficacy of Janda’s approach versus Lumbar stabilization along with myofascial release in patients with nonspecific low back pain

Efficacy of Janda’s approach versus Lumbar stabilization along with myofascial release in patients with nonspecific low back pain

Abdominal Wall-targeted Myofascial Release Therapy in Pediatric Patients with Irritable Bowel Syndrome: A Feasibility and Acceptability Study.

Myofascial release (MFR) is a form of massage therapy that involves identifying and releasing restrictions in the fascia and muscles. MFR-like techniques have shown improvement in abdominal pain, distention, constipation, and quality of life (QoL) in adults. Therefore, MFR may be helpful in patients with irritable bowel syndrome (IBS), a disorder of gut-brain interaction or functional gastrointestinal disorder, mainly presenting with prolonged abdominal pain, bloating, and altered defecation patterns, leading to impairment in QoL. Treatments for IBS are limited and do not always completely relieve pain. To date, no studies have evaluated the feasibility and acceptability of MFR for children with IBS as a potential therapy. The aim of the study is to assess the feasibility and acceptability of administering abdominal wall-targeted MFR in children with IBS. This study was approved and conducted at Children's Hospital of Philadelphia. Males and females aged 13-18 years meeting Rome IV criteria for IBS were included in the study. Participants underwent six 1-h weekly sessions of abdominal wall-targeted MFR with a licensed massage therapist (LMT) and performed self-MFR at home between sessions. Feasibility and acceptability data were collected via REDCap (Research Electronic Data Capture) by the study team and LMTs. Symptoms and QoL were assessed before and after the intervention period using child and parent versions of validated pediatric questionnaires. Of 10 participants aged 14-18 years, 60% females underwent the MFR intervention and completed the 6-week protocol. The median visit compliance with questionnaire completion was 90%. All participants received self-MFR education and performed self-MFR between sessions. Fascia restrictions were identified and released in all participants, as reported by the LMTs. Most participants voluntarily provided positive feedback on MFR. All participants reported no or minimal soreness during or after MFR, and no adverse events were reported. Abdominal wall-targeted MFR is feasible to administer and well accepted in pediatric IBS patients.

Effect of myofascial release on spinal curvature, premenstrual symptoms, and quality of life in scoiliotic females with dysmenorrhea: a randomized controlled trial

BackgroundIdiopathic scoliosis is a common musculoskeletal disorder that affects spinal and pelvic alignment and exacerbates menstrual discomfort in young females. Studies have reported the importance of involving myofascial components in treating scoliotic patients; however, few studies have been conducted. Therefore, this study aimed to investigate the effect of adding myofascial release (MFR) to corrective stabilizing exercise on spinal curvature, premenstrual symptoms, and health-related quality of life (HRQOL) in young females with idiopathic scoliosis.MethodsFifty-two females with idiopathic scoliosis, aged 18–25 years, and with a body mass index (BMI) of 18.5–24.9 kg/m2 were randomly assigned to two groups equal in number. The control group received corrective stabilizing exercises two sessions/week for 8 weeks. The MFR group received the same exercises and MFR therapy two sessions/week for 8 weeks. The scoliometer was used to evaluate thoracic and lumbar angles, Italian Spine Youth Quality of Life (ISYQOL) to assess HRQOL, and menstrual symptoms questionnaire (MSQ) to evaluate premenstrual symptoms before and after the treatment.ResultsThere was a significant decrease (p < 0.05) in the thoracic and lumbar angles, menstrual backache, and PMS score and a significant increase (p < 0.05) in the HRQOL score in the control and MFR groups. However, there were no significant differences (p > 0.05) between both groups after treatment.ConclusionCorrective stabilizing exercises with or without MFR effectively improve thoracic and lumbar angles, HRQOL, menstrual backache, and premenstrual symptoms. The addition of MFR to stabilizing exercises produced changes that are clinically important for females with idiopathic scoliosis.

Efficacy of Myofascial Release Therapy and Positional Release Therapy in Patients with Upper Trapezius Trigger Points: Study Protocol of a Double-blinded Randomized Clinical Trial.

Myofascial trigger points are incredibly prevalent and are a painful aspect of almost everyone's life at some point. Myofascial trigger point pain can be excruciating and severely impair the quality of life. Therefore, in patients with neck pain caused by upper trapezius trigger, this current clinical trial will demonstrate the effectiveness of myofascial release therapy and positional release therapy in improving the level of pain, neck impairment, pain threshold, and standard of life. A double-blinded randomized clinical trial will be conducted. Fifty-two participants with active myofascial trigger points in the upper trapezius muscle will be recruited based on selection criteria. They will be randomly allocated into group A (conservative treatment + myofascial release technique) or group B (conservative treatment + positional release technique). Both groups will receive the intervention three times a week for 2 weeks. The study will use the Numeric Pain Rating Scale, pressure algometer, Neck Disability Index, and a 36-Item Short-form Questionnaire as outcome measures. This trial will help identify the effectiveness of the positional and myofascial release techniques in active upper trapezius muscle trigger points and their effect on physical parameters. This trial has been prospectively registered at the Clinical Trials Registry-India (CTRI/2023/07/055126) on 12 July 2023.

A Comparative Study of Soft Tissue Release and Stretching in Treating Axillary Web Syndrome After Breast Cancer Surgery

Background: Axillary Web Syndrome (AWS) is increasingly recognized as a side effect of post-breast cancer treatment. It is one of the primary contributors to discomfort and reduced range of motion following breast cancer surgery. Due to severe pain, patients often experience difficulty moving their arms, particularly with shoulder flexion and abduction, which are the most affected movements. After an axillary lymph node dissection (ALND), cords, webs, or adhesions can be felt and seen in areas such as the axilla, breast, antecubital region, chest wall, hands, and arms. These fibrous bands restrict shoulder movement, especially limiting flexion and abduction. Methodology: The study was a randomized clinical trial that commenced after receiving approval from the ethical research committee. Data collection took place at HACC Hospital in Ahmedabad, across the In-patient Department, Out-patient Department, and Physiotherapy Department. Thirty patients were contacted two months after their breast cancer surgery. The ST-AWS questionnaire was used to assess the risk of developing axillary web syndrome and to assist patients in determining if they had AWS by completing a self-assessment. Result: Data analysis and distribution for both groups were conducted using Excel 2016. In the experimental group, the pre-therapy score was 76%, while the post-therapy score dropped to 36%, reflecting a 40% difference between pre-and post-therapy. For the control group, the pre-therapy score was also 76%, with the post-therapy score decreasing to 41%, resulting in a 35% difference between pre-and post-therapy. Conclusion: The study concludes that both soft tissue mobilization and stretching are effective treatments for patients with AWS. However, soft tissue mobilization proves to be more effective than stretching. Furthermore, prehabilitation can also play an important role in reducing the risk of axillary web syndrome. Keywords: Axillary web syndrome, post breast cancer surgery, soft tissue release, stretching, exercise therapy

Efficacy of muscle energy technique with stretching versus muscle energy technique with myofascial release in upper cross syndrome

INTRODUCTION: Cervical pain represents one of the most prevalent musculoskeletal disorders, with the potential for secondary complications if left untreated. The primary causes of neck pain are cervical spine and soft tissue disorders, while neck pain due to postural abnormalities is known as upper cross syndrome (UCS). Epidemiological studies indicate that neck pain is prevalent in the general population but is significantly more common among office workers. Optimal management strategies require further investigation to improve treatment outcomes. This study aims to evaluate and compare two therapeutic approaches for managing Upper Cross Syndrome (UCS): Muscle Energy Technique (MET) combined with Myofascial Release Therapy (MFR), and MET combined with Muscle Stretching Exercises. MATERIAL AND METHODS: This non-randomized, active-controlled trial enrolled 40 patients with neck pain, assigned to two intervention groups of 20 participants each: Muscle Energy Technique (MET) with Myofascial Release Therapy (MFR), and MET with Muscle Stretching Exercises. The study assessed pain intensity using the Visual Analogue Scale (VAS) and forward head posture using the Craniovertebral Angle (CVA) at baseline and three weeks post-treatment. RESULTS: VAS score for pain showed a mean change of 1.7 and 1.8 in the MET with MFR group and MET with the Muscle Stretching Exercises group after 11 sessions. The CVA increased by 2.08° in the MET with MFR group and by 1.78° in the MET with the Muscle Stretching Exercises group. Both groups showed significant improvements in pain and forward head posture (p&lt;0.001), with no significant difference between the interventions. CONCLUSION: Both MET combined with MFR and MET with Muscle Stretching Exercises demonstrate improvement in pain and CVA.

Use of Biologic and Biosynthetic Mesh for Ventral Hernia Repair in Current Practice

Originally developed for use in contaminated fields, there is growing evidence against the use of biologic and biosynthetic mesh in ventral hernia repair. However, its prevalence and patterns of use in current practice are largely unknown. To describe the prevalence of biologic and biosynthetic mesh use in ventral hernia repair and to identify factors associated with its use. This retrospective cohort study used a statewide clinical registry in Michigan to identify adults who underwent mesh-based ventral hernia repair between January 1, 2021, and December 31, 2023. Data analysis was performed from February to May 2024. Use of biologic or biosynthetic mesh vs synthetic mesh. The main outcome was use of biologic or biosynthetic mesh, abstracted directly from the operative report. Multivariable logistic regression was used to identify factors associated with use of biologic or biosynthetic mesh. A total of 10 838 patients (mean [SD] age, 55.7 [14.0] years; 4619 [42.6%] female) who underwent mesh-based ventral hernia repair were identified, among whom 1174 repairs (10.8%) were performed with biologic or biosynthetic mesh and 9664 (89.2%) were performed with synthetic mesh. Of the 1174 cases using biologic or biosynthetic mesh, 1023 (87.1%) had a clean wound classification and 1039 (88.5%) were performed electively. In multivariable logistic regression, wound contamination was associated with increased odds of biologic or biosynthetic mesh use (clean-contaminated: adjusted odds ratio [aOR], 2.17 [95% CI, 1.62-2.89]; contaminated: aOR, 2.95 [95% CI, 1.63-5.34]; dirty or infected: aOR, 36.22 [95% CI, 12.20-107.56]). Other operative factors associated with increased odds of biologic or biosynthetic mesh use included urgent or emergent surgical priority (aOR, 1.69 [95% CI, 1.33-2.16]), laparoscopic or robotic approach (aOR, 1.31 [95% CI, 1.15-1.50]), larger hernia width (aOR, 1.03 [95% CI, 1.01-1.04] per centimeter), and use of myofascial release (aOR, 2.10 [95% CI, 1.64-2.70]). In this large cohort of patients undergoing ventral hernia repair, 1 in 10 mesh-based repairs was performed with biologic or biosynthetic mesh. Although urgent or emergent repair and wound contamination were associated with increased odds of biologic or biosynthetic mesh use, nearly 90% of biologic and biosynthetic mesh use occurred in elective repairs with clean wound classifications. These results raise questions regarding the appropriateness of its application in current practice.

The Effect of Myofascial Release Iliotibial Band on Reducing Pain and Increasing Functional Activity in Knee Osteoarthritis

Background: Knee osteoarthritis is the most common case suffered by elderly women. The population at high risk of experiencing knee osteoarthritis is women at 18% compared to men at around 9.6% worldwide, older age, excessive body weight, and having had a knee injury or having had previous knee surgery. Methods: The design of this study was a two-group pre-and post-test design. The research compares the effect of the myofascial release of the iliotibial band on reducing pain and increasing functional activity in knee osteoarthritis. The research subjects were all clients who had been diagnosed with osteoarthritis by a doctor. Results: The results of the test for the difference in pain scores with VAS before and after treatment in group 1 showed a value of p = 0.000 or a value of p &lt; 0.05, while the functional ability scores with WOMAC before and after group 1 treatment showed a p-value = 0.000 or a p-value &lt; 0.05, which means that there was an effect of standard therapy on reducing pain and increasing functional activity in osteoarthritis knees in group 1 so that the hypothesis was accepted. Conclusion: There is a difference in effect between standard therapy and standard therapy plus myofascial release of the iliotibial band to increase functional activity in knee osteoarthritis. There is a difference in the effect of standard therapy and standard therapy plus myofascial release iliotibial band on increasing functional activity (p = 0.00) in knee osteoarthritis.

Effect of instrument-assisted soft tissue mobilization versus myofascial release therapy for pain, mobility, and disability in chronic low backache patients: a quasi-experimental study

Effect of instrument-assisted soft tissue mobilization versus myofascial release therapy for pain, mobility, and disability in chronic low backache patients: a quasi-experimental study

Effects of Myofascial Release on the Pain and Quality of Life in Patients with Fibromyalgia

Objectives: To investigate the effects of myofascial release technique on pain and quality of life (QoL) in patients with fibromyalgia (FM). Methods: A quasi-experimental study was conducted to investigate the effects of myofascial release technique on patients with FM in Shalamar Hospital Lahore, Pakistan. After initial screening, 28 patients aged 25 to 45 years of both genders meeting the predetermined inclusion criteria were selected using convenience sampling. They were divided into two groups. Group A was treated with myofascial release therapy and passive stretching, while group B was treated with passive stretching alone. The McGill pain questionnaire (MPQ) was used to assess the pain, and the revised FM impact questionnaire (FIQR) was used to evaluate QoL. Results: Out of 28 participants, 11(39.3%) were male and 17(60.7%) were females. Pre- and post-treatment mean scores of pain rating index on MPQ were 46.76±10.47 and 23.79±7.43 for the experimental group and 43.36±12.7 and 30.0±9.89 for the control group, respectively (P&gt;0.05). Mean pre- and post-treatment FIQR scores were 52.9±13.6 and 33.02±13.75 for the experimental group and 57.77±23.04 and 46.59±19.37 for the control group, respectively. The difference in the means of post-treatment scores of the two groups for FIQR was significant (P=0.042). Discussion: Compared with passive stretching alone, the myofascial release method for FM did not demonstrate significant improvement in alleviating pain among such patients. However, it is remarkable that myofascial release therapy unveiled a positive impact by improving the overall QoL for FM patients.

Current Practice Patterns in the Management of Bell's Palsy Among Physiotherapists of Sargodha, Pakistan

Objectives: We intend to find out current practice patterns in managing Bell’s palsy among the physiotherapists of Sargodha, Pakistan. Methods: A cross-sectional study was conducted from May to August 2022. Data were obtained from 50 physiotherapists working in various clinical settings of Sargodha with more than 2 years of clinical experience. They were selected using convenient sampling. A self-designed questionnaire was used to gather all necessary information regarding the physical therapy practice patterns of Bell’s palsy. The obtained data were analyzed by using SPSS software, version 20. Results: Proprioceptive neuromuscular facilitation (PNF) was the preferred (42%) neurodevelopmental technique used in current practice patterns to manage Bell’s palsy. The most used therapeutic exercises by the physiotherapists were facial expression coordination exercises (66%). Also, 44% of physiotherapists used electrical muscle stimulation as the preferred electrotherapeutic modality in their current practice. Soft tissue release (54%) was the most preferred manual therapy technique in Bell’s palsy patients. The combination of electrical muscle stimulation, facial exercises, and biofeedback was the most used (54%) among physiotherapists. Discussion: Current practice for Bell’s palsy treatment includes PNF techniques, facial expression coordination exercises, soft tissue release, and electrical muscle stimulation by most physiotherapists in Sargodha. The most preferred combination was facial exercises, electrical stimulation, and biofeedback.

A Multidisciplinary Approach to Hypermobility Spectrum Disorder, Raynaud's Phenomenon, and Biomechanical Soft Tissue Injuries in an Adolescent Boy: A Case Report.

A 16-year-old male with hypermobility spectrum disorder (HSD) and Raynaud's phenomenon (RP) was referred to a clinical exercise physiologist (CEP) by their pediatric rheumatologist. The patient presented with arthralgia in the left knee and shoulder. Specifically, the left knee presented discomfort during activities of daily living (ADL), and the left shoulder had a reduced range of motion resulting from pain. Finally, complaints of painful fingers were also significant due to increased RP flare-ups during winter. A posture analysis was conducted, indicating relatively poor posture. Range of motion and manual muscle testing were suboptimal in the shoulders, but optimal in the knees and hips. The Kendal test, patella compression test, and Clarke's sign were conducted due to knee pain. Functional tests included a pelvic bridge, squat, Neer's test, and wall push-up. Finally, the modified pediatric clinical test of sensory interaction in balance (mPCTSIB) was completed to determine the interaction between balance systems. Analysis of all the tests conducted above confirmed the diagnosis of HSD and also indicated scapula dyskinesia, supraspinatus impingement, and patellofemoral pain syndrome. Consequently, the CEP treatment focused on strengthening the foot, knee, and hip kinetic chain, as a 12-week home program, along with hand exercises as needed to aid in the pain and stiffness experienced during RP flare-ups. The physiotherapist treatment was more hands on in the use of myofascial release, electrotherapy, taping, and posture correction of the neck and shoulder over four in-house visits. Finally, a 6-month follow-up was conducted by the CEP, in which the patient showed improvement with a pain-free range of motion and the ability to optimally conduct ADLs.

Considerations in Correction of Wrist Deformity in Arthrogryposis.

The wrist is affected in all the forms of arthrogryposis and is a common site requiring surgical intervention. The wrist usually has a flexion and ulnar deviation deformity of varying severity. A flexion deformity of >40° results in a weak hand grip and gives an 'abnormal' look to the patient as a whole and hence, is a common reason for patients to desire surgical correction. However, as children tend to adjust to whatever posture they have as they grow, the most important thing a surgeon should be aware of, is when and whom not to operate. This article discusses all these possibilities in detail and provides authors preferred surgical plan. We have found a combination of volar fascia release, intercarpal wedge resection osteotomy and extensor carpi ulnaris to extensor carpi radialis brevis tendon transfer to be most effective and reliable. Patient and parental satisfaction with early surgical intervention is often satisfactory. Level of Evidence: Level V (Therapeutic).