9.3 Congenital and Pediatric Musculoskeletal Conditions

Congenital and Pediatric Musculoskeletal Conditions

Pediatric musculoskeletal disorders comprise congenital deformities present at birth and developmental conditions that emerge during rapid skeletal growth. Effective physical therapy management relies on early identification, precise biomechanical examination, knowledge of skeletal growth plates, and the application of evidence-based conservative protocols.

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Congenital Muscular Torticollis (CMT)

CMT typically presents in infancy with the head tilted toward the involved sternocleidomastoid (SCM) and the chin turned away. Right SCM involvement therefore commonly presents with right tilt and left rotation. Some infants have a palpable SCM mass or restricted passive range. Others have a postural preference with symmetric passive range.

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Examination and Head Shape

Measure active and passive rotation and lateral flexion, observe movement symmetry and feeding positions, and assess skull shape and development. Poor visual tracking, unusual tone, atypical or late-onset posture or other nonmuscular findings warrant referral for medical assessment. Check for associated hip concerns.

Positional plagiocephaly can accompany a persistent head-turn preference. Occipital flattening often corresponds to the side toward which the infant turns in supine. The flattened side can also have frontal prominence and an anterior ear shift. Look at the infant’s actual head shape and contact pattern. Atypical skull shape, a suspected fused suture or an uncertain diagnosis warrants medical assessment.

First-Choice Therapy for CMT

The 2024 APTA pediatric guideline recommends five components: neck passive range work if restricted, active neck and trunk motion, symmetrical movement, environmental adaptations and caregiver education. For right CMT, work gently toward left lateral flexion and right rotation if those directions are limited. Use active play to encourage movement toward the restricted side, and coach comfortable positioning during feeding and care.

Use short bouts of supervised prone play while the infant is awake and build time as tolerated. For sleep, place the infant on the back on a firm, flat surface and keep the sleep space clear of pillows and positioners, consistent with Saudi MOH safe-sleep guidance. Discuss specialist assessment for persistent moderate-to-severe positional asymmetry after conservative care. A specialist determines whether a molding orthosis is appropriate based on age, severity and response.

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Developmental Dysplasia of the Hip (DDH)

DDH ranges from acetabular dysplasia to instability, subluxation or dislocation. Breech presentation, family history and a history of clinical instability are important screening factors. Reassess the hips as the infant grows.

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• Barlow: With the hip flexed, gentle adduction during palpation checks whether the femoral head slips out of the socket. Avoid applying a posteriorly directed force.
• Ortolani: Gentle abduction with an anterior lift can reduce a dislocated, reducible hip. The finding is a palpable relocation of the femoral head.
• Later findings: Limited or asymmetric hip abduction and apparent limb shortening or unequal knee heights (Galeazzi sign) can increase concern. Interpret skin-fold asymmetry alongside stronger findings.

The Saudi MOH DDH pathway calls for neonatal assessment, immediate contact and referral before discharge if a hip is dislocated or dislocatable at birth, and subsequent examinations for infants with an initially normal examination. In an infant with risk factors such as breech presentation and a normal exam, selective ultrasound at 4–6 weeks may be recommended. The pathway identifies AP radiography as an imaging option from 4 months for DDH assessment. Clinical instability requires referral even when imaging is pending.

Orthopaedic Treatment and Harness Monitoring

The orthopaedic team selects observation, bracing or reduction according to age, stability and imaging. A Pavlik harness is one early bracing option for selected infants. The team confirms the diagnosis, fits the harness and follows reduction and development with serial examination and imaging. For infants under 6 months, the Saudi guideline advises abandoning the harness if reduction has not occurred by 4 weeks.

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Congenital Talipes Equinovarus (Clubfoot)

Idiopathic clubfoot is a three-dimensional foot deformity involving cavus, adduction, hindfoot varus and equinus. Assess flexibility and screen for associated conditions, since the treatment course can differ in complex or syndromic cases.

Pathoanatomy: The CAVE Deformities

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1. Cavus: High arch from plantarflexion of the first ray relative to the rest of the foot.
2. Adduction: The forefoot is turned toward the midline.
3. Varus: The hindfoot is inverted.
4. Equinus: The ankle rests in plantarflexion with restricted dorsiflexion.

The Ponseti Method

In idiopathic clubfoot, a trained team uses serial manipulation and long-leg casting, often starting in the first few weeks. Correct cavus first by elevating the first ray and aligning the forefoot with the hindfoot. Then abduct the foot around the stabilized talar head to correct adduction and heel varus together. Avoid blocking the calcaneus during this correction. Address equinus last, after the other components have corrected. A percutaneous Achilles tenotomy is commonly needed for residual equinus, followed by a final cast.

The foot-abduction brace maintains correction after casting. One AAP protocol uses about 23 hours a day for the first 3 months, then during naps and at night, about 12–14 hours daily, until age 4–5. Follow the clubfoot team’s schedule and check fit, skin and adherence. Help caregivers troubleshoot brace wear, which is important for reducing relapse.

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Adolescent Idiopathic Scoliosis (AIS)

AIS is a structural spinal curve that develops from age 10 through adolescence without an identified underlying cause. A Cobb angle of at least 10 degrees with rotation is consistent with scoliosis in the appropriate clinical setting. Progression risk depends on curve size, growth remaining and prior change.

Screening and Radiographs

The Adam forward-bend test can reveal rib or lumbar prominence. A scoliometer measures angle of trunk rotation. It helps guide referral under the local screening protocol. Radiographs are used when indicated to characterize the curve.

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• Cobb angle: Measure the angle between the upper endplate of the upper end vertebra and the lower endplate of the lower end vertebra of the curve. The apical vertebra identifies the curve’s apex. Standing posteroanterior views are preferred when feasible to reduce anterior radiation exposure.
• Risser sign: Describes ossification and fusion of the iliac apophysis. Lower grades generally indicate more remaining growth. Interpret it alongside growth history and other maturity measures.

Management

For example, a 32-degree curve at Risser 1 warrants timely specialist bracing assessment. In BrAIST, adolescents at risk of progression were assigned a brace prescription of at least 18 hours daily in the bracing group. The individual schedule and follow-up depend on the brace, maturity and specialist plan.

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Juvenile Idiopathic Arthritis (JIA)

JIA includes several forms of persistent arthritis beginning in childhood. In the ILAR classification, onset is before age 16 and arthritis persists for at least 6 weeks after other causes are excluded. Oligoarthritis affects up to four joints in the first six months. Polyarthritis affects five or more joints in the first six months and can be rheumatoid factor positive or negative. Systemic JIA, also called pediatric Still disease, can present with recurring fever, transient rash and arthritis. Classification and treatment are coordinated by pediatric rheumatology.

Chronic anterior uveitis can be asymptomatic. Follow the ophthalmology screening schedule set for the child’s risk. The 2026 ACR JIA recommendations conditionally support physical therapy, occupational therapy and physical activity alongside medical management.

• During a known flare: Coordinate with the team. Use comfortable active movement and adapt load, duration and impact to symptoms. A new acutely hot swollen joint with fever or systemic illness warrants urgent medical assessment for infection or other causes.
• When symptoms settle: Progress strength, aerobic activity and play toward the child’s goals. Choose activities such as cycling, walking or pool exercise by tolerance and access. Reassess pain, mobility, participation and recovery after exercise.