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Commentary on “Reliability of Common Lower Extremity Biomechanical Measures for Children With and Without Obesity”

Quijano, Katrice PT, DPT; Richards, Amber PT, MPT, PCS

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Pediatric Physical Therapy: Fall 2015 - Volume 27 - Issue 3 - p 257
doi: 10.1097/PEP.0000000000000157
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“How should I apply this information?”

Children and adolescents who are obese are likely to present with joint pain caused by impaired musculoskeletal alignment, limiting physical activity. Decreased femoral anteversion, genu valgum, and increased foot pronation are common lower extremity malalignments in this population. Clinically, the tibiofemoral angle, Foot Posture Index-6, and sit-and-reach test can be used as quick and reliable measures to assess genu valgum, foot posture, and general flexibility, respectively, on the basis of the reliability found in this study. Although the Craig test for femoral anteversion had the lowest reliability, it may still be a useful measure that can be performed in the clinic setting and if used with caution. Accurate measurement of these impairments guides intervention and progression.

“What should I be mindful about in applying this information?”

Raters had extensive training and comparable training may be required for similar results. A significant limitation, discussed in this article, was the order in which the participants were recruited and tested. Participants who were obese were assessed later in the study; thus, practice by the raters might have contributed to the decreased variability of measures in these participants. The lack of randomization of the order of testing, the small sample and a sample of convenience, also limits applicability. The Foot Posture Index-6 requires quiet stance for at least 2 minutes. This may be difficult for younger children or for those with cognitive and/or behavioral impairments. Results for the Craig test were inconsistent with the literature, which supports decreased femoral anteversion in the obese population. This may have been the result of exclusion of orthopedic conditions prevalent in this population (eg, slipped capital femoral epiphysis), which has been associated with a decrease in femoral anteversion.1 In addition, lower interrater reliability was likely due to variability in the palpation of the greater trochanter.2 Even if patients have normal alignment, monitoring may be indicated to prevent progressive deformities, especially if weight is not being effectively managed. Appropriate referrals to a multidisciplinary team including physicians, nutritionists, and psychologists who are experienced in working with the population of children with obesity may be necessary.

Katrice Quijano, PT, DPT

Amber Richards, PT, MPT, PCS

Children's Hospital Los Angeles, Los Angeles, California


1. Gelberman RH, Cohen MS, Shaw BA, Kasser JR, Griffin PP, Wilkinson RH. The association of femoral retroversion with slipped capital femoral epiphysis. J Bone Joint Surg Am. 1986;68(7):1000–1007.
2. Moriguchi CS, Carnaz L, Silva LCCB, et al. Reliability of intra- and inter-rater palpation discrepancy and estimation of its effects on joint angle measurements. Manual Ther. 2009;14(3):299–305.
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