Joint HypermobilityNCT06998563
The Effect of Lower Extremity Rotational Profile on Postural Control, Muscle Strength, Functional Capacity and Lower Extremity Function in Children With Generalized Joint Hypermobility
An observational study of Joint Hypermobility and Femoral Anteversion, run by Bezmialem Vakif University at 1 site in Turkey (Türkiye).
Trial summary
Generalized joint hypermobility is when the range of motion in synovial joints exceeds its physiological limits. The aim of this investigation is to investigate the effect of lower extremity rotational profile on postural control, muscle strength, functional capacity and lower extremity function in children with… Read more about this study
- Who is it for?
- Ages 7 to 16 yearsHealthy volunteers can take part
- Conditions the study is for
- Joint Hypermobility, Femoral Anteversion, Postural Control
- What is being tested?
- Rotational Profile- Hip Internal and External Rotation Measurement, Rotational Profile- Craig's Test Measurement and Rotational Profile- Foot/Thigh Angle Measurement
- How many people
- 48 participants
- Where
- 1 siteTurkey (Türkiye)
- Study dates
- 1 Jul 2025to 12 Jul 2025
- Phase
- Observational
- Are there results?
- None posted in the registry
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 7 to 16 years
- All sexes
- Healthy volunteers accepted
- Child
Study population: The sample size of the study was calculated with the G*Power 3.1.9.4 analysis program. In the calculation of the sample size, 6-minute walking distance, one of the parameters evaluated in the study of Kepenek-Varol et al. in which individuals with generalized joint hypermobility were compared with their healthy peers, was taken into consideration. The analysis was performed with a priori power analysis ANOVA (One-way) approach for the three groups. Accordingly, the effect size obtained was Cohen's d = 0.64, while the total minimum sample size to be reached for the three groups was calculated as 42 individuals in order to obtain 95% power at α=0.05 level. Considering that there might be missing data during the research phase, this number was increased by 10% and the number of participants for each group was determined as 16 and 48 in total.
Who may be able to join
- Being between 7-16 years old
- Having a body mass index (BMI) within normal limits (18.5-24.9 kg/m2)
- Beighton Score ≥ 5
- Having a lower extremity rotational profile problem according to Staheli rotational profile assessment
- Being between 7-16 years old
- Having a BMI within normal limits (18.5-24.9 kg/m2)
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- Beighton Score ≥ 5
- Having a normal lower extremity rotational profile problem according to Staheli rotational profile assessment
- Being between 7-16 years old
- Having a BMI within normal limits (18.5-24.9 kg/m2)
- Beighton Score < 5
- Having a normal lower extremity rotational profile problem according to Staheli rotational profile assessment
Who cannot join
- Having any neurological, rheumatic, musculoskeletal, metabolic and connective tissue disease
- History of surgery related to the vertebral column and lower extremities
- Having cognitive, mental and/or severe psychiatric illness
- Participated in any exercise program or sportive activity in the last six months
Trial locations and contacts
1 site in 1 country.
Turkey (Türkiye)1 site
Bezmialem Vakif University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation
Istanbul
About this study
Generalized joint hypermobility is when the range of motion in synovial joints exceeds its physiological limits. The aim of this investigation is to investigate the effect of lower extremity rotational profile on postural control, muscle strength, functional capacity and lower extremity function in children with generalized joint hypermobility. Within the scope of this cross-sectional study, permission was obtained from Bezmialem Vakif University Non-Interventional Clinical Research Ethics Committee with the decision number 177310 dated 31.12.2024. Following the Ethics Committee approval, data collection started and the study will be conducted in accordance with the Declaration of Helsinki. "Informed Voluntary Consent Form" prepared for both parents and children and approved by Bezmialem Vakıf University Non-Interventional Clinical Research Ethics Committee will be signed.
All children participating in the study and their parents will be informed about the study and those who voluntarily agree to participate in the study will be invited by appointment.
Read more
All evaluations will be carried out in the Pediatric and Cardiac Physiotherapy and Rehabilitation Education and Research Laboratories of the Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Bezmialem Vakıf University. Forty-eight children who meet the specified inclusion/exclusion criteria will be included in the study sample.
Within the scope of the study, demographic information of the children will be recorded with the sociodemographic evaluation form and clinical evaluations will be performed on the same day. All assessments will be administered to all children in all three groups by the same researcher in the following order.
The evaluation process will start with the completion of the sociodemographic information form. Then, the general joint hypermobility status of the participants will be evaluated with the Beighton Score. Within the scope of clinical measurements, bilateral lower extremity rotational profile will be determined by Craig's test, foot-thigh angle, foot progression angle, navicular drop test, Heel Bisector Line Test and Q angle measurements. Lower extremity muscle shortness and flexibility will be evaluated using bilateral Thomas test, Duncan-Ely test, Ober test, popliteal angle test, Silfverskiöld test and sit-to-stand test. Bilateral hip internal and external rotation angles and ankle dorsiflexion angle measurements will be performed to measure range of motion. Bilateral leg length measurements will be performed and general pain status will be questioned using the Visual Analog Scale.
Postural control will be assessed using the Biodex Balance System, muscle strength will be assessed using the MicroFET2 hand dynamometer, functional capacity will be assessed using the 6-minute walk test and lower extremity functionality will be assessed using the Lower Extremity Functional Scale .
Read the detailed description
Generalized joint hypermobility is characterized by an excessive range of motion in multiple joints without the presence of hereditary connective tissue disorders. Despite the clinical relevance of biomechanical changes such as increased femoral anteversion in children with Generalized Joint Hypermobility , limited research exists on how these alterations affect postural control, muscle strength, functional capacity, and lower extremity function. This observational cross-sectional study aims to evaluate the influence of lower extremity rotational profile on these parameters in children with Generalized Joint Hypermobility.
The sample size of the study was calculated with G*Power 3.1.9.4 analysis program. In the calculation of the sample size, 6-minute walking distance, one of the parameters evaluated in the study of Kepenek-Varol et al. in which individuals with generalized joint hypermobility were compared with their healthy peers, was taken into consideration. The analysis was performed with a priori power analysis ANOVA (one-way) approach for three groups. Accordingly, while the effect size obtained was Cohen's d = 0.64, the total minimum sample size to be reached for the three groups was calculated as 42 individuals in order to obtain 95% power at α=0.05 level. Considering that there may be missing data during the research phase, this number was increased by 10% and the number of participants for each group was determined as 16 and 48 people in total. This study will include a total of 48 children who will be divided into three groups.
Inclusion Criteria for Group 1:
- Being between 7-16 years old
- Having a body mass index within normal limits (18.5-24.9 kilograms/meter2)
- Beighton Score ≥ 5
- Having a lower extremity rotational profile problem according to Staheli rotational profile assessment
Inclusion Criteria for Group 2:
- Being between 7-16 years old
- Having a body mass index within normal limits (18.5-24.9 kilograms/meter2)
- Beighton Score ≥ 5
- Having a normal lower extremity rotational profile problem according to Staheli rotational profile assessment
Inclusion Criteria for the Control Group;
- Being between 7-16 years old
- Having a body mass index within normal limits (18.5-24.9 kilograms/meter2)
- Beighton Score < 5
- Having a normal lower extremity rotational profile problem according to Staheli rotational profile assessment
Exclusion criteria for all groups;
- Having any neurological, rheumatic, musculoskeletal, metabolic and connective tissue disease
- History of surgery related to the vertebral column and lower extremities
- Having cognitive, mental and/or severe psychiatric illness
- Participated in any exercise program or sportive activity in the last six months
Applications will be carried out in the Cardiac Physiotherapy and Rehabilitation Education and Research Laboratories of Bezmialem Vakif University Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation after permission is obtained.
Within the scope of this cross-sectional study, permission was obtained from Bezmialem Vakif University Non-Interventional Clinical Research Ethics Committee with the decision number 177310 dated 31.12.2024. Following the approval of the Ethics Committee, data collection will begin and the study will be conducted in accordance with the Declaration of Helsinki. "Informed Voluntary Consent Form" prepared for both parents and children and approved by Bezmialem Vakıf University Non-Interventional Clinical Research Ethics Committee will be signed.
All children participating in the study and their parents will be informed about the study and those who voluntarily agree to participate in the study will be invited by appointment.
All evaluations will be performed in the Pediatric and Cardiac Physiotherapy and Rehabilitation Education and Research Laboratories of the Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Bezmialem Vakif University. Forty-eight children who meet the specified inclusion/exclusion criteria will be included in the study sample.
Within the scope of the study, demographic information of the children will be recorded with the sociodemographic evaluation form and clinical evaluations will be performed on the same day. All assessments will be administered to all children in all three groups by the same researcher in the following order.
The evaluation process will start with the completion of the sociodemographic information form. Then, the general joint hypermobility status of the participants will be evaluated with the Beighton Score. Within the scope of clinical measurements, bilateral lower extremity rotational profile will be determined by hip internal and external rotation measurements, Craig's test, foot-thigh angle, heel bisector line, Q angle, navicular drop test and foot progression angle. Lower extremity muscle shortness and flexibility will be evaluated using bilateral Thomas test, popliteal angle test, Silfverskiöld test, Ober test, Duncan-Ely and sit-to-stand test. Bilateral ankle dorsiflexion angle and bilateral leg length measurements will be performed to measure range of motion. General pain status will be questioned using the Visual Analog Scale.
Postural control will be assessed with the Biodex Balance System, muscle strength with the MicroFET2 hand dynamometer, functional capacity with the 6-minute walk test and lower extremity functionality with the Lower Extremity Functional Scale.
In order to prevent fatigue from having a negative effect on the test results, the order of administration of each test will be determined in accordance with the position of the children. Lying tests will be performed in the supine position, while prone tests will be performed in the prone position. Standing tests will be performed in the standing position respectively. During the assessments, children will be tested in their underwear only and the temperature of the environment will be controlled to ensure their comfort. Only researchers and children will be present in the laboratory to avoid distractions during the tests.
Demographic information form All children's gender, age, body weight, height and dominant side information will be recorded before clinical evaluations. The body mass index (kilogram/meter2) of the child will be calculated and recorded with the recorded body weight (kilogram) and height (meter) values.
Clinical evaluations:
Evaluation of joint hypermobility according to the Beighton score:
The Beighton Score is one of the most preferred scoring methods due to its bilateral evaluation of the joints and easy applicability. It was created by Beighton in 1973 by modifying the Carter and Wilkinson criteria. The Beighton Score is a valid and reliable measurement tool that is widely used in the evaluation of joint hypermobility in childhood and adolescence. In this study, the Beighton Score will be used to define asymptomatic generalized joint hypermobility. Although variable threshold values have been proposed in the literature according to different age groups, in this study, a Beighton score of ≥5 points and above will be accepted as the criterion for hypermobility in children aged 7-16 years. Children who reach this threshold are classified as children with generalized joint hypermobility.
The Beighton Score is a measurement tool evaluated over a total of 9 points. The evaluation is based on the following criteria:
- Passive dorsiflexion of the 5th finger in both hands exceeding 90° (1 point per side),
- Contact of the thumb with the volar side (flexor side) of the forearm with flexion in both hands (1 point per side),
- Hyperextension of more than 10° at both elbows (1 point per side),
- Hyperextension of more than 10° in both knees (1 point per side),
- Palms touching the ground during forward flexion of the trunk with the knees in extension (1 point).
Evaluation of lower limb rotational profile:
In the study, Staheli's rotational profile tests will be applied to evaluate the rotational profile of the lower extremities of the children. All children in all three groups underwent the following tests;
Hip internal and external rotation angles measurement:
In the study, hip range of motion evaluations will be performed. Measurements will be performed using a universal goniometer. The children will be positioned in the prone position with their knees flexed 90° and placed on the edge of the bed. The tuberositas tibia will be chosen as the pivot point of the goniometer, and the movable arm will be aligned with the tibial crista. The fixed arm will be placed perpendicular to the floor and the movable arm will be guided by the tibial crista. During hip rotation, it will be ensured that the hip remains stable and the movement occurs only in the hip joint.
Craig's test The Ryder test, also known as the 'Trochanteric Prominence Angle Test', will be performed on the children included in the study according to the following protocol. The children will be placed in a prone position. The physiotherapist stood on the opposite side of the hip to be tested. The hips of the children will be placed in the extension position and the knee on the side to be tested will be held in the 90° flexion position. The physiotherapist palpated the trochanter major with the left hand and internal rotated the hip with the right hand. At the point where the trochanteric process will be most prominent, the angle between the tibia and the vertical plane will be measured using a goniometer and the femoral anteversion angle will be recorded.
Foot/thigh angle measurement:
This assessment will be performed by measuring the angle between the long axis of the femur bone and the foot with a goniometer in the prone position. One arm of the goniometer will be placed parallel to the long axis of the femur, while the other arm will be placed so that it passes through the 2nd and 3rd metatarsals. Normally, the thigh-foot angle should be in external rotation between 10-15°. In young children, this angle can be considered normal up to 30°. A decrease in the thigh-foot angle will indicate internal tibial torsion (expressed as a negative value), which is the internal rotation of the tibia. In this case, there is an abnormal internal rotation of the tibia. If the measured foot-thigh angle exceeds 30°, it is considered to be external tibial torsion (external rotation of the tibia).
Heel bisector line:
The heel bisector line test will be an evaluation method that helps diagnose metatarsus adductus. During the test, the child will be placed in the prone position with the heel between the physiotherapist's fingers. Then, the midpoint of the lines drawn from the malleoli will be determined. From this point, a perpendicular line will be drawn from the heel to the toes along the foot axis with the help of a goniometer. Normally, this line should end between the 1st and 2nd toes. If the line ends at the 3rd, 4th or 5th toes, this may indicate the presence of metatarsus adductus.
Q angle measurement:
Q-angle is defined as the angle formed between an imaginary line connecting the anterior superior iliac spine of the pelvis to the midpoint of the patella and the proximal projection of the line extending from the tibial tubercle to the center of the patella. The child will first be placed in a supine position, with legs extended and muscles relaxed, and the midpoint of the patella is marked with a colored pencil. Then, the goniometer will be placed at the exact midpoint of the patella, and care is taken to fix the mobile arm so that it points to the anterior superior iliac spine and the fixed arm so that it follows the tibia, and the angle in between will be recorded. The measurement will be recorded in two different positions: lying down and standing. The Q angle is considered normal between 10-15 ° in boys and 15- 20 ° in girls.
Navicular drop test:
The navicular drop test is a widely used test in the clinic to evaluate the presence and degree of pes planus. This test will be started with the child in a sitting position, with the feet only in contact with the floor, without weight bearing. In the first step, the navicular tubercle will be palpated and marked. While the child is in a sitting position, the distance between the navicular tubercle and the floor will be measured. This measurement will be made when the feet are only in contact with the floor without any weight bearing. Then, the child is asked to stand and the distance between the navicular tubercle and the floor will be measured again in a position where the feet are equally weight bearing. Measurements will be made bilaterally, separately for each foot, and the results will be recorded in millimeters.
In the navicular drop test, the difference between weighted and unweighted measurements is interpreted as follows: Differences between 5-9 millimeter are considered normal (neutral), differences of 10 milimeter and above are considered as an indicator of pronation (inward rotation) in the foot, while differences of 4 millimeter and below are associated with supination (outward rotation) in the foot. This test is an important measurement tool for determining the degree of pes planus
Foot progression angle:
Foot progression angle is used as an important parameter in determining potential disorders and alignment errors in the child's walking pattern by reflecting the rotational relationships between the femur, tibia and foot. For this measurement, two chairs will first be placed opposite each other with a distance of 2 m between them. Then, the child will be asked to sit on the chair. In the sitting position, the middle of the heel and the second toe will be marked with colored paint. After the marking, the child will be asked to walk naturally on a flat surface to the chair opposite. The child will stand up from the sitting position and walk approximately 5-6 steps on a flat surface to the chair opposite. Then, the child will be asked to sit on the chair opposite and clean the paint on his foot. This colored marking will be made in a way that will create the child's walking traces. When the child finishes walking, these traces will be measured in degrees using a goniometer. To measure the foot progression angle with a goniometer; One arm will be positioned so that it is aligned with the direction of the footprints, and the other arm will be positioned parallel to the axis of the tibia. The angle between the foot and the tibia will be recorded in degrees with a goniometer.
Measurement of ankle joint dorsiflexion range of motion:
With the knee joint in full extension and 90° flexion, the subtalar joint in a neutral position, the ankle dorsiflexion will be measured with the fixed arm of the universal goniometer on the fibula shaft and the mobile arm following the fifth metatarsal shaft. The measured angles will be recorded in degrees (°). Measurements will be made bilaterally.
Leg length measurement:
The child will be placed in a supine position. The legs will be positioned in extension and the muscles will be relaxed. The physiotherapist will measure and record the child's right leg length from the anterior superior iliac spine bone to the medial malleolus with a flexible metal tape measure. Measurements will be made bilaterally.
Muscle shortness/flexibility assessments
Thomas test:
The Thomas test will be performed to evaluate shortness/tightness in the hip flexor muscle group, especially in the iliopsoas muscle. The child will be placed in the supine position, the lumbar spine will be fixed and the assessment will begin. During the test, while the assessed hip is in knee extension, the opposite hip and knee will be passively flexed by the physiotherapist, and the hip movement of the assessed side will be observed during this time. The Thomas test will be recorded as negative if no flexion movement is observed in the assessed hip. In the presence of shortness/tightness, the assessed hip is seen to be flexed, and in this case, the Thomas test will be recorded as positive.
Popliteal angle test:
The popliteal angle test will be used to evaluate shortness or tightness of the hamstring muscles. The hip and knee will be placed in a 90° flexion position while the child is in the supine position. While the physiotherapist passively moves the knee joint towards extension, the popliteal angle will be measured using a goniometer. While one arm of the goniometer is placed parallel to the lateral surface of the femur, the other arm is held parallel to the fibula head and the angle will be measured. The knee joint will be extended until it encounters resistance and the angle between the tibia and the vertical plane will be recorded as the popliteal angle.
Silfverskiold test:
Gastrocnemius assessment will be evaluated with the Silfverskiold test for all children participating in the study. The assessment will be performed bilaterally in supine positions where the child does not bear weight on their feet. The knee joint will be in full extension and 90° flexion, the subtalar joint will be in a neutral position, and the ankle dorsiflexion will be measured with the fixed arm of the universal goniometer on the fibula shaft and the mobile arm following the fifth metatarsal shaft. The measured angles will be recorded in degrees (°). Passive ankle dorsiflexion of ≤ 10° with the knee extended and a minimum of 10° increase in dorsiflexion with the knee flexed will be considered as isolated gastrocnemius muscle shortness.
Ober test:
The Ober test will be an assessment performed to measure the length of the iliotibial band. There are also some modifications of this test, such as the modified Ober test described by Kendall in 1953. Both the Ober test and the modified Ober test are widely used and accepted tests to assess iliotibial band length. During the test, the child will be placed in a side-lying position with the lower leg slightly flexed at the hip and knee. The knee of the upper leg is ensured to be in 90° flexion. After the positioning is completed, the physiotherapist will hold the ankle of the upper leg with one hand and stabilize the hip with the other hand. Then, the leg will be abducted and the knee will be extended, and the leg will be moved until the femur is in line with the body. Finally, the thigh will be allowed to fall towards the surface in this plane, and the result of the test will be evaluated according to the amount of adduction of the hip. If the knee hangs in the air, the test will be recorded as positive. If the leg falls towards the surface, the test will be evaluated as negative.
Duncan-ely test:
The Duncan-Ely test will be used to evaluate the shortness and tightness of the rectus femoris muscle. While the child is lying in the prone position, the hip will be fixed with one hand by the physiotherapist and the hip and knee will be kept in extension. In this position, the knee joint will be passively flexed in order to stretch the rectus femoris muscle on the tested side. If no shortness or tightness is observed in the rectus femoris muscle on the same side during the test and hip extension is maintained, the Duncan-Ely test will be recorded as negative. However, when the knee is flexed and a flexion movement is observed in the hip, the test will be recorded as positive.
Sit-reach test:
This test is a frequently used test to evaluate the flexibility of the hamstring and lower back muscle groups. The S\&R Sit and Reach® table will be used for this test. The child will sit in front of the table with dimensions of 55 centimeters long, 35 centimeters wide, and 30 centimeters high, and his/her feet will be positioned on the foot surface of the table. The child will be asked to place his/her hands on top of each other and stretch forward in a slow and controlled manner, bringing the ruler on the table forward. He/she will be asked to wait 1-2 seconds at the farthest point without stretching forward or backward. Scoring will be done according to the ruler on the table. (On this table, the child's ability to bring the ruler to the tips of his/her toes corresponds to 23 centimeters). The test will be repeated three times for each child to ensure reliability, and the highest value will be recorded in centimeters.
Postural control assessment with Biodex balance system Biodex Balance System is a valid and reliable equipment that will be used to assess postural stability, stability limits and fall risk. It consists of a balance platform, arm supports, a screen and printer. The platform can be adjusted as static or mobile (12 levels of movement amount; level 12 is the most stable, level 1 is the least stable level that can move up to 20 degrees in each direction) according to the test that will be applied. Before the evaluation, explanatory information about the test steps will be given to all children included in the study. The axes where the heel and toe tips of each child will be recorded according to the medial and lateral (B, C, D, E, F, G, H, I, J) axes, the angles in the anterior and the axes in the posterior (1, 2, 3…,21). The arm support and test screen height will be adjusted specifically for each child. The child's information and stance position information will be entered into the balance beam screen. The device will be evaluated with three separate tests: postural stability test, stability limits test and balance sensory integration test.
Postural Stability (Test of Postural Stability) This test will evaluate the child's ability to maintain the center of balance on a stable platform and record the deviations from the center. General, anterior/posterior and medial/lateral stability indexes will be calculated and recorded as degrees. The general stability index reflects the variability of the platform relative to the horizontal plane during all movements performed in the test. Anterior/posterior stability index reflects the variability for movements in the sagittal plane, medial/lateral stability index reflects the variability for movements in the frontal plane. A high score value will indicate that postural stability is affected more. In this test, three 20-second measurements will be made with 10 seconds between each measurement.
Stability limits test This test, performed on a static platform, will evaluate the child's ability to move and control the center of gravity between the body's support surfaces. Directional control (general, forward, backward, left, right, forward/left, forward/right, backward/left, backward/right) will be evaluated and expressed as a percentage value. High scores indicate good postural control (100% = perfect control).
Sensory integration of balance test This test will evaluate how the child's various senses contribute to balance and how well they can compensate for balance when one or more of these senses are eliminated. The test will be performed on a hard surface with the static platform setting, with eyes open, eyes closed, and on a foam surface with eyes open, eyes closed, and the sway index values will be recorded for each of the four positions. In this test, four measurements will be made with a 10-second rest between each measurement and each test duration of 30 seconds.
Lower extremity muscle strength measurement Micro-FET2:
Muscle tests will be performed using the MicroFET 2 digital hand dynamometer according to the device manual. The measurement will be performed in supine, prone, side-lying and sitting positions by preventing compensatory movements. During the test, the arms will be positioned so that they will not receive power from anywhere on/to the side of the body. Measurements will be performed bilaterally. While the child to whom the test will be applied is expected to perform the requested movement with all his/her strength, the evaluating physiotherapist will apply resistance in the opposite direction in proportion to the strength. During the evaluation of the same muscle, a 30-second break will be given between repetitions, and a five-minute rest will be given before moving on to the test for a different muscle. Isometric muscle strength of the Iliopsoas, Gluteus Maximus, Gluteus Medius, Quadriceps, Hamstring, Tibialis Anterior, and Gastrosoleus muscles will be evaluated in the measurement. Strength measurements will be repeated 3 times and the highest measured strength value will be recorded with a kilogram/force value and evaluated.
6-Minute Walking test: The test will be performed on a smooth and flat track that is 30 meters long, marked every 3 meters, and the start and finish lines are marked with a visible line. Before starting the test, the child will rest in a chair for 15 minutes. During this time, the patient's contraindications for the 6-minute walking test will be questioned. If there are no contraindications, the patient's blood pressure, oxygen saturation with a pulse oximeter, pulse, and the patient's dyspnea and fatigue level according to the Borg scale will be checked after the patient rests. If any medications are taken before the test, these will be recorded. The child will be brought to the starting line. The child will be given; The patient is informed that the patient should walk at their own pace for 6 minutes on the track, that they can end the test at any time if they have any complaints, that they can stop and rest if needed during the test and that they should continue the test until the command "test is over" is given, and the chronometer is started and the test will be started with the command "test is started" and the test will be ended with the command "test is over". If the patient stops and rests during the test and pauses the test, the chronometer will not be stopped. The test will be ended if the child has chest pain, intolerable shortness of breath, leg cramps, staggering, diaphoresis, bruising or pallor and oxygen saturation is <85%. After the test is over, the child is seated on a chair, the patient's oxygen saturation, pulse and dyspnea and fatigue levels according to the Borg scale will be checked with a pulse oximeter and the distance the patient walked for 6 minutes will be calculated and the test will be ended. If the child has complaints such as chest pain, dizziness, hip pain or leg pain during the test, it will be recorded.
Lower extremity functional scale:
The Lower Extremity Functional Scale is a questionnaire that will be used to evaluate the functional ability of the entire lower extremity in individuals with musculoskeletal disorders. This scale will question the difficulty experienced in various daily activities due to the problem in the lower extremity with 20 items. Each item is scored between 0-4 on a Likert scale (0=extremely difficult/too difficult to do the activity; 4=not difficult at all). The total score varies between 0-80 and the higher the score, the higher the functional level. A validity and reliability study has been conducted for the Turkish version of the scale to be used in evaluating lower extremity functions.
The Statistical Package for the Social Sciences 26.0 for Windows package program will be used in the statistical analysis of the data obtained. Descriptive statistics (mean±standard deviation, minimum-maximum, number and percentile) will be given for discrete and continuous variables. Groups will be compared with one-way ANOVA. Post hoc test will be performed according to normality with the Shapiro-Wilk test and homogeneity of variance between groups with Levene's test. Categorical groups will be compared with the chi-square (χ2) test. p<0.05 will be considered statistically significant.
- Conditions
- Joint Hypermobility, Femoral Anteversion, Postural Control, Lower Extremity Muscle Strength, Functional Capacity, Lower Extremity Functional Scale
- Being tested
- Rotational Profile- Hip Internal and External Rotation Measurement, Rotational Profile- Craig's Test Measurement, Rotational Profile- Foot/Thigh Angle Measurement, Rotational Profile- Heel Bisector Line Measurement, Rotational Profile- Q Angle Measurement
- Keywords
- Generalized joint hypermobility, Lower extremity rotational profile, postural control, muscle strength, lower extremity functional scale, functional capacity
- Medical subject headings
- Joint Instability
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
Rotational Profile- Hip Internal and External Rotation MeasurementOther
Also called Hip internal/external rotation measurement
Hip internal and external rotation angles measurement, hip range of motion evaluations will be performed. Measurements will be performed using a universal goniometer. The children will be positioned in the prone position with their knees flexed 90° and placed on the edge of the bed. The tuberositas tibia will be chosen as the pivot point of the goniometer, and the movable arm will be aligned with the tibial crista. The fixed arm will be placed perpendicular to the floor and the movable arm will be guided by the tibial crista. During hip rotation, it will be ensured that the hip remains stable and the movement occurs only in the hip joint.
Rotational Profile- Craig's Test MeasurementOther
Also called Craig's test, Ryder test
The Craig's (Ryder) test, also known as the 'Trochanteric Prominence Angle Test', will be performed on the children included in the study according to the following protocol. The children will be placed in a prone position. The physiotherapist stood on the opposite side of the hip to be tested. The hips of the children will be placed in the extension position and the knee on the side to be tested will be held in the 90° flexion position. The physiotherapist palpated the trochanter major with the left hand and internal rotated the hip with the right hand. At the point where the trochanteric process will be most prominent, the angle between the tibia and the vertical plane will be measured using a goniometer and the femoral anteversion angle will be recorded.
Rotational Profile- Foot/Thigh Angle MeasurementOther
Also called foot/thigh angle
Foot/thigh angle assessment will be performed by measuring the angle between the long axis of the femur bone and the foot with a goniometer in the prone position. One arm of the goniometer will be placed parallel to the long axis of the femur, while the other arm will be placed so that it passes through the 2nd and 3rd metatarsals. Normally, the thigh-foot angle should be in external rotation between 10-15°. In young children, this angle can be considered normal up to 30°. A decrease in the thigh-foot angle will indicate internal tibial torsion (expressed as a negative value), which is the internal rotation of the tibia. In this case, there is an abnormal internal rotation of the tibia. If the measured foot-thigh angle exceeds 30°, it is considered to be external tibial torsion (external rotation of the tibia).
Rotational Profile- Heel Bisector Line MeasurementOther
Also called heel bisector line
The heel bisector line test is an evaluation method that helps diagnose metatarsus adductus. During the test, the child will be placed in the prone position with the heel between the physiotherapist's fingers. Then, the midpoint of the lines drawn from the malleoli will be determined. From this point, a perpendicular line will be drawn from the heel to the toes along the foot axis with the help of a goniometer. Normally, this line should end between the 1st and 2nd toes. If the line ends at the 3rd, 4th or 5th toes, this may indicate the presence of metatarsus adductus.
Rotational Profile- Q Angle MeasurementOther
Also called Q angle
The Q-angle is defined as the angle formed between an imaginary line connecting the anterior superior iliac spine of the pelvis to the midpoint of the patella and the proximal projection of the line from the tibial tubercle to the center of the patella. The child will first be placed in a supine position with legs extended and muscles relaxed, and the midpoint of the patella will be marked with a colored pencil. Then, the goniometer will be placed at the midpoint of the patella and care will be taken to fix the movable arm so that it points to the anterior superior iliac spine and the fixed arm so that it follows the tibia and the angle between the two will be recorded. The measurement will be recorded in two different positions, lying and standing. Q angle between 10-15° in boys and 15-20° in girls will be considered normal.
Rotational Profile- Navicular Drop Test MeasurementOther
Also called navicular drop test
The navicular drop test is commonly used in clinics to assess pes planus. It will begin with the child sitting, feet flat on the floor, and no weight bearing. The navicular tubercle will be palpated and marked first, then the distance from the tubercle to the floor will be measured. The child will then stand with equal weight on both feet and the distance will be measured again. Measurements will be taken bilaterally and recorded in millimeters. The difference between the weighted and unweighted measurements will indicate foot posture: 5-9 millimeters is normal (neutral), 10 millimeters or more will indicate pronation (inward rotation), and 4 millimeters or less will indicate supination (outward rotation). This test is important for assessing the degree of pes planus.
Rotational Profile- Foot Progression Angle MeasurementOther
The foot progression angle will be used as an important parameter in determining potential disorders and alignment errors in the child's walking pattern by reflecting the rotational relationships between the femur, tibia and foot. For this measurement, two chairs will first be placed opposite each other with a distance of 2 m between them. Then, the child will be asked to sit on the chair. In the sitting position, the middle of the heel and the second toe will be marked with colored paint. After the marking, the child will be asked to walk naturally on a flat surface to the chair opposite. The child will stand up from the sitting position and walk approximately 5-6 steps on a flat surface to the chair opposite. Then, the child will be asked to sit on the chair opposite and clean the paint off his foot. This colored marking will be made in a way that will create the child's walking traces. When the child finishes walking, these traces will be measured in degrees using a goniometer.
Muscle Shortness/Flexibility- Thomas Test MeasurementOther
Also called thomas test
The Thomas test will be performed to evaluate shortness/tightness in the hip flexor muscle group, especially in the iliopsoas muscle. The child will be placed in the supine position, the lumbar spine will be fixed and the assessment will begin. During the test, while the assessed hip is in knee extension, the opposite hip and knee will be passively flexed by the physiotherapist, and the hip movement of the assessed side will be observed during this time. The Thomas test will be recorded as negative if no flexion movement is observed in the assessed hip. In the presence of shortness/tightness, the assessed hip is seen to be flexed, and in this case, the Thomas test will be recorded as positive.
Muscle Shortness/Flexibility- Popliteal Angle MeasurementOther
Also called popliteal angle
The popliteal angle test will be used to evaluate shortness or tightness of the hamstring muscles. The hip and knee will be placed in a 90° flexion position while the child is in the supine position. While the physiotherapist passively moves the knee joint towards extension, the popliteal angle will be measured using a goniometer. While one arm of the goniometer is placed parallel to the lateral surface of the femur, the other arm is held parallel to the fibula head and the angle will be measured. The knee joint will be extended until it encounters resistance and the angle between the tibia and the vertical plane will be recorded as the popliteal angle.
Muscle Shortness/Flexibility- Silfverskiöld Test MeasurementOther
Also called silfverskiöld test
Gastrocnemius assessment will be evaluated with the Silfverskiold test for all children participating in the study. The assessment will be performed bilaterally in supine positions where the child does not bear weight on their feet. The knee joint will be in full extension and 90° flexion, the subtalar joint will be in a neutral position, and the ankle dorsiflexion will be measured with the fixed arm of the universal goniometer on the fibula shaft and the mobile arm following the fifth metatarsal shaft. The measured angles will be recorded in degrees (°). Passive ankle dorsiflexion of ≤ 10° with the knee extended and a minimum of 10° increase in dorsiflexion with the knee flexed will be considered as isolated gastrocnemius muscle shortness.
Muscle Shortness/flexibility- Ober Test MeasurementOther
Also called ober test
The Ober test will be performed to measure the length of the iliotibial band. Both the Ober test and the modified Ober test are widely used and accepted tests to assess iliotibial band length. During the test, the child will be placed in a supine position with the lower leg slightly bent at the hip and knee. The upper leg will be in 90° flexion of the knee. Once positioning is complete, the physiotherapist will hold the ankle of the upper leg with one hand and stabilize the hip with the other hand. The leg will then be abducted and the knee extended and the leg moved until the femur is in line with the body. Finally, the thigh will be allowed to fall towards the surface in this plane and the result of the test will be judged by the amount of adduction of the hip. If the knee hangs in the air, the test is positive. If the knee falls, the test is negative
Muscle Shortnes/flexibility- Duncan-Ely Test MeasurementOther
Also called duncan-ely test
The Duncan-Ely test will be used to evaluate the shortness and tightness of the rectus femoris muscle. While the child is lying in the prone position, the hip will be fixed with one hand by the physiotherapist and the hip and knee will be kept in extension. In this position, the knee joint will be passively flexed in order to stretch the rectus femoris muscle on the tested side. If no shortness or tightness is observed in the rectus femoris muscle on the same side during the test and hip extension is maintained, the Duncan-Ely test will be recorded as negative. However, when the knee is flexed and a flexion movement is observed in the hip, the test will be recorded as positive.
Muscle Shortness/Flexibility- Sit-Reach Test MeasurementOther
Also called sit-reach test
The Sit-Reach test will be used to evaluate the flexibility of the hamstring and lower back muscle groups. The S\&R Sit and Reach® table will be used for this test. The child will sit in front of the table with dimensions of 55 centimeters long, 35 centimeters wide, and 30 centimeters high, and his/her feet will be positioned on the foot surface of the table. The child will be asked to place his/her hands on top of each other and stretch forward in a slow and controlled manner, bringing the ruler on the table forward. He/she will be asked to wait 1-2 seconds at the farthest point without stretching forward or backward. Scoring will be done according to the ruler on the table. (On this table, the child's ability to bring the ruler to the tips of his/her toes corresponds to 23 centimeters). The test will be repeated three times for each child to ensure reliability, and the highest value will be recorded in centimeters.
Postural Control Assessment with Biodex Balance System (BBS)Other
Also called Biodex Balance System
Postural stability, limits of stability, and sensory integration of balance will be assessed using the Biodex Balance System®. Biodex Balance System is a validated and reliable device used to evaluate postural stability, limits of stability, and fall risk. It consists of a balance platform, arm supports, a screen, and a printer. The platform can be set to static or dynamic mode (12 levels; level 12 = most stable, level 1 = least stable with up to 20° movement in all directions). Prior to testing, children will be informed about the procedures. The heel and toe positions will be recorded based on medial-lateral (B-J), anterior, and posterior (1-21) axes. Arm support and screen height will be individually adjusted. Child-specific posture and identification data will be entered into the system. Three tests will be performed: postural stability, limits of stability, and sensory integration of balance.
Muscle Strength Assessment with Micro-FET2Other
Also called Micro-FET2
Muscle tests will be performed using the MicroFET 2 digital hand dynamometer according to the device manual. The measurement will be performed in supine, prone, side-lying and sitting positions by preventing compensatory movements. During the test, the arms will be positioned so that they will not receive power from anywhere on/to the side of the body. Measurements will be performed bilaterally. While the child to whom the test is applied is expected to perform the requested movement with all his/her strength, the evaluating physiotherapist will apply resistance in the opposite direction in proportion to the strength. During the evaluation of the same muscle, a 30-second break will be given between repetitions, and a five-minute rest will be given before moving on to the test for a different muscle. Isometric muscle strength of the Iliopsoas, Gluteus Maximus, Gluteus Medius, Quadriceps, Hamstring, Tibialis Anterior, and Gastrosoleus muscles will be evaluated.
Functional Capacity Assessmnet with 6 Minute Walk Test MeasurementOther
Also called 6MWT
The 6MWT will be done on a flat 30-meter track marked every 3 meters, with clear start and finish lines. Before the test, the child rests 15 minutes while contraindications will be checked. If none, blood pressure, oxygen saturation, pulse, and Borg scale scores for dyspnea and fatigue will be recorded. Medications taken will be noted. The child will be instructed to walk at their own pace for 6 minutes, allowed to stop or rest, and continue until "test is over" is announced. The test will start with "test is started" and end with "test is over." The timer will run continuously even if paused. The test ends if chest pain, severe breathlessness, cramps, unsteadiness, sweating, pallor, or oxygen saturation <85% occurs. Afterward, the child will be sits and post-test vitals and Borg scores will be recorded. Distance walked and any complaints during the test will be noted.
Lower Extremity Functional ScaleOther
Also called LEFS
The Lower Extremity Functional Scale will be used to evaluate the functional ability of the entire lower extremity in individuals with musculoskeletal disorders. This scale will question the difficulty experienced in various daily activities due to the problem in the lower extremity with 20 items. Each item will be scored between 0-4 on a Likert scale (0=extremely difficult/too difficult to do the activity; 4=not difficult at all). The total score varies between 0-80 and the higher the score, the higher the functional level. A validity and reliability study has been conducted for the Turkish version of the scale to be used in evaluating lower extremity functions.
Pain Assessment with Viusal Analog ScaleOther
Also called VAS
The Visual Analog Scale is a simple and reliable tool that is widely used to assess subjective experiences such as pain. It consists of a 10 cm horizontal line with one end indicating "no pain" and the other end indicating "worst pain imaginable". Individuals will mark the point that reflects their perception of intensity, which will then be measured in millimeters or centimeters to obtain a numerical score. Higher values will indicate greater severity. The Visual Analog scale is valid and reliable in a variety of populations and conditions, including musculoskeletal pain.
Demographic Information FormOther
All children's gender, age, body weight, height and dominant side information will be recorded before clinical evaluations. The body mass index (kilogram/meter2) of the child will be calculated and recorded with the recorded body weight (kilogram) and height (meter) values.
Ankle Joint Dorsiflexion Range of Motion MeasurementOther
Also called ROM
Dorsiflexion range of motion with the knee joint in full extension and 90° flexion, the subtalar joint in a neutral position, the ankle dorsiflexion will be measured with the fixed arm of the universal goniometer on the fibula shaft and the mobile arm following the fifth metatarsal shaft. The measured angles were recorded in degrees (°). Measurements will be made bilaterally.
Leg Length MeasurementOther
Leg Length Measurement, the child will be placed in a supine position. The legs will be positioned in extension and the muscles will be relaxed. The physiotherapist will measure and record the child's right leg length from the SIAS bone to the medial malleola with a flexible metal tape measure. Measurements will be made bilaterally.
| Study group | Role | What they receive |
|---|---|---|
| Group 1 | Inclusion criteria for Group 1:
Inclusion Criteria for Group 1:
1. Being between 7-16 years old
2. Having a body mass index within normal limits (18.5-24.9 kilogram/meter2)
3. Beighton Score ≥ 5
4. Having a lower extremity rotational profile problem according to Staheli rotational profile assessment
Exclusion criteria for all groups;
1. Having any neurological, rheumatic, musculoskeletal, metabolic and connective tissue disease
2. To have a surgical history associated with vertebral column and lower extremity
3. Having cognitive, mental and/or serious psychiatric illness
4. To participate in any exercise program or a sporty activity in the last six months Receives: Other: Rotational Profile- Hip Internal and External Rotation Measurement; Other: Rotational Profile- Craig's Test Measurement; Other: Rotational Profile- Foot/Thigh Angle Measurement; Other: Rotational Profile- Heel Bisector Line Measurement; Other: Rotational Profile- Q Angle Measurement; Other: Rotational Profile- Navicular Drop Test Measurement; Other: Rotational Profile- Foot Progression Angle Measurement; Other: Muscle Shortness/Flexibility- Thomas Test Measurement; Other: Muscle Shortness/Flexibility- Popliteal Angle Measurement; Other: Muscle Shortness/Flexibility- Silfverskiöld Test Measurement; Other: Muscle Shortness/flexibility- Ober Test Measurement; Other: Muscle Shortnes/flexibility- Duncan-Ely Test Measurement; Other: Muscle Shortness/Flexibility- Sit-Reach Test Measurement; Other: Postural Control Assessment with Biodex Balance System (BBS); Other: Muscle Strength Assessment with Micro-FET2; Other: Functional Capacity Assessmnet with 6 Minute Walk Test Measurement; Other: Lower Extremity Functional Scale; Other: Pain Assessment with Viusal Analog Scale; Other: Demographic Information Form; Other: Ankle Joint Dorsiflexion Range of Motion Measurement; Other: Leg Length Measurement | |
| Group 2 | Inclusion criteria for group 2:
1. Being between 7-16 years old
2. Having a body mass index within normal limits (18.5-24.9 kilogram/meter2)
3. Beighton Score ≥ 5
4. Having a normal lower extremity rotational profile problem according to Staheli rotational profile assessment
Exclusion criteria for all groups;
1. Having any neurological, rheumatic, musculoskeletal, metabolic and connective tissue disease
2. To have a surgical history associated with vertebral column and lower extremity
3. Having cognitive, mental and/or serious psychiatric illness
4. To participate in any exercise program or a sporty activity in the last six months Receives: Other: Rotational Profile- Hip Internal and External Rotation Measurement; Other: Rotational Profile- Craig's Test Measurement; Other: Rotational Profile- Foot/Thigh Angle Measurement; Other: Rotational Profile- Heel Bisector Line Measurement; Other: Rotational Profile- Q Angle Measurement; Other: Rotational Profile- Navicular Drop Test Measurement; Other: Rotational Profile- Foot Progression Angle Measurement; Other: Muscle Shortness/Flexibility- Thomas Test Measurement; Other: Muscle Shortness/Flexibility- Popliteal Angle Measurement; Other: Muscle Shortness/Flexibility- Silfverskiöld Test Measurement; Other: Muscle Shortness/flexibility- Ober Test Measurement; Other: Muscle Shortnes/flexibility- Duncan-Ely Test Measurement; Other: Muscle Shortness/Flexibility- Sit-Reach Test Measurement; Other: Postural Control Assessment with Biodex Balance System (BBS); Other: Muscle Strength Assessment with Micro-FET2; Other: Functional Capacity Assessmnet with 6 Minute Walk Test Measurement; Other: Lower Extremity Functional Scale; Other: Pain Assessment with Viusal Analog Scale; Other: Demographic Information Form; Other: Ankle Joint Dorsiflexion Range of Motion Measurement; Other: Leg Length Measurement | |
| Control group | Criteria for inclusion for the control group;
1. Being between 7-16 years
2. Having body mass index at normal limits (18.5-24.9 kilogram/meter2)
3. Beighton score <5
4. Lower extremity rotational profile problem according to the steheli rotational profile evaluation is to be normal
Exclusion criteria for all groups;
1. To have any neurological, rheumatic, musculoskeletal, metabolic and connective tissue disease
2. To have a surgical history associated with vertebral column and lower extremity
3. Having cognitive, mental and/or serious psychiatric illness
4. To participate in any exercise program or a sporty activity in the last six months Receives: Other: Rotational Profile- Hip Internal and External Rotation Measurement; Other: Rotational Profile- Craig's Test Measurement; Other: Rotational Profile- Foot/Thigh Angle Measurement; Other: Rotational Profile- Heel Bisector Line Measurement; Other: Rotational Profile- Q Angle Measurement; Other: Rotational Profile- Navicular Drop Test Measurement; Other: Rotational Profile- Foot Progression Angle Measurement; Other: Muscle Shortness/Flexibility- Thomas Test Measurement; Other: Muscle Shortness/Flexibility- Popliteal Angle Measurement; Other: Muscle Shortness/Flexibility- Silfverskiöld Test Measurement; Other: Muscle Shortness/flexibility- Ober Test Measurement; Other: Muscle Shortnes/flexibility- Duncan-Ely Test Measurement; Other: Muscle Shortness/Flexibility- Sit-Reach Test Measurement; Other: Postural Control Assessment with Biodex Balance System (BBS); Other: Muscle Strength Assessment with Micro-FET2; Other: Functional Capacity Assessmnet with 6 Minute Walk Test Measurement; Other: Lower Extremity Functional Scale; Other: Pain Assessment with Viusal Analog Scale; Other: Demographic Information Form; Other: Ankle Joint Dorsiflexion Range of Motion Measurement; Other: Leg Length Measurement |
What is being measured
The primary outcome is the main question the study is designed to answer.
Rotational Profile- Hip Internal and External Rotation Measurement
Hip internal and external rotation angles measurement, hip range of motion evaluations will be performed. Measurements will be performed using a universal goniometer. The children will be positioned in the prone position with their knees flexed 90° and placed on the edge of the bed. The tuberositas tibia will be chosen as the pivot point of the goniometer, and the movable arm will be aligned with the tibial crista. The fixed arm will be placed perpendicular to the floor and the movable arm will be guided by the tibial crista. During hip rotation, it will be ensured that the hip remains stable and the movement occurs only in the hip joint.
Measured: Day 1
Rotational Profile- Craig's Test Measurement
The Craig's (Ryder) test, also known as the 'Trochanteric Prominence Angle Test', will be performed on the children included in the study according to the following protocol. The children will be placed in a prone position. The physiotherapist stood on the opposite side of the hip to be tested. The hips of the children will be placed in the extension position and the knee on the side to be tested will be held in the 90° flexion position. The physiotherapist palpated the trochanter major with the left hand and internal rotated the hip with the right hand. At the point where the trochanteric process will be most prominent, the angle between the tibia and the vertical plane will be measured using a goniometer and the femoral anteversion angle will be recorded.
Measured: Day 1
Rotational Profile- Foot/Thigh Angle Measurement
Foot/thigh angle, assessment will be performed by measuring the angle between the long axis of the femur bone and the foot with a goniometer in the prone position. One arm of the goniometer will be placed parallel to the long axis of the femur, while the other arm will be placed so that it passes through the 2nd and 3rd metatarsals. Normally, the thigh-foot angle should be in external rotation between 10-15°. In young children, this angle can be considered normal up to 30°. A decrease in the thigh-foot angle will indicate internal tibial torsion (expressed as a negative value), which is the internal rotation of the tibia. In this case, there is an abnormal internal rotation of the tibia. If the measured foot-thigh angle exceeds 30°, it is considered to be external tibial torsion (external rotation of the tibia).
Measured: Day 1
Rotational Profile- Heel Bisector Line Measurement
The heel bisector line test is an evaluation method that helps diagnose metatarsus adductus. During the test, the child will be placed in the prone position with the heel between the physiotherapist's fingers. Then, the midpoint of the lines drawn from the malleoli will be determined. From this point, a perpendicular line will be drawn from the heel to the toes along the foot axis with the help of a goniometer. Normally, this line should end between the 1st and 2nd toes. If the line ends at the 3rd, 4th or 5th toes, this may indicate the presence of metatarsus adductus.
Measured: Day 1
Rotational Profile- Q Angle Measurement
Q-angle is defined as the angle formed between an imaginary line connecting the anterior superior iliac spine of the pelvis to the midpoint of the patella and the proximal projection of the line extending from the tibial tubercle to the center of the patella. The child will first be placed in a supine position, with legs extended and muscles relaxed, and the midpoint of the patella will be marked with a colored pencil. Then, the goniometer will be placed at the exact midpoint of the patella, and care is taken to fix the mobile arm so that it points to the anterior superior iliac spine and the fixed arm so that it follows the tibia, and the angle in between will be recorded. The measurement will be recorded in two different positions: lying down and standing. The Q angle is considered normal between 10-15 ° in boys and 15- 20 ° in girls.
Measured: Day 1
Rotational Profile- Navicular Drop Test Measurement
The navicular drop test is commonly used in clinics to assess pes planus. It will begin with the child sitting, feet flat on the floor, and no weight bearing. The navicular tubercle will be palpated and marked first, then the distance from the tubercle to the floor will be measured. The child will then stand with equal weight on both feet and the distance will be measured again. Measurements will be taken bilaterally and recorded in millimeters. The difference between the weighted and unweighted measurements will indicate foot posture: 5-9 millimeters is normal (neutral), 10 millimeters or more will indicate pronation (inward rotation), and 4 millimeters or less will indicate supination (outward rotation). This test is important for assessing the degree of pes planus.
Measured: Day 1
Rotational Profile- Foot Progression Angle
The angle of foot progression is an important parameter to identify possible gait disorders and alignment problems by reflecting the rotational relationship between the femur, tibia and foot. For the test, two chairs facing each other will be placed 2 meters apart. The child will sit on a chair and the middle of the heel and the second toe will be marked with colored paint. The child will then stand up and walk naturally on a flat surface for about 5-6 steps towards the opposite chair and leave footprints. The child will then sit on the opposite chair and clean the paint from his feet. The footprints will be measured with a goniometer: one arm will be aligned with the direction of the footprints, the other will be parallel to the axis of the tibia. The angle between the foot and the tibia will be recorded in degrees.
Measured: Day 1
Postural Control Assessment with the Biodex Balance System
Postural stability, limits of stability, and sensory integration of balance will be assessed using the Biodex Balance System®. It consists of a balance platform, arm supports, a screen, and a printer. The platform can be set to static or dynamic mode (12 levels; level 12 = most stable, level 1 = least stable with up to 20° movement in all directions). Prior to testing, children will be informed about the procedures. The heel and toe positions will be recorded based on medial-lateral (B-J), anterior, and posterior (1-21) axes. Arm support and screen height will be individually adjusted. Child-specific posture and identification data will be entered into the system. Three tests will be performed: postural stability, limits of stability, and sensory integration of balance.
Measured: Day 1
Muscle Strength Assessment with Micro-FET 2
Muscle tests will be performed using the MicroFET 2 digital hand dynamometer according to the device manual. The measurement will be performed in supine, prone, side-lying and sitting positions by preventing compensatory movements. During the test, the arms will be positioned so that they will not receive power from anywhere on/to the side of the body. Measurements will be performed bilaterally. While the child to whom the test is applied is expected to perform the requested movement with all his/her strength, the evaluating physiotherapist will apply resistance in the opposite direction in proportion to the strength. During the evaluation of the same muscle, a 30-second break will be given between repetitions, and a five-minute rest will be given before moving on to the test for a different muscle. Isometric muscle strength of the Iliopsoas, Gluteus Maximus, Gluteus Medius, Quadriceps, Hamstring, Tibialis Anterior, and Gastrosoleus muscles will be evaluated.
Measured: Day 1
Functional Capacity Assessment with 6 Minute Walk Test
A 6 6-minute walk test will be done on a flat 30-meter track marked every 3 meters, with clear start and finish lines. Before the test, the child rests 15 minutes while contraindications will be checked. If none, blood pressure, oxygen saturation, pulse, and Borg scale scores for dyspnea and fatigue will be recorded. Medications taken will be noted. The child will be instructed to walk at their own pace for 6 minutes, allowed to stop or rest, and continue until "test is over" is announced. The test will start with "test is started" and end with "test is over." The timer runs continuously even if paused. The test ends if chest pain, severe breathlessness, cramps, unsteadiness, sweating, pallor, or oxygen saturation <85% occurs. Afterward, the child sits and post-test vitals and Borg scores will be recorded. Distance walked and any complaints during the test will be noted.
Measured: Day 1
Lower Extremity Functional Scale
The Lower Extremity Functional Scale is a questionnaire that will evaluate the functional ability of the entire lower extremity in individuals with musculoskeletal disorders. This scale will question the difficulty experienced in various daily activities due to the problem in the lower extremity with 20 items. Each item is scored between 0-4 on a Likert scale (0=extremely difficult/too difficult to do the activity; 4=not difficult at all). The total score varies between 0-80 and the higher the score, the higher the functional level. A validity and reliability study has been conducted for the Turkish version of the scale to be used in evaluating lower extremity functions.
Measured: Day 1
Secondary outcomes (7)
Muscle Shortness/Flexibility- Thomas Test Measurement
The Thomas Test will be performed to evaluate shortness/tightness in the hip flexor muscle group, especially in the iliopsoas muscle. The child will be placed in the supine position, the lumbar spine will be fixed and the assessment will begin. During the test, while the assessed hip is in knee extension, the opposite hip and knee will be passively flexed by the physiotherapist, and the hip movement of the assessed side will be observed during this time. The Thomas test will be recorded as negative if no flexion movement is observed in the assessed hip. In the presence of shortness/tightness, the assessed hip is seen to be flexed, and in this case, the Thomas test will be recorded as positive.
Measured: Day 1
Muscle Shortness/Flexibility- Popliteal Angle Measurement
The popliteal angle test will be used to evaluate shortness or tightness of the hamstring muscles. The hip and knee will be placed in a 90° flexion position while the child is in the supine position. While the physiotherapist passively moves the knee joint towards extension, the popliteal angle will be measured using a goniometer. While one arm of the goniometer is placed parallel to the lateral surface of the femur, the other arm is held parallel to the fibula head and the angle will be measured. The knee joint will be extended until it encounters resistance and the angle between the tibia and the vertical plane will be recorded as the popliteal angle.
Measured: Day 1
Muscle Shortness/Flexibility- Silfverskiöld Test Measurement
Gastrocnemius assessment will be evaluated with the Silfverskiold test for all children participating in the study. The assessment will be performed bilaterally in supine positions where the child does not bear weight on their feet. The knee joint will be in full extension and 90° flexion, the subtalar joint will be in a neutral position, and the ankle dorsiflexion will be measured with the fixed arm of the universal goniometer on the fibula shaft and the mobile arm following the fifth metatarsal shaft. The measured angles will be recorded in degrees (°). Passive ankle dorsiflexion of ≤ 10° with the knee extended and a minimum of 10° increase in dorsiflexion with the knee flexed will be considered as isolated gastrocnemius muscle shortness.
Measured: Day 1
Muscle Shortness/Flexibility- Ober Test Measurement
The Ober test will be an assessment to measure the length of the iliotibial band. During the test, the child will be placed in a supine position with the lower leg slightly flexed at the hip and knee. The upper leg will be in 90° flexion at the knee. Once positioning is complete, the physiotherapist will hold the ankle of the upper leg with one hand and stabilize the hip with the other hand. The leg will then be abducted and the knee extended and the leg moved until the femur is in line with the body. Finally, the thigh will be allowed to fall towards the surface in this plane and the result of the test will be judged by the amount of adduction of the hip. If the knee hangs in the air, the test will be recorded as positive; if the knee falls, the test will be recorded as negative.
Measured: Day 1
Muscle Shortness/Flexibility- Duncal-Ely Test Measurement
The Duncan-Ely test will be used to evaluate the shortness and tightness of the rectus femoris muscle. While the child will be lying in the prone position, the hip will be fixed with one hand by the physiotherapist and the hip and knee will be kept in extension. In this position, the knee joint will be passively flexed to stretch the rectus femoris muscle on the tested side. If no shortness or tightness is observed in the rectus femoris muscle on the same side during the test and hip extension is maintained, the Duncan-Ely test will be recorded as negative. However, when the knee is flexed and a flexion movement is observed in the hip, the test will be recorded as positive.
Measured: Day 1
Muscle Shortness/Flexibility- Sit-Reach Test Measurement
The sit-Reach test will be a frequently used test to evaluate the flexibility of the hamstring and lower back muscle groups. The S\&R Sit and Reach® table will be used for this test. The child will sit in front of the table with dimensions of 55 cm long, 35 centimeters wide, and 30 centimeters high, and his/her feet will be positioned on the foot surface of the table. The child will be asked to place his/her hands on top of each other and stretch forward in a slow and controlled manner, bringing the ruler on the table forward. He/she will be asked to wait 1-2 seconds at the farthest point without stretching forward or backward. Scoring will be done according to the ruler on the table. (On this table, the child's ability to bring the ruler to the tips of his/her toes corresponds to 23 centimeters). The test will be repeated three times for each child to ensure reliability, and the highest value will be recorded in centimeters.
Measured: Day 1
Pain Assessment with Visual Analog Scale
The Visual Analog Scale is a simple and reliable tool that is widely used to assess subjective experiences such as pain. It will consist of a 10-centimeter horizontal line with one end indicating "no pain" and the other end indicating "worst pain imaginable". Individuals will mark the point that reflects their perception of intensity, which will then be measured in millimeters or centimeters to obtain a numerical score. Higher values will indicate greater intensity. The Visual Analog Scale is valid and reliable in a variety of populations and conditions, including musculoskeletal pain.
Measured: Day 1
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted31 May 2025
- Study start1 Jul 2025
- Primary completion12 Jul 2025
- Study completion12 Jul 2025
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Other trials for Joint HypermobilityStudies of the same condition, open and under way.
- More trials run by Bezmialem Vakif UniversityThe sponsor's other registered studies.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Observational
- Observational model
- Case-control
- Time perspective
- Cross-sectional
- Enrolment
- 48 participants (actual)
Sponsor and investigators
- Lead sponsor
- Bezmialem Vakif University
- Sponsor type
- University, hospital or other
- Responsible party
- Principal investigator, Deniz Tuncer, Bezmialem Vakif University
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT06998563
- Sponsor's protocol ID
- 31.12.2024-177310
- Status last verified
- Jul 2025
- First submitted
- 22 May 2025
- Last updated
- 15 Jul 2025
- Results posted
- No
- Data monitoring committee
- No
- FDA-regulated drug
- No
- FDA-regulated device
- No
- Individual data sharing
- Undecided
Study at a glance
From the registry record, last updated by the sponsor on 15 Jul 2025. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- The Effect of Lower Extremity Rotational Profile on Postural Control, Muscle Strength, Functional Capacity and Lower Extremity Function in Children With Generalized Joint Hypermobility
- ClinicalTrials.gov ID
- NCT06998563
- Acronym / sponsor ID
- 31.12.2024-177310
- Conditions
- Joint Hypermobility, Femoral Anteversion, Postural Control, Lower Extremity Muscle Strength, Functional Capacity, Lower Extremity Functional Scale
- Keywords
- Generalized joint hypermobility, Lower extremity rotational profile, postural control, muscle strength, lower extremity functional scale, functional capacity
- Study type
- Observational
- Recruitment status
- Completed
- Enrolment
- 48 participants (actual)
- Lead sponsor
- Bezmialem Vakif UniversityUniversity, hospital or other
- Study start
- 1 Jul 2025 (actual)
- Primary completion
- 12 Jul 2025 (actual)
- Study completion
- 12 Jul 2025 (actual)
- First posted
- 31 May 2025 (actual)
- Results
- Not posted in the source record
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
Generalized joint hypermobility is when the range of motion in synovial joints exceeds its physiological limits. The aim of this investigation is to investigate the effect of lower extremity rotational profile on postural control, muscle strength, functional capacity and lower extremity function in children with generalized joint hypermobility. Within the scope of this cross-sectional study, permission was obtained from Bezmialem Vakif University Non-Interventional Clinical Research Ethics Committee with the decision number 177310 dated 31.12.2024. Following the Ethics Committee approval, data collection started and the study will be conducted in accordance with the Declaration of Helsinki. "Informed Voluntary Consent Form" prepared for both parents and children and approved by Bezmialem Vakıf University Non-Interventional Clinical Research Ethics Committee will be signed.
All children participating in the study and their parents will be informed about the study and those who voluntarily agree to participate in the study will be invited by appointment.
All evaluations will be carried out in the Pediatric and Cardiac Physiotherapy and Rehabilitation Education and Research Laboratories of the Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Bezmialem Vakıf University. Forty-eight children who meet the specified inclusion/exclusion criteria will be included in the study sample.
Within the scope of the study, demographic information of the children will be recorded with the sociodemographic evaluation form and clinical evaluations will be performed on the same day. All assessments will be administered to all children in all three groups by the same researcher in the following order.
The evaluation process will start with the completion of the sociodemographic information form. Then, the general joint hypermobility status of the participants will be evaluated with the Beighton Score. Within the scope of clinical measurements, bilateral lower extremity rotational profile will be determined by Craig's test, foot-thigh angle, foot progression angle, navicular drop test, Heel Bisector Line Test and Q angle measurements. Lower extremity muscle shortness and flexibility will be evaluated using bilateral Thomas test, Duncan-Ely test, Ober test, popliteal angle test, Silfverskiöld test and sit-to-stand test. Bilateral hip internal and external rotation angles and ankle dorsiflexion angle measurements will be performed to measure range of motion. Bilateral leg length measurements will be performed and general pain status will be questioned using the Visual Analog Scale.
Postural control will be assessed using the Biodex Balance System, muscle strength will be assessed using the MicroFET2 hand dynamometer, functional capacity will be assessed using the 6-minute walk test and lower extremity functionality will be assessed using the Lower Extremity Functional Scale .
Detailed description
Generalized joint hypermobility is characterized by an excessive range of motion in multiple joints without the presence of hereditary connective tissue disorders. Despite the clinical relevance of biomechanical changes such as increased femoral anteversion in children with Generalized Joint Hypermobility , limited research exists on how these alterations affect postural control, muscle strength, functional capacity, and lower extremity function. This observational cross-sectional study aims to evaluate the influence of lower extremity rotational profile on these parameters in children with Generalized Joint Hypermobility.
The sample size of the study was calculated with G*Power 3.1.9.4 analysis program. In the calculation of the sample size, 6-minute walking distance, one of the parameters evaluated in the study of Kepenek-Varol et al. in which individuals with generalized joint hypermobility were compared with their healthy peers, was taken into consideration. The analysis was performed with a priori power analysis ANOVA (one-way) approach for three groups. Accordingly, while the effect size obtained was Cohen's d = 0.64, the total minimum sample size to be reached for the three groups was calculated as 42 individuals in order to obtain 95% power at α=0.05 level. Considering that there may be missing data during the research phase, this number was increased by 10% and the number of participants for each group was determined as 16 and 48 people in total. This study will include a total of 48 children who will be divided into three groups.
Inclusion Criteria for Group 1:
- Being between 7-16 years old
- Having a body mass index within normal limits (18.5-24.9 kilograms/meter2)
- Beighton Score ≥ 5
- Having a lower extremity rotational profile problem according to Staheli rotational profile assessment
Inclusion Criteria for Group 2:
- Being between 7-16 years old
- Having a body mass index within normal limits (18.5-24.9 kilograms/meter2)
- Beighton Score ≥ 5
- Having a normal lower extremity rotational profile problem according to Staheli rotational profile assessment
Inclusion Criteria for the Control Group;
- Being between 7-16 years old
- Having a body mass index within normal limits (18.5-24.9 kilograms/meter2)
- Beighton Score < 5
- Having a normal lower extremity rotational profile problem according to Staheli rotational profile assessment
Exclusion criteria for all groups;
- Having any neurological, rheumatic, musculoskeletal, metabolic and connective tissue disease
- History of surgery related to the vertebral column and lower extremities
- Having cognitive, mental and/or severe psychiatric illness
- Participated in any exercise program or sportive activity in the last six months
Applications will be carried out in the Cardiac Physiotherapy and Rehabilitation Education and Research Laboratories of Bezmialem Vakif University Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation after permission is obtained.
Within the scope of this cross-sectional study, permission was obtained from Bezmialem Vakif University Non-Interventional Clinical Research Ethics Committee with the decision number 177310 dated 31.12.2024. Following the approval of the Ethics Committee, data collection will begin and the study will be conducted in accordance with the Declaration of Helsinki. "Informed Voluntary Consent Form" prepared for both parents and children and approved by Bezmialem Vakıf University Non-Interventional Clinical Research Ethics Committee will be signed.
All children participating in the study and their parents will be informed about the study and those who voluntarily agree to participate in the study will be invited by appointment.
All evaluations will be performed in the Pediatric and Cardiac Physiotherapy and Rehabilitation Education and Research Laboratories of the Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Bezmialem Vakif University. Forty-eight children who meet the specified inclusion/exclusion criteria will be included in the study sample.
Within the scope of the study, demographic information of the children will be recorded with the sociodemographic evaluation form and clinical evaluations will be performed on the same day. All assessments will be administered to all children in all three groups by the same researcher in the following order.
The evaluation process will start with the completion of the sociodemographic information form. Then, the general joint hypermobility status of the participants will be evaluated with the Beighton Score. Within the scope of clinical measurements, bilateral lower extremity rotational profile will be determined by hip internal and external rotation measurements, Craig's test, foot-thigh angle, heel bisector line, Q angle, navicular drop test and foot progression angle. Lower extremity muscle shortness and flexibility will be evaluated using bilateral Thomas test, popliteal angle test, Silfverskiöld test, Ober test, Duncan-Ely and sit-to-stand test. Bilateral ankle dorsiflexion angle and bilateral leg length measurements will be performed to measure range of motion. General pain status will be questioned using the Visual Analog Scale.
Postural control will be assessed with the Biodex Balance System, muscle strength with the MicroFET2 hand dynamometer, functional capacity with the 6-minute walk test and lower extremity functionality with the Lower Extremity Functional Scale.
In order to prevent fatigue from having a negative effect on the test results, the order of administration of each test will be determined in accordance with the position of the children. Lying tests will be performed in the supine position, while prone tests will be performed in the prone position. Standing tests will be performed in the standing position respectively. During the assessments, children will be tested in their underwear only and the temperature of the environment will be controlled to ensure their comfort. Only researchers and children will be present in the laboratory to avoid distractions during the tests.
Demographic information form All children's gender, age, body weight, height and dominant side information will be recorded before clinical evaluations. The body mass index (kilogram/meter2) of the child will be calculated and recorded with the recorded body weight (kilogram) and height (meter) values.
Clinical evaluations:
Evaluation of joint hypermobility according to the Beighton score:
The Beighton Score is one of the most preferred scoring methods due to its bilateral evaluation of the joints and easy applicability. It was created by Beighton in 1973 by modifying the Carter and Wilkinson criteria. The Beighton Score is a valid and reliable measurement tool that is widely used in the evaluation of joint hypermobility in childhood and adolescence. In this study, the Beighton Score will be used to define asymptomatic generalized joint hypermobility. Although variable threshold values have been proposed in the literature according to different age groups, in this study, a Beighton score of ≥5 points and above will be accepted as the criterion for hypermobility in children aged 7-16 years. Children who reach this threshold are classified as children with generalized joint hypermobility.
The Beighton Score is a measurement tool evaluated over a total of 9 points. The evaluation is based on the following criteria:
- Passive dorsiflexion of the 5th finger in both hands exceeding 90° (1 point per side),
- Contact of the thumb with the volar side (flexor side) of the forearm with flexion in both hands (1 point per side),
- Hyperextension of more than 10° at both elbows (1 point per side),
- Hyperextension of more than 10° in both knees (1 point per side),
- Palms touching the ground during forward flexion of the trunk with the knees in extension (1 point).
Evaluation of lower limb rotational profile:
In the study, Staheli's rotational profile tests will be applied to evaluate the rotational profile of the lower extremities of the children. All children in all three groups underwent the following tests;
Hip internal and external rotation angles measurement:
In the study, hip range of motion evaluations will be performed. Measurements will be performed using a universal goniometer. The children will be positioned in the prone position with their knees flexed 90° and placed on the edge of the bed. The tuberositas tibia will be chosen as the pivot point of the goniometer, and the movable arm will be aligned with the tibial crista. The fixed arm will be placed perpendicular to the floor and the movable arm will be guided by the tibial crista. During hip rotation, it will be ensured that the hip remains stable and the movement occurs only in the hip joint.
Craig's test The Ryder test, also known as the 'Trochanteric Prominence Angle Test', will be performed on the children included in the study according to the following protocol. The children will be placed in a prone position. The physiotherapist stood on the opposite side of the hip to be tested. The hips of the children will be placed in the extension position and the knee on the side to be tested will be held in the 90° flexion position. The physiotherapist palpated the trochanter major with the left hand and internal rotated the hip with the right hand. At the point where the trochanteric process will be most prominent, the angle between the tibia and the vertical plane will be measured using a goniometer and the femoral anteversion angle will be recorded.
Foot/thigh angle measurement:
This assessment will be performed by measuring the angle between the long axis of the femur bone and the foot with a goniometer in the prone position. One arm of the goniometer will be placed parallel to the long axis of the femur, while the other arm will be placed so that it passes through the 2nd and 3rd metatarsals. Normally, the thigh-foot angle should be in external rotation between 10-15°. In young children, this angle can be considered normal up to 30°. A decrease in the thigh-foot angle will indicate internal tibial torsion (expressed as a negative value), which is the internal rotation of the tibia. In this case, there is an abnormal internal rotation of the tibia. If the measured foot-thigh angle exceeds 30°, it is considered to be external tibial torsion (external rotation of the tibia).
Heel bisector line:
The heel bisector line test will be an evaluation method that helps diagnose metatarsus adductus. During the test, the child will be placed in the prone position with the heel between the physiotherapist's fingers. Then, the midpoint of the lines drawn from the malleoli will be determined. From this point, a perpendicular line will be drawn from the heel to the toes along the foot axis with the help of a goniometer. Normally, this line should end between the 1st and 2nd toes. If the line ends at the 3rd, 4th or 5th toes, this may indicate the presence of metatarsus adductus.
Q angle measurement:
Q-angle is defined as the angle formed between an imaginary line connecting the anterior superior iliac spine of the pelvis to the midpoint of the patella and the proximal projection of the line extending from the tibial tubercle to the center of the patella. The child will first be placed in a supine position, with legs extended and muscles relaxed, and the midpoint of the patella is marked with a colored pencil. Then, the goniometer will be placed at the exact midpoint of the patella, and care is taken to fix the mobile arm so that it points to the anterior superior iliac spine and the fixed arm so that it follows the tibia, and the angle in between will be recorded. The measurement will be recorded in two different positions: lying down and standing. The Q angle is considered normal between 10-15 ° in boys and 15- 20 ° in girls.
Navicular drop test:
The navicular drop test is a widely used test in the clinic to evaluate the presence and degree of pes planus. This test will be started with the child in a sitting position, with the feet only in contact with the floor, without weight bearing. In the first step, the navicular tubercle will be palpated and marked. While the child is in a sitting position, the distance between the navicular tubercle and the floor will be measured. This measurement will be made when the feet are only in contact with the floor without any weight bearing. Then, the child is asked to stand and the distance between the navicular tubercle and the floor will be measured again in a position where the feet are equally weight bearing. Measurements will be made bilaterally, separately for each foot, and the results will be recorded in millimeters.
In the navicular drop test, the difference between weighted and unweighted measurements is interpreted as follows: Differences between 5-9 millimeter are considered normal (neutral), differences of 10 milimeter and above are considered as an indicator of pronation (inward rotation) in the foot, while differences of 4 millimeter and below are associated with supination (outward rotation) in the foot. This test is an important measurement tool for determining the degree of pes planus
Foot progression angle:
Foot progression angle is used as an important parameter in determining potential disorders and alignment errors in the child's walking pattern by reflecting the rotational relationships between the femur, tibia and foot. For this measurement, two chairs will first be placed opposite each other with a distance of 2 m between them. Then, the child will be asked to sit on the chair. In the sitting position, the middle of the heel and the second toe will be marked with colored paint. After the marking, the child will be asked to walk naturally on a flat surface to the chair opposite. The child will stand up from the sitting position and walk approximately 5-6 steps on a flat surface to the chair opposite. Then, the child will be asked to sit on the chair opposite and clean the paint on his foot. This colored marking will be made in a way that will create the child's walking traces. When the child finishes walking, these traces will be measured in degrees using a goniometer. To measure the foot progression angle with a goniometer; One arm will be positioned so that it is aligned with the direction of the footprints, and the other arm will be positioned parallel to the axis of the tibia. The angle between the foot and the tibia will be recorded in degrees with a goniometer.
Measurement of ankle joint dorsiflexion range of motion:
With the knee joint in full extension and 90° flexion, the subtalar joint in a neutral position, the ankle dorsiflexion will be measured with the fixed arm of the universal goniometer on the fibula shaft and the mobile arm following the fifth metatarsal shaft. The measured angles will be recorded in degrees (°). Measurements will be made bilaterally.
Leg length measurement:
The child will be placed in a supine position. The legs will be positioned in extension and the muscles will be relaxed. The physiotherapist will measure and record the child's right leg length from the anterior superior iliac spine bone to the medial malleolus with a flexible metal tape measure. Measurements will be made bilaterally.
Muscle shortness/flexibility assessments
Thomas test:
The Thomas test will be performed to evaluate shortness/tightness in the hip flexor muscle group, especially in the iliopsoas muscle. The child will be placed in the supine position, the lumbar spine will be fixed and the assessment will begin. During the test, while the assessed hip is in knee extension, the opposite hip and knee will be passively flexed by the physiotherapist, and the hip movement of the assessed side will be observed during this time. The Thomas test will be recorded as negative if no flexion movement is observed in the assessed hip. In the presence of shortness/tightness, the assessed hip is seen to be flexed, and in this case, the Thomas test will be recorded as positive.
Popliteal angle test:
The popliteal angle test will be used to evaluate shortness or tightness of the hamstring muscles. The hip and knee will be placed in a 90° flexion position while the child is in the supine position. While the physiotherapist passively moves the knee joint towards extension, the popliteal angle will be measured using a goniometer. While one arm of the goniometer is placed parallel to the lateral surface of the femur, the other arm is held parallel to the fibula head and the angle will be measured. The knee joint will be extended until it encounters resistance and the angle between the tibia and the vertical plane will be recorded as the popliteal angle.
Silfverskiold test:
Gastrocnemius assessment will be evaluated with the Silfverskiold test for all children participating in the study. The assessment will be performed bilaterally in supine positions where the child does not bear weight on their feet. The knee joint will be in full extension and 90° flexion, the subtalar joint will be in a neutral position, and the ankle dorsiflexion will be measured with the fixed arm of the universal goniometer on the fibula shaft and the mobile arm following the fifth metatarsal shaft. The measured angles will be recorded in degrees (°). Passive ankle dorsiflexion of ≤ 10° with the knee extended and a minimum of 10° increase in dorsiflexion with the knee flexed will be considered as isolated gastrocnemius muscle shortness.
Ober test:
The Ober test will be an assessment performed to measure the length of the iliotibial band. There are also some modifications of this test, such as the modified Ober test described by Kendall in 1953. Both the Ober test and the modified Ober test are widely used and accepted tests to assess iliotibial band length. During the test, the child will be placed in a side-lying position with the lower leg slightly flexed at the hip and knee. The knee of the upper leg is ensured to be in 90° flexion. After the positioning is completed, the physiotherapist will hold the ankle of the upper leg with one hand and stabilize the hip with the other hand. Then, the leg will be abducted and the knee will be extended, and the leg will be moved until the femur is in line with the body. Finally, the thigh will be allowed to fall towards the surface in this plane, and the result of the test will be evaluated according to the amount of adduction of the hip. If the knee hangs in the air, the test will be recorded as positive. If the leg falls towards the surface, the test will be evaluated as negative.
Duncan-ely test:
The Duncan-Ely test will be used to evaluate the shortness and tightness of the rectus femoris muscle. While the child is lying in the prone position, the hip will be fixed with one hand by the physiotherapist and the hip and knee will be kept in extension. In this position, the knee joint will be passively flexed in order to stretch the rectus femoris muscle on the tested side. If no shortness or tightness is observed in the rectus femoris muscle on the same side during the test and hip extension is maintained, the Duncan-Ely test will be recorded as negative. However, when the knee is flexed and a flexion movement is observed in the hip, the test will be recorded as positive.
Sit-reach test:
This test is a frequently used test to evaluate the flexibility of the hamstring and lower back muscle groups. The S\&R Sit and Reach® table will be used for this test. The child will sit in front of the table with dimensions of 55 centimeters long, 35 centimeters wide, and 30 centimeters high, and his/her feet will be positioned on the foot surface of the table. The child will be asked to place his/her hands on top of each other and stretch forward in a slow and controlled manner, bringing the ruler on the table forward. He/she will be asked to wait 1-2 seconds at the farthest point without stretching forward or backward. Scoring will be done according to the ruler on the table. (On this table, the child's ability to bring the ruler to the tips of his/her toes corresponds to 23 centimeters). The test will be repeated three times for each child to ensure reliability, and the highest value will be recorded in centimeters.
Postural control assessment with Biodex balance system Biodex Balance System is a valid and reliable equipment that will be used to assess postural stability, stability limits and fall risk. It consists of a balance platform, arm supports, a screen and printer. The platform can be adjusted as static or mobile (12 levels of movement amount; level 12 is the most stable, level 1 is the least stable level that can move up to 20 degrees in each direction) according to the test that will be applied. Before the evaluation, explanatory information about the test steps will be given to all children included in the study. The axes where the heel and toe tips of each child will be recorded according to the medial and lateral (B, C, D, E, F, G, H, I, J) axes, the angles in the anterior and the axes in the posterior (1, 2, 3…,21). The arm support and test screen height will be adjusted specifically for each child. The child's information and stance position information will be entered into the balance beam screen. The device will be evaluated with three separate tests: postural stability test, stability limits test and balance sensory integration test.
Postural Stability (Test of Postural Stability) This test will evaluate the child's ability to maintain the center of balance on a stable platform and record the deviations from the center. General, anterior/posterior and medial/lateral stability indexes will be calculated and recorded as degrees. The general stability index reflects the variability of the platform relative to the horizontal plane during all movements performed in the test. Anterior/posterior stability index reflects the variability for movements in the sagittal plane, medial/lateral stability index reflects the variability for movements in the frontal plane. A high score value will indicate that postural stability is affected more. In this test, three 20-second measurements will be made with 10 seconds between each measurement.
Stability limits test This test, performed on a static platform, will evaluate the child's ability to move and control the center of gravity between the body's support surfaces. Directional control (general, forward, backward, left, right, forward/left, forward/right, backward/left, backward/right) will be evaluated and expressed as a percentage value. High scores indicate good postural control (100% = perfect control).
Sensory integration of balance test This test will evaluate how the child's various senses contribute to balance and how well they can compensate for balance when one or more of these senses are eliminated. The test will be performed on a hard surface with the static platform setting, with eyes open, eyes closed, and on a foam surface with eyes open, eyes closed, and the sway index values will be recorded for each of the four positions. In this test, four measurements will be made with a 10-second rest between each measurement and each test duration of 30 seconds.
Lower extremity muscle strength measurement Micro-FET2:
Muscle tests will be performed using the MicroFET 2 digital hand dynamometer according to the device manual. The measurement will be performed in supine, prone, side-lying and sitting positions by preventing compensatory movements. During the test, the arms will be positioned so that they will not receive power from anywhere on/to the side of the body. Measurements will be performed bilaterally. While the child to whom the test will be applied is expected to perform the requested movement with all his/her strength, the evaluating physiotherapist will apply resistance in the opposite direction in proportion to the strength. During the evaluation of the same muscle, a 30-second break will be given between repetitions, and a five-minute rest will be given before moving on to the test for a different muscle. Isometric muscle strength of the Iliopsoas, Gluteus Maximus, Gluteus Medius, Quadriceps, Hamstring, Tibialis Anterior, and Gastrosoleus muscles will be evaluated in the measurement. Strength measurements will be repeated 3 times and the highest measured strength value will be recorded with a kilogram/force value and evaluated.
6-Minute Walking test: The test will be performed on a smooth and flat track that is 30 meters long, marked every 3 meters, and the start and finish lines are marked with a visible line. Before starting the test, the child will rest in a chair for 15 minutes. During this time, the patient's contraindications for the 6-minute walking test will be questioned. If there are no contraindications, the patient's blood pressure, oxygen saturation with a pulse oximeter, pulse, and the patient's dyspnea and fatigue level according to the Borg scale will be checked after the patient rests. If any medications are taken before the test, these will be recorded. The child will be brought to the starting line. The child will be given; The patient is informed that the patient should walk at their own pace for 6 minutes on the track, that they can end the test at any time if they have any complaints, that they can stop and rest if needed during the test and that they should continue the test until the command "test is over" is given, and the chronometer is started and the test will be started with the command "test is started" and the test will be ended with the command "test is over". If the patient stops and rests during the test and pauses the test, the chronometer will not be stopped. The test will be ended if the child has chest pain, intolerable shortness of breath, leg cramps, staggering, diaphoresis, bruising or pallor and oxygen saturation is <85%. After the test is over, the child is seated on a chair, the patient's oxygen saturation, pulse and dyspnea and fatigue levels according to the Borg scale will be checked with a pulse oximeter and the distance the patient walked for 6 minutes will be calculated and the test will be ended. If the child has complaints such as chest pain, dizziness, hip pain or leg pain during the test, it will be recorded.
Lower extremity functional scale:
The Lower Extremity Functional Scale is a questionnaire that will be used to evaluate the functional ability of the entire lower extremity in individuals with musculoskeletal disorders. This scale will question the difficulty experienced in various daily activities due to the problem in the lower extremity with 20 items. Each item is scored between 0-4 on a Likert scale (0=extremely difficult/too difficult to do the activity; 4=not difficult at all). The total score varies between 0-80 and the higher the score, the higher the functional level. A validity and reliability study has been conducted for the Turkish version of the scale to be used in evaluating lower extremity functions.
The Statistical Package for the Social Sciences 26.0 for Windows package program will be used in the statistical analysis of the data obtained. Descriptive statistics (mean±standard deviation, minimum-maximum, number and percentile) will be given for discrete and continuous variables. Groups will be compared with one-way ANOVA. Post hoc test will be performed according to normality with the Shapiro-Wilk test and homogeneity of variance between groups with Levene's test. Categorical groups will be compared with the chi-square (χ2) test. p<0.05 will be considered statistically significant.
Study design
- Observational model
- Case-control
- Time perspective
- Cross-sectional
- Number of arms
- 3
| Arm | Type | Receives |
|---|---|---|
| Group 1 | – | Other: Rotational Profile- Hip Internal and External Rotation Measurement, Other: Rotational Profile- Craig's Test Measurement, Other: Rotational Profile- Foot/Thigh Angle Measurement, Other: Rotational Profile- Heel Bisector Line Measurement, Other: Rotational Profile- Q Angle Measurement, Other: Rotational Profile- Navicular Drop Test Measurement, Other: Rotational Profile- Foot Progression Angle Measurement, Other: Muscle Shortness/Flexibility- Thomas Test Measurement, Other: Muscle Shortness/Flexibility- Popliteal Angle Measurement, Other: Muscle Shortness/Flexibility- Silfverskiöld Test Measurement, Other: Muscle Shortness/flexibility- Ober Test Measurement, Other: Muscle Shortnes/flexibility- Duncan-Ely Test Measurement, Other: Muscle Shortness/Flexibility- Sit-Reach Test Measurement, Other: Postural Control Assessment with Biodex Balance System (BBS), Other: Muscle Strength Assessment with Micro-FET2, Other: Functional Capacity Assessmnet with 6 Minute Walk Test Measurement, Other: Lower Extremity Functional Scale, Other: Pain Assessment with Viusal Analog Scale, Other: Demographic Information Form, Other: Ankle Joint Dorsiflexion Range of Motion Measurement, Other: Leg Length MeasurementInclusion criteria for Group 1: Inclusion Criteria for Group 1: 1. Being between 7-16 years old 2. Having a body mass index within normal limits (18.5-24.9 kilogram/meter2) 3. Beighton Score ≥ 5 4. Having a lower extremity rotational profile problem according to Staheli rotational profile assessment Exclusion criteria for all groups; 1. Having any neurological, rheumatic, musculoskeletal, metabolic and connective tissue disease 2. To have a surgical history associated with vertebral column and lower extremity 3. Having cognitive, mental and/or serious psychiatric illness 4. To participate in any exercise program or a sporty activity in the last six months |
| Group 2 | – | Other: Rotational Profile- Hip Internal and External Rotation Measurement, Other: Rotational Profile- Craig's Test Measurement, Other: Rotational Profile- Foot/Thigh Angle Measurement, Other: Rotational Profile- Heel Bisector Line Measurement, Other: Rotational Profile- Q Angle Measurement, Other: Rotational Profile- Navicular Drop Test Measurement, Other: Rotational Profile- Foot Progression Angle Measurement, Other: Muscle Shortness/Flexibility- Thomas Test Measurement, Other: Muscle Shortness/Flexibility- Popliteal Angle Measurement, Other: Muscle Shortness/Flexibility- Silfverskiöld Test Measurement, Other: Muscle Shortness/flexibility- Ober Test Measurement, Other: Muscle Shortnes/flexibility- Duncan-Ely Test Measurement, Other: Muscle Shortness/Flexibility- Sit-Reach Test Measurement, Other: Postural Control Assessment with Biodex Balance System (BBS), Other: Muscle Strength Assessment with Micro-FET2, Other: Functional Capacity Assessmnet with 6 Minute Walk Test Measurement, Other: Lower Extremity Functional Scale, Other: Pain Assessment with Viusal Analog Scale, Other: Demographic Information Form, Other: Ankle Joint Dorsiflexion Range of Motion Measurement, Other: Leg Length MeasurementInclusion criteria for group 2: 1. Being between 7-16 years old 2. Having a body mass index within normal limits (18.5-24.9 kilogram/meter2) 3. Beighton Score ≥ 5 4. Having a normal lower extremity rotational profile problem according to Staheli rotational profile assessment Exclusion criteria for all groups; 1. Having any neurological, rheumatic, musculoskeletal, metabolic and connective tissue disease 2. To have a surgical history associated with vertebral column and lower extremity 3. Having cognitive, mental and/or serious psychiatric illness 4. To participate in any exercise program or a sporty activity in the last six months |
| Control group | – | Other: Rotational Profile- Hip Internal and External Rotation Measurement, Other: Rotational Profile- Craig's Test Measurement, Other: Rotational Profile- Foot/Thigh Angle Measurement, Other: Rotational Profile- Heel Bisector Line Measurement, Other: Rotational Profile- Q Angle Measurement, Other: Rotational Profile- Navicular Drop Test Measurement, Other: Rotational Profile- Foot Progression Angle Measurement, Other: Muscle Shortness/Flexibility- Thomas Test Measurement, Other: Muscle Shortness/Flexibility- Popliteal Angle Measurement, Other: Muscle Shortness/Flexibility- Silfverskiöld Test Measurement, Other: Muscle Shortness/flexibility- Ober Test Measurement, Other: Muscle Shortnes/flexibility- Duncan-Ely Test Measurement, Other: Muscle Shortness/Flexibility- Sit-Reach Test Measurement, Other: Postural Control Assessment with Biodex Balance System (BBS), Other: Muscle Strength Assessment with Micro-FET2, Other: Functional Capacity Assessmnet with 6 Minute Walk Test Measurement, Other: Lower Extremity Functional Scale, Other: Pain Assessment with Viusal Analog Scale, Other: Demographic Information Form, Other: Ankle Joint Dorsiflexion Range of Motion Measurement, Other: Leg Length MeasurementCriteria for inclusion for the control group; 1. Being between 7-16 years 2. Having body mass index at normal limits (18.5-24.9 kilogram/meter2) 3. Beighton score <5 4. Lower extremity rotational profile problem according to the steheli rotational profile evaluation is to be normal Exclusion criteria for all groups; 1. To have any neurological, rheumatic, musculoskeletal, metabolic and connective tissue disease 2. To have a surgical history associated with vertebral column and lower extremity 3. Having cognitive, mental and/or serious psychiatric illness 4. To participate in any exercise program or a sporty activity in the last six months |
Who may qualify
- Ages
- 7 to 16 years
- Sex
- All
- Healthy volunteers
- Accepted
- Age groups
- Child
- Study population
- The sample size of the study was calculated with the G*Power 3.1.9.4 analysis program. In the calculation of the sample size, 6-minute walking distance, one of the parameters evaluated in the study of Kepenek-Varol et al. in which individuals with generalized joint hypermobility were compared with their healthy peers, was taken into consideration. The analysis was performed with a priori power analysis ANOVA (One-way) approach for the three groups. Accordingly, the effect size obtained was Cohen's d = 0.64, while the total minimum sample size to be reached for the three groups was calculated as 42 individuals in order to obtain 95% power at α=0.05 level. Considering that there might be missing data during the research phase, this number was increased by 10% and the number of participants for each group was determined as 16 and 48 in total.
Key inclusion criteria (12 listed)
- Being between 7-16 years old
- Having a body mass index (BMI) within normal limits (18.5-24.9 kg/m2)
- Beighton Score ≥ 5
- Having a lower extremity rotational profile problem according to Staheli rotational profile assessment
- Being between 7-16 years old
Key exclusion criteria (4 listed)
- Having any neurological, rheumatic, musculoskeletal, metabolic and connective tissue disease
- History of surgery related to the vertebral column and lower extremities
- Having cognitive, mental and/or severe psychiatric illness
- Participated in any exercise program or sportive activity in the last six months
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| Rotational Profile- Hip Internal and External Rotation MeasurementAlso: Hip internal/external rotation measurementHip internal and external rotation angles measurement, hip range of motion evaluations will be performed. Measurements will be performed using a universal goniometer. The children will be positioned in the prone position with their knees flexed 90° and placed on the edge of the bed. The tuberositas tibia will be chosen as the pivot point of the goniometer, and the movable arm will be aligned with the tibial crista. The fixed arm will be placed perpendicular to the floor and the movable arm will be guided by the tibial crista. During hip rotation, it will be ensured that the hip remains stable and the movement occurs only in the hip joint. | Other | Control group, Group 1, Group 2 |
| Rotational Profile- Craig's Test MeasurementAlso: Craig's test, Ryder testThe Craig's (Ryder) test, also known as the 'Trochanteric Prominence Angle Test', will be performed on the children included in the study according to the following protocol. The children will be placed in a prone position. The physiotherapist stood on the opposite side of the hip to be tested. The hips of the children will be placed in the extension position and the knee on the side to be tested will be held in the 90° flexion position. The physiotherapist palpated the trochanter major with the left hand and internal rotated the hip with the right hand. At the point where the trochanteric process will be most prominent, the angle between the tibia and the vertical plane will be measured using a goniometer and the femoral anteversion angle will be recorded. | Other | Control group, Group 1, Group 2 |
| Rotational Profile- Foot/Thigh Angle MeasurementAlso: foot/thigh angleFoot/thigh angle assessment will be performed by measuring the angle between the long axis of the femur bone and the foot with a goniometer in the prone position. One arm of the goniometer will be placed parallel to the long axis of the femur, while the other arm will be placed so that it passes through the 2nd and 3rd metatarsals. Normally, the thigh-foot angle should be in external rotation between 10-15°. In young children, this angle can be considered normal up to 30°. A decrease in the thigh-foot angle will indicate internal tibial torsion (expressed as a negative value), which is the internal rotation of the tibia. In this case, there is an abnormal internal rotation of the tibia. If the measured foot-thigh angle exceeds 30°, it is considered to be external tibial torsion (external rotation of the tibia). | Other | Control group, Group 1, Group 2 |
| Rotational Profile- Heel Bisector Line MeasurementAlso: heel bisector lineThe heel bisector line test is an evaluation method that helps diagnose metatarsus adductus. During the test, the child will be placed in the prone position with the heel between the physiotherapist's fingers. Then, the midpoint of the lines drawn from the malleoli will be determined. From this point, a perpendicular line will be drawn from the heel to the toes along the foot axis with the help of a goniometer. Normally, this line should end between the 1st and 2nd toes. If the line ends at the 3rd, 4th or 5th toes, this may indicate the presence of metatarsus adductus. | Other | Control group, Group 1, Group 2 |
| Rotational Profile- Q Angle MeasurementAlso: Q angleThe Q-angle is defined as the angle formed between an imaginary line connecting the anterior superior iliac spine of the pelvis to the midpoint of the patella and the proximal projection of the line from the tibial tubercle to the center of the patella. The child will first be placed in a supine position with legs extended and muscles relaxed, and the midpoint of the patella will be marked with a colored pencil. Then, the goniometer will be placed at the midpoint of the patella and care will be taken to fix the movable arm so that it points to the anterior superior iliac spine and the fixed arm so that it follows the tibia and the angle between the two will be recorded. The measurement will be recorded in two different positions, lying and standing. Q angle between 10-15° in boys and 15-20° in girls will be considered normal. | Other | Control group, Group 1, Group 2 |
| Rotational Profile- Navicular Drop Test MeasurementAlso: navicular drop testThe navicular drop test is commonly used in clinics to assess pes planus. It will begin with the child sitting, feet flat on the floor, and no weight bearing. The navicular tubercle will be palpated and marked first, then the distance from the tubercle to the floor will be measured. The child will then stand with equal weight on both feet and the distance will be measured again. Measurements will be taken bilaterally and recorded in millimeters. The difference between the weighted and unweighted measurements will indicate foot posture: 5-9 millimeters is normal (neutral), 10 millimeters or more will indicate pronation (inward rotation), and 4 millimeters or less will indicate supination (outward rotation). This test is important for assessing the degree of pes planus. | Other | Control group, Group 1, Group 2 |
| Rotational Profile- Foot Progression Angle MeasurementThe foot progression angle will be used as an important parameter in determining potential disorders and alignment errors in the child's walking pattern by reflecting the rotational relationships between the femur, tibia and foot. For this measurement, two chairs will first be placed opposite each other with a distance of 2 m between them. Then, the child will be asked to sit on the chair. In the sitting position, the middle of the heel and the second toe will be marked with colored paint. After the marking, the child will be asked to walk naturally on a flat surface to the chair opposite. The child will stand up from the sitting position and walk approximately 5-6 steps on a flat surface to the chair opposite. Then, the child will be asked to sit on the chair opposite and clean the paint off his foot. This colored marking will be made in a way that will create the child's walking traces. When the child finishes walking, these traces will be measured in degrees using a goniometer. | Other | Control group, Group 1, Group 2 |
| Muscle Shortness/Flexibility- Thomas Test MeasurementAlso: thomas testThe Thomas test will be performed to evaluate shortness/tightness in the hip flexor muscle group, especially in the iliopsoas muscle. The child will be placed in the supine position, the lumbar spine will be fixed and the assessment will begin. During the test, while the assessed hip is in knee extension, the opposite hip and knee will be passively flexed by the physiotherapist, and the hip movement of the assessed side will be observed during this time. The Thomas test will be recorded as negative if no flexion movement is observed in the assessed hip. In the presence of shortness/tightness, the assessed hip is seen to be flexed, and in this case, the Thomas test will be recorded as positive. | Other | Control group, Group 1, Group 2 |
| Muscle Shortness/Flexibility- Popliteal Angle MeasurementAlso: popliteal angleThe popliteal angle test will be used to evaluate shortness or tightness of the hamstring muscles. The hip and knee will be placed in a 90° flexion position while the child is in the supine position. While the physiotherapist passively moves the knee joint towards extension, the popliteal angle will be measured using a goniometer. While one arm of the goniometer is placed parallel to the lateral surface of the femur, the other arm is held parallel to the fibula head and the angle will be measured. The knee joint will be extended until it encounters resistance and the angle between the tibia and the vertical plane will be recorded as the popliteal angle. | Other | Control group, Group 1, Group 2 |
| Muscle Shortness/Flexibility- Silfverskiöld Test MeasurementAlso: silfverskiöld testGastrocnemius assessment will be evaluated with the Silfverskiold test for all children participating in the study. The assessment will be performed bilaterally in supine positions where the child does not bear weight on their feet. The knee joint will be in full extension and 90° flexion, the subtalar joint will be in a neutral position, and the ankle dorsiflexion will be measured with the fixed arm of the universal goniometer on the fibula shaft and the mobile arm following the fifth metatarsal shaft. The measured angles will be recorded in degrees (°). Passive ankle dorsiflexion of ≤ 10° with the knee extended and a minimum of 10° increase in dorsiflexion with the knee flexed will be considered as isolated gastrocnemius muscle shortness. | Other | Control group, Group 1, Group 2 |
| Muscle Shortness/flexibility- Ober Test MeasurementAlso: ober testThe Ober test will be performed to measure the length of the iliotibial band. Both the Ober test and the modified Ober test are widely used and accepted tests to assess iliotibial band length. During the test, the child will be placed in a supine position with the lower leg slightly bent at the hip and knee. The upper leg will be in 90° flexion of the knee. Once positioning is complete, the physiotherapist will hold the ankle of the upper leg with one hand and stabilize the hip with the other hand. The leg will then be abducted and the knee extended and the leg moved until the femur is in line with the body. Finally, the thigh will be allowed to fall towards the surface in this plane and the result of the test will be judged by the amount of adduction of the hip. If the knee hangs in the air, the test is positive. If the knee falls, the test is negative | Other | Control group, Group 1, Group 2 |
| Muscle Shortnes/flexibility- Duncan-Ely Test MeasurementAlso: duncan-ely testThe Duncan-Ely test will be used to evaluate the shortness and tightness of the rectus femoris muscle. While the child is lying in the prone position, the hip will be fixed with one hand by the physiotherapist and the hip and knee will be kept in extension. In this position, the knee joint will be passively flexed in order to stretch the rectus femoris muscle on the tested side. If no shortness or tightness is observed in the rectus femoris muscle on the same side during the test and hip extension is maintained, the Duncan-Ely test will be recorded as negative. However, when the knee is flexed and a flexion movement is observed in the hip, the test will be recorded as positive. | Other | Control group, Group 1, Group 2 |
| Muscle Shortness/Flexibility- Sit-Reach Test MeasurementAlso: sit-reach testThe Sit-Reach test will be used to evaluate the flexibility of the hamstring and lower back muscle groups. The S\&R Sit and Reach® table will be used for this test. The child will sit in front of the table with dimensions of 55 centimeters long, 35 centimeters wide, and 30 centimeters high, and his/her feet will be positioned on the foot surface of the table. The child will be asked to place his/her hands on top of each other and stretch forward in a slow and controlled manner, bringing the ruler on the table forward. He/she will be asked to wait 1-2 seconds at the farthest point without stretching forward or backward. Scoring will be done according to the ruler on the table. (On this table, the child's ability to bring the ruler to the tips of his/her toes corresponds to 23 centimeters). The test will be repeated three times for each child to ensure reliability, and the highest value will be recorded in centimeters. | Other | Control group, Group 1, Group 2 |
| Postural Control Assessment with Biodex Balance System (BBS)Also: Biodex Balance SystemPostural stability, limits of stability, and sensory integration of balance will be assessed using the Biodex Balance System®. Biodex Balance System is a validated and reliable device used to evaluate postural stability, limits of stability, and fall risk. It consists of a balance platform, arm supports, a screen, and a printer. The platform can be set to static or dynamic mode (12 levels; level 12 = most stable, level 1 = least stable with up to 20° movement in all directions). Prior to testing, children will be informed about the procedures. The heel and toe positions will be recorded based on medial-lateral (B-J), anterior, and posterior (1-21) axes. Arm support and screen height will be individually adjusted. Child-specific posture and identification data will be entered into the system. Three tests will be performed: postural stability, limits of stability, and sensory integration of balance. | Other | Control group, Group 1, Group 2 |
| Muscle Strength Assessment with Micro-FET2Also: Micro-FET2Muscle tests will be performed using the MicroFET 2 digital hand dynamometer according to the device manual. The measurement will be performed in supine, prone, side-lying and sitting positions by preventing compensatory movements. During the test, the arms will be positioned so that they will not receive power from anywhere on/to the side of the body. Measurements will be performed bilaterally. While the child to whom the test is applied is expected to perform the requested movement with all his/her strength, the evaluating physiotherapist will apply resistance in the opposite direction in proportion to the strength. During the evaluation of the same muscle, a 30-second break will be given between repetitions, and a five-minute rest will be given before moving on to the test for a different muscle. Isometric muscle strength of the Iliopsoas, Gluteus Maximus, Gluteus Medius, Quadriceps, Hamstring, Tibialis Anterior, and Gastrosoleus muscles will be evaluated. | Other | Control group, Group 1, Group 2 |
| Functional Capacity Assessmnet with 6 Minute Walk Test MeasurementAlso: 6MWTThe 6MWT will be done on a flat 30-meter track marked every 3 meters, with clear start and finish lines. Before the test, the child rests 15 minutes while contraindications will be checked. If none, blood pressure, oxygen saturation, pulse, and Borg scale scores for dyspnea and fatigue will be recorded. Medications taken will be noted. The child will be instructed to walk at their own pace for 6 minutes, allowed to stop or rest, and continue until "test is over" is announced. The test will start with "test is started" and end with "test is over." The timer will run continuously even if paused. The test ends if chest pain, severe breathlessness, cramps, unsteadiness, sweating, pallor, or oxygen saturation <85% occurs. Afterward, the child will be sits and post-test vitals and Borg scores will be recorded. Distance walked and any complaints during the test will be noted. | Other | Control group, Group 1, Group 2 |
| Lower Extremity Functional ScaleAlso: LEFSThe Lower Extremity Functional Scale will be used to evaluate the functional ability of the entire lower extremity in individuals with musculoskeletal disorders. This scale will question the difficulty experienced in various daily activities due to the problem in the lower extremity with 20 items. Each item will be scored between 0-4 on a Likert scale (0=extremely difficult/too difficult to do the activity; 4=not difficult at all). The total score varies between 0-80 and the higher the score, the higher the functional level. A validity and reliability study has been conducted for the Turkish version of the scale to be used in evaluating lower extremity functions. | Other | Control group, Group 1, Group 2 |
| Pain Assessment with Viusal Analog ScaleAlso: VASThe Visual Analog Scale is a simple and reliable tool that is widely used to assess subjective experiences such as pain. It consists of a 10 cm horizontal line with one end indicating "no pain" and the other end indicating "worst pain imaginable". Individuals will mark the point that reflects their perception of intensity, which will then be measured in millimeters or centimeters to obtain a numerical score. Higher values will indicate greater severity. The Visual Analog scale is valid and reliable in a variety of populations and conditions, including musculoskeletal pain. | Other | Control group, Group 1, Group 2 |
| Demographic Information FormAll children's gender, age, body weight, height and dominant side information will be recorded before clinical evaluations. The body mass index (kilogram/meter2) of the child will be calculated and recorded with the recorded body weight (kilogram) and height (meter) values. | Other | Control group, Group 1, Group 2 |
| Ankle Joint Dorsiflexion Range of Motion MeasurementAlso: ROMDorsiflexion range of motion with the knee joint in full extension and 90° flexion, the subtalar joint in a neutral position, the ankle dorsiflexion will be measured with the fixed arm of the universal goniometer on the fibula shaft and the mobile arm following the fifth metatarsal shaft. The measured angles were recorded in degrees (°). Measurements will be made bilaterally. | Other | Control group, Group 1, Group 2 |
| Leg Length MeasurementLeg Length Measurement, the child will be placed in a supine position. The legs will be positioned in extension and the muscles will be relaxed. The physiotherapist will measure and record the child's right leg length from the SIAS bone to the medial malleola with a flexible metal tape measure. Measurements will be made bilaterally. | Other | Control group, Group 1, Group 2 |
Primary outcome
Rotational Profile- Hip Internal and External Rotation Measurement
Time frame: Day 1
Hip internal and external rotation angles measurement, hip range of motion evaluations will be performed. Measurements will be performed using a universal goniometer. The children will be positioned in the prone position with their knees flexed 90° and placed on the edge of the bed. The tuberositas tibia will be chosen as the pivot point of the goniometer, and the movable arm will be aligned with the tibial crista. The fixed arm will be placed perpendicular to the floor and the movable arm will be guided by the tibial crista. During hip rotation, it will be ensured that the hip remains stable and the movement occurs only in the hip joint.
Rotational Profile- Craig's Test Measurement
Time frame: Day 1
The Craig's (Ryder) test, also known as the 'Trochanteric Prominence Angle Test', will be performed on the children included in the study according to the following protocol. The children will be placed in a prone position. The physiotherapist stood on the opposite side of the hip to be tested. The hips of the children will be placed in the extension position and the knee on the side to be tested will be held in the 90° flexion position. The physiotherapist palpated the trochanter major with the left hand and internal rotated the hip with the right hand. At the point where the trochanteric process will be most prominent, the angle between the tibia and the vertical plane will be measured using a goniometer and the femoral anteversion angle will be recorded.
Rotational Profile- Foot/Thigh Angle Measurement
Time frame: Day 1
Foot/thigh angle, assessment will be performed by measuring the angle between the long axis of the femur bone and the foot with a goniometer in the prone position. One arm of the goniometer will be placed parallel to the long axis of the femur, while the other arm will be placed so that it passes through the 2nd and 3rd metatarsals. Normally, the thigh-foot angle should be in external rotation between 10-15°. In young children, this angle can be considered normal up to 30°. A decrease in the thigh-foot angle will indicate internal tibial torsion (expressed as a negative value), which is the internal rotation of the tibia. In this case, there is an abnormal internal rotation of the tibia. If the measured foot-thigh angle exceeds 30°, it is considered to be external tibial torsion (external rotation of the tibia).
Rotational Profile- Heel Bisector Line Measurement
Time frame: Day 1
The heel bisector line test is an evaluation method that helps diagnose metatarsus adductus. During the test, the child will be placed in the prone position with the heel between the physiotherapist's fingers. Then, the midpoint of the lines drawn from the malleoli will be determined. From this point, a perpendicular line will be drawn from the heel to the toes along the foot axis with the help of a goniometer. Normally, this line should end between the 1st and 2nd toes. If the line ends at the 3rd, 4th or 5th toes, this may indicate the presence of metatarsus adductus.
Rotational Profile- Q Angle Measurement
Time frame: Day 1
Q-angle is defined as the angle formed between an imaginary line connecting the anterior superior iliac spine of the pelvis to the midpoint of the patella and the proximal projection of the line extending from the tibial tubercle to the center of the patella. The child will first be placed in a supine position, with legs extended and muscles relaxed, and the midpoint of the patella will be marked with a colored pencil. Then, the goniometer will be placed at the exact midpoint of the patella, and care is taken to fix the mobile arm so that it points to the anterior superior iliac spine and the fixed arm so that it follows the tibia, and the angle in between will be recorded. The measurement will be recorded in two different positions: lying down and standing. The Q angle is considered normal between 10-15 ° in boys and 15- 20 ° in girls.
Rotational Profile- Navicular Drop Test Measurement
Time frame: Day 1
The navicular drop test is commonly used in clinics to assess pes planus. It will begin with the child sitting, feet flat on the floor, and no weight bearing. The navicular tubercle will be palpated and marked first, then the distance from the tubercle to the floor will be measured. The child will then stand with equal weight on both feet and the distance will be measured again. Measurements will be taken bilaterally and recorded in millimeters. The difference between the weighted and unweighted measurements will indicate foot posture: 5-9 millimeters is normal (neutral), 10 millimeters or more will indicate pronation (inward rotation), and 4 millimeters or less will indicate supination (outward rotation). This test is important for assessing the degree of pes planus.
Rotational Profile- Foot Progression Angle
Time frame: Day 1
The angle of foot progression is an important parameter to identify possible gait disorders and alignment problems by reflecting the rotational relationship between the femur, tibia and foot. For the test, two chairs facing each other will be placed 2 meters apart. The child will sit on a chair and the middle of the heel and the second toe will be marked with colored paint. The child will then stand up and walk naturally on a flat surface for about 5-6 steps towards the opposite chair and leave footprints. The child will then sit on the opposite chair and clean the paint from his feet. The footprints will be measured with a goniometer: one arm will be aligned with the direction of the footprints, the other will be parallel to the axis of the tibia. The angle between the foot and the tibia will be recorded in degrees.
Postural Control Assessment with the Biodex Balance System
Time frame: Day 1
Postural stability, limits of stability, and sensory integration of balance will be assessed using the Biodex Balance System®. It consists of a balance platform, arm supports, a screen, and a printer. The platform can be set to static or dynamic mode (12 levels; level 12 = most stable, level 1 = least stable with up to 20° movement in all directions). Prior to testing, children will be informed about the procedures. The heel and toe positions will be recorded based on medial-lateral (B-J), anterior, and posterior (1-21) axes. Arm support and screen height will be individually adjusted. Child-specific posture and identification data will be entered into the system. Three tests will be performed: postural stability, limits of stability, and sensory integration of balance.
Muscle Strength Assessment with Micro-FET 2
Time frame: Day 1
Muscle tests will be performed using the MicroFET 2 digital hand dynamometer according to the device manual. The measurement will be performed in supine, prone, side-lying and sitting positions by preventing compensatory movements. During the test, the arms will be positioned so that they will not receive power from anywhere on/to the side of the body. Measurements will be performed bilaterally. While the child to whom the test is applied is expected to perform the requested movement with all his/her strength, the evaluating physiotherapist will apply resistance in the opposite direction in proportion to the strength. During the evaluation of the same muscle, a 30-second break will be given between repetitions, and a five-minute rest will be given before moving on to the test for a different muscle. Isometric muscle strength of the Iliopsoas, Gluteus Maximus, Gluteus Medius, Quadriceps, Hamstring, Tibialis Anterior, and Gastrosoleus muscles will be evaluated.
Functional Capacity Assessment with 6 Minute Walk Test
Time frame: Day 1
A 6 6-minute walk test will be done on a flat 30-meter track marked every 3 meters, with clear start and finish lines. Before the test, the child rests 15 minutes while contraindications will be checked. If none, blood pressure, oxygen saturation, pulse, and Borg scale scores for dyspnea and fatigue will be recorded. Medications taken will be noted. The child will be instructed to walk at their own pace for 6 minutes, allowed to stop or rest, and continue until "test is over" is announced. The test will start with "test is started" and end with "test is over." The timer runs continuously even if paused. The test ends if chest pain, severe breathlessness, cramps, unsteadiness, sweating, pallor, or oxygen saturation <85% occurs. Afterward, the child sits and post-test vitals and Borg scores will be recorded. Distance walked and any complaints during the test will be noted.
Lower Extremity Functional Scale
Time frame: Day 1
The Lower Extremity Functional Scale is a questionnaire that will evaluate the functional ability of the entire lower extremity in individuals with musculoskeletal disorders. This scale will question the difficulty experienced in various daily activities due to the problem in the lower extremity with 20 items. Each item is scored between 0-4 on a Likert scale (0=extremely difficult/too difficult to do the activity; 4=not difficult at all). The total score varies between 0-80 and the higher the score, the higher the functional level. A validity and reliability study has been conducted for the Turkish version of the scale to be used in evaluating lower extremity functions.
7 secondary outcomes
Muscle Shortness/Flexibility- Thomas Test Measurement
Time frame: Day 1
Muscle Shortness/Flexibility- Popliteal Angle Measurement
Time frame: Day 1
Muscle Shortness/Flexibility- Silfverskiöld Test Measurement
Time frame: Day 1
Muscle Shortness/Flexibility- Ober Test Measurement
Time frame: Day 1
Muscle Shortness/Flexibility- Duncal-Ely Test Measurement
Time frame: Day 1
Muscle Shortness/Flexibility- Sit-Reach Test Measurement
Time frame: Day 1
Pain Assessment with Visual Analog Scale
Time frame: Day 1
Results and safety
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 15 Jul 2025.
- Individual participant dataSharing planned: Undecided
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Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part. This study is not recruiting at the moment.
The record lists no contact. Use the official record to reach the sponsor.
1 site in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
An observational study of Joint Hypermobility and Femoral Anteversion, run by Bezmialem Vakif University at 1 site in Turkey (Türkiye).
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 12 inclusion and 4 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: finished, as of the sponsor's last update on 15 Jul 2025. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 1 site in Turkey (Türkiye). Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
Are results available for this study?
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
How can a doctor refer a patient or contact the research team?
The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Rotational Profile- Hip Internal and External Rotation Measurement (time frame: Day 1). The study lists 11 primary outcomes in all. It is what the study was designed to measure, not a finding.
Where can I read the original study information?
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 15 Jul 2025.