Lower extremity Flashcards
Triceps surae (gastrocnemius and soleus)
Gastrocnemius:
– assessment:
—- straighten the leg straight up to 90 degrees hip flexion, try and dorsiflex the foot to 90 degrees
—- if there is full movement there is no tightness
—- if there is a bind before 90 degrees then there may be tightness
Then:
—- keep hip flexed 90 degrees but flex the knee slightly to take the pressure off the gastroc
—- if it moves fine then it was the gastroc that was fine
However:
– if there is still tightness then it is more likely the soleus muscle or a restriction in the hamstring
MET procedure:
– leg straight
– dorsiflexion of the foot
Soleus:
– knee bent, best if your knee is under patients
– dorsiflexion of the foot
Hamstrings
Assessment:
– straight leg, flex the hip up, should see 80-90 degrees
– if there’s less than 80 then there is a tightness in the hamstrings
– can assess the seperate hamstrings to see which one is the tightest one
MET procedure:
– non specific:
—- place pt’s leg onto shoulder with the leg straight
—- pt asked to push down into shoulder, take the hip into further flexion in the refractory period
Inerstion of hamstrings:
– same thing but knee flexed, get them to flex their knee more into your shoulder
RI for hamstrings:
– pt is asked to flex their leg like the insertion method
– during the relaxation phase they are asked to extend their knee which was flexed promoting relaxation of the hamstrings
TFL
Assessment:
– Obers test (tightness of the iliotibial band)
MET procedure:
– Best method to use to promote the relaxation and change in tone of the TFL
– as even 1 tonne of pressure will not change the ITB length by more than 1%
– cross pots leg over and control the crossed over leg with your hand on the pt’s knee
– pts straight leg placed into a position of adduction, get them to abduct and stretch it more
– can get the pt to adopt a side bending position to encourage more lengthening of the QL and TFL
Adductors
Assessment:
– hip abduction test
– abduct out the patients leg straight and feel for a bind
– normal is 45 degrees, if the bind is before that then it may be shortened
However:
– if the ROM is less than 45 degrees is can also be a tight semimemb and semitend
To identify if the hamstrings are the restrictive muscles:
– passively flex the knee then carry on with the abduction, if the ROM improves, the hamstrings are the restrictive tissues and not the short adductors
MET procedure:
there are multiple ways
Short adductors:
– push down both the pts legs at the same time, from the point of bind the pt is asked to adduct their legs to contract the short adductors
MET of the long adductors:
– move leg out straight and get the pt to adduct their leg in (polyarticular)
– can use leg if its too much pressure on the arm
MET treatment of the short adductors:
– move leg out until you feel a bind with the knee flexed and get the pt to adduct their leg inwards
Isolating individuals adductors:
– please, baby, love, my, groin
Iliopsoas
Assessment:
– Thomas test
– modified Thomas test (pt has their legs off the couch with their hips on the couch, if the knee is below the hip it suggests normal level of the psoas, if the knee is the same level or higher it suggests a shortened position
MET procedure:
– in the modified Thomas position, pts foot into your side other leg straight down
– get pt to lift up leg and push into your body
– in the relaxation period, push their leg back and push their leg down lower
Prone:
– COUCH LOW
– lift up their knee and stabilise over the PSIS
– get them to push their leg back down and resist
– in the relaxation period lift up their leg even more
Quadriceps (rectus femoris)
Assessment:
– modified Thomas test again
– look at knee to ankle ratio
– knee should be 90 degrees
– if its more than that and leg is more extended, then it could suggest a short rectus femoris
MET procedure:
– prone position
– get them to flex their leg up and find the bind
– flexion of the knee stretches the rec fem and therefore causes anterior rotation of the pelvis due to its attachment to the AIIS
– so put caudal pressure on the PSIS to reduce the anterior rotation on the pelvis and put a pillow under the pelvis to ease this
– you dont want it to cause lumbar spine damage
– get the pt to extend out their knee and resist, in the relaxation period flex the knee more further stretching the quadriceps and rec fem
Alternative position:
– modified Thomas position, push the rec fem back by flexing the knee more
– get the pt to kick out their leg and resist
– in the relaxation period flex the knee back more
Note:
– bilateral hypertonicity of the rec fem will cause an anterior tilt of the pelvis, leading to lower back pain and an increased lumbar lordosis
– this can cause the facets to approximate leading to an increased likelihood of lumbar facet dysfunction and problems with the discs
Piriformis and hip complex
Assessment:
– general observation, you may see the leg being held in an externally rotated position, if there is an external rotation of the foot this may mean that there is a shortened piriformis on that side
– shortened piriformis can pull the sacrum downwards in a diagonal motion due to its attachment onto the anterior sacrum, leading to sacral wedging which can lead to a loss of mobility in the SIJ
Passive assessment of piriformis:
– prone
– push the leg outwards into internal rotation to see for tightness
– if there is a decreased range of motion then its shortened
– you can also do the prone MET from this position
MET treatment:
- Technique 1
– push the leg out into internal rotation and get them to push their leg in and you resist
– in the relaxation period you push their leg further out
Technique 2:
– MAY BE A PREFERED WAY:
– cross leg over and take it to the point of bind and push leg
– get pt to push their knee towards you and in relaxation phase push it further away
Stabilising contact:
– can be on iliac crest nearest to you
– can be on contralateral iliac crest and pull closer towards you as the pt may feel it more
Technique 3:
– knee flexed up and hip flexed
– move foot inside into lateral rotation (piriformis becomes an internal rotator after 60 degrees of hip flexion)
– get them to push their foot out
– then in the relaxation phase push them foot further in
– in the refractory period you can use a mobilisation technique of the piriformis
Quadratus lumborum and erector spinae
Assessment of QL:
– standing or supine side bending test
– get the pt to sidebend and see how far they can get their fingers
– if it touches the fibula head then it is classed as normal
– if there is restriction and it gets nowhere near the fibula head then it is classed as shortened
MET procedure:
PIR
– pt asked to adopt a banana shape, opposite hand placed under their head, leg on the side of the lengthening QL over their other leg.
– therapist places their hand underneath the pt’s head and cradles the opposite axilla
– other hand is used to stabilise the pt’s pelvis
– pt is asked to bend their body to the other side
– this will contract the QL
– increase the banana from this position
RI:
– same but get the pt to reach their other hand down the leg closest to you
– this will induce a contraction of the other QL and get the opposite QL to relax, allowing a lengthening to occur
Alternative methods:
– sidelying with top leg off top of couch
– stabilise pts lower back, and get them to abduct their leg against your resistance
– in the relaxation period, the practitioner takes the leg into further adduction to further stretch the QL
– can also do this off the end of the couch where the therapist squats over the patients leg and pull on their iliac crest
Erector spinae
Assessment:
– get the pt to reach for their toes with their legs straight,
– this test will also highlight if the pt has any tightness within the hamstrings, gastrocnemius and the soleus
– normal length is that the pt can reach their toes
Lumbar erector spinae length test test:
– pt sits at the end of a couch and is asked to roll their chin to their chest and to continue flexing down vertebrae by vertebrae.
– therapist palpates the top of their patients iliac crest and the PSIS with their thumbs, and when they feel the muscular tension increase to their hands the test is complete, measure the distance
– more than 15cm or 8 inches from their head to their knees is a tight lumbar ES
MET treatment for lumbar ES:
– pt prone with a pillow underneath their abdomen
– place left hand on pt’s lower thoracic spine and right hand on sacrum.
– pt asked to lift their shoulder off the couch to contract the lumbar erector spinae
– in the relaxation period, push up more (cephalic) with the upper hand and more caudally with the lower hand
NOTE:
– shortened erector spinae can put the pelvis into a position of anterior tilt/rotation
