Clinical Applications of Neuromuscular Techniques The Lower Body Volume 2

THE KNEE 475 The MCL and the LCL are assessed by applying valgus and varus stress to the knee in 30° of flexion and in full extension. Note: Following the testing procedures below, as pressure is released a 'clunking' sensation may be noted, especially if laxity is a feature, and the patient should be forewarned. Assessing for MCL damage (abduction stress test) Figure 1 3.24 Abduction stress test. The left hand stabilizes the thigh while the right hand applies the abduction force (adapted from Petty & • The patient lies supine with the leg to be tested lying Moore 1 998). at the edge of the table. • If a significant degree of gapping of the lateral aspect • The lower extremity is abducted so that the leg is of the knee joint occurs this suggests impairment of eased off the edge of the table, with the knee placed the LCL and possibly also the arcuate-popliteus in 30° of flexion and the foot supported by the complex, the posterolateral joint capsule, the iliotibial practitioner. band and the biceps femoris tendon (Petty & Moore 1998). • Valgus stress is applied by pressing medially on the lateral aspect of the knee with the thumb of one • Comparison of the degree of gapping should be hand, while the fingers of the same hand palpate the made between the affected and non-affected knees. medial aspect of the joint. The second hand directs the ankle laterally, effectively 'opening' the medial • Mennell (1964) points out that if the knee is in full aspect of the knee joint. extension, it is impossible to tilt the joint open laterally, if the lateral collateral ligament is intact. • If a significant degree of gapping of the medial aspect of the knee joint occurs this suggests impairment of • Mennell further suggests using just 'two or three the MCL (Levy 2001 ). degrees of flexion' for testing regular joint play, when ligament status is not specifically being evaluated . • Comparison of the degree of gapping should be 'Because the knee joint is unlocked by minimal flexion, made between the affected and non-affected knees. this tilting open of the lateral joint space is the extent of normal [joint play] movement and has nothing to • If the knee is placed in extension and there is do with determination of the integrity of the LCV increased medial joint laxity when an abduction (valgus) force is applied to the leg, there may be The Lachman maneuver (to confirm ACL integrity) additional (to MCL damage) involvement of posterior structures, such as the posterior joint capsule, • The patient lies supine with the knee flexed to 20-30°, posterior oblique ligament, posteromedial capsule draped over the practitioner's knee (which has been and/ or the PCL (Fig. 1 3.24). placed onto the table). • Mennell (1 964) points out that if the knee is in full • Posteriorly directed pressure on the patient's femur extension, it is impossible to tilt the joint open should be applied with one hand, while the other medially, when the medial collateral ligament is hand attempts to move the proximal tibia anteriorly, intact. testing the degree of joint play. • Equally, if the vastus medialis muscle is weakened for • An excessive degree of forward motion of the tibia, some reason, the quadriceps mechanism that locks without a firm endpoint (i.e. soft end-fee!), suggests the joint is impaired and an abnormal degree of side ACL damage (compare both knees). tilting medially may occur. • This test also assesses the arcuate-popliteus complex • Mennell further suggests just 'two or three degrees of and the posterior oblique ligament. flexion' for testing regular joint play, when ligament status is not specifically being evaluated. Assessing for LCL damage (adduction stress test) • In order to test for lateral knee joint stability the hand positions should be reversed . • Varus stress is applied by pressing on the medial aspect of the knee joint (while it is in 30° of flexion) with one hand, while directing the leg (held in slight external rotation) medially with the other, effectively opening the lateral aspect of the knee joint.

476 CLINICAL APPLICATION OF NMT VOLUME 2 Anterior drawer test (to evaluate soundness of ACL) Figure 1 3.25 Posterior drawer test. The practitioner stabilizes the patient's loot by sitting lightly on it. An anteroposterior lorce is applied • The patient lies supine with the hip flexed to 45° and to the tibia (adapted Irom Petty & Moore 1 998). the knee to 90°, so that the patient's foot rests firmly on the examination table. • The practitioner sits on the dorsum of the foot, placing both hands behind the knee and onto the proximal lower leg. • Once the hamstrings seem to be relaxed, a gentle force is applied to ease the proximal leg anteriorly, evaluating joint play between the tibial condyles and the femoral condyles. • The normal range of joint play in this test is said to be 6 mm (Petty & M oore 1 998). • This 'anterior drawer test' is said to be less sensitive for ACL damage than the Lachman maneuver (Levy 2001 ). As in that test, an excessive degree of forward motion of the tibia, without a firm endpoint, suggests ACL damage (compare both knees). • Additionally this test evaluates the posterolateral joint capsule, the MCL and the IT band. Posterior drawer test (to evaluate soundness of PCL) Pivot shift test (to confirm posterolateral capsular damage and/or injury to the ACL, arcuate-popliteus • The patient lies supine with the hip flexed to 45° and complex and IT band) the knee to 90°, so that the patient's foot rests firmly on the examination table (Fig. 1 3 .25). • If the ACL is impaired, the tibia tends to subluxate anteriorly during knee extension. • The practitioner sits (lightly) on the dorsum of the foot and places both hands behind the knee, with • The supine patient is lying with knee extended and in thumbs wrapping to the front of the tibia. order to create a valgus stress a moderate degree of pressure should be applied on the lateral aspect of • Once the hamstrings seem to be relaxed, a gentle the knee, directed medially, while the knee is being force is applied to ease the proximal leg posteriorly, actively flexed (with the lower leg held in medial evaluating joint play between the tibial condyles and rotation) . the femoral condyles. • As the knee joint approaches 20-40° o f flexion, a • Instability arising from PCL injury manifests as an sudden jerking movement will occur if the ACL is abnormal increase in posterior tibial translation. impaired (Fig. 1 3.26). If there is confusion when trying to distinguish whether McMurray tests (to confirm meniscal disorders) abnormal translation of the tibia on the femur originates from excessive ACL or PCL laxity, the tibial sag test Medial meniscus (Fig. 1 3.27) should be utilized. • The patient lies supine with the affected knee in Tibial sag test (to confirm PCL instability) maximum flexion. • The supine patient's hips and knees are both flexed to • The posteromedial margin is palpated with one hand 90° and the patient's heels are supported by the while the foot is supported by the other hand. practitioner. • The lower leg is externally (laterally) rotated as far as • In this position, the PCL impaired knee will clearly possible, while at the same tinl.e the tibia is abducted, sag backward (tibia 'falls' toward the floor in this thereby creating a valgus strain. While holding these position) from the effects of gravity (also known as positions, the knee joint is slowly extended. the Godfrey sign) (Levy 2001 ) . • In the case of a tear involving the medial meniscus, • This will not occur if the ACL is impaired. 'an audible, palpable, and painful movement' occurs at the moment that the femur passes over the damaged portion of the meniscus (Levy 2001 ) .

THE KNEE 477 Figure 1 3.26 Lateral pivot shift. The practitioner applies abduction should be placed over the posterolateral aspect of the stress to the lower leg while moving the knee from extension to flexion knee joint, at which time maximal pain-free internal while the leg is maintained in medial rotation (adapted from Petty & rotation of the lower leg should be introduced . Moore 1 998). • The tibia is then placed into adduction, creating a varus strain, as the leg is slowly extended. Figure 1 3.27 McMurray test for medial meniscus dysfunction. • In the case of a tear involving the lateral meniscus, Lateral meniscus 'an audible, palpable, and painful movement' occurs at the moment that the femur passes over the • In order to evaluate the lateral meniscus, a similar damaged portion of the meniscus. method is repeated but this time, as the leg is • Levy (2001 ) warns: 'Clicks unassociated with pain or supported at the foot by one hand, the other hand joint-line tenderness, especially during lateral meniscus testing, may represent a normal variant and should not be interpreted as evidence of a meniscal tear'. Further tests for meniscal and ligamentous damage include: • Apley's compression test, in which the prone patient's knee is taken to 90° flexion. The practitioner stabilizes the thigh and at the same time applies com­ pression to the menisci through the long axis of the femur, via pressure on the heel. The tibia is slowly rotated medially and laterally while compression is maintained. Pain noted during rotation of the tibia, either medially or laterally, implicates the meniscus on that side • Apley's distraction test, in which precisely the same positioning is maintained, with distraction rather than compression being introduced, as medial and lateral tibial rotation is applied. Pain resulting from this procedure suggests medial or lateral ligamentous dysfunction. Compression mobilization in rehabilitation after knee surgery Noel et al (2000) suggest that because cyclical loading of the knee joint, during normal use, stimula tes 'bio­ synthetic activity of the chondrocytes', addition of com­ pression to joint mobilization after surgery should assist in joint repair. In order to assess the validity of this approach, half of a group of 30 patients were treated, as part of standard rehabilitation physical therapy after intraarticular reconstructive surgery of the ACL, by the addition of compressive force during movement of the knee from end of range of motion (flexion) into the range of motion. This was performed in four series of approximately 20 repetitions daily. Initially, the flexion range of motion (FROM) was measured using a goniometer. The group who received compression with range of motion exercise achieved a FROM of 1 30° within an average of six treat­ ments, compared with 1 1 treatments for those who did not have compression added. The method was as follows. • The patient lies prone with a small pad l sandbag under the knee, proximal to the patella.

478 CLINICAL APPLICATION OF NMT VOLUME 2 • The practitioner takes the knee into flexion, carefully postural muscles, for example hamstrings, rectus establishing the pain-free end of range. femoris and TFL/iliotibial band (Liebenson 1 996) . • The practitioner then progressively exerts long See individual muscles for details of appropriate strength axis compression from the calcaneum toward the or shortness tests, which are described where appropriate. knee. Positional release methods for knee • The d egree of pressure exerted is the maximum damage and injury involving ligaments and possible without causing pain. tend ons • Maintaining this degree of compression, the PRT for patellar tendon dysfunction practitioner passively eases the knee toward extension over a range of 1 0-15°. • Tender points related to dysfunction involving the patellar tendon are located close to the apex of the • The compression is released and the range reassessed patella, on one or both sides, or in the center of the and held at the maximal limit of pain-free flexion, as tendon. the procedure is repeated. • Digital pressure, applied medially or laterally, or by • In between each series of 20 repetitions, several slow means of compression between finger and thumb passive movements of the knee through its entire helps to localize the most sensitive area on the range are performed. tendon. CAUTION: The researchers report: 'All patients receiving • The discomfort created in the most sensitive point is registered by the patient as a pain score of '10'. mobilizations with compression described the first • The patient lies supine with the leg to be treated session as \"very unpleasant\" or even painful. When straight, as the practitioner, standing alongside the knee, maintains direct pressure onto the tender point pain was experienced, it was located in the knee fold with her caudad hand. and/or around the incision at the ligamentum patella. • The knee should be in extension with the lower calf supported on a small cushion or rolled-up towel, to The pain was felt in the extreme flexion position only, create slight hyperextension of the knee. and disappeared as soon as mobilization toward exten­ • The patient reports on changes in perceived discomfort as the practitioner places her cephalad sion was started, indicating that the pain was not due to hand just proximal to the patella, easing the patella caudad while at the same time creating medial compression . . . . The unpleasant sensation decreased at rotation of the lower leg. The combination of mild hyperextension of the knee, medial rotation of the the end of each session and from session to session.' tibia and caudad depression of the patella should reduce the perceived discomfort to a score of '3' or The researchers report that Van Wingerden ( 1 995) less (without additional pain elsewhere). 'relates the pain to a decrease of the gliding properties • This final position of ease (for the tendon) is held for 90 seconds before slowly releasing. of the femur on the menisci following the alteration of PRT for MGL dysfunction (Fig. 1 3.28) lubrication after a surgical procedure'. • The tender point relating to MeL dysfunction is This caution emphasizes the need to avoid taking the found on the medial surface of the knee, usually on flexed knee beyond a tolerable end range and to advise the anterior aspect of the ligament. the patient to anticipate discomfort, which will most probably rapidly diminish and which is not a result of • The patient is supine with the affected leg at the edge damage to the knee but rather of the distressed and of the table. unlubrica ted tissues being taken into a slight stretch. • The practitioner stands or sits alongside facing the Patellar apprehension test table, cephalad hand enfolding the posterior aspect of the knee, so that the index or middle finger presses The supine patient's leg is held and supported in 30° of onto the tender point on the medial knee. flexion at the knee. A firm, laterally directed force is applied against the medial aspect of the patella. The test • The practitioner's caudad hand supports the foot as is positive if there is excessive patella movement and /or the lower extremity is abducted off the table and if the patient displays anxiety (apprehension) and flexed at the knee to approximately 40° or until some attempts to protect the knee from this pressure. This suggests a patellar subluxation or dislocation. Additionally it is necessary, as in all other joint areas, to examine the muscular component. • The relative strength of the phasic muscles should be tested, for example the quadriceps (apart from rectus femoris) and particularly V MO. • Shortness should be tested for in the regions of

THE KNEE 479 • The flexed knee of the abducted lower extremity is held in place as, using the caudad hand, fine tuning is introduced, involving external (rarely internal) rotation of the tibia, as well as slight abduction of the tibia (a valgus force). • Very rarely ease may be enhanced by an adduction rather than an abduction of the tibia. • Additional ease of discomfort may be achieved by means of mild long-axis compression, from the foot toward the knee. • Once reported discomfort in the tender point has reduced from '10' to 3' ', or less (without additional pain elsewhere), the final position of ease is held for at least 90 seconds before a slow return to neutral. Figure 1 3.28 PRT treatment of medial coliateral ligament PRT for PCL dysfunction dysfu nction. • The tender point for PCL dysfunction is located at the reduction is reported in the tenderness in the very center of the popliteal space. Care should be palpated point. taken to avoid compressing the popliteal artery. • The flexed knee is held in place as, using the caudad hand, fine tuning is introduced involving internal • The patient lies supine and the practitioner stands rotation, as well as slight adduction, of the tibia (a ipsilaterally facing cephalad, with the index or varus force). middle finger of her non-tableside hand in contact • Additional ease of discomfort may be achieved by with the tender point. means of mild long-axis compression, from the foot toward the knee. • A rolled towel is placed just distal to the popliteal • Once reported discomfort in the tender point has space, supporting the proximal tibia. This placement reduced from '10' to '3', or less (without additional should reduce reported tender point discomfort pain elsewhere), the final position of ease is held for slightly. at least 90 seconds before a slow return to neutral. • Using her tableside hand, the practitioner introduces PRT for LCL dysfunction internal rotation of the tibia, until a further reduction in tenderness in the palpated point is reported. The • The tender point relating to LCL dysfunction is found leg is left in the degree of internal rotation of the tibia on the lateral surface of the knee, usually on the which provides the greatest reduction in reported anterior aspect of the ligament. pain. • The patient is supine with the affected leg at the edge • The practitioner then places her hand on the distal of the table. thigh, just superior to the patella, and introduces a posteriorly directed force (slightly hyperextending • The practitioner stands or sits alongside facing the the knee) as the patient reports on changes in table, cephalad hand enfolding the posterior aspect of perceived pain in the tender point. the knee, so that the thumb presses onto the tender point on the lateral knee. • Once reported discomfort in the tender point has reduced from ' 1 0' to '3', or less (without additional • The practitioner 's caudad hand supports the foot as pain elsewhere), the final position of ease is held for the lower extremity is abducted off the table and at least 90 seconds before a slow return to neutral. flexed at the knee to approximately 40° or until some reduction is reported in the tenderness in the PRT for ACL dysfunction (Fig. 13.29) palpated point. • There are ACL tender points on both the anterior and posterior surfaces of the knee. • The posterior points will be used and treated in this description. These lie in the medial and lateral quadrants of the superior popliteal space. • The patient lies supine and the practitioner stands ipsilaterally facing cephalad, with the index or middle finger of her non-tableside hand in contact

480 CLINICAL APPLICATION OF NMT VOLUME 2 Figure 1 3.29 PRT treatment for anterior cruciate ligament • Using her tableside hand the practitioner introduces dysfunction. internal rotation of the tibia, until a further reduction in tenderness in the palpated point is reported. The with one of the ACL tender points in the superior leg is left in the degree of internal rotation of the tibia popliteal space. which provides the greatest reduction in reported • A rolled towel is placed just proximal to the popliteal pain. space, supporting the distal femur. This placement should reduce reported tender point discomfort • The practitioner then places her hand on the slightly. proximal tibia, just inferior to the patella, and introduces a posteriorly d irected force (slightly hyperextending the knee) as the patient reports on changes in perceived pain in the tender point. • Once reported discomfort in the tender point has reduced from '10' to '3', or less (without additional pain elsewhere), the final position of ease is held for at least 90 seconds before a slow return to neutral. MUSCLES OF THE KNEE JOINT Muscles which d irectly affect movement of the knee include four extensors (collectively known as the quadri­ ceps femoris muscle) and seven flexors (the hamstring group, sartorius, gracilis, popliteus and gastrocnemius). Box 1 3.1 0 Articulation/mobilization of the knee (Schiowitz 1 99 1 ) CAUTION: These articulation methods derive from osteopathic • The patient is supine and the practitioner stands ipsilaterally and techniques and might be construed as manipulation in some facing the table. states. Practitioners should ensure that their licensure allows them to perform these essentially safe mobilization • The patient's knee and hip are flexed to 900 and the hip is techniques. abducted and externally rotated to a comfortable, painless, end-of-range position. Schiowitz ( 1 99 1 ) has detailed mobilization methods which derive from osteopathic joint mobilization methodology. He describes them • The practitioner maintains the knee in its position by placing her as 'myofascial ligament release techniques' for treatment of cephalad hand onto its medial surface while at the same time, somatic dysfunction of joints such as the knee, hip or ankle. They with the other (caudad) hand, she holds the distal tibial shaft are essentially the same as many of the assessment methods which she externally rotates to its pain-free end of range. described earlier in this chapter (and others). involving repetition and slightly greater force than would be used in assessment. • These positions, in which hip and knee are held at their external rotation barriers, is held for 3-4 seconds before, 'while While largely 'knee focused', the first of the methods described maintaining pressure with both hands, the practitioner slowly involves the knee and the hip, as the movements used are returns the patient's hip and knee to full extension on the table, compound. Schiowitz points out that: releasing the pressure of both hands only at the last 50 of full extension. Any of these methods can be modified by introducing isometric resistance to create myofascial relaxation. The joint is placed at its • This process is then repeated once more. barrier of motion, then the patient actively attempts to reverse the motion against the isometric resistance supplied by the practitioner. Knee mobilization See Chapter 9 of this volume and Volume 1 , Chapter 1 0 for For enhancing flexion and extension of the knee utilizing descriptions of muscle energy techniques ( M ET). anteroposterior glide. Ideal for knee restrictions which are not accompanied by any ligamentous laxity or internal damage. CAUTION: None of these methods should be continued if pain is created by their performance, and none is meant to be used • The patient is supine with hip and knee flexed to 900 and the in the presence of acute dysfunction, active arthritic practitioner stands ipsilaterally at the side of the table, facing the conditions, inflammation or where tissue damage (tears, etc.) head. is suspected. • The patient's ankle is tucked into, and held firmly by, the Hip and knee mobilization practitioner's tableside axilla, while both her hands enfold the proximal tibia so that thumbs lie anteriorly and the fingers Specifically indicated if lateral knee structures are chronically interlock in the popliteal space. shortened (e.g. IT band). • The practitioner rocks forward slightly, increasing the degree of knee flexion slightly, while simultaneously gliding the tibia posteriorly with her thumbs. (continued overleaf)

THE KNEE 481 Box 1 3. 1 0 Articulation/mobilization o f t h e knee ( cont'd) • After a few seconds the practitioner rocks backward while on the femur and leans backward to apply traction. simultaneously gliding the tibia anteriorly. • After a few seconds the traction and glide are slowly released as • 'The to and fro rocking motion is repeated three to four times, the practitioner rocks forward. increasing the anterior and posterior slide motions each time' • The practitioner then introduces posterior glide of the tibia on the (Schiowitz 1 99 1 ). femur and again applies traction by leaning backward. Knee mobilization • This is released after a few seconds as the practitioner rocks For enhancing internal and external rotation of the knee. Ideal for forward. knee r!3strictions which are not accompanied by any ligamentous • The practitioner introduces internal rotation of the tibia on the laxity or internal damage. femur together with traction, then releases this and introduces • The patient lies supine with a pillow beneath the knee to create external rotation of the tibia on the femur with traction and approximately 1 5° of flexion. releases this. • This sequence of anterior glide, posterior glide, internal and then • The practitioner sits on the table ipsilaterally and distal to the external rotation, each accompanied by traction, is then knee, facing the head. repeated. • The practitioner holds the patient's ankle/lower shin firmly. If there is a wish to add MET methodology to any of these • The practitioner's hands enfold the patient's proximal tibia so that mobilization sequences, the patient should be instructed to actively attempt to reverse the movement which the practitioner has thumbs lie anteriorly and the fingers interlock in the popliteal introduced, utilizing no more than 20% of available strength, for space. 5-7 seconds, against resistance from the practitioner, after which • The practitioner introduces anterior translation (glide) of the tibia the mobilization continues as described. Box 1 3.1 1 Mobilization with movement (MWM) techniques for the knee (see Chapter 9) Mulligan ( 1 999), who developed MWM methods, suggests, 'MWMs should always be tried when there is loss of movement that is obviously not the result of serious trauma'. MWM utilizes joint play, gliding, as a primary tool, after which the patient actively attempts to perform the movement which was previously restricted. If restriction is painlessly reduced as the joint is held in a glide or translation, it is performed again several times, after which it should be tested without the addition of translation and should have improved. Mulligan suggests: 'Medial glide with medial knee pain and lateral glide with lateral knee pain' and that flexion loss (as might occur in collateral ligament strain) is usually likely to be more assisted by MWMs than extension loss. Many of the MWM applications to the knee require the use of a strap/seatbelt type device, to assist in production of stabilization and sustained glide. These are not described in this text as they require instruction in their usage which should be acquired via normal physical therapy training procedures or through advanced workshops. MWM for flexion pain and/or restriction of the knee (Fig. 1 3.30) Figure 1 3.30 MWM using internal tibial rotation and fibula glide to increase flexion range. • The patient is supine, with the knee flexed to just short of the position where pain or restriction would be noted. • The practitioner stands ipsilaterally, at waist level, facing the foot of the table, with both her hands enfolding the proximal tibia so that her fingers lie on the anterior tibial shaft, with the thenar eminence of the non-tableside hand resting posterior to the head of the fibula. • The tibia is internally rotated by the practitioner's hands and at the same time slight ventral (anteriorly directed) glide is introduced to the fibula. • While these light forces are maintained, the patient is asked to actively increase the range of flexion, without passing any point where pain is noted. • Light overpressure may be added by the practitioner when the patient reaches the end of the (new) range. (See Box 1 3.8 on overpressure.) • The process should be repeated at least once more. (continued overleaf)

482 CLINICAL APPLICATION OF NMT VOLUME 2 Box 1 3.1 1 Mobilization with movement (MWM) techniques for are discussed earlier in this chapter with the ligamentous the knee (cont'd) complex. The plantaris, though it crosses the knee joint, makes little contribution to knee movement and is MWM self-treatment traditionally discussed as a plantarflexor of the foot. It is included in Chapter 1 4 with the ankle and foot on p. 534. • The patient stands and places his right foot (in this example) flat onto the seat of a chair. EXTENSORS OF THE KNEE: THE QUADRICEPS FEMORIS GROUP (Fig. 1 3.31) • He places his hands around the proximal leg, so that fingers (see also Fig. 12.17) meet anteriorly and the thenar eminence of his right hand rests posterior to the fibula head. The four heads of quadriceps femoris muscle group are the only extensor components of the knee joint, being three • With his hands he internally rotates the tibia while times stronger than the flexors (Kapandji 1987). Rectus simultaneously easing the fibula anteriorly. femoris is the only one of the quadriceps which crosses both the knee and hip joints. The hip flexor function of • Maintaining these forces of tibial rotation and anterior fibula rectus femoris is considered in Chapter 1 2 while its knee glide, the patient increases the previously restricted, or extension tasks are considered here with the quadriceps painful, range of knee flexion, provided there is no pain on femoris group. Also included here is the articularis genus, flexion. which contracts during extension to retract the supra­ patellar bursa. • Mulligan reports: 'I have my patients with OA knees do this on a regular basis as a home treatment. When . . .[this]. . .is Rectus femoris successful, tape the tibia in internal rotation on the femur'. Mulligan suggests that taping with the lower leg in internal Attachments: From the anterior inferior iliac spine rotation is frequently useful for patellofemoral problems (straight head) and the supraacetabular groove and where tracking of the patella is faulty. (See Box 1 3.3 on capsule of hip joint (reflected head) to insert into the taping procedures.) upper border of the patella and continue distal to the patella (as the patellar ligament) to attach to the tibial Box 1 3. 1 2 I maging tuberosity Levy (200 1 ) reports that I n most patients sustaining severe Innervation: Femoral nerve (L2-4) ligamentous or meniscal damage, plain film findings are Muscle type: Postural, prone to shortening under stress normal. Fewer than 1 5% of knee radiographs reveal clinically Function: Flexion of the thigh at the hip (or pelvis on the significant findings. thigh depending upon which segment is fixed) and Plain film radiographs are suggested for the following extension of the leg at the knee individuals with an acute knee injury: Synergists: For hip flexion: iliopsoas, pectineus, sartorius, • older than 55 years • if experiencing tenderness over the fibular head gracilis, tensor fasciae latae and (sometimes) adductors • reporting discomfort confined to the patella upon palpation brevis, longus and magnus • if unable to flex the knee to 900 • if incapable of bearing weight, immediately and for at least For knee extension: vastus medialis, vastus lateralis and four steps. vastus intermedius Although plain radiography is not very helpful in diagnosis of Antagonists: To hip flexion: gluteus maximus, the ham­ soft issue injuries, certain findings are suggestive of ligamentous, meniscal or tendon damage. Crucially, however, a string group and adductor magnus 450 flexion, weight-bearing radiograph can show joint space loss and point to early osteoarthritic changes. To knee extension: biceps femoris, semimembranosus, CT scans offer effective imaging to corroborate the presence semitendinosus, gastrocnemius, popliteus, gracilis and of knee fractures. Ultrasound assessment may be able to help sartorius in differentiation of a Baker's cyst, popliteal artery aneurysm and thrombophlebitis. Vastus lateralis (Fig. 1 3.32) MRI is currently the method of choice for evaluating soft Attachments: From the anterior and lower surfaces of the tissue injuries of the knee, especially if surgery is greater trochanter, intertrochanteric line of femur, contemplated. gluteal tuberosity, lateral intermuscular septum and lateral lip of linea aspera to insert into the lateral Many of these also serve as rotators of the tibia, details of border of the patella and continue distal to the patella which are discussed with each muscle. (as the patellar ligament) to attach to the tibial tuberosity. Some fibers merge into the lateral patellar Also involved in functional knee movement is the retinaculum articularis genus muscle, which attaches to the supra­ patellar bursa and serves to retract it and avoid entrap­ ment of the capsule when the knee is extending. The iliotibial band crosses the knee joint laterally and serves to stabilize the extended knee. Since its contributing muscles produce no apparent knee movements, it is discussed on p. 357 and p. 421 with its contributing muscles. Its anatomical attachments at the knee region

THE KNEE 483 Greater trochanter of femur Rectus femoris (cut end) Lesser trochanter of femur Vastus Figure 1 3.32 The trigger points of vastus lateralis are extensive and have numerous target zones of referral (adapted with permission from lateralis --t-- Travell & Simons 1 992). ---; Vastus medialis Innervation: Femoral nerve (L2-4) Muscle type: Phasic, prone to weakening under stress Vastus Function: Extends the leg at the knee and draws the intermedius --\\--+ patella laterally Synergists: For knee extension: rectus femoris, vastus medialis and vastus intermedius Antagonists: To knee extension: biceps femoris, semi­ membranosus, semitendinosus, gastrocnemius, popliteus, gracilis and sartorius Rectus femoris Vastus medialis (Fig. 1 3.33) tendon (cut end) Lateral patellar -\"'\"-� Patella Attachments: From the entire length of the postero­ retinaculum ---,.;:t -+-- Medial patellar medial aspect of the shaft of the femur, medial inter­ retinaculum muscular septum, medial lip of linea aspera, upper Patellar ligament --'+-' -+-+ part of medial supracondylar line, lower half of the +-!-i'T bial tuberosity intertrochanteric line and the tendons of adductors magnus and longus and to merge with the tendons of rectus femoris and vastus intermedius to attach to the medial border of the patella and continue distal to the patella (as the patellar ligament) to attach to the tibial -i--Tibia tuberosity. Some fibers fmibeerrgsewinhticohtahreemmeodsitaol bplaiqteu'lelalyr retinaculum. The distal Figure 1 3.31 The rectus femoris has been removed to expose vastus intermedius which lies deep to it (adapted from Travell & Simons 1 992). oriented are called the vastus medialis oblique Innervation: Femoral nerve (L2-4) Muscle type: Phasic, prone to weakening under stress Function: Extension of the leg at the knee

484 CLINICAL APPLICATION OF NMT VOLUME 2 continue distal to the patella (as the patellar ligament) to attach to the tibial tuberosity. This muscle lies deep to rectus femoris and a portion lies deep to vastus lateralis into which some of its fibers merge Innervation: Femoral nerve (L2-4) Muscle type: Phasic, prone to weakening under stress Function: Extension of the leg at the knee Synergists: For knee extension: rectus femoris, vastus lateralis and vastus medialis Antagonists: To knee extension: biceps femoris, semimem­ branosus, semitendinosus, gastrocnemius, popliteus, gracilis and sartorius Figure 1 3.33 Two common trigger points of vastus medialis include Articularis genus common target zones of referral into the medial knee region (adapted with permission from Travell & Simons 1 992). Attachments: From the anterior surface of the shaft of the femur just distal to the end of the vastus intermedius to Synergists: For knee extension: rectus femoris, vastus attach to the suprapatellar bursa lateralis and vastus intermedius Innervation: Not established Muscle type: Not established Antagonists: To knee extension: biceps femoris, semimem­ Function: Retracts the suprapatellar bursa and joint cap­ branosus, semitendinosus, gastrocnemius, popliteus, sule of the knee to protect it from entrapment during gracilis and sartorius extension Synergists: None Vastus intermedius (Fig. 1 3.34) Antagonists: Flexion movement of the knee joint Attachments: From the anterior and lateral surface of the Indications for treatment of quadriceps group femur to insert into the upper border of the patella and • Lower anterior thigh or anterior knee pain • Pain deep in the knee joint • Buckling knee syndrome • Weakness of knee extension • Patellar imbalance or 'stuck' patella • Disturbed sleep due to knee or thigh pain • Difficulty going downstairs (rectus femoris) or upstairs (vastus intermedius) Figure 1 3.34 The trigger points of vastus intermedius lie within its Special notes common target zone of referral which spreads over the anterior thigh. This trigger point is difficult to locate as it lies deep to the rectus Besides the obvious tasks of extending the knee when the femoris (adapted with permission from Travell & Simons 1 992). foot is free to move (as in kicking a ball) and flexing the hip (rectus femoris only), the quadriceps group also plays a role in controlling knee flexion (lengthening contrac­ tions), in straightening the leg during gaiting and stair climbing and by influencing tracking of the patella (especially vasti medialis and lateralis). Kapandji (1987) notes that: The medialis is more powerful and extends more distally than the lateralis and its relative predominance is meant to check lateral dislocation of the patella. The normally balanced contraction of these vasti produce a resultant upward force along the long axis of the thigh, but, if there is imbalance of these muscles, e.g. if the vastus lateralis predominates over a deficient medialis, the patella 'escapes' laterally. This is one of

THE KNEE 485 the mechanisms responsible for recurrent d islocation of the Figure 1 3.35 The trigger points of rectus femoris include the lower patella, which always occurs laterally. Conversely, it is possible thigh and anterior knee (adapted with permission from Travell & to correct this lesion by selectively strengthening the vastus Simons 1 992). medialis. ment for shortness as well as NMT and MET of rectus While most clinicians look to the dysfunctional influences femoris is discussed in Chapter 1 2 on p. 411 while tests the quadriceps muscles can have on patellar function, and for the vasti are listed below. resultant injury to its posterior surface, it is also im­ Test for weakness of the vasti muscles (Fig. 1 3.36) portant to understand the influences which the patella The vasti are phasic muscles with a tendency to has on the muscles themselves. Levangie & Norkin (2001) weakening when chronically stressed. observe: • The patient sits on the edge of the treatment table, Mechanically, the efficiency of the quadriceps muscle is legs hanging freely. affected by the patella; the patella lengthens the moment arm (MA) of the quad riceps by i.ncreasing the distance of the • In sitting, with the hip in flexion, rectus femoris is quadriceps tendon and the patellar ligament from the axis of partially deactivated. Therefore, for evaluation of the vasti, the knee joint. The patella, as an anatomic pulley, deflects the action line of the quadriceps femoris away from the joint, Figure 1 3.36 Testing the quadriceps while stabilizing the thigh increasing the angle of pull and the ability of the muscle to posteriorly, to prevent pressure on rectus femoris (adapted from Janda generate a flexion torque. . . . Regardless of joint (1 983» . position. . .substantial decreases in the strength (torque) of the quadriceps of up to 49% have been found following removal of the patella because the MA of the quadriceps is substantially reduced at most points in the ROM . The role o f these muscles i n gaiting occurs primarily at heel strike (presumably to control flexion) and: at toe-off to stabilize the knee in extension. Surprisingly, the quadriceps were found to be silent during the early phase of knee extension during the swing phase. Thus, extension of the leg at the knee probably occurs as the result of passive swing (Travell & Simons 1992). Increased speed of walking increases activity, as does the wearing of high heels. The most common trigger point in rectus femoris lies near the pelvic attachment and refers pain in and around the patella and deep into the knee joint. Additionally, particularly at night, it refers a severe, deep aching pain over the thigh above the anterior knee (Travell & Simons 1992) (Fig. 13.35). Since this target zone lies a significant distance from the location of its associated trigger point, it can easily be overlooked as a source of knee pain. Addi­ tional trigger points in rectus femoris which lie near the knee may be a source of deep knee pain. Trigger points in vastus intermedius spread across the anterior thigh (see Fig. 13.34), in vastus medialis refer primarily to the medial knee (see Fig. 1 3.33) and in vastus lateralis make signifi­ cant contributions to pain on the lateral hip, entire length of thigh and into the lateral and posterior knee (see Fig. 1 3.32) (Travell & Simons 1 992) . As noted by Greenman (1 996) i n Chapter 12, where assessment and treatment of shortness of the rectus femoris muscle are detailed, when rectus femoris is dys­ functional it becomes 'facilitated, short and tight [whilel the other three components of the quadriceps group . . . [the vastil . . . when dysfunctional, become weak'. Specific treatment of these muscles is called for if any portion of the muscle has shortened or if they test as weak. Assess-

486 CLIN ICAL APPLICATION OF NMT VOLUME 2 with relatively reduced rectus involvement, the seated medialis course in the opposite direction (upward and position is ideal. If the quadriceps as a whole are to be away from the mid-line of the thigh) (see Fig. 13.31). tested, the patient should be supine with hip in neutral Specific taut fibers which may be associated with trigger position and the leg hanging freely over the end of the points in the muscles may be more distinctly felt by table, so that rectus can operate at full strength. gliding transversely across the fibers. Once located and the center of the band isolated, examination may reveal a • The practitioner places one hand onto the distal thigh, dense nodular region associated with a central trigger holding it to the table (to prevent thigh rotation and sub­ point. Static compression of a dense nodule may stitution of other muscles), and the other hand on the reproduce a referral pattern, indicating the presence of a distal tibia, just proximal to the malleoli, as the patient trigger point, which can be treated by applying isolated attempts to extend the knee against the resistance of the compression. (See Chapters 1 and 9 as well as Volume 1 , practitioner. Chapter 6 for more specific details regarding trigger points.) • If rectus is also being assessed, the knee should be stabilized by a hand holding the posterior thigh to prevent On the most medial aspect of this region, separating undue pressure onto rectus femoris (Fig. 1 3.36). the quadriceps group from the adductor group and represented by a line running from the medial knee to the • The relative strength of each leg is tested. ASIS, will be found the belly of sartorius. Sartorius is a • Weakness of the vasti should be readily apparent. knee flexor and is discussed later in this section, but its • Lateral rotation of the tibia activates primarily belly is easily treated at this time with the quadriceps medialis, medial rotation activates lateralis, although full group. It may be more easily reached with the knee extension movements should be avoided to prevent auto­ flexed and the leg resting against the practitioner (see matic rotation of the tibia at full extension. It is valuable Fig. 11 .47). to test the medial and lateral vasti separately due to their antagonistic relationship at the patella. If medialis is weak CAUTION: The following step should not be performed and lateralis is strong, the patella will track laterally, leading to patellofemoral articular dysfunction, possibly if the knee shows evidence of inflammation, swelling including patellar dislocation. or severe capsular damage, which might be aggravated N MT for quadriceps group by the application of fridion. The patient is supine with the leg extended and with the knee supported on a small cushion. The practitioner Any bolster or knee support is now removed and the leg stands at the level of the knee and faces the patient's allowed to lie fully extended on the table. Free patellar head. The practitioner's thumbs, palm or forearm may be movement is checked in all directions (proximally, used to apply lubricated repetitious gliding strokes from d istally, medially, la terally, rotating clockwise and the patella toward the AIlS to treat the bellies of vastus counterclockwise). The patella is then stabilized by lateralis, rectus femoris and vastus medialis. At the most the practitioner 's caudad hand while the thumb of the lateral aspect of the anterior thigh (just anterior to the cephalad hand is used to examine all attachments on the iliotibial band), the fibers of vastus lateralis will be proximal surface of the patella. If not excessively tender, encountered . Although some of its fibers are located deep medial to lateral friction can be applied to the quadriceps to the IT band and continue posterior to the band, these tendon and retinacular attachments surrounding the are not easily treated in a supine position and are best patella (Fig. 1 3.37). A similar technique can be applied to addressed with the patient sidelying (see p. 422). As the the distal end of the patella and the tibial attachment of thumbs (palm or forearm) are moved medially, another the patellar ligament, by switching the supporting and portion of vastus lateralis will be addressed. The gliding treatment hands. strokes are repeated 8-1 0 times before the hands are moved again medially to encounter the rectus femoris. The patella can also be displaced laterally and the prac­ Deeper pressure, if appropriate, can be applied through titioner's fingers hooked under the lateral aspect of the the rectus femoris to address the underlying vastus patella to examine for tenderness. This can be repeated intermedius. for the medial aspect (Fig. 1 3.38). The gliding strokes are repeated, continuing to move I Positional release for rectus femoris medially until all the quadriceps group has been treated. As the gliding thumbs examine the superficial bipennate • A number of tender points are located superior to fibers of rectus femoris, fiber direction may be dis­ and on the periphery of the patella (Fig. 1 3.39). tinguished as coursing diagonally and upward toward the mid-line of the muscle while the vastus lateralis and • The tender point relating to rectus femoris is found directly superior to the mid-point of the patella where the muscle narrows to form its patellar attachment.

THE KNEE 487 Figure 1 3.37 Tissues attaching to the patella should be non-tender and have an elastic quality (as opposed to fibrous or rigid). Figure 1 3.39 Positional release of the tender point relating to rectus femoris, which lies directly superior to the patella. • Additional fine tuning to reduce the tenderness further is accomplished by introduction of rotation of the patella, clockwise or anticlockwise, whichever reduces the reported tenderness in the palpated point most. • When the pain 'score' has dropped from ' 1 0' to '3' or less, the position of ease is held for at least 90 seconds, before slowly releasing the appljed pressure. Figure 1 3.38 The patel la on a fully extended leg should easily FLEXORS OF THE KNEE displace medially and laterally. The practitioner's fingers can be hooked under the edges of the patella to check for tenderness. Seven muscles serve t o flex the knee, with all o f them crossing two joints except popliteus and the short head of • The supine patient's leg is flat on the table or flexed biceps. The total force produced by the flexors is about at the hip and supported by the practitioner 's thigh one-third that produced by the quadriceps (Kapandji with the practitioner's knee flexed and her foot 1 987). The strength and efficiency of the biarticular muscles supported on the table. The patient's knee must be in are affected by the position of the hip, while the mono­ extension, whichever leg position is chosen. articular components are not. Some of these muscles also influence rotation of the tibia on the fixed femur: medial • The practitioner isolates and applies pressure to the tibial rotation is produced by popliteus, gracilis, semi­ tender point with one hand and with the other cups membranosus and semitendinosus while lateral rotation the patella and eases it cephalad until there is a is produced by biceps femoris only. reported reduction in tenderness in the palpated point. Details and treatment of the bellies and proximal attach­ ments of most of these muscles are discussed elsewhere

488 CLI NICAL APPLICATION OF NMT VOLUME 2 (as noted with each muscle) while their influences on the For flexion of the knee: hamstring group knee as well as treatment of the knee attachments are For medial rotation of the leg at the knee: semimem­ covered here. Gastrocnemius is a significant stabilizer of the knee and powerful extensor of the ankle but it '. . . is branosus, semitendinosus, popliteus and (sometimes) practically useless as a knee flexor.. .' (Kapandji 1 987) . sartorius While some details are d iscussed here, gastrocnemius is more fully addressed with the ankle and foot complex in Antagonists: To thigh adduction: the glutei and tensor Chapter 14, p. 531 , as the superficial layer of the posterior leg. fasciae latae Sartorius (see Fig. 1 0.62) To flexion of the knee: quadriceps femoris To medial rotation of the leg at the knee: biceps femoris Attachments: ASIS to the medial proximal anterior tibia just below the condyle (as one of the pes anserinus Sartorius, the longest muscle in the body, is primarily muscles) involved in hip movements, producing flexion, abduc­ tion and lateral rotation of the hip. At the knee, it serves Innervation: Femoral nerve (L2-3) as a medial stabilizer against valgus forces and has Muscle type: Phasic (type 2), prone to weakness and influences on medial rotation of the tibia and usually knee flexion, although occasionally, due to variations in lengthening if chronically stressed its tibial attachment, it can sometimes produce extension Function: Flexes the hip joint and knee during gaiting; instead (Levangie & Norkin 2001). It is most important when the hip and knee are simultaneously flexed, as in flexes, abducts and laterally rotates the femur stair climbing. Its action at the knee is not affected by hip position because tendinous inscriptions traverse it in Synergists: For hip flexion during gaiting: iliacus and several locations and allow its distal parts to act independently of its proximal portions. 'It appears to be tensor fasciae latae relatively impervious to active insufficiency' (Levangie & Norkin 200 1 ) . This configuration also allows for an For knee flexion during gaiting: biceps femoris exceptional distribution of myoneural junctions resulting For thigh flexion : iliopsoas, pectineus, rectus femoris in relatively scattered trigger point formation potential throughout the sartorius belly. Its trigger point referral and tensor fasciae latae pattern primarily runs along the course of the muscle. For thigh abductio n : gluteus medius and minimus, Proximally, the sartorius has been noted to cause entrapment of the lateral femoral cutaneous nerve, which tensor fasciae latae and piriformis can affect sensory d istribution on the lateral thigh. At mid-thigh, sartorius lies directly over the femoral neuro­ For lateral rotation of the thigh: long head of biceps vascular structures and converts this area into a 'channel' (Hunter's canal), with sartorius being the 'ceiling' of this femoris, the deep six hip rotators, gluteus maximus, passageway for the femoral vessels and saphenous nerve. iliopsoas and posterior fibers of gluteus medius and This passage ends at the adductor hiatus as the vessels minimus course through the adductor magnus to the posterior thigh. Antagonists: To thigh flexion : gluteus maximus and ham­ Distally, sartorius is one of three muscles (with gracilis string group and semitendinosus) which form the 'pes anserinus superficialis', a merging of these three tendons at the To thigh abduction: adductor group and gracilis medial proximal tibia. This region is often tender and is To lateral rotation : tensor fasciae latae specifically addressed below with gracilis, while other portions of this muscle are treated with the adductor Indications for treatment muscle group on p. 354 and with rectus femoris on p. 414. • Superficial sharp or tingling pain on anterior thigh Gracilis produces hip flexion and adduction while its • Meralgia paresthetica (entrapment of lateral femoral influences at the knee, like sartorius, include stabilization of the medial knee against valgus forces, knee flexion and cutaneous nerve) medial rotation of the tibia. It easily becomes actively insufficient, 'ceasing activity if the hip and knee are Gracilis (see Fig. 10.62) permitted to flex simultaneously' (Levangie & Norkin 200 1 ) . Attachments: From near the symphysis on the inferior ramus of the pubis to the medial proximal tibia (pes Gracilis is separated from the medial collateral anserinus superficialis) ligament by the tibial intertendinous bursa. It attaches to Innervation: Obturator nerve (L2-3) Muscle type: Phasic (type 2), with tendency to weaken and lengthen if chronically stressed Function: Adducts the thigh, flexes the knee when knee is straight, medially rotates the leg at the knee Synergists: For thigh adduction : primarily adductor group and pectineus

THE KNEE 489 the tibia just anterior to the semitendinosus, while the upper edge of its tendon is overlapped by the sartorius tendon, making it the middle of the three pes anserine ('goose's foot') attaclunents. Gracilis trigger points produce a 'local, hot, stinging (not prickling), superficial pain that travels up and down along the inside of the thigh' (Travell & Simons 1 992). Sartorius and gracilis, along with semitendinosus (a hamstring muscle), together form a common tendon, the ptiebsia.aTnsheer' ainnuses,rinwehbicuhrsaatltiaecshdeeseptotothtehemcoemdimalopnrtoexnidmoanl attachment. N MT for medial knee region Figure 1 3.40 The treating hand is continuously pulled proximally to the mid-thigh region, while its direction of travel can vary along the The patient is supine with the hip and knee flexed to 90° paths of the three muscles contributing to the pes anserinus. and supported by the practitioner. The practitioner stands beside the table just below the level of the flexed posterior thigh). This pulling, gliding stroke is repeated knee and faces the tibial shaft. She could sit on the table on each muscle portion several times before moving onto distal to the flexed leg if comfortable. the next muscle. The medial proximal tibia is located, which is approxi­ Biceps femoris (see Fig. 1 2.36) mately 1-2 inches (2.5-5 cm) medial to the tibial tuberosity. As the practitioner's thumb is slid directly cephalad across Attachments: Long head: from the ischial tuberosity and this region, the diagonally oriented pes anserinus tendon can usually be felt or else the patient will report the sacrotuberous ligament to the lateral aspects of the tenderness which is usually associated with the tendons. head of the fibula and tibia Sometimes all three tendons may be distinguished and at other times, they will feel like one solitary mass, some­ Short head: from the lateral lip of the linea aspera, times thick or 'puffy' . This region is often tender and application of lightly lubricated gliding strokes, mild supracondylar line of the femur and the lateral friction or increased pressure is applied only if appro­ intermuscular septum to merge with the tendon of the priate, always maintaining consideration of the patient's long head and attach to the lateral aspects of the head discomfort level and the possibility of inflammation of of the fibula and tibia the tendons. Innervation: Sciatic nerve (L5-S2) Muscle type: Postural (type 1 ), with tendency to shorten Once the tendons have been located and gently treated, when chronically stressed the practitioner turns to face the caudad end of the table and moves to the mid-thigh region. Her tableside hand is Function: Long head: extends, laterally rotates and used to perform the next step while the other hand is used to stabilize the lateral aspect of the flexed knee to adducts the thigh at the hip, posteriorly rotates the prevent any degree of hip rotation or abduction of the pelvis on the hip, flexes and laterally rotates the lower thigh. leg at the knee The finger's of the practitioner's treating hand are curved Short head: flexes the knee and laterally rotates the leg to form a C-shape and placed onto the pes anserinus attachment. As the hand is pulled proximally, the fingers at the knee simultaneously press into the tendon and, eventually, after passing the knee joint region and reaching the femur, Synergists: For thigh extension: gluteus maximus, semi­ rotate to become a broadly placed stroke (Fig. 13.40), while sinking into the muscles with a more penetrating membranosus, semitendinosus, adductor magnus pressure (if tolerable). The treating hand is continuously (inferior fibers) and posterior fibers of gluteus medius pulled proximally to the mid-thigh region, while its path and minimus of treatment can vary slightly to first address distal portions of the sartorius (diagonally oriented across the For lateral rotation of the thigh: gluteus maximus, the thigh), then repeated for gracilis (up the inner line of the thigh) and finally semitendinosus (on the medial deep six hip rotators (especially piriformis), sartorius,

490 CLINICAL APPLICATION OF NMT VOLUME 2 posterior fibers of gluteus medius and minimus and To adductio n : gluteal group, tensor fasciae latae, (maybe weakly) iliopsoas sartorius, piriformis and (maybe weakly) iliopsoas For adduction: remaining true hamstrings, adductors To posterior pelvic rotation: rectus femoris, TFL, anterior brevis, longus and magnus, pectineus, portions of gluteus maximus and gracilis fibers of gluteus medius and minimus, iliacus, sartorius For posterior pelvic rotatio n : remaining hamstrings, To knee flexion : quadriceps group adductor magnus, abdominal muscles Semimembranosus For knee flexio n : remaining hamstrings, sartorius, Attachments: From the ischial tuberosity to the posterior gracilis, gastrocnemius and plantaris surface of the medial condyle of the tibia Antagonists: To hip extension : mainly iliopsoas and rectus Innervation: Sciatic nerve (LS-S2) Muscle type: Postural (type 1), with tendency to shorten femoris and also pectineus, adductors brevis and longus, sartorius, gracilis, tensor fasciae latae when chronically stressed Function: Extends, medially rotates and adducts the thigh To lateral rotation of the h ip: mainly adductors and also at the hip, posteriorly rotates the pelvis on the hip, semitendinosus, semimembranosus, iliopsoas, pectineus, flexes and medially rotates the leg at the knee the most anterior fibers of gluteus minimus and medius and tensor fasciae latae Synergists: For hip extension : gluteus maximus, semi­ To adductio n : glu teal group, tensor fasciae la tae, tendinosus, biceps femoris, adductor magnus and posterior fibers of gluteus medius and minimus sartorius, piriformis and (maybe weakly) iliopsoas For medial rotation of the thigh: semitendinosus, the most To posterior pelvic rotation: rectus femoris, TFL, anterior anterior fibers of gluteus medius and minimus, tensor fibers of gluteus medius and minimus, iliacus, sartorius fasciae latae and (perhaps) some adductors To knee flexion : quadriceps group For adduction: remaining true hamstrings, adductor Semitendinosus group and portions of gluteus maximus Attachments: From a common tendon with biceps For posterior pelvic rotation: remaining true hamstrings, femoris on the ischial tuberosity to curve around the posteromedial tibial condyle and attach to the medial adductor magnus, abdominal muscles proximal anterior tibia as part of the pes anserinus For knee flexion: remaining hamstrings including short Innervation: Sciatic nerve ( LS-S2) Muscle type: Postural (type 1 ), with tendency to shorten head of biceps femoris, sartorius, gracilis, gastrocnemius and plantaris when chronically stressed Function: Extends, medially rotates and adducts the thigh Antagonists: To hip extensio n: mainly iliopsoas and rectus at the hip, posteriorly rotates the pelvis on the hip, femoris and also pectineus, adductors brevis and longus, flexes and medially rotates the leg at the knee sartorius, gracilis, tensor fasciae latae Synergists: For h ip extensio n : gluteus maximus, semi­ To medial rotation: long head of biceps femoris, the deep membranosus, biceps femoris, adductor magnus and six hip rotators, gluteus maximus, sartorius, posterior posterior fibers of gluteus medius and minimus fibers of gluteus medius and minimus and psoas major For medial rotation of the thigh : semimembranosus, the To adductio n : gluteal group, tensor fasciae latae, most anterior fibers of gluteus medius and minimus, sartorius, piriformis and (maybe weakly) iliopsoas tensor fasciae latae, and (perhaps) some adductors To posterior pelvic rotation: rectus femoris, TFL, anterior For hip adduction: remaining true hamstrings, adductor fibers of gluteus medius and minimus, iliacus, sartorius group and portions of gluteus maximus To knee flexion : quadriceps group For posterior pelvic rotation: remaining true hamstrings, Indications for treatment of hamstring group adductor magnus, abdominal muscles • Posterior thigh or knee pain For knee flexion : remaining hamstrings including short • Pain or limping when walking • Pain in buttocks, upper thigh or knee when sitting head of biceps femoris, sartorius, gracilis, gastrocnemius • Disturbed or non-restful sleep due to posterior thigh and plantaris pain Antagonists: To hip extensio n: mainly iliopsoas and rectus • Sciatica or pseudo-sciatica • Forward head or other postures forward of normal femoris and also pectineus, adductors brevis and longus, sartorius, gracilis, tensor fasciae latae coronal alignment • Inability to fully extend the knee, especially when the To medial rotation of the thigh: long head of biceps thigh is in neutral position femoris, the deep six hip rotators, gluteus maximus, • 'Growing pains' in children sartorius, posterior fibers of gluteus medius and minimus and psoas major

THE KNEE 491 • Pelvic distortions and SI joint dysfunction partial dislocation of the tibia backwards, with slight lateral • Tendinitis or bursitis at any of the hamstring rotation, probably due to biceps femoris. attachment sites Contractures have been associated with trigger point for­ • Inability to achieve 90° straight leg raise mation in muscles which, in the case of the hamstrings, are primarily located in the lower half of the muscles. Except for the short head of biceps femoris, all ham­ (Fig. 1 3.41 ) . Travell & Simons (1 992) describe the trigger strings muscles arise from the ischial tuberosity and point target zone of referral for the medial hamstrings attach below the knee. They are therefore two-joint as including the ischial region, medial aspect of the muscles, making their influence on knee flexion to some posterior thigh and upper medial posterior calf, while degree determined by the position of the hip. They work trigger points in the biceps femoris refer to the postero­ most efficiently at the knee if the hip is simultaneously lateral thigh, posterior knee region and sometimes into flexed. While all hamstrings are synergists for knee flexion, the calf. the biceps femoris is the only lateral rotator of the tibia while semimembranosus and semitendinosus antagonize NMT, MET and other soft tissue manipulation this movement with medial rotation. methods for assessing and treating the hamstring group are described in Chapter 12 on p. 432. Additionally, a Biceps femoris short head is a single-joint muscle which portion of the hamstring structures may be reached on provides lateral rotation of the tibia and is substantially the inner aspect of the thigh when the pa tient is influential on knee flexion, regardless of hip position. sidelying, as described on p. 420. On the medial aspect of the posterior thigh, semi­ P RT for treatment of biceps femoris tendinosus overlies the deeper semimembranosus, with the bulk of fibers of the superficial muscle lying proxi­ • The tender point for biceps femoris is fou nd on the mally and the bulk of deeper muscle lying distally. Semi­ tendinous attachment, on the posterolateral surface of tendinosus, named for its lengthy distal tendon, is nor­ the head of the fibula. mally divided by a tendinous inscription which separates it into two segments, each having distinctly separate • The tender point is located and compressed to endplate bands (Travell & Simons 1 992). produce a pain score of '10'. Semimembranosus, though usually independent of the • The patient i s supine, affected leg off the edge of the overlying muscle, may be completely fused with it, may table so that the thigh is extended and slightly be double in size or may even be absent (Platzer 1 992) . abducted, with the knee flexed. The tendon of semimembranosus divides into several parts which course to the posteromedial surface of the • Adduction or abduction, as well as external or medial condyle of the tibia, to the medial margin of the internal rotation of the tibia, is introduced for fine tibia, to the fascia of the popliteus and to the posterior tuning, to reduce reported sensitivity in the palpated wall of the capsule as the oblique popliteal ligaments. It tender point by at least 70% . also has a fibrous attachment to the medial meniscus which, during knee flexion, pulls the medial meniscus • This position is held for not less than 9 0 seconds posteriorly (Levangie & Norkin 2001). The significance of before slowly returning the leg to the neutral start this function is discussed with popliteus below. position. The two heads of biceps femoris course along the \" P RT for semimembranosus lateral aspect of the thigh and unite into a common ten­ don which separates into several slips. The main part is • The tender point for semimembranosus is found on attached to the head of the fibula, while other portions the tibia's posteromedial surface on its tendinous fuse with the lateral collateral ligament or a ttach to the attachment. lateral condyle of the tibia. It may also attach to the IT band and to the lateral joint capsule via retinacular fibers, • The tender point is located and compressed to implying it may play a role in lateral stabilization of the produce a pain score of '10'. knee (Levangie & Norkin 200 1 ) . Coursing near it is the peroneal nerve which lies exposed across the posterior • The patient is supine, affected leg off the edge of the aspect of the head of the fibula. Caution should be table so that thigh is extended and slightly abducted, exercised when palpating the biceps femoris tendon to with the knee flexed. avoid traumatizing the nerve. • Internal rotation of the tibia is applied for fine tuning Gray's anatomy (1 995) notes: to reduce reported sensitivity in the tender point by at least 70%. In disease of the knee joint, contracture of the flexor tendons is a frequent complication; this causes flexion of the leg, and a • This position is held for not less than 90 seconds before slowly returning the leg to the neutral start position.

492 CLINICAL APPLICATION OF NMT VOLUME 2 -tI-'-I-f1 Semitendinosus Biceps femoris IH-'-!If- Semimembranosus (both heads) A Figure 1 3.41 Trigger points in hamstring muscles usually occur in the lower half of the muscles and are often perpetuated by compression on the muscles from ill-fitting chairs (adapted with permission from Travell & Simons 1 992). Popliteus (Fig. 1 3.42, 1 3.43) collateral ligament and the tendon of biceps femoris. An additional head may arise from a sesamoid in Attachments: From the lateral condyle of the femur, capsule of the knee joint, lateral meniscus and head of gastrocnemius' lateral head (Gray's anatomy 1 995). The the fibula via the arcuate ligament to attach to the upper medial aspect of the posterior tibia proximal to popliteus bursa, which is usually an extension of the the soleal line synovial membrane, separates it from the lateral femoral condyle. Innervation: Tibial nerve (L4-S1 ) Muscle type: not established Popliteus rotates the tibia medially in an open chain Function: Medially rotates the tibia (or laterally rotates movement or rotates the femur laterally when the tibia is fixed. It serves to 'unlock' the fully extended knee at the femur, when the tibia is fixed) during flexion initiation of flexion; however, knee flexion can occur Synergists: Medial hamstrings, sartorius and gracilis passively without the muscle's involvement. Its meniscal Antagonists: Biceps femoris attachment has significance, as explained by Levangie & Norkin (2001). Indications for treatment The popliteus muscle is commonly attached to the lateral • Pain in the back of the knee when walking, running meniscus as the semimembranosus muscle is to the medial or crouching meniscus. Because both the semimembranosus and the popliteus are knee flexors, activity in these muscles will not • Weakness in medial rotation of the lower leg only generate a flexion torque but will actively contribute to • Loss of range of motion at the knee the posterior movement of the two menisci on the tibial condyles that should occur during knee flexion as the femur Special notes begins its rolling motion. The ability of the menisci to distort during motion ensures that the slippery surface is present Popliteus courses diagonally across the posterior upper throughout the femoral ROM. tibia and a portion of the joint capsule to lie as the deepest muscle of the posterior knee region. Its tendon The posterior movement of the menisci by these muscles pierces the joint capsule but does not enter the synovium helps decrease the chance of meniscal entrapment and and is crossed by the arcuate ligament, the lateral the resultant limitation of knee flexion which would occur. Travell & Simons (1 992) also note that the popliteus prevents forward displacement of the femur on the tibial

THE KNEE 493 +-+-- Femur Femur Oblique popliteal Fibular collateral Rectus femoris tendon ligament ligament ---t+ Popliteus muscle Patella -�,.- Lateral patellar r e t i n ac u l u m Patellar ligament Fibular collateral Fibula Tibia l igament �-+-+ Arcuate popliteal ligament ---+,' Popliteus muscle Figure 1 3.43 Right popliteus muscle shown from a lateral view (adapted with permission from Travell & Simons 1 992). Fibula neurovascular tissues which course through the popliteal fossa. Only a portion of the popliteus can be safely palpated due to the neurovascular structures which overlie it. The attachment on the tibial shaft can usually be reached as well as the tendon at the femoral condyle. Since trigger points may be more centrally located, spray-and-stretch techniques, as described by Travell & Simons (1 992, p. 347), may be the best choice for treatment if manual treatment of the palpable portions of the muscle fails to relieve the referral pattern. Figure 1 3.42 Right popliteus muscle shown passing deep to the N MT for popliteus arcuate popliteal ligament and lateral collateral ligament (adapted with permission from Travell & Simons 1 992). • The patient is prone with the knee passively flexed and supported by the practitioner as she stands plateau. 'Its contraction specifically prevents the lateral beside the table just below knee level and faces the femoral condyle from rotating forward off the lateral tibial patient's head. plateau.' Their described trigger point referral pattern for popliteus is primarily into the back of the knee. • Her tableside arm cradles the leg so that the foot lies across her biceps brachii, her fingers lie across the Enlargements of bursae in the posterior knee, which anterior surface of the tibia, her thumb lies on the are continuous with the synovial cavity, are commonly medial aspect of the upper posterior shaft of the tibia called Baker's cysts. This collection of synovial fluid about 3 inches distal to the tibial condyle (Fig. 1 3.44). which has escaped from the knee joint to form a 'cyst' in the popliteal space is often a result of knee injury or • The thumb is slid proximally along the posteromedial disease, such as a meniscal tear or rheumatoid arthritis aspect of the tibia while applying a mild to moderate (Travell & Simons 1 992) . If more conservative measures pressure to the attachment of popliteus and while fail to reduce the swelling, surgical removal may be displacing the overlying soleus laterally as much as necessary, especially when the cyst encroaches on the possible. • This tissue (which may also include soleus) often displays a surprising degree of tenderness and

494 CLIN ICAL APPLICATION OF NMT VOLUME 2 • Additional fine tuning to reduce the score to'3' or less is achieved by introducing internal (medial) rotation of the tibia. • Once the score has dropped to '3' or less the position is held for 90 seconds before a slow release and return to neutral. Figure 1 3.44 A small portion of popliteus can be palpated on the Gastrocnemius (see Fig. 14.25) proximal medial posterior shaft of the tibia. Attachments: Two heads attaching to the proximal aspect attention should be paid to the degree of discomfort of the medial and lateral femoral condyles and from the patient is experiencing. the capsule of the knee joint to course distally (merging • The gliding stroke is applied 6-8 times with mild to with the soleus, forming triceps surae) to insert onto moderate pressure, depending upon the discomfort the calcaneus as the tendo calcaneus (Achilles or calcaneal level. tendon) A lateral portion of the popliteus may be palpated Innervation: Tibial nerve (51-2) between the biceps femoris tendon and the more medially Muscle type: Postural (type 1 ), prone to shortening placed plantaris and gastrocnemius (lateral head). The attachment onto the femoral condyle may be found just under stress anterior to the lateral collateral ligament or reached just Function: Plantarflexion of the foot, contributing very posterior to the same ligament. Caution should be exercised as one nears the posterior aspect of the fibular weakly to knee flexion and more likely stabilization of head where the peroneal nerve lies relatively exposed. the knee \" f Positional release for popliteus Synergists: For plantarflexion: soleus, plantaris, peroneus Tender points for popliteus are to be found by palpation, longus and brevis, flexor hallucis longus, flexor on the posterior, medial surface of the proximal tibia and digitorum longus and tibialis posterior also on the lateral aspect of the posterior joint space of the knee. For knee flexion: hamstrings, sartorius, gracilis and • The patient lies prone with the knee flexed to 90°, (perhaps very weakly) plantaris supported by the practitioner at the heel. Antagonists: To plantarflexion: tibialis anterior, extensor • The practitioner's other hand localizes the tender point and applies anteriorly directed pressure to it, hallucis longus, extensor digitorum longus sufficient to create a discomfort which the patient grades as '10'. To knee flexion : quadriceps femoris • The practitioner applies long-axis compression Indications for treatment through the tibia (from the heel) which will usually reduce the pain 'score' . • Calf cramps (especially at night) • Intermittent claudication • Pain in the posterior knee when walking on rocky or slanted surface or when climbing a steep slope Special notes The gastrocnemius is an excellent plantarflexor and has very little influence over knee joint movements. It plays more of a role at the knee as a dynamic stabilizer, apparently preventing hyperextension (Levangie & Norkin 2001). Because its contribution is almost exclusively to plantarflexion and because it is accompanied both in location and in function by the plantaris muscle, both are discussed and treated with the foot and ankle on p. 531 .

THE KNEE 495 REFERENCES Johansson E, Aparisi T 1 982 Congenital absence of the cruciate ligament. Clinical Orthopaedics 1 62 : 1 08 Alt W, Lohrer H, Gollhofer A 1 995 Functional properties of adhesive ankle taping: neuromuscular and mechanical effects before and after Kaltenborn F 1985 Mobilization of the extremity jOints. Olaf Novlis exercise. Foot and Ankle International 20(4):238-245 Bokhandel, Oslo Bach B R, Bush-Joseph C 1 992 The surgical approach to lateral Kapandji I 1 987 The physiology of the joints, vol. 2, lower limb, 5th meniscal repair. Arthroscopy 8:269-273 edn. Churchill Livingstone, Edinburgh Bae D et al 1998 The cJinical significance of the complete type of Kibler B 1 998 The role of the scapula in athletic shoulder function. suprapatellar membrane. Arthroscopy 1 4 :830 American Journal of Sports Medicine 26(2):325-337 Baquie P, Brukner P 1 997 Injuries presented to an Australian Sports Kneeshaw D 2002 Shoulder taping in the clinical setting. 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496 CLINICAL APPLICATION OF NMT VOLUME 2 Petty N, Moore A 1 998 Neuromusculoskeletal examination and Schiowitz S 1 991 The lower extremity. I n : DiGiovanna E, Schiowitz S assessment. Churchill Livingstone, Edinburgh (eds) An osteopathic approach to diagnosis and treatment. Lippincott, Philadelphia Platzer W 1 992 Color atlas and textbook of human anatomy, volume 1 . Thieme, New York Small N C 1 992 Complications in arthroscopic surgery. In: Aichroth P Powers C, Landel R, Sosnick T et al 1 997 The effects of patellar taping M, Cannon W D (eds) Knee surgery. Martin Dunitz, London on stride characteristics and joint motion in subjects with Tinetti M E, Speechley M 1 989 Prevention of falls among the elderly. patellofemoral pain. Journal of Sports Physical Therapy New England Journal of Medicine 320(16) : '1055-1059 26(6):286-291 Tinetti M E, Speechley M, Ginter S F 1 988 Risk factors for falls among Radin et al 1 984 Role of the menisci in distribution of stress in the knee. Clinical Orthopaedics 1 85:290-293 elderly persons living in the community. New England Journal of Rauschining W 1 980 Anatomy and function of the communication Medicine 3 1 9(26) : 1 701-1 707 between knee joint and popliteal bursae. Annals of the Rheumatic Tipper S 1 992 Closed chain exercises. Orthopedic and Physical Diseases 39:354-358 Therapy Clinics of North America ( 1 ) :253 Refshauge K M, Kilbreath S L, Raymond J 2000 The effect of recurrent Toghill P 1 99 1 Examining the patient: an introduction to clinical ankle inversion sprain and taping on proprioception at the ankle. medicine. Edward Arnold, London Medicine and Science in Sports and Exercise 32( 1 ) : 1 0-15 Tolo V 1 981 Congenital absence of the menisci and cruciate ligaments Robbins S 1 995 Ankle taping improves proprioception before and after of the knee. Journal of Bone and Joint Surgery 63A:'I022 exercise in young men. British Journal of Sports Medicine 29:242-247 Travel! J, Simons D 1 992 M yofascial pain and dysfunction: the trigger Sattin R 1 992 Falls among older persons: a public health perspective. point manual, vol 2: the lower extremities. Williams and Wilkins, Annual Review of Public Health 1 3:489-508 Baltimore Van Wingerden B 1 995 Connective tissue in rehabilitation. Scipro Verlag, Vaduz

CHAPTER CONTENTS The leg and foot The leg 497 The leg is composed of the tibia, fibula and the extrinsic Box 14.1 Semantics: clarifying terminology 498 muscles which operate the foot. The foot is much more The proximal tibiofibular joint 498 complex, being composed of 26 bones (seven tarsals, five Mobilization with movement (MWM) to release the fibula head 501 metatarsals and 14 phalanges), 25 component joints, and MET for releasing restricted proximal tibiofibular joint 501 is divided into three functional segments (forefoot, midfoot, hindfoot). Some of the terminology regarding The ankle joint and hindfoot 502 movements of the foot is not universally agreed upon The ankle ligaments 503 and clarifications are listed in Box 1 4. 1 . Movements of the ankle joint 504 The talocalcaneal (subtalar) joint 505 The most significant joints of foot mechanics include Ankle sprains 507 the talocrural (ankle) joint, the subtalar (talocalcaneal) Box 14.2 Rehabilitation of disequilibrium/loss of balance 509 joint, transverse tarsal (talonavicular and calcaneocuboid) Box 14.3 Complications associated with ankle sprain (and notes on joint, the metatarsophalangeal joints and the inter­ arthroscopy) 510 phalangeal joints. Additionally the compound joint, the Box 14.4 Therapeutic considerations for RSD 511 talocalcaneonavicular joint, plays an important role in directing weight-bearing forces placed on the talus above Assessment and treatment of the ankle joint and hindfoot 511 both toward the heel and into the forefoot. Functional MET treatment of dorsiflexion restriction at the talotibiofibular joint 514 integrity of the plantar vault, or arch, system of the foot MET treatment of plantarilexion restriction at the talotibiofibular joint 514 is dependent upon the integrity of each of these joints PRT treatment of medial (deltoid) ligament dysfunction 514 which are, in turn, dependent upon a functional arch PRT·treatment of anterior talofibular ligament dysfunction 515 system. MWM treatment of restricted talotibiofibular joint and for postinversion THE LEG sprain 515 MWM for eversion ankle sprains 515 The tibia, the second longest bone in the body and its Common disorders of the hindfoot 515 companion, the fibula, are vertically oriented and Calcaneal spur syndrome (and plantar fasciitis) 515 articulate at both their upper and lower ends (Figs 1 4. 1 , Epiphysitis of the calcaneus (Sever's disease) 516 1 4.2). While the fibula has n o articulation a t the knee joint Posterior Achilles tendon bursitis (Haglund's deformity) 516 itself, it does indeed have a proximal articulation with the Anterior Achilles tendon bursitis (Albert's disease) 517 tibia on the inferior surface of the tibia's lateral Achilles tendinitis and rupture 517 projection. Both bones are included in the ankle joint, Posterior tibial nerve neuralgia 517 their distal ends forming a mortise which receives the The midfoot 517 head of the talus. The two leg bones are also connected Box 14.5 Common fractures of the ankle and foot 518 through their entire length by the interosseous mem­ Talocalcaneonavicular (TCN) jOint 519 brane, a tough, fibrous sheath which strengthens the Transverse tarsal joint 521 tibiofibular syndesmosis, offers a broad surface for Tarsometatarsal (TMT) joints 523 muscular attachment and provides separation of the The arches of the foot 523 anterior and posterior compartments of the leg. Common disorders of the midfoot 523 Pes planus (flat foot) 523 The proximal tibia (described on p. 448) has (on the Box 14.6 The plantar vault 524 inferior surface of its lateral projection) a fibular facet The forefoot 526 Sesamoid bones of the lower extremity 527 497 Common disorders of the forefoot 527 Metatarsalgia 527 Morton's syndrome 527 Hallux valgus 528 Bunion 528 Calluses and corns 528 Plantar warts 528 Gout 528 Hallux rigidus 528 Functional hallux limitus (FHL) 528 Box 14.7 Assessment of functional hallux limitus (FHL) 529 Box 14.8 Diabetes and the foot 529 Neuromusculoskeletal assessment of the foot 530 Muscles of the leg and foot 530 Muscles of the leg 530 Posterior compartment of the leg 531 Gastrocnemius 531 Soleus 531 Achilles tendon 534 Plantaris 534 NMT for superiicial layer of posterior leg 535 NMT for Achilles tendon 538 MET assessment and treatment of tight gastrocnemius and soleus 538 PRT for gastrocnemius and soleus 540 Flexor hallucis longus 541 Flexor digitorum longus 541 Tibialis posterior 543 NMT for deep layer of posterior leg 544 PRT for deep layer of posterior leg 545 Lateral compartment of the leg 545 Peroneus longus 545 Peroneus brevis 546 Box 14.9 Neural impingement and neurodynamic testing 547 NMT for lateral compartment of leg 549 Anterior compartment of the leg 550 Tibialis anterior 550 Box 14.10 'Shin splints' and compartment syndromes 552 Extensor hallucis longus 552 Extensor digitorum longus 553 Peroneus tertius 553 NMT for anterior compartment of leg 554 PRT for tibialis anterior 554 PRT for extensor digitorum longus 555 Muscles of the foot 555 Dorsal foot muscles 556 Box 14.11 Movements of the toes 556 NMT for dorsal intrinsic muscles of the foot 557 Plantar foot muscles 558 Actions of the intrinsic muscles of the foot 562 NMT for the plantar intrinsic muscles of the foot 563 Goodheart's positional release protocols 565 Mulligan's MWM and compression methods for the foot 565 Box 14.12 Goodheart's PRT guidelines 566 Box 14.13 Mulligan's MWM and compression methods for the foot 566

498 CLINICAL APPLICATION OF NMT VOLUM E 2 Box 1 4.1 Semantics: clarifying terminology In considering the terminology used to describe the foot's position inversion and eversion of the foot. However, one set of terms often and movements, differences in nomenclature are commonly found relates to movement about a longitudinal axis while the other set which create confusion for most readers. The following points are defines a simultaneous triplanar movement about the longitudinal, offered to help clarify the terms adopted in this text. horizontal and vertical axis. It is not surprising that these are confused since definitive texts have no universal alignment • Standard anatomical position describes the foot divided into regarding their usage. It is most important to remember, regardless the tarsus (seven bones), metatarsus (five) and phalanges ( 1 4 + of the term employed to describe it, that the movement which turns two sesamoids) ( Gray's anatomy 1 995). However, regarding the sole of foot toward the mid-line and elevates its medial aspect functionality, the foot can be better divided into three functional (whether called supination or inversion) is a triaxial movement segments: the hindfoot (calcaneus and talus), the midfoot involving rotation about a vertical, longitudinal and horizontal axis. (navicular, cuboid and three cuneiforms) and the forefoot (five Regarding this terminology issue, Levangie & Norkin (200 1 ) metatarsals, 1 4 phalanges and two sesamoids). explain: 'Although pronation/supination and inversion/eversion are often substituted for each other, there is consensus across the • Dorsal and plantar surfaces replace the terms anterior and l iterature in using varus-valgus of the calcaneus to refer to the posterior respectively, while proximal and distal are used in their frontal plane component of subtalar motion. Regardless of how the normal manner. terms are used, it should be noted that subtalar supination is invariably linked with subtalar inversion and calcaneovarus, • 'Crural' pertains to the leg. whereas subtalar pronation is invariably linked with subtalar eversion and calcaneovalgus. . .Terms used in research and • Flexion of a joint approximates the joint surfaces so as to published literature should carefully be defined to impart the most create a more acute angle. (The reader might reflect on whether and clearest information'. this descriptive 'rule' is used consistently, for example in relation to normal cervical and lumbar curves where the creation of more • Regarding this particular terminology debate, Gray's anatomy acute joint angles occurs when these areas are extended, rather than flexed (i.e. backward bending should really be called 'flexion of (1 995) points out that the non-weight bearing and the weight­ the lumbar spine'!) which might add confusion rather than clarity to bearing foot function differently. 'The complex actions of inversion texts.) In regards to the foot, moving the dorsal surface of the foot and eversion . . . refer to changes in the whole foot (with minor toward the tibia constitutes flexion of the ankle joint. Therefore, movements of the talus), when it is off the ground. . .When the foot movement in the opposite direction constitutes extension of the joint. However, with the foot, these movements are usually termed is transmitting weight or thrust these movements are modified to dorsiflexion and plantarflexion, respectively. While some authors maintain plantigrade contact. The distal tarsus and metatarsus are feel the use of the term plantarflexion is inappropriate (Kapandji pronated or supinated relative to the talus, pronation involving a 1 987), it does clarify a movement which might otherwise be even downward rotation of the medial border and hallux; supination more unclear. Some of the confusion surrounding the use of flexion being the reverse, both bring the lateral border into plantigrade and extension regarding the ankle is due to the fact that the toe contact. extensors assist in creating ankle flexion while the toe flexors assist in ankle extension. The terms dorsi- and plantarflexion help • For simplicity in this text, the term supination is used to in this dilemma and are therefore used in this text to define flexion and extension of the ankle, respectively. describe the lifting of the medial border of the foot and pronation to describe the lifting of the lateral border of the foot. Inversion and • Supination and pronation are often used synonymously with eversion may also be used to describe the same movements. which faces distally and posterolaterally to receive the The fibula has a proximal head, a long, thin shaft and a fibular head. This articulation comprises the proximal distal projection, the lateral malleolus. The head offers a tibiofibular joint. While this joint does not provide a high round facet, which articulates with the tibia. Like the degree of movement, dysfunctions within this joint are tibia, the fibula has three borders and surfaces, the details an important consideration when the ankle is being assessed due to the potential impact this may have on the of both being well described by Gray's anatomy (1 995). Its distal tibiofibular joint. distal end articulates with the lateral talar surface. The triangular shaft of the tibia has a medial, lateral Both the proximal and distal tibiofibular joints are and posterior surface, the borders of which are fairly sharply defined . The medial surface is immediately stabilized by anterior and posterior tibiofibular ligaments. recognizable as the 'shin', while the interosseous border Additionally, the distal end also possesses an inferior is the attachment site for the interosseous membrane. transverse ligament and the crural tibiofibular interosseous When compared to the proximal end, the distal end of the ligament, which offer support to the distal joint, as does tibia, where its medial malleolus projects inferomedially, the interosseous membrane. is noted to be rotated laterally (tibial torsion) about 30°, The proximal tibiofibular joint this being significantly more in Africans (Eckhoff et al The proximal tibiofibular joint is a synovial joint which is 1 994). The distal surface, which articulates with the talus, not directly connected with the knee joint. When the knee is concave sagittally and convex transversely and is con­ is flexed, this joint plays a part in rotation of the leg, tinuous with the malleolar articular surface. The medial allowing small degrees of supplementary abduction and malleolus lies anterior and proximal to the lateral adduction of the fibula (Lewit 1 985) or, as Kuchera & malleolus. Various ligaments (described below) and the Goodridge (1997) term it, 'anterolateral and posteromedial joint capsule a ttach to it. glide of the fibular head'.

THE LEG AND FOOT 499 Lateral condyle ,---,-____ Tubercles of G roove for ---,_______ Lateral condyle of tibia intercondylar tendon of of tibia eminence popliteus Apex Apex of head Head of fibula Medial Groove on of fibula condyle medial condyle Head of fibula Anterior border of tibia of tibia I nterosseous ---�\" Tuberosity border of tibia Medial crest Soleal l i ne -----l-i' :-,--- :t' Anterior Interosseous Nutrient Medial crest su rface border foramen Medial part of Posterior posterior surface Anterior Vertical line border Lateral border Medial border surface I nterosseous I I border L Medial 1 surface � G roove for I tibialis �I \\ posterior tendon Triangular __\"\" �_e:���I- Medial Medial --i�t�.I:.t�. ri---- G roove for subcutaneous peroneal I malleolus malleolus tendons area .,_-, _ Lateral malleolus Lateral _�I�' Figure 1 4.2 Surface features of the proximal aspect of the right tibia malleolus (reproduced with permission from Gray's anatomy 1 995). Figure 1 4.1 Anterior aspect of the right tibia and fibula (reproduced with permission from Gray's anatomy 1 995). Greenman (1996) notes that the behavior of the fibular treating a fibular head dysfunction, the [practitioner] head is strongly influenced by the biceps femoris muscle should completely examine the distal articulation as well, which attaches to it, suggesting that any dysfunction of at the ankle joint'. Kuchera & Goodridge (1997) point out the tibiofibular joint calls for assessment of this muscle, that: 'The distal tibiofibular articulation is a syndesmosis for length, strength and localized dysfunction (trigger . . .[which] . . . allows the fibula to move laterally from the points). Schiowitz (1991) notes that: 'When evaluating or tibia, to accommodate the increased width of the talus, presented during dorsiflexion. Restricted dorsiflexion of

500 CLIN ICAL APPLICATION OF NMT VOLUME 2 the ankle warrants examination and treatment of this syndesmosis'. T he proximal tibiofibular joint's role in ankle sprains A Reciprocal motions C Details regarding ankle sprains involving the talotibio­ A fibular (distal tibiofibular) joint are discussed on p. 507. Il- In addition to those considerations, Kuchera & Goodridge (1997) suggest that in cases of recurrent ankle sprain, examination for fibular head dysfunction should be carried out, 'because with trauma the physiologic, re­ ciprocal motion [between the distal and proximal tibiofibular articulations] may not occur'. Greenman (1996), discussing the problem of recurrent ankle sprain, suggests they 'are difficult to treat' and that 'structural diagnostic findings in this population con­ sistently show dysfunction at the proximal tibiofibular joint and dorsiflexion restrictions of the talus at the talotibial articulation'. Greenman further observes that common findings include loss of subtalar joint play, pronation of the cuboid and weakness of the peroneal muscles and tibialis anterior. • In cases involving a pronation sprain of the ankle joint, 'the distal talofibular joint glides posteriorly and the head of the fibula glides anteriorly'. • In cases of supination ankle sprain, 'the distal fibula is often found to be anterior and the fibular head is posterior' (Kuchera & Goodridge 1997). Proximal tibiofibular joint play 8+--\"1'+ Lewit (1985) reports joint play at the proximal tibiofibular Reciprocal fibular motion joint as involving an anteroposterior glide as well as Figure 1 4.3 External rotation of the tibia (A) moves the distal fibula some rotation potential of the fibular head on the tibia. posteriorly (8) while the fibular head moves anteriorly (C). All these movements are reversed for internal rotation of the tibia, (after Ward • When the tibia and ankle are externally rotated, the 1 997). proximal fibular head elevates and glides (translates) anteriorly, to accommodate this movement (Kuchera • Care should be taken to avoid excessive pressure on the posterior aspect of the fibula head, as the peroneal & Goodridge 1997) (Fig. 14.3). nerve lies close by (Kuchera & Goodridge 1997). • Similarly, when the tibia and ankle are internally rotated, the proximal fibular head depresses and • The thumb resting on the anterior surface of the glides (translates) posteriorly, to accommodate this fibula should be reinforced by placing the thumb of movement. the other hand over it. Testing joint play and mobilizing the proximal tibiofibular • A movement which takes the fibular head firmly joint posteriorly and anteriorly, in a slightly curved manner (i.e. not quite a straight backward-and­ • The patient is supine with hip and knee flexed so that forward movement, but more back and slightly the sole of the foot is flat on the table. curving inferiorly, followed by forward and slightly • The practitioner sits so that her buttock rests on the curving superiorly, at an angle of approximately 30° - patient's toes, stabilizing the foot to the table. • The head of the fibula is grasped between thumb and index finger of one hand as the other hand holds the tibia firmly, inferior to the patella.

THE LEG AND FOOT 501 see Fig. 14.3), determines whether there is freedom of may well normalize it (Mulligan 1999, Petty & Moore 1998). joint glide in each direction. • If restriction is noted in either direction, repetitive MET for releasing restricted proximal tibiofibular joint rhythmical springing of the fibula at the end of its range should restore normal joint play. For posterior fibular head dysfunction (where anterior • It is worth noting that when the fibular head glides glide is restricted) anteriorly there is automatic reciprocal movement posteriorly at the distal fibula (lateral malleolus), • The patient sits on the treatment table with legs while posterior glide of the fibula head results in hanging over the edge. anterior movement of the distal fibula. Restrictions at the distal fibula are, therefore, likely to influence • The practitioner sits in front of the patient supporting behavior proximally and vice versa. the foot with her contralateral hand (i.e. left foot, right hand). Petty & Moore (1998) utilize a similar anteroposterior • The practitioner 's other hand engages the posterior glide to that described above, but suggest a prone position aspect of the fibular head and introduces an for the posteroanterior assessment. anteriorly directed force. • The prone patient's leg is supported proximal to the • At the same time the other hand passively inverts, ankle on a cushion, so that the knee is in slight plantarflexes and internally (medially) rotates the flexion. foot (creating adduction), to the first resistance barriers in these directions. • The practitioner 's thumbs are applied to the posterior aspect of the fibula head while avoiding the peroneal • When slack has been removed via these movements, nerve, with fingers curved around the proximal leg to the patient is asked to evert and dorsiflex the foot, offer support for the hands as well as to stabilize the using a moderate degree of effort ('Try to use no leg. more than 25% of your strength, while I resist your • On-and-off combined thumb pressure is applied to assess anterior glide potential of the head of the effort') . fibula. • According t o Goodridge & Kuchera (1997) the Entrapment possibility muscles which are likely to be involved in this As observed above, care is required to avoid undue resisted isometric effort include extensor digitorum pressure on the posterior aspect of the fibula head due to longus and tibialis anterior. The sustained contraction should 'draw the fibula anteriorly along the tibial neural structure proximity. Kuchera & Goodridge (1997) articular surface'. Additionally, the isometric action of these muscles should inhibit their antagonists, which point out additionally that dysfunction which involves may be holding the fibular head posteriorly (see the fibular head being locked in a posteriorly translated direction 'may cause symptoms related to entrapment discussion of muscle energy technique in Chapter 9). neuropathy or compression of the common peroneal • This isometric effort is held for 5-7 seconds nerve' (see Box 14.9). (Greenman [1996] suggests just 3-5 seconds). Mobilization with movement (MWM) • Following.complete relaxation of the muscular effort to release the fibula head by the patient, slack is removed by the contacts on the fibular head and also the foot, as a new barrier is If knee pain is reported in the posterolateral aspect of the engaged (i.e. increased inversion and internal knee joint and no internal knee dysfunction is apparent, rotation) and the process is repeated once or twice joint play of the tibiofibular joint may be restricted . more. • The patient i s lying o r standing. For anterior fibular head dysfunction (where posterior • The practitioner applies anterior or posterior pressure glide is restricted) to the fibula head (with thumb pressure toward the • The patient sits on the treatment table with legs d irection of joint play restriction), as the patient hanging over the edge. actively, slowly, flexes and extends the knee several times. • The practitioner sits in front of the patient supporting • If the pain-free range is increased during the exercise, the foot with her contralateral hand (i.e. left foot, the indication is that the problem is of a mechanical right hand) . nature, at the tibiofibular joint and this procedure • The practitioner's other hand engages the anterior aspect of the fibular head and introduces a posteriorly directed force.

502 CLINICAL APPLICATION OF NMT VOLUM E 2 • At the same time the other hand passively inverts Lateral Trochlear surface for tibia and dorsiflexes the foot. tubercle For medial malleolus • When slack has been removed via these movements, For the patient is asked to evert and plantarflex the foot, navicular using a moderate degree of effort ('Try to use no more ligament For plantar than 25% of your strength, while I resist your effort'). calcaneonavicular ligament G roove for flexor • The muscles which are likely to be involved in this hallucis longus resisted isometric effort include peroneus longus, 'to A draw the fibula laterally from the tibia, making posterior gliding easier' and soleus, 'to draw the For lateral malleolus fibula posteriorly along the tibial articular surface' Trochlear surface (Goodridge & Kuchera 1997). Additionally, the I isometric action of these muscles should inhibit their Posterior process antagonists, which may be holding the fibular head anteriorly (see discussion of MET in Chapter 9). • This isometric effort is held for 5-7 seconds (Greenman [1996] suggests just 3-5 seconds). • Following complete relaxation of the muscular effort by the patient, slack is removed by the contacts on the fibular head, and also the foot, as a new barrier is engaged (i.e. increased inversion and dorsiflexion) and the process is repeated once or twice more. TH E AN KLE JOI NT A N D H I N DFOOT For Posterior calcanean navicular facet on plantar The ankle joint, the most congruent joint in the body, is surface composed of the malleoli of the tibia and fibula, the distal Sulcus Lateral surface of the tibia and the body of the talus (see Figs tali process 14.1,14.2, 14.4). The tibia is weight-bearing onto the head 6 of the talus, while the fibula has very little weight­ Figure 1 4.4 The (A) medial and (6 ) lateral aspects of the talus. (reproduced with permission from Gray's anatomy 1 995). bearing responsibility, with 'no more than 10% of the foot is important 'when setting up manipulative tech­ weight that comes through the femur being transmitted niques addressing this joint'. through the fibula' (Levangie & Norkin 2001). The tibia rests on the proximal trochlear surface of the talus. The talus projects a long neck which ends in a The tibiofibular component supplies three facets which rounded distal head for articulation with the navicular together form an almost continuously concave surface, bone, a facet for each of the malleoli and three articulations resembling an adjustable mortise (similar to an adjust­ with the calcaneus (Fig. 14.4). able wrench) . Levangie & Norkin (2001) observe: The talus has no direct muscular attachments so its The adjustable mortise is more complex than a fixed mortise ligamentous structure is significant (see below). Its because it combines mobility and stability functions. The movements are influenced by muscular action on bones mortise of the ankle is adjustable, relying on the proximal and distal tibiofibular joints to both permit and control the changes which lie above and below it (Greenman 1996). Because in the mortise. of the strong ligaments of the ankle, the shape of the The proximal head of the talus is a wedge-shaped crural concavity and the length of the lateral malleolus on structure, wider anteriorly than posteriorly, which is held the talus, joint dislocation is extremely unlikely unless in an arch (mortise) created by the internal (tibial) and accompanied by fracture. external (fibular) malleoli. Approximately one-third of the medial aspect of the talus is bounded by the tibial The ankle mortise (also called talocrural, tibiotalar or malleolus, while the lateral aspect of the talus is entirely talotibiofibular joint) is designed to handle enormous bounded by the fibular malleolus which is more posteriorly situated when compared to the tibial malleolus. The rela­ degrees of force. Gray's anatomy (1995) reports that: tive oblique axis between the malleoli results in 'a toeing out (by about 15°) of the free foot . . . with dorsiflexion and toeing in, with plantarflexion'. We are reminded by Goodridge & Kuchera (1997) that this position of the free

THE LEG AND FOOT 503 Compressive forces transmitted across the joint during gait • deep peroneal nerve reach five times body weight while tangential shear forces, the • extensor digitorum longus. result of internally rotating muscle forces and externally rotating inertial forces associated with the body moving over Posterior to the medial malleolus: the foot, may reach 80% body weight. • tibialis posterior Gray's anatomy (1995) describes the ankle joint as • flexor digitorum longus • flexor hallucis longus follows. • the posterior tibial vessels • tibial nerve. The joint is approximately uniaxial. The lower end of the tibia and its medial malleolus, with the lateral malleolus of the Posterior to the lateral malleolus (in a groove): fibula and inferior transverse tibiofibular ligament, form a deep recess for the body of the talus. . . .Although it appears a • tendons of peroneus longus and brevis. simple hinge, usually styled 'uniaxial', its axis of rotation is dynamic, shifting during dorsi- and plantarflexion'. The arterial blood supply to the joint is from the malleolar rami of the anterior tibial and peroneal arteries. During dorsiflexion, the fibula and tibia spread away Nerve supply to the joint derives from the deep peroneal from each other, to accommodate the wider anterior aspects and tibial nerves. of the head of the talus. The close-packed position for this joint is full dorsiflexion where the joint is most congruent The ankle ligaments and the ligaments are taut. The bones which make up the crural arch (the d istal tibia The line of the joint is usually considered to be at the and the medial and lateral malleoli) are connected to the anterior margin of the tibia's distal end. This can be talus by the joint capsule and powerful ligaments (Figs palpated if the superficial tendons are relaxed. Along with those tendons will be found a variety of structures which 14.5,14,6). are listed here in relation to the malleoli. • Medial (deltoid) Anterior to the malleoli on the dorsum of the talocrural • Anterior talofibular joint: • Posterior talofibular • Calcaneofibular • tibialis anterior • extensor hallucis longus • peroneus tertius • the anterior tibial vessels Talonavicular l igament Dorsal cuneonavicular ligaments --.,- Ligaments of first Plantar tarso-metatarsal joint LI Dorsal 1��i����: Parts of ��-;--?'-\"- ';\"_'\" ____ Tibio- deltoid calcanean ligament T-:-'- ::-:': ?r-� Ti b i 0- :-;--::.7-::7- -:':-':-\" '.-- .\".-'-':'\":-\"--:-': - navicular First metatarsal --7- Tuberosity of navicular Sustentaculum tali Long plantar ligament Plantar calcaneonavicular ligament Figure 1 4.5 The ligaments of the lateral ankle and tarsal joints (reproduced with permission from Gray's anatomy 1 995).

504 CLINICAL APPLICATION OF NMT VOLUME 2 Anterior tibiofibular ligament --,'-\"r:; Talonavicular ligament Posterior tibiofibular ligament -';.________ � Dorsal cuneonavicular ligaments Vi Dorsal cuneocuboid ligament Posterior talofibular ligament --:-__ _ _ _ _=__ _____ Dorsal Anterior talofibular ligament -='=-------- --:-= :.;.:= --- '-- I I_ tarsometatarsal ligaments � Calcaneofibular ligament ---=--7-::-:-:7\"'\"'- Long plantar Dorsal intermetatarsal ligaments ligament Dorsal tarsometatarsal ligaments Bifurcated ligament Figure 1 4.6 The ligaments of the medial ankle and tarsal jOints (reproduced with permission from Gray's anatomy 1 995). Medial (deltoid) ligament Calcaneofibular ligament This extremely powerful, medially located ligament is This is 'a long cord, [which] runs [inferiorly] from a triangular in shape with its superior attachments on the depression anterior to the apex of the fibular malleolus, apex as well as the anterior and posterior borders of the to a tubercle on the lateral calcaneal surface and is crossed medial malleolus. Inferiorly it has a variety of fibers and by the tendons of peroneus longus and brevis' (Gray's attachments, as described by Gray's anatomy (1995). anatomy 1995). . . . the anterior (tibionavicular [fibers]) pass forwards to the Movements of the ankle joint navicular tuberosity and behind this blend with the medial margin of the plantar calcaneonavicular ligament; Kuchera & Goodridge (1997) suggest that the ankle joint intermediate (tibiocalcaneal) fibers descend almost vertically to the whole length of the sustentaculum tali; posterior fibers is in fact two joints, which should be considered together (posterior tibiotalar) pass posterolaterally to the medial side of as a functional unit: the talocrural joint (ankle mortise) the talus and its medial tubercle. The deep fibers (anterior and the subtalar joint (described below). They point to tibiotalar) pass from the tip of the medial malleolus to the 110n­ articular part of the medial talar surface. the research of Inman (1976) who showed that during the Anterior talofibular ligament gait cycle, as weight is taken on the foot, there is 'visible medial rotation of the tibia [which] is greater than can be This ligament attaches to the anterior margin of the attributed to movement solely at the talocrural joint'. lateral (fibular) malleolus from which it runs inferiorly, Inman demonstrated that the increased tibial rotation anteriorly and medially to attach at both the lateral resulted from 'relative calcaneal eversion about the articular facet of the talus and the lateral aspect of its subtalar axis' . As the stance phase progresses the tibia neck. then externally (laterally) rotates, at the same time as calcaneal inversion occurs, again about the subtalar axis Posterior talofibular ligament (see Box 14.1). This attaches to the lower aspect of the lateral malleolus from where it runs virtually horizontally to the lateral The motions of the ankle joint are as follows. tubercle of the posterior talar process. Gray's anatomy • Plantarflexion (50°) achieved by soleus and (1995) reports that: 'A \"tibial slip\" of fibres connects it to gastrocnemius, assisted by plantaris, peroneus longus the medial malleolus'. and brevis, tibialis posterior, flexor digitorum longus and flexor hallucis longus. • Dorsiflexion (20°) achieved largely by tibialis anterior, extensor digitorum longus and peroneus tertius,

THE LEG AND FOOT 505 assisted by extensor hallucis longus (Schiowitz 1 99 1 , Posterior articular �____ Middle articular Travell & Simons 1 992). surface for talus surface for talus • Accessory minor motions of anterior glide with plantar I surface for talus flexion and posterior glide with dorsiflexion (Goodridge & Kuchera 1 997). Lateral process Peroneal trochlea of calcaneal For calcaneofibular ligament • Gray's anatomy (1 995) reports that: 'Dorsi- and tuberosity plantarflexion are increased by intertarsal movements, Figure 1 4.7 The lateral aspect of the calcaneus (reproduced with adding about 1 0° to the former, 20° to the latter'. permission from Gray's anatomy 1 995). • Additionally, Kuchera & Goodridge ( 1 997) note that: 'Plantar flexion is accompanied by adduction and Posterior articular surface for talus supination of the foot. . .[andl... the proximal fibular Sustentaculum tali head glides posteriorly and inferiorly. . . [andl. . . the talus glides anteriorly, placing the narrow position of Anterior ---k­ the talus in the ankle mortise, a less stable position'. articular • During plantarflexion 'slight amounts of side-to-side surface gliding, rotation, abduction and adduction are for talus permitted' (Gray's anatomy 1995). Medial process of Posterior calcaneal tuberosity s u rface • Stability during symmetrical standing requires continuous action by soleus, which increases during Figure 1 4.8 The medial aspect of the calcaneus (reproduced with forward leaning (often involving gastrocnemius) and permission from Gray's anatomy 1 995). decreases with backward sway. If a backward movement takes the center of gravity posterior to the surfaces (Figs 1 4.7, 1 4.8). The largest of these three surfaces transverse axes of the ankle joints, the plantarflexors lies posterior to the tarsal canal while the anterior and middle facets lie anterior to it. These surfaces are further relax and the dorsiflexors contract (Gray's anatomy divided into anterior and posterior independent components by the interosseous talocalcaneal ligament, 1 995). which lies obliquely between them, separating them into two compartments. The posterior portion has its own Dorsiflexion stability synovial cavity while the anterior and middle facets share one. These three articulating surfaces are collectively called Gray's anatomy (1 995) describes the solidity of the joint the talocalcaneal joint, though it is helpful to consider the two different components of this joint separately. To during dorsiflexion. distinguish them, the posterior component can be called the subtalar joint proper (or posterior subtalar joint) and Dorsiflexion is the 'close-packed' position, with maximal the anterior component called the talocalcaneonavicular congruence and ligamentous tension; from this position all (TeN) joint. major thrusting movements are exerted, in walking, running and jumping. The malleoli embrace the talus; even in relaxation no appreciable lateral movement can occur without stretch of the inferior tibiofibular syndesmosis and slight bending of the fibula. During dorsiflexion the widest part of the talus has glided posteriorly into the 'embrace of the malleoli' and it is this stability which is being exploited when ankle sprains are taped, usually emphasizing dorsiflexion (Goodridge & Kuchera 1 997) Goodridge & Kuchera (1 997) note that the distal tibiofibular joint is a syndesmosis (a fibrous joint in which relatively distant opposing surfaces are united by ligaments), which allows the accommodation of the wedge-shaped talus, as it separates the tibia from the fibula during dorsiflexion of the foot. For this reason, 'Restricted dorsiflexion of the ankle warrants examin­ ation and treatment of this syndesmosis'. The talocalcaneal (subtalar) joint The talocalcaneal joint is a composite joint formed by the articulation of the talus with the calcaneus at three

506 CLINICAL APPLICATION OF NMT VOLUME 2 In collectively describing these surfaces, Cailliet ( 1 997) synovial membrane is separate from other tarsal writes: joints (Gray's anatomy 1 995). Much of the inversion and eversion of the foot occurs at this • Lateral talocalcaneal ligament: this descends obliquely joint. The entire body and part of the head of the talus, rest on the anterior two thirds of the calcaneus, which is divided into posteriorly from the lateral talar process to the lateral three areas: 1) the posterior third, which is saddle-shaped; 2) calcaneal surface. It attaches anterosuperiorly to the the anterior third, which forms a horizontal surface; and 3) the calcaneofibular ligament. intermediate third, which forms an inclined plane between the other areas. • Medial talocalcaneal ligament: this joins the medial talar The calcaneus is the largest tarsal bone, with the muscles tubercle to the posterior aspect of the sustentaculum of the calf attaching to its projecting posterior surface. In tali and the adjacent medial surface of the calcaneus. addition t o the three articulations with the talus, its anterior Its fibers become continuous with the medial surface offers a convex surface for articulation with the (deltoid) ligament. cuboid . The smooth facets contrast with the remaining rough surfaces of the calcaneus, where numerous • Interosseous talocalcaneal ligament: this descends ligaments and muscles attach. The sustentaculum tali projects medially from it and (dorsally) offers the middle obliquely and laterally from the sulcus tali to sulcus facet which articulates with the talus, making it also part calcanei. of the TCN joint. • Cervical ligament: this is attached to the superior The posterior saddle-shaped (convex) articular surface of the calcaneus receives the concave talar facet. The calcaneal surface and ascends medially to an middle and anterior articular surfaces include convex inferolateral tubercle on the talar neck. talar and concave calcaneal facets, therefore being the Between the posterior and middle articulations lies a reverse of the posterior articulation. Since the talocalcaneal deep groove which forms the obliquely oriented tarsal joint is composed of several joints lying in different tunnel (canal). The larger end of this tunnel, the sinus planes, this unique configuration 'permits simultaneous tarsi, lies just anterior to the lateral malleolus, while its movement in different directions' (Cailiiet 1 997). Triplanar smaller end emerges between the medial malleolus and movement around a single joint axis and functional the sustentaculum tali (medially projecting ledge on the weight-bearing at this joint are 'critical for dampening calcaneus). Within the tunnel resides the interosseous the rotational forces imposed by the body weight while talocalcaneal ligament, which divides the subtalar from maintaining contact of the foot with the supporting surface' the TCN joint. (Levangie & Norkin 2001 ). The subtalar joint has been described as a 'shock absorber' by Kuchera & Kuchera (1 994), a designation Levangie & Norkin (2001 ) explain: earned, they say, because 'in coordination with the inter­ tarsal joints, it determines the distribution of forces upon Although the subtalar [talocalcaneal] joint is composed of the skeleton and soft tissues of the foot'. three articulations, the alternating convex-concave facets limit Kapandji (1 987) calls the talus 'an unusual bone' (due the potential mobility of the joint. When the talus moves on to the fact that it has no muscular attachments) and in the posterior facet of the calcaneus, the articular surface of the view of its role as a 'distributor' of loads over the entire talus should slide in the same direction as the bone moves foot (Fig. 1 4.9); also, because 'it is entirely covered by (concave surface moving on a stable convex surface). However, at the middle and anterior joints, the talar surfaces Figure 14.9 The distribution of body weight through the talus should slide in a direction opposite to movement of the bone (reproduced with permission from Kapandji 1 987). (convex surface moving on a stable concave surface). Motion of the talus, therefore, is a complex twisting (or screwlike motion), that can continue only until the posterior and the anterior and middle facets, can no longer accommodate simultaneous and opposite, motions. The rest is a triplanar motion of the talus around a single oblique joint axis. The subtalar [talocalcaneal] joint is, therefore, a uniaxial joint with 1° of freedom: supination /pronation. Capsule and ligaments of the subtalar joint The bones of the subtalar joint proper are connected by a fibrous capsule and by lateral, medial, interosseous talocalcaneal and cervical ligaments. • The fibrous capsule envelops the joint, attaching via short fibers to its articular margins. The joint's

THE LEG AND FOOT 507 articular surfaces and ligamentous insertions; hence its calcaneus (or talus) twists across its three articular surfaces. name of \"relay station\"' . Although some of the component motions can be observed more readily than others, the motions always occur together. Mennell ( 1 964) graphically describes this shock­ (their italics) absorbing potential. Ankle s prains Its most important movement is a rocking movement of the talus upon the calcaneus, which is entirely independent of Note: See also the notes in the previous section of this voluntary muscle action. It is this movement which takes up all the stresses and strains of stubbing the toes and that spares chapter which discuss the relationship between the the ankle from gross trauma, both on toe-off and at heel-strike, proximal and distal tibiofibular joints and ankle sprain. in the normal function of walking and when abnormal stresses . . .are inflicted on the ankle joint. If it were not for the Plantarflexion is the position in which ankle sprains are involuntary rocking motion at the subtalar joint, fracture most likely to occur. Schiowitz ( 1 991 ) reports that: 'The dislocations would be more commonplace. most common [ankle] sprain represents an inversion and is usually caused by a combination of plantarflexion, Gray's anatomy ( 1 995) notes that there are anterior and internal rotation and inversion. The lateral ligaments sustain the initial impact' (Fig. 1 4. 1 0). posterior articulations between the calcaneus and talus as described above. However, the subtalar joint, as described Gray's anatomy ( 1 995) clarifies the mechanisms of ankle in Gray's anatomy, relates only to the posterior articulation, sprain. which has its own joint capsule. The anterior articulation Posterior right between the talus and calcaneus is then seen to be part of i n nomi nate the TeN joint, a viewpoint which has merit and which is discussed later in this chapter. As mentioned elsewhere, Sacrum rotated there is value in considering these joints individually as right on a right well as collectively with regard to foot movements. oblique axis Schiowitz (1991 ) describes the major motions of the Femur rotated subtalar joint as: internally • calcaneal abduction (valgus) which creates foot External rotation eversion (involving peroneus longus and brevis) of the tibia • adduction (varus) which creates foot inversion, in T = Talus: posterolateral relation to the talus (involving tibialis anterior and glide of the talus posterior). C = Cuboid: plantar glide N = Navicular: plantar glide It is worth remembering that these movements cannot and plantar surface and plantar surface occur in isolation but are mandatory simultaneous rotates laterally rotates medially movements in the three planes of space. The terms used to describe these movements are subject to confusion (see Figure 14.10 Structural stress occurring in common supination ankle Box 1 4 . 1 ) based on lack of agreement; however, regardless sprain, (after Ward 1 997). of the term chosen, they move the foot simultaneously in its vertical, horizontal and longitudinal axes. As the medial aspect of the foot is elevated, it is simultaneously adducted and plantarflexed. As the lateral aspect of the foot is elevated, it is simultaneously abducted and dorsi­ flexed . These movements cannot happen in isolation but instead are triaxial. Kuchera & Goodridge ( 1 997) describe the joint's action as being 'like a mitred hinge' in which movements of the calcaneus induce rotation of the tibia. Inversion of the calcaneus produces external rotation of the tibia and the talus glides posterolaterally over the calcaneus. Eversion of the calcaneus produces medial rotation of the tibia and anteromedial glide of the talus on the calcaneus. Levangie & Norkin (200 1 ) note that: ... subtalar motion is more complex than that of the ankle joint and that subtalar component motions cannot and do not occur independently. The components occur simultaneously as the

508 CLIN ICAL APPLICATION OF NMT VOLUME 2 So-called sprains of the joint are almost always abduction peroneal reaction time, which appears to be a peripheral sprains of subtalar joints, although some medial (deltoid) reflex. Proprioception and eversion muscle strength improve fibers may also be torn. True sprains are usually due to with the use of passive supportive devices. Balance and forcible plantarflexion, resulting in capsular tears in front postural control of the ankle appear to be diminished after a (most commonly of the anterior talofibular ligament) and lateral ankle sprain and can be restored through training that bruising by impaction of structures behind the joint. is mediated through central nervous mechanisms. Merck (2001 ) report that in ankle sprain, the anterior Murphy (2000) points out that: talofibular ligament (ATL) usually ruptures first after which the fibulocalcaneal ligament (FCL) may separate. For the nervous system to stabilize the head and neck, it must Merck suggest that if the ATL is ruptured, examination be aware of the position of the head in space. This requires . . . for associated trauma to the lateral FCL should be carried knowledge of the head position in relation to the trunk, which, out. Palpation of the lateral ankle usually rapidly deter­ in turn, is dependent on knowledge of the position of the mines the site of the ligamentous injury. If ATL is trunk relative to the ground. ruptured during a sprain, anterior displacement of the talus becomes possible. To test this the patient sits on the Knowledge of trunk position requires that normal side of a table with legs hanging freely. The practitioner afferentation from the foot is forthcoming. However, 'In places one hand in front of the patient's leg, while the the presence of foot dysfunction, the afferentation is com­ other hand grasps the patient's heel posteriorly and promised and additional responsibility may be placed on attempts to move the talus anteriorly. the cervical spine for this function' . Types of ankle sprain O'Connel's proprioception experiment Kuchera & Goodridge ( 1 997) note that: Murphy reports on O'Connel's ( 1 971 ) experiment in which healthy students were placed on a large swing and were Because the biomechanical stresses associated with supination asked, as the swing moved forward, to jump off and land strain progress from anterior to posterior, ankle sprains are on a large mat. The time taken to achieve erect stance after often named by type according to the extent of ligamentous the jump was noted and postural responses recorded. The irivolvement: test was conducted in three phases. 1 . Type 1 : Involves anterior talofibular ligament only 2. Type 2: Involves the anterior talofibular and calcaneofibular 1 . Without visual impedance or altered foot afference (see 2 and 3). ligaments 3. Type 3: Involves all three lateral supporting ligaments. 2. Blindfolded. 3. Blindfolded and after the feet had been immersed in Instability or loss of neuromuscular control? ice water for 20 minutes (virtually anesthetizing the Merck (2001 ) state: feet). Persons with ligamentous laxity who have extensive subtalar The results showed that, with the unimpeded jump, inversion ranges are often prone to inversion injury. Weakness erect stance was achieved in periods ranging from 0.21 to of the peroneal tendons is an occasional predisposing factor 0.53 seconds. When blindfolded, erect stance was achieved that may occur with lumbar disk disease. Forefoot valgus, in in times ranging from 0.22 to 0.77 seconds. When blind­ which the forefoot tends to evert during the gait cycle, causing folded and anesthetized, none of the students was able to the subtalar joint to compensate by inversion, may predispose achieve erect stance without assistance. The input to the to ankle sprain. Some persons have an inherited tendency to brain from the feet is vital. A simple test offers some develop inverted subtalar joints (subtalar varus). evidence for the efficiency of this input. [See notes on hypermobility in Chapter 1 1 .] Test for postural foot reaction Richie (2001 ), who has reviewed the clinical syndrome of functional ankle instability, finds that instability is • The patient stands erect and looks straight ahead and usually not a result of hypermobility. He asserts that recent is asked to lean the body forward, so that weight is evidence has demonstrated that the majority of patients shifted to the forefoot with functional instability of the ankle emphatically do not have mechanical hypermobility of the ankle joint but • A normal reaction is one in which the intrinsic foot that functional instability of the ankle results from a loss muscles contract to produce flexion of the distal of neuromuscular control. interphalangeal joints. Richie states: • Abnormal findings (positive test) which suggest poor foot stabilization may include (Murphy 2000): The components of neuromuscular control include 1 . flexion of proximal interphalangeal joints and proprioception, muscle strength, muscle reaction time and postural control. Proprioceptive deficits lead to a delay in

THE LEG AND FOOT 509 Box 14.2 Rehabi litation of disequilibri u m/loss of balance (See Chapter 2 for more detail) .. Balance retraining using tactics of stand ing and walking on thick foam can reduce evidence of ataxia within 2 weeks (Brandt & • Adaptive patterns of use such as altered posture and gait, commonly associated with loss of balance, may result from Krafczyk 1 98 1 ) . musculoskeletal conditions rang ing from ankle sprain to low back pain (Mientjes & Frank 1 999, Takala & Korhonen 1 998). S . • ,ifTicaai ncthlyi exercises, performed regularly and long ter m, 1 , Wolf enhance balance in the elderly (Jancewicz 200 • Normal ization of balance problems through sensory motor i gn retraining has been shown to lead to reduction in back pain more 1 996, Wolfson & Whipple 1 996). effiCiently than active (manipulative) treatment (Karlberg et al 1 995' • I n order to encourage normal foot function, Janda & Va'vrova Liebenson 2001 ) . (1 996) suggest establ ishing a 'short foot' . This involves creating a • For patients with poor posture involving poor foot reaction to postural stress (see test on p. 508), Murphy (2000) describes shortened longitudinal arch with no flexion of the toes balan�e training in which, initial ly, the patient performs a 'marching acllon (marching on the spot), lifting the knees as high as possible, (accomplished by 'scrunching' and raising the arch of the foot while ensuring that movement is isolated to the hips, i.e. 'hiking of the iliac crests is avoided'. This action is first performed barefoot without flexing the toes, thereby shortening the arch) (Bullock­ and once the pattern of movement is being well performed, Saxton et al 1 993, Janda & Va'vrova 1 996). This leads to an wearing balance sandals (which have a hemisphere on the soles). Once marching on the spot in balance sandals has been mastered' increased proprioceptive outflow (see Fig. 2.44). slow progression of marching (still raising the knees high) while moving slowly forward and then back, or sideways, is performed. • Lewit ( 1 999) and Liebenson (200 1 ) suggest that with both the Perturbations may also be added (see below). feet maintained in a 'short foot' state, exercises should proceed • Liebenson (2001 ) describes rehabilitation objectives when loss of equilibrium has manifested. ' I mproving balance and speed of from sitting to standing and then on to balance retraining on both contraction is crucial in spinal stabilization because the activation of stabilizers is necessary to control the neutral zone. The goal of stable and labile (such as foam or a rocker board) surfaces. sensorimotor exercise is to integrate peripheral function with central programming. Movements that require conscious and willful • In standing, the individual may be encouraged to balance activation may be monotonous and prematurely fatiguing to the participant. In contrast, movements that are subcortical and standing on one foot (in a doorway so that support is available if reflexive in nature require less concentration, are faster acting and may be eventually automatized'. balance is los!!) repetitively, until it is possible to achieve 30 • Mcilroy & Makin ( 1 995) created deliberate 'perturbation' in seconds on each foot. order to challenge the stabilizing mechanisms as a rehabilitation strategy. 'U nexpected perturbations lead to reactive responses. , • Additional balance exercises, maintaining 'short feet', might Expected perturbations lead to anticipatory postural adjustments (APAs) . Training can lead to the incorpo ration of APAs into reactive I nvolve standing, one leg forward of the other, while maintaining situations. During a jostle from a stance position the stance leg hip abductors undergo \"intense\" activation . After APA training the load balance In a forward lean (lunge) position. is decreased.' • With the patient maintaining 'short feet', Liebenson (200 1 ) • Balance board and wobble board training encourage greater and more rapid strength restoration than isotonic exercises suggests: ' I n order to elicit fast, reflexive responses the patient is (Balogun & Adesinasi 1 992) (see Fig. 2.42). \"pushed\" quickly but gently about the torso and shoulders. This • Balance sandals encourage hip stabilizer contraction efficiency (Bullock-Saxton et al 1 993) (see Fig. 2.43). challenges the patient to remain upright and respond to sudden changes in their center of g ravity. These pushes are performed in two-leg and in single-leg standing with the eyes open. Closing the eyes while performing these exercises focuses the participant's awareness on kinesthetic sense and is more challenging to perfo r m ' . • Additional challenges may be introduced when the patient is on an unstable su rface (such as a rocker board, on two legs or one) involving a variety of tactics to modify the center of g ravity (catching balls, turning the head, etc.). Care should be exercised with elderly or fragile patients to prevent them from fal ling. • Tactics similar to the flat su rface trainings may be used while both participants are standing in water at about lower chest plerevve�l nt which is especially helpful when working with the elderly to injuries from falling on hard surfaces. These steps may eventually take place I n the ocean under calm conditions where m i ld waves add to the balance challenges. extension of distal interphalangeal joints ('hammer is usually only used if surgical correction of a toe') ruptured ligament is planned. 2. no reaction when falling forward. • MRI can indicate the integrity of the collateral ligaments of the ankle and this assessment method If the test is positive, Murphy (2000) says, 'It is important may be used if the patient is allergic to the dye used to assess the foot for local dysfunction. This includes in arthrography. examination for joint dysfunction and improper positional relationships' (see Box 14.2). Wider implications of ankle sprain injuries Clinical diagnosis of damage due to ankle sprain Goodridge & Kuchera ( 1 997) describe the sometimes un­ predictable somatic dysfunctions which may occur, in • Stress X-rays of the ankle may be useful in addition to obvious ligamentous stress, during sprain determining the extent of ligamentous damage. injury of the ankle joint. • Arthrography of the ankle may help determine the • Eversion of the calcaneus. exact site and extent of ligamentous injury (if • Stretching of peroneus (as well as anterior performed within a few days of the trauma) but this

51 0 CLINICAL APPLICATION OF NMT VOLUME 2 compartment) muscles, encouraging trigger point at d istant sites due to the patient's involuntary attempts to development. compensate for continued dysfunction. • The distal fibula may be drawn anteriorly with reciprocal posterior glide of the fibular head, or This important warning is one which the authors • 'if the anterior talofibular ligament is torn, the distal heartily endorse and which practitioners of all disciplines fibula may move posteriorly with anterior glide of should heed. The chain reaction of adaptive influences the fibular head'. which result from apparently trivial foot and ankle injury • Additionally, the tibia may externally rotate, 'with an or dysfunction do not seem to be well comprehended (by anteromedial glide of the tibial plateau'. many in the health-care professions as well as the public). • If this occurs, the femur will internally rotate. In the haste to restore local function following sprains and minor injuries, wider influences resulting from Goodridge & Kuchera ( 1 997) expand on the wider reper­ compensation patterns are often ignored or overlooked. cussions which may follow such a spread of effects from An educational effort is needed which encourages the an ankle sprain. patient to become aware of the vital need for 'sound foundations' in general and for the integrity of the struc­ Myofascial forces then continue upward into the pelvis and tures and proprioceptive functions of the ankles and feet. spine. Failure to diagnose, and treat or rehabilitate beyond the This is a message which the information in this chapter ankle itself increases recurrence rates, and prolongs the will hopefully reinforce. healing and rehabilitation process. It also increases complaints Box 1 4.3 Complications associated with ankle sprain (and notes on arth roscopy) Meniscoid body proportion to the clinical findings in cases of RSD. Merck (200 1 ) suggest: 'Multiple trigger points of pain moving from one site to Impingement of a small nodule may occur between the lateral another and changes in skin moisture or color are characteristic'. malleolus and the talus, following severe ankle sprains, leading to Kappler & Ramey ( 1 997) report that early recognition and marked synovitis and possibly chronic fibrotic swelling and treatment are im portant to prevent permanent disability. RSD may induration (Merck 200 1 ) . Standard treatment is by means of be reversible in its early phases. (See Box 1 4 .4 for discussion of corticosteroid injections and local anesthetic, introduced between therapeutic approaches for RSD.) the talus and the lateral malleolus. Adj unctive care should aim at ensuring normal joint play, muscle tone, strength and length, with Sinus tarsi syndrome attention to the gait cycle. Rehabi litation exercises should be introduced to counteract the compensation habits which may have The precise cause of persistent pain at the sinus tarsi following been acquired. When inflammation is active, hydrotherapy and ankle sprains is unclear, although a partial rupture of the nutritional strategies, as outlined in Chapter 7, may be useful for interosseous talocalcaneal ligament or the stem of the inferior symptom relief. cruciate ligament may be to blame (Merck 200 1 ) . Misdiagnosis is not uncommon, because if the ATL is tender near the sinus tarsi, Neuralgia of the intermediate dorsal cutaneous nerve patients with persistent pain over the ATL may be misdiagnosed as having sinus tarsi pai n . Oloff et al (200 1 ) report that when 29 A branch of the superficial peroneal nerve crosses over the ATL consecutive patients were examined for sinus tarsi syndrome, and this is commonly traumatized during inversion sprains of the using arth roscopy, it was found that there was a history of trauma ankle. Local anesthetic nerve blocks may be helpful. Adjunctive in 86%, with an inversion sprain being the most common care should include ensuring normal joint play, muscle tone, predisposing injury (63%). Twenty-six patients who had additional strength and length, with attention to the gait cycle. M R I eval uation all demonstrated chronic synovitis of the subtalar joint and/or fibrosis. Oloff suggests that: 'Subtalar joint arthroscopy Peroneal tenosynovitis [is] a relatively safe and effective diagnostic and therapeutic technique in the management of sinus tarsi syndrome'. Other Chronic eversion of the subtalar joint while walking may lead to standard treatment methods include injection with lidocaine- type swelling below the lateral malleolus resulting from tenosynovitis of drugs. the peroneal tendons. When inflammation is active, hydrotherapy and nutritional strategies, as outlined in Chapter 7, may be useful Ankle arth roscopy for symptom relief. Attention should be given to the underlying eversion of the subtalar joint by means of orthotics, wedges and/or 'Keyhole' arth roscopic investigation and surgery involves the use of taping, as well as normalizing joint play and balancing muscle tone, needle·like probes, which may contain minute cameras, lasers or strength and length, with focus on posture and the gait cycle. surgical instruments. Use of small instruments and incisions reduces trauma to surrounding tissue and hastens rehabilitation Reflex sympathetic dystrophy (Sudeck's posttraumatic reflex and recovery, so that surgery of this sort may not require a hospital atrophy) stay. Localized osteoporosis may result from angiospasm, secondary to A variety of procedures can be carried out arthroscopically ankle sprain, leading to a painfully swollen foot. Differential including diagnosis, biopsy, arthroplasty, fusion (in cases of assessment is necessary to screen for ligamentous injury as a arthritis, for example), excision of fragments/loose bodies, ligament cause of the effusion. The reported pain is likely to be out of repair for instability or damage, and cartilage repair or removal.

THE LEG AND FOOT 51 1 Box 1 4.4 Therapeutic considerations for RSD The etiology of reflex sympathetic dystrophy (RSD) is not yet fully In the 1 950s, the group of symptoms that behaved as though they understood. The condition is characterized by pain and tenderness, depended on abnormal sympathetic nervous system activity was usually involving a distal extremity (commonly hand, wrist, ankle or included in the generic term 'reflex sympathetic dystrophy'. By the foot). Apart from pai n, signs may include trophic skin changes, beginning of the 1990s, it became clear that this term was an vasomotor instability and demineralization of bone. RSD is most oversimplification. It was officially replaced (Merskey & Bogduk common in people over 50 years of age who have suffered an 1994) by the noncommittal term 'complex regional pain syndrome event such as a stroke, trauma, peripheral neural damage or a (CRPS) ', which the authors defined as including CRPS type I, myocardial infarction. Excessive sympathetic activity is a feature which had no known neurological lesion to account for the pain, and this may relate to thoracic spinal dysfunction. Nerve blocks are and CRPS type II, which was associated with partial injury of a reported to be effective for a short time but do not appear to offer nerve. lasting benefit (Wilson 1 99 1 ) . They suggest that the clin ical characteristics include: The progression o f R S D commonly follows three stages: 1) pain that is intermittent or continuous and often exacerbated by • In two-thirds of cases, a precipitating event results, within a few physical or emotional stressors; 2) sensory changes that include weeks, in intense burning pain and warm edema, particularly hyperesthesia to any modality and allodynia in response to light affecting the joints (whole hand or whole foot usually). Sweating touch, thermal stimulation (cold or warm), deep pressure, orjoint and increased hair g rowth may be noted i n the area. movement; 3) sympathetic dysfunction observed as vasomotor or sudomotor instability in the involved limb; 4) edema of either the • Over a period of 3-6 months the overlying skin becomes thinner pitting or brawny type, that may or may not respond to dependency and shiny and the area cools, although the main symptoms of and elevation of the limb; and 5) motor dysfunctions that may pain remain. include tremor, dystonia, loss of strength, and loss of endurance of the affected muscle groups. • Over a further 3-6 months contractures of a potentially irreversible nature appear, as the skin and subcutaneous tissues atrophy. Since these listed characteristics parallel those produced by trigger points, it would be reasonable to i nvestigate the degree to which Kappler & Ramey ( 1 997) note that: trigger points may be i nvolved in perpetuating the condition. Mense & Simons note that clinicians have found that 'a C RPS seemed to Appropriate mobilization of the patient following a myocardial dispose to the development of TrPs in the affected musculature. infarction, stroke or injury may help prevent this condition. Pain Frequently, inactivation of the TrPs markedly improved, if not relieved, the symptoms, especially if the intervention occurred should be properly controlled. Exercises are helpful . . . treatment within a month or so of onset'. The degree to which trigger points are i nvolved i n this, and other chronic pain syndromes is in need of should focus on reduction of sympathetic tone to the extremity. This focused clinical and scientific research. includes correcting cervical, upper thoracic and upper rib dysfunctions. They recommend osteopathic articulation and mobil ization methods involving the whole person. Mense & Simons (200 1 ) sum marize the basic science aspects, and clinical aspects, of RSD. In this summary they state: ASSESSMENT AND TR EATMENT OF T H E • The practitioner, using her contralateral thumb and AN KLE JOINT A N D H I N DFOOT index finger (to the leg being examined), takes hold of the lateral malleolus and glides (translates) it Greenman (1 996) strongly suggests that evaluation and anteriorly and posteriorly while the remainder of the treatment of both the proximal and distal tibiofibular ankle/ heel is held firmly in place by the other hand . joints are necessary before 'addressing the talotibiofibular mortise articulation' . See discussion and treatment • Any restriction in either direction is noted and suggestions for tibiofibular joints on pp. 498-502. compared with the other leg. Testing joint play and mobilizing the talotibiofibular joint Assessment of distraction joint play at the talotibiofibular and subtalar joints, utilizing long-axis extension • As with most paired joints, assessment of the (Fig. 1 4. 1 1 ) dysfunctional side is helped by comparing it with its normal pair, which requires that the 'normal' side be • The practitioner sits on the edge of the table, assessed first. approximately halfway along its length, with her back to the supine patient's torso. • The patient is supine with the practitioner at the foot of the table holding the leg to be evaluated in her • The patient's hip (on the side on which the ipsilateral hand (right leg, right hand) . practitioner is seated) is abducted, externally rotated and flexed to not less than 90°. • The patient's foot should b e quite relaxed and not dorsiflexed in any way. • Additionally the knee is flexed to 90° and hooked around the practitioner's torso (see Fig. 1 4 . 1 1 ) . • The patient's heel should rest in the palm of the hand with the fingers wrapping around the medial aspect. • The practitioner grasps the leg around the ankle so that the webbing of one hand (if this is the patient's

5 1 2 CLIN ICAL APPLICATION OF N M T VOLUME 2 Figure 1 4. 1 1 Practitioner is seated with back to patient in order to the hand which is behind the Achilles tendon, induce long-axis distraction evaluating joint play at the talotibiofibular thereby rocking the calcaneus forward on the talus. and subtalar jOints (adapted from Mennell 1 964). • Then, the [practitioner] pushes backward and downward with the hand that is on the anterodorsal right leg, it will be her right hand) overlays the aspect of the foot to produce the posterior rock of the dorsum of the foot, close to the talus. calcaneus on the talus. • The webbing of the practitioner's other hand overlies • These movements have nothing to do with the Achilles tendon. plantarflexion and dorsiflexion, which must be • Both of the practitioner's thumbs rest on the medial avoided (during this procedure)'. aspect of the calcaneus. • A degree of joint play involving side tilt (medially • The practitioner leans backward (against the posterior aspect of the patient's thigh) in order to and laterally) is also possible when the joints remove soft tissue slack, easing the foot away from (talotibiofibular and subtalar) are fully distracted. the mortise joint (the foot must remain at right angles through ou t ) . • In order to assess joint play, which tilts the calcaneus • A small degree of joint play should be present. If this in a medial direction, the practitioner's thumbs, is absent, repetition of the procedure several times, which lie on the medial aspect of the calcaneus, apply without force, may mobilize joint play. 'pressure laterally upon the calcaneus, tilting the • M ET procedures may be incorporated, in which, subtalar joint open on its medial aspect. This before the attempted long-axis distraction, the patient movement is one of pure tilt of the calcaneus on the is asked to introduce a moderately strong isometric talus and is not simple eversion of the foot at the contraction of the muscles of the ankle joint, resisted subtalar joint'. by the practitioner for 5-7 seconds, before the maneuver is attempted . • In order to assess joint play which tilts the calcaneus in a lateral direction, the practitioner 's fingers (of Medial and lateral joint play tilt between calcaneus and both hands), which lie on the lateral aspect of the talus calcaneus, apply pressure medially upon the calcaneus, while the thumbs are used as a pivot, so Additional, subtle joint play movements are possible tilting the subtalar joint open on its lateral aspect (i.e. during long-axis distraction of the joints, as suggested by the calcaneus tilts on the talus). Mennell (1 964). • 'Holding the foot and leg with the [joint] .. .in a Assessment of the talotibiofibular joint for position at the limit of long axis extension, the anteroposterior glide (joint play) [practitioner] now pushes upward and forward with • The patient is supine with the knee and ankle at 90° and with the sole of the foot resting on the table. • The practitioner stands at the side of the foot of the table, facing the ankle to be assessed, holding the patient's leg just above the malleoli with her left hand and the dorsum of the foot with the other. • The right hand is placed on the dorsum of the foot so that the webbing between index finger and thumb spans the anterior talus, stabilizing this throughout the assessment procedure. • The practitioner 's left hand alternately draws the leg forward and pushes it posteriorly, so inducing anteroposterior glide of the articulating surfaces of the tibia and fibula on the talus (Fig. 1 4 . 1 2) . • There should b e a small degree o f joint play. I f this is absent, repetition of the procedure several times, without force, may mobilize joint play. • MET procedures may be incorporated in which, before the attempted long-axis distraction, the patient is asked to introduce a moderately strong isometric contraction of the muscles of the ankle joint, resisted by the practitioner for 5-7 seconds, before the maneuver is attempted.

THE LEG AND FOOT 513 Figure 14.12 Assessment for anteroposterior glide of the Figure 14.13 Hand and leg positions for eliciting pure dorsiflexion talotibiofibular joint. and plantarflexion of the talotibiofibular joint (after Menne\" 1 964). Testing and mobilizing restricted joint play at the distal • The patient is supine, with hip flexed and the knee talocalcaneal (subtalar) joint and ankle (of the side to be tested) both at right angles, with the foot resting on the table surface, on • The patient is supine with the practitioner at the foot the heel ( 'the postero-inferior angle of the calcaneus'), of the table, holding the anterior ankle area on the with the sole of the foot unsupported. side to be evaluated in her ipsilateral hand (right leg, right hand) which is oriented to span the anterior • The practitioner is at the foot of the table and, with foot so that the webbing between thumb and index one hand, holds the anterior aspect of the leg, finger overlays the neck of the talus, stabilizing it. approximately 15 cm (6 inches) proximal to the ankle joint, while placing the flat of her other hand against • A 90° angle should be maintained between foot and the sole of the foot to offer it support and to maintain leg as the contralateral hand holds the calcaneus and it in an unchanging plane during the subsequent introduces glide movements of the calcaneus, under procedures. the talus, in posterolateral and anteromedial directions. • The hand holding the leg exerts a series of long-axis movements, caudad and cephalad, along the shaft • The quality of joint play on both sides should be (long-axis) of the tibia, which lightly rocks on the heel compared. support, 'thereby producing plantarflexion and dorsiflexion of the foot at the mortise joint' (Fig. • If restriction is noted in either direction, repetitive 14.1 3). rhythmical springing of the talus at the end of its range should restore normal joint play. • Mennell states that: 'If these movements are full, free and painless, there is obviously no pathological • Alternatively, generalized isometric contractions, condition of this [talotibiofibular] joint' . involving the patient contracting the muscles of the foot firmly, for 5-7 second periods, followed by For the subtalar joint the procedure is as follows. repetitive gliding/translating movements, may induce a release. • All elements of the previous (talotibiofibular) test are maintained. However, in order to assess the subtalar Differentiating talotibiofibular from talocalcaneal joint, 'Instead of stopping the plantar-flexion (subtalar) dysfunction movement at its limit, the [practitioner] now pushes through the limit of this movement, thereby Mennell (1 964) insisted that it was important to differ­ producing a rocking of the talus on the calcaneus' . entiate subtalar (talocalcaneal) problems from those involving the talotibiofibular (or as he termed them 'mortise • The movement this produces, Mennell states, is not joint') problems. one of hyperflexion (in a plantar direction), which would only assess discomfort in the anterior For the talotibiofibular joint, the procedure is as ligaments of the ankle joint. follows. • Instead, this test depends for its efficacy on a resistance, or friction, effect between the heel and the

5 1 4 CLIN ICAL APPLICATION OF N M T VOLUME 2 Figure 1 4.1 4 Hand and leg positions for eliciting rocking of the talar • The practitioner sits/squats in front of the patient on the calcaneus to test for subtalar dysfunction (adapted from and supports the plantar surface of the forefoot with MenneIl 1 964). one hand, while placing the webbing between index finger and thumb, of the other hand, against the neck table surface, as the caudally directed push is made of the talus. on the tibia (Fig. 14.14). • Mennell explains: 'This friction force is sufficient to • The easy (unforced) dorsiflexion barrier is engaged stabilize the calcaneus while the talus rocks forward by a combination of hand efforts which upon it. Pain on the performance of this movement simultaneously dorsiflex the foot and apply posterior indicates [dysfunction] giving rise to pain at the force to the neck of the talus. subtalar joint'. • The patient is asked to plantarflex against the Assessment for plantar and/or dorsiflexion restriction at practitioner 's unyielding resistance, for 5-7 seconds, the talotibiofibular joint utilizing no more than 25% of available muscle strength. • The patient sits on the edge of the table with both legs hanging freely over the edge. • On complete relaxation the practitioner takes out slack and engages a new restriction barrier. • The practitioner sits / squats in front of the patient, supporting both feet in her hands. • The process is repeated once or twice more. • The practitioner simultaneously, or separately, MET treatment of plantarflexion assesses and compares plantarflexion. restriction at the talotibiofibular joint • Still supporting the feet, the practitioner places her • The patient is supine with the affected leg extended thumbs onto the anterior surface of the neck of the at hip and knee. talus, on each foot. • The practitioner is at the foot of the table, lateral to • The practitioner moves the feet posteriorly toward the leg to be treated. the table, inducing dorsiflexion at the ankle. • The practitioner cups the patient's heel in her non­ • As this occurs the talus should glide posteriorly and tableside hand, while placing the palm of her the d egree and feel of this movement are compared . tableside hand over the dorsal surface of the foot. • Greenman ( 1 996) notes that there is likely to be • The ankle should be plantarflexed to its easy (non­ tenderness on the side of a palpated talus which fails painful) barrier. to adequately move posteriorly on dorsiflexion. • The patient is asked to dorsiflex the foot ('Try to flex • A muscular cause of restricted dorsiflexion would be your ankle by bringing your toes and the top of your shortness of gastrocnemius and / or soleus. foot toward your knee, against the pressure of my hand, using only about a quarter of your strength'). MET treatment of dorsiflexion restriction at the talotibiofibular joint • The practitioner resists the effort, so inducing an isometric contraction which should be held for • The patient sits on the edge of the table with both approximately 7 seconds. legs hanging freely over the edge. • On complete relaxation, the foot should be taken to its new restriction barrier, without force and the process repeated. P RT treatment of medial (deltoid) ligament dysfunction • Tender points for dysfunction involving the medial ligament are located inferior to the medial malleolus. The area should be palpated and the most sensitive 'point' identified. • The patient is sidelying, affected leg uppermost, flexed at hip and knee, with the distal calf supported by a cushion, with the affected ankle extended over the edge of the table. • The practitioner stands close to the foot facing the side of the table and with the index or middle finger

THE LEG AND FOOT 51 5 of her caudad hand locates and applies pressure to MWM treatment of restricted the previously identified tender point, inferior to the talotibiofibular jOint and for postinversion medial malleolus. The patient is asked to register a s prain score of ' 1 0' for the discomfort noted at the point of pressure. Mulligan ( 1 999) suggests that this joint may display loss • The practitioner holds the patient's calcaneus with of joint play following inversion sprains of the ankle. He her cephalad hand and with this contact induces an describes a slightly different hold, when using MWM, adduction of the calcaneus (inversion of the ankle), from that outlined in the assessment above, although that folding it over the contact finger on the tender point hold is also effective. which should reduce the reported 'pain score'. • Further fine tuning toward a position of ease for the • The patient is supine and the practitioner is at the joint may involve rotation or compression of the foot of the table. ankle, with score reductions indicating that the directions being produced are helpful (and vice • The practitioner applies her contralateral thenar versa ) . eminence to the anterior aspect of the lateral • The final position of maximum ease, once a 70% malleolus, fingers wrapped loosely around the reduction in the original pain has been achieved, is Achilles tendon. held for 90 seconds before returning slowly to neutral. • The other hand is placed so that the thenar eminence lies posterior to the medial malleolus, with fingers PRT treatment of anterior talofibular overlapping posteriorly. ligament dysfunction • The fibula is painlessly glided posteriorly and slightly • The tender point for dysfunction involving the superiorly (along the line of the anterior talofibular anterior talofibular ligament is located approximately ligament) while at the same time the patient is asked 2 cm (0.8 inches) anterior and inferior to the lateral to slowly invert the foot. malleolus, in a slight depression on the talus. The point should be located by palpation. • This movement should be more easily accomplished while the fibula is held in this translation position. • The patient is sidelying, affected leg on the treatment table, flexed at hip and knee, distal fibula supported • If the inversion is painless, the patient is asked to by a cushion, with the affected ankle extended over repeat this 5-1 0 times. the edge of the table. • If the fibular glide is uncomfortable the angle of • The practitioner stands close to the foot facing the pressure on it should be slightly modified. side of the table, and with the index or middle finger of her caudad hand locates and applies pressure to • Mulligan suggests that: 'The repositioning of the the previously identified tender point, inferior and fibula should be undertaken as soon as possible after anterior to the lateral malleolus. The patient is asked an inversion sprain'. He also suggests that taping be to register a score of '10' for the discomfort noted at used to hold the fibula in a posterior / superior the point of pressure. direction for several days, during the period when RICE protocols are being followed and that within • The practitioner holds the patient's calcaneus with 48 hours MWM should be attempted. her cephalad hand and with this contact induces an abduction of the calcaneus (eversion of the ankle). \" MWM for eversion ankle s prains • The reported pain score should decrease markedly In the case of this less common injury, a ventral glide of once the correct angle of eversion is achieved. the fibula is performed while the patient performs repeti­ tions of slow and painless eversions of the foot. • Further fine tuning toward a position of ease for the joint may involve rotation or compression of the COMMON DISORDERS OF THE H I N DFOOT ankle, with score reductions indicating that the directions being produced are helpful (and vice Calcaneal s pur syndrome (and plantar versa) . fasciitis) • The final position o f maximum ease, once a 70% The calcaneal spur syndrome is characterized by the reduction in the original pain has been achieved, is presence of a benign growth extending away from the held for 90 seconds before returning slowly to bone and often extreme heel pain, in the area of the neutral. inferior calcaneus, caused by the pull of the plantar fascia (and sometimes by the insertion of the Achilles tendon)

516 CLINICAL APPLICATION OF NMT VOLUME 2 on the periosteum. There may be no obvious evidence of incomplete, excessive strain involving vigorous activities may cause a break in the cartilage which connects the a heel spur on X-ray (Merck 200 1 ) . Note: A negative X-ray two, as yet non-united bones. Diagnosis is based on the patient's age, the identification of pain along the heel for bone spur is not conclusive, as in the early stages growth centers on the margins of the heel and a history of visual evidence is often minimal. vigorous activity. Warmth and swelling may occasionally be present. The condition cannot be diagnosed Spurs may result from excessive traction on the radiographically. calcaneal periosteum by the plantar fascia. The stretching may lead to pain along the inner border of the plantar Heel pads may be helpful in reducing the pull of the fascia (plantar fasciitis). It is considered that flat feet and Achilles tendon on the heel, as might treatment of the contracted heel cords may contribute to the development triceps surae. Immobilization in a cast is usually required of spurs through increased plantar fascial tension (Merck and recovery may take several months. Subsequent 2001 ). attention should focus on achieving normal muscle tone, strength and length, with particular focus on the • If there i s n o X-ray evidence of a spur, pain in this individual's gait cycle, with use of rehabilitation exercises region may be the result of active trigger points (for to counteract the compensation habits acquired during example, from quadratus plantae or soleus) (Travell immobilization. & Simons 1 992). Posterior Achilles tendon bursitis • A bursa may develop and become inflamed (inferior (Haglund's deformity) calcaneal bursitis), in which case the heel may start to throb and become warm. Assessment: firm thumb This condition, which occurs mostly in young women, pressure onto the center of the heel will evoke a involves an inflamed bursa overlying the Achilles tendon painful response. attachment, commonly resulting from variations in heel position and function and inappropriate footwear. Merck • If pain is reported when firm digital pressure is (2001 ) state: applied along the inner border of the fascia with the ankle in dorsiflexion, plantar fasciitis is probable. The heel tends to function in an inverted position throughout Manual release of triceps surae and plantaris may be the gait cycle, excessively compressing the soft tissue between helpful. the posterolateral aspect of the calcaneus and the shoe counter (the stiff, formed heel portion). This aspect of the calcaneus • Differential diagnosis is necessary to distinguish becomes prominent, can be palpated easily and often is simple fasciitis and calcaneal spur from ankylosing mistaken for an exostosis. spondylitis, Reiter's syndrome, rheumatoid arthritis and gout, any of which might involve moderate-to­ Early signs include increased redness and induration, severe inflammation and swelling. Differential often 'protected' by adhesive tape to ease shoe pressure. diagnosis may require scan, X-ray and blood test If the inflamed bursa enlarges, a painful red Ilill1p develops evidence. over the tendon. In time, the bursa may become fibrotic. First aid involves the RICE protocol and introducing mild Treatment might involve foam rubber or felt heel pads, antiinflammatory strategies (see Chapters 6 and 7). in order to elevate the heel (as well as padding around Treatment may involve methods which release excessive the bursa initially), plus ensuring that shoe pressure is tension in the plantarflexors and fascia and deactivate minimized. Use of an orthotic to prevent abnormal heel associated trigger points. Attention should also focus on motion may also be helpful. Antiinflammatory medication achieving normal muscle tone, strength and length, with offers short-term benefit only. Medical treatment might particular focus on the individual's gait cycle, with use of involve infiltration of a soluble corticosteroid to ease rehabilitation exercises to counteract any compensation inflammation. Excision of the posterolateral aspect of the habits acquired during periods of pain. Orthotic control calcaneus is sometimes suggested by surgeons, in severe and strapping may be useful in rehabilitation. Short-term recurrent cases. use of NSAID medication and, in extreme circumstances, steroid injections and / or surgery may be called for. Adjunctive care should include ensuring normal muscle tone, strength and length, with attention to the gait cycle, E piphysitis of the calcaneus (Sever's with use of rehabilitation exercises to counteract the disease) compensation habits which may have been acquired. When inflammation is active, hydrotherapy and nutritional This condition involves painful cartilage break in the heel, strategies, as outlined in Chapters 6 and 7, may be useful affecting children. for symptom relief. Usually, before age 1 6, when ossification of the calcaneus (which develops from two centers of ossification) is

THE LEG AND FOOT 51 7 Anterior Achilles tendon bursitis (Albert's tendon stress, may help. Careful stretching is necessary disease) and diligent warm-up protocols should be followed if active exercise is continued. There remains a risk of tendon The bursa, which lies anterior to attachment of the rupture. If this occurs pain may be marked and there will Achilles tendon to the calcaneus, may become inflamed be an inability to stand on tiptoe on the injured foot. due to injury or in association with inflammatory arthritis. Surgery or a cast is required. Any massage applied should It would be aggravated by anything which added strain be careful to avoid actively inflamed tissue but manual to the Achilles tendon, including inappropriately high or lymphatic drainage and gentle massage and stretching of rigid shoes. healing tissue (after the first 2 weeks or so) may reduce Symptoms may arise suddenly in case of trauma, whereas · if the bursa is being irritated by a systemic scar tissue formation. problem, such as arthritis, a slow evolution is likely. Swelling and heat, together with pain, will be noted in Posterior tibial nerve neuralgia the retrocalcaneal space. Walking and tight shoes are likely to aggravate the symptoms, which over time extend The posterior tibial nerve passes through a canal at the medially and laterally, beyond the area anterior to the level of the ankle, where it divides into the medial and tendon . lateral plantar nerves. Fibroosseous compression of the nerve within the canal (tarsal tunnel syndrome), synovitis Differential diagnosis is necessary to distinguish involving the flexor tendons of the ankle or inflammatory bursitis from a fractured posterolateral tubercle (see below) arthritis creating pressure on the nerve may all induce or degenerative changes to the calcaneus (as may occur in neuralgia. If swelling accompanies the neuralgia its rheumatoid arthritis). These conditions would be con­ source should be established (venous, inflammatory, firmed by X-ray, whereas the bursitis is characterized by rheumatic, traumatic, etc.). warmth and swelling contiguous to the tendon, with pain noted mainly in the soft tissues. Rest and hydrotherapy Symptoms include pain (sometimes of a burning or may offer relief but when inflammation is severe, an tingling nature) in and around the ankle, which com­ intrabursal injection of a soluble corticosteroid is commonly monly reaches the toes. The pain is worse on walking helpful. Subsequent attention should focus on achieving (and sometimes on standing) and eased by rest. normal muscle tone, strength and length, with particular focus on the individual's gait cycle, with use of rehabi­ When the nerve is irritated, tapping or applying light litation exercises to counteract the compensation habits pressure to the posterior tibial nerve below the medial acquired during immobilization. malleolus, at a site of compression or injury, often produces distal tingling (Tinel's sign). Confirmation of the Achilles tendinitis and rupture (Clement 1984, diagnosis of posterior tibial nerve neuralgia is by electro­ diagnostic testing. Rolf & Movin 1 997, Teitz et al 1 997) Treatment is commonly by means of strapping the foot Athletic overuse, change of terrain such as unaccustomed into a neutral or slightly inverted position or may involve running up hill, a sudden increase in distance covered or the wearing of orthotic supports which maintain inversion, the wearing of inappropriate shoes can all cause extreme so reducing tension on the nerve. If there is no neural stress to the Achilles tendon. Tendinitis is characterized compression within the canal, corticosteroid injections or, by persistent pain and swelling and often by grating or in severe unremitting cases, surgery may be suggested. crackling sensations as the ankle is moved into flexion Subsequent attention should focus on achieving normal and extension. muscle tone, strength and length, with particular focus on the individual's gait cycle, with use of rehabilitation There may be clinical evidence of inflammation (redness, exercises to counteract the compensation habits acquired swelling, etc.) without histological evidence, in which during immobilization. case the correct term is tendinosis rather than tendinitis. Tendinosis may be related to localized areas of diminished THE MIDFOOT blood supply just above the tendon insertion and may remain subclinical until a rupture occurs. Heel cord The foot can be divided into three functional segments: contractures may be present. Training errors in adults in the hindfoot {calcaneus and talus), the rnidfoot (navicular, their 30s and 40s, most commonly associated with runign , cuboid and three cuneiforms) and the forefoot (five are major contributory features. metatarsals, 14 phalanges and two sesamoids). These segments interact to create a multitude of movement Antiinflammatory strategies (RICE, etc.) are called for possibilities. The talocrural (ankle) joint and the talo­ as well as avoiding undue pressure on the tendon. Use of calcaneal (subtalar) joint, constituting the ankle and cushioned shoes, and sometimes raising the heel to ease hindfoot, have been discussed. The complex components

51 8 CLINICAL APPLICATION OF NMT VOLUME 2 Box 14.5 Common fractures of the ankle and foot Thordarson ( 1 996) reports that some of the most common, and displaced malleolus fractures to guarantee an anatomic reduction. potentially serious, ankle and hindfoot fractures involve the tibial An added benefit of operative treatment in an athlete is a more plafond, malleolus, calcaneus and talus (including osteochondral aggressive, early rehabilitation. Range-of-motion exercises can be lesions). He suggests that many fractures, such as that of the started after wound healing, but compliance with non-weight lateral process of the talus, can be managed conservatively with bearing must be emphasized. casts, but that severe or displaced fractures usually require surgery. Standard rehabilitation protocols typically focus on rest as He further suggests that: well as strengthening and stretching exercises. • Most patients with a malleolus fracture require 6 weeks of Fractures of the ankle and hindfoot usually occur as the result of immobilization. a traumatic episode whereas chronic injuries, such as stress fractures, are more likely in the midfoot and forefoot (and the leg). • Patients with a displaced ankle fracture that has undergone McBryde ( 1 976) reported that 95% of all stress fractures in successful closed reduction will typically require 2 to 4 weeks in athletes involve the lower extremity, with the upper third of the tibia a long-leg cast and then an additional 2 to 4 weeks in a short­ (the site of approximately 50% of all stress fractures seen in leg nonwalking cast. adolescents), the metatarsals and the fibula also being common sites (see notes on stress fracture in Chapter 5). • Patients with an initially nondisplaced fracture or who were treated surgically will generally require 4 weeks of non-weight Adjunctive rehabilitation following most fractures requires bearing in a short-leg cast or removable walking boot, followed application of the methods outlined in this text: normalization of by 2 weeks in a walking cast or boot. The removable boot will joint play, range of motion, muscle balance (involving normalizing allow for earlier range-of-motion exercises. shortness and/or weakness), deactivation of trigger points and a combination of toning, stretching and general rehabilitation • In patients treated nonoperatively, follow-up radiographs must be exercises. obtained weekly for the first 2 to 3 weeks following injury to rule out fracture displacement. Ankle fractures • Following fracture healing, patients can begin physical therapy An important initial distinction with ankle fractures is whether the for range-of-motion and strengthening exercises. Most patients malleolus is involved or the more severe tibial plafond (pilon) who sustain a malleolus fracture will miss at least 3 months from intraarticular impaction fracture. most sports, and frequently 6 months or more from impact sports. Tibial piafond fracture Maisonneuve fracture Tibial plafond fractures usually result from a high-energy axial load, such as occurs in a fall from a height or an MVA. Pain would be This serious i njury involves an external rotation injury of the ankle immediate and walking impossible. Assessment demonstrates with an associated fracture of the proximal third of the fibula. This significant swelling with or without deformity. Thordarson ( 1 996) is often misdiagnosed and can result in long-term disability. notes that: 'These fractures - in contrast to malleolus fractures - involve the weight-bearing surface of the plafond and generally Presentation will involve external rotation of the foot and medial require open reduction and internal fixation. Results are frequently ankle pain. Tenderness on palpation will be noted over the deltoid poor despite operative intervention'. ligament and the fracture site. Anyone who reports proximal fibular tenderness after a twisting injury to the ankle should be referred for Malleolus fracture X-rays of the ankle, the tibia and fibula. These are relatively common and can involve the lateral or medial If a fibula fracture is found, an open reduction and internal malleolus or both. The cause is usually an external rotation injury fixation with screws is usual. These are generally removed to the ankle. Accompanying ligament damage is routine, most often 8-1 2 weeks after surgery. of the deltoid ligament and of the anterior and posterior tibiofibular ligaments. There is immediate pain and difficulty in walking. Calcaneus fractures Effusion and bony sensitivity are noted over the fracture site(s), with or without a visible deformity. Malleolus fractures are typically These occur most commonly after high-energy axial loads, classified by the position of the foot at the time of injury or i n frequently during athletic activity, or in association with an avulsion relation t o the level o f the fibular fracture, relative t o the ankle joint. of the Achilles tendon. About three-quarters of calcaneal fractures extend into the subtalar joint (De Lee 1 993). The standard medical treatment for displaced malleolus fractures is closed reduction and casting followed by ice and elevation. Thordarson ( 1 996) notes that: However, Thordarson (1 996) points to some of the hazards relating to the setting of the reduced fracture. Following a fracture, patients have severe heel pain and cannot walk. They have moderate-to-severe hindfoot swelling and If an anatomic reduction is obtained, these fractures can be tenderness on exam. . .any displacement warrants a computed managed with a cast. However, post-reduction radiographs must tomography (CT) scan. Initial treatment for displaced and show that the joint space is symmetric on a mortise view, because nondisplaced intra-articular fractures includes immobilization in a even 1 to 2 mm of displacement of the talus within the mortise can bulky dressing and splint, with ice and elevation to control edema. cause dramatic changes in the contact area and pressures within Most displaced fractures are managed operatively, but these the ankle. One study (Ramsey & Hamilton 1976) demonstrated a patients typically experience residual stiffness of their subtalarjoint 40% decrease in contact area with a 1-mm lateral shift of the talus. that will adversely affect future athletic performance. For Because of this potential for change in the contact area and nondisplaced extra-articular calcaneus fractures, patients wear a pressure in the ankle with an intraarticular fracture, surgeons short-leg cast or walking boot for about 6 weeks. recommend open reduction and internal fixation of persistently When the fracture results from avulsion this usually involves a violent contraction of the gastrocnemius and soleus. This form of calcaneal fracture can usually be managed in a plantarflexed short­ leg cast for 6 weeks followed by physical therapy involving stretching. However, surgery is needed if displacement is significant. (continued overleaf)

THE LEG AND FOOT 51 9 Box 1 4.5 Common fractures of the ankle and foot (cont'd) Talus neck fractures Medical treatment, as for most fractures, is by immobilization in a cast for 4-6 weeks, with standard use of antiinflammatory and These are relatively uncommon and result from trauma involving pain-relieving medication. Rarely, surgery may be necessary. hyperdorsiflexion of the ankle. This might occur in an MVA where Adjunctive care should include ensuring normal muscle tone, the ankle is hyperdorsiflexed by the brake pedal. An extremely strength and length, with attention to the gait cycle. Rehabilitation serious concern relates to the potential complication of avascular exercises should be introduced to counteract the compensation necrosis of the talus. Severe hindfoot pain and moderate-to-severe habits which may have been acquired during immobilization. When edema, tenderness and ecchymosis are the presenting features. inflammation is active, hydrotherapy and nutritional strategies, as The body of the talus may be palpable in the posteromedial ankle outlined in Chapters 6 and 7, may be useful for symptom relief. area. Thordarson ( 1 996) insists that: Fracture of the lateral talar process Displaced talar neck fractures are true surgical emergencies. The fracture must be reduced immediately to minimize the risk of The typical mechanism of this trauma involves acute avascular necrosis or skin slough. The talus has limited hyperdorsiflexion with inversion. The patient will report lateral ankle vascularization; most of its blood supply enters the neck via an pain and effusion and local tenderness will be noted. A lateral anastomotic sling and flows posteriorly A fracture, therefore, X-ray shows a fragment of the lateral process along the inferior disrupts the intraosseous portion of the blood supply, and the aspect of the talus. Surgery may be called for and a short-leg cast greater the displacement, the greater the disruption of the blood for 6 weeks is usual. supply and likelihood of necrosis. Avascular necrosis may lead to collapse of the body of the talus, resulting in arthritic changes that Osteochondral injury of the talus dome necessitate ankle fusion. Even without avascular necrosis, many patients develop a significant degree of subtalar arthrosis or Thordarson ( 1 996) notes that: arthritis, which leads to residual hindfoot stiffness and pain. Treatment for patients who have a nondisplaced talar neck fracture A more common talus injury in sports is an osteochondral fracture typically involves a short-leg nonwalking cast for 6 to 8 weeks of the dome of the talus that results from an inversion injury A followed by range-of-motion exercises. related, chronic condition probably caused by repetitive trauma is osteochondritis dissecans (OCD). . . . it is postulated that the corner Fracture of the posterolateral talar tubercle of the talus fractures as the dome rotates laterally through the mortise . . . If the fragment displaces, they will experience locking or A plantarflexion injury which forces the posterior inferior lip of the clicking. tibia against the talar tubercle may result in fracture. This sort of injury may occur following a sudden jump onto the ball of the foot Examination reveals tenderness over the lateral aspect of the talar or toes, such as may occur in basketball or tennis, or when dome. Radiographs may demonstrate a small flake of bone off the stepping backward and down with force, after standing on a chair. lateral dome of the talus. Patients tend to report a gradual onset of Individuals with elongated lateral talar tubercles seem particularly pain which is activity related. If the fragment displaces, locking may prone to this injury (Merck 2001 ). occur. Treatment may involve arthroscopy (see Box 1 3.2 and notes in Box 1 4.3) or other forms of surgery and the use of a cast for 6 Signs and symptoms include pain and swelling behind the ankle, weeks. Patients are cautioned to avoid weight bearing for 6 weeks with difficulty walking downhill or downstairs. There may be while fibrocartilage is forming, although range-of-motion exercises unremitting swelling, but obvious inflammation is seldom more than should be performed. mild. Pain is brought on by the action of plantarflexion, while dorsiflexion of the large toe may also aggravate the pain. The diagnosis is confirmed by means of a lateral X-ray. of the talocalcaneonavicular joint (TeN) are considered Talocalcaneonavicular (TeN) joint independent of the transverse tarsal (or midtarsal) joint, a compound joint composed of the talonavicular and The talonavicular joint is the most anterior part of a more calcaneocuboid joints. The tarsometatarsal joints and complex joint, the talocalcaneonavicular (TeN) joint (Fig. interphalangeal joints, collectively known as the forefoot, 1 4 . 1 7) . Like the subtalar joint, it is a triplanar joint add to the elaborate structure of the foot (Figs 1 4. 1 5, producing simultaneous movements across longitudinal, 14.16). vertical and horizontal axis (supination/ pronation, inversion/ eversion). Because the TeN joint is a compound The transverse tarsal joint, also known as the mid­ joint, having several articular surfaces in different planes, tarsal joint, transects the foot to divide the hindfoot from any movement produced by the talus results in mandatory the midfoot (see Fig. 14. 1 8) . This 'S'-shaped compound motion at each of these surfaces. joint is one of two common sites of amputation of the foot. Though the talonavicular joint is considered as part Levangie & Norkin (2001 ), who describe the TeN as of the transverse tarsal joint (see discussion below), it is the 'key to foot function', skillfully illustrate an interest­ also helpful to consider it as part of a more complex, ing view with their description of this joint. multiaxial, compound articulation known as the talocal­ caneonavicular joint. The talonavicular articulation is formed proximally by the anterior portion of the head of the talus and distally by the

520 CLIN ICAL APPLICATION OF NMT VOLUME 2 Extensors digitorum longus and b revis --,��Extensor hallucis 10nguS Extensor hallucis brevis --\"-.?!;+:t� r.'--rtm:=.�T1f Dorsal interossei Abductor hallucis --_... Extensor dig ito rum longus ltII.'IOI�-;�r Abductor digiti minimi [Plantar interossei ---t'pf;1�+I Dorsal interossei 1 st --11_-lI{�i'+ 2nd 3rd ---=�fH+!l 4th --J;-.\"�i+tIHl Medial cuneiform ____ ,-_- __ Peroneus tertius I ntermediate cuneiform ___ 'f-- Peroneus b revis Lateral cuneiform -__ '-- Cuboid 1-- Extensor digitorum brevis Tu berosity of Neck of talus --__ Facet for medial malleolus �____ Sustentaculum tali ____ Trochlear su rface ____--' Posterior tubercle of talus --- ,-_____ Calcaneus Plantaris _____---' \"'-______ Tendo calcaneus Figure 1 4.1 5 Dorsal aspect of the bones of the foot (reproduced with permission from Gray's anatomy 1 995). concave posterior navicular. The talar head, however, also All of this is enclosed by a single capsule, hence the articulates inferiorly with the anterior and medial facets of the description of this complex as being a 'joint'. calcaneus and with the plantar ca!caneonavicular [spring] ligament, that spans the gap between the calcaneus and The TeN joint capsule is reinforced by ligamentous navicular below the talar head. Consequently, we can visualize support from the superomedial portion of the cartilage­ the TCN as a ball and socket joint where the large convexity of covered calcaneonavicular ligament (forming a sling for the head of the talus is received by a large 'socket' formed by the head of the talus which articulates with it), the inferior the concavity of the navicular, the concavities of the anterior calcaneonavicular ligament, the medial and lateral and medial calcaneal facets, by the plantar calcaneonavicular collateral ligaments, inferior extensor retinacular struc­ ligament and by the deltoid ligament medially and the tures, cervical ligament and the dorsal talocalcaneal and bifurcate ligaments laterally.

THE LEG AND FOOT 521 ,--. --.-- --,-Flexor digitorum longus ___ __ _ Flexor hallucis longus '--',1t Flexor digitorum brevis E':\"c-\";: Adductor hallucis and flexor hallucis brevis \"Iil',�- Abductor hallucis ---.+ Flexor hallucis brevis Dorsal interossei __��-I'\" -==j���!JUAbductor digiti minimi _Plantar interossei [ 1 st Dorsal interossei 2nd ---H�f ]3rd 4th 1 st ��-,-'-! 2nd Plantar interossei Opponens digiti minimi �I___ '-P.�,\"-},\":;�' 3rd Adductor hallucis, oblique head ___ �--\"-__ Tibialis anterior �:-7--- Peroneus longus = ---, Tibial is posterior !�����LJt ��===-=:- =Flexor digiti minimi brevis ----�J ���F:�'s:. Abductor digiti minimi --.'\\-�s Peroneus b revis ____�\"'.! .\" ::c-'!'--, Plantar calcaneonavicular Flexor hallucis b revis �_____ ligament Short plantar ligament --!-_____ Extensor digitorum brevis ---j I\\'-!�!'!!\"-r Flexor accessorius ---Long plantar ligament Abductor digiti minimi --- IaE�-- Abductor hallucis '*'�-- Flexor digitorum b revis :;;_-'\" Tendo calcaneus Figure 14. 16 Plantar aspect of the bones of the foot (reproduced with permission from Gray's anatomy 1 995). interosseous ligaments. Additionally, it gains support taneous gliding of the talonavicular and calcaneocuboid from related ligaments associated with the adjacent joints. As the medial edge of the foot is lifted (supinated, calcaneocuboid joint. inverted) the talar head rotates on the navicular while cuboid glides down the calcaneus in an opposite Transverse tarsal joint movement. This transverse tarsal movement adds to the supination/pronation ranges occurring as a result of The talonavicular and calcaneocuboid joints together subtalar movement, and allows 'the forefoot to remain flat on the ground while the hindfoot is in varus or form the compound transverse tarsal joint, an '5'-shaped valgus' (Levangie & Norkin 2001). joint which divides the hindfoot from the midfoot (Fig. An important function of this joint is allowing tibial 14.18). Forefoot range of movement in triaxial rotation rotation to be absorbed by the hindfoot, without trans- (supination/ pronation) is thereby increased by simul-

522 CLIN ICAL APPLICATION OF NMT VOLUME 2 1 st metatarsal 5th metatarsal (for large toe) --+- f--I' Dorsal tarsometatarsal ligaments Dorsal intercuneiform ligs. --L:�-\\f' Tuberosity of 5th metatarsal Dorsal cuneonavicular ligs. --=�.tfT-,oIhri '--1HP.;fI Dorsal cuneocuboid ligament Posterior navicular facet (with talus) ---/;IFt.' -H-I-- Cuboid bone Navicular bone I'rftf'--+.f Dorsal calcaneocuboid ligament _�r�Plantar calcaneonavicular ligament Tendon, peroneus brevis muscle Middle calcaneal facet (with talus) --'-+\\1 Anterior calcaneal facet (with talus) Interosseous talocalcaneal lig. Posterior calcaneal facet (with talus) Calcaneus Calcaneal tuberosity Figu re 14.17 The 'socket' of the talocalcaneonavicular joint (adapted from Platzer 1 992). hindfoot and subsequently, through the ankle joint, into the leg, knee and hip. Talonavicular joint On the distal end of the anteriorly protruding neck of the talus is a convex facet which articulates with the concave proximal surface of the navicular bone. The wider talar surface allows for significant gliding, resulting in supination/pronation as the talus moves on the relatively fixed navicular bone. On the navicular's distal surface are three concave surfaces which articulate with three cuneiform bones. Weight is transferred through the talus to the navicular which in turn transfers it to the three cuneiforms. Figure 1 4.1 8 The transverse tarsal joint and the Calcaneocuboid joint metatarsophalangeal joints (adapted from Platzer 1 992). Lateral to the talonavicular joint lies the calcaneocuboid lating these destabilizing forces into the forefoot, a joint where the cuboid is effectively interposed between response which is critical to stability of the gaiting foot. the calcaneus proximally and the 4th and 5th metatarsals The converse is also true, especially when on rough distally. The peroneus longus crosses the cuboid in a terrain. That is, if the forefoot must adjust to a rocky groove on the plantar surface. On the cuboid's medial surface, the transverse tarsal joint absorbs forefoot surface lies an oval facet for the lateral cuneiform and rotation, reducing the translation of these forces into the usually another (proximal medial surface) for the navicular, 'the two forming a continuous surface separated by a smooth vertical ridge' (Gray's anatomy 1 995). Proxi­ mally the cuboid and calcaneus form a complex, obliquely set concavoconvex articular facet. Due to the unique joint

THE LEG AND FOOT 523 shape (see below), movement at this joint is more limited required. However, when the hindfoot is inadequate to than at the talonavicular joint. provide full compensation, the TMT joints may rotate to provide further adjustment of forefoot position. Levangie & Norkin (200 1 ) explain its movements. As the weight-bearing hindfoot moves in inversion and The articular surfaces of both the calcaneus and the cuboid are eversion patterns, the midfoot and forefoot move in the complex, being reciprocally concave/convex across both opposite direction to counterrotate the forefoot, in order dimensions. The reciprocal shape makes available motion at to maintain plantar contact. This compensation usually the calcaneocuboid joint more restricted than that of the ball­ occurs first in the transverse tarsal joint and, if necessary, and-socket-shaped talonavicular joint; the calcaneus, as it further compensation occurs at the TMT joints, including moves at the subtalar joint in weight-bearing, must meet the varying dorsiflexion and plantarflexion of the rays of the conflicting arthrokinematic demands of the saddle-shaped foot. For example, if the calcaneus is inverted surfaces, resulting in a twisting motion. . . . The longitudinal (supinated), the forefoot must produce relative pronation and oblique axes together provide a total range of in order to maintain contact with the ground, otherwise supination/pronation that is one-third to one half of the range the medial aspect would lift from the ground and create available at the TeN joint. instability. Most of the forefoot pronation will occur at the transverse tarsal joint but, if calcaneal movement is Levangie & Norkin (200 1 ) note elsewhere: extreme, then tarsometatarsal joints must also compensate, which may include dorsi- and plantarflexion as well as The TeN joint and the transverse tarsal joint are mechanically rotational movements of the rays about the second toe, linked by the shared talonavicular joint. Any subtalar and commonly referred to as a supination twist (Levangie & therefore TeN, motion must include motion at the Norkin 2001 ) . This rotation about the second ray will talonavicular joint. Because talonavicular motion is increase or decrease the curvature of the anterior arch interdependent with calcaneocuboid motion, subtalar/TeN (Kapandji 1 987). The configuration of the forefoot will motion will involve the entire transverse tarsal joint. As the vary depending upon the surface to which the foot is TeN supinates, its linkage to the transverse tarsal joint carries adjusting. the calcaneocuboid with it via the talonavicular joint. The arches of the foot Full supination results in both TeN and transverse tarsal joints being placed in a locked, close-packed position, The midfoot region of the foot is usually associated with while pronation results in both joints being loose packed the arch system. Although the arches truly span over and mobile. almost the full length of the foot, dysfunction of the medial longitudinal arch is usually most visible in the midIoot Tarsometatarsal (TMT) joints region. The arches are fully discussed in Box 1 4.6. The tarsometatarsal joints, composed of the articulation COMMON DISO R DERS OF T H E MI DFOOT of the distal surface of the three cuneiforms and cuboid with the bases of the five metatarsals, have varying Pes planus (flat foot) mobility (least mobile is the second metatarsal) and some If the medial longitudinal arch is lost this is known as pes shared capsules (2 and 3 share, 4 and 5 share). planus. It can be flexible or rigid. Mechanically this may occur because of hyperpronation or from increased In the medial column, the navicular articulates with eversion of the subtalar joint. This leads to the calcaneus the three wedge-like cuneiform bones, which in turn arti­ lying in valgus and external rotation relative to the talus. culate with the first three metatarsals. Laterally, the It is most noticeable in the midfoot region where associ­ cuboid articulates directly with the last two metatarsal ated sagging of the midfoot may be due to dorsal bones. The cuneiform bones wedge together to form a subluxation of the navicular on the talus (Staheli et al transverse arch (see Box 1 4.6). Additionally, the medial 1 987). and lateral cuneiforms project distally beyond the middle one, which forms a recess for the second metatarsal base The incidence of pes planus is approximately 20% in and stabilizes it against motion. adults, the majority of which are flexible. Flat feet are not necessarily uncomfortable, as long as there is no heel The articular surfaces with adjoining metatarsals allow cord contracture, but flat feet associated with heel cord a little movement between them. Stability is reinforced by contracture may limit function and lead to discomfort numerous ligaments, including the deep transverse meta­ when walking. Heel cord contracture is associated with tarsal ligament, which helps prevent splaying (Levangie lateral deviation of Achilles when weight bearing (Staheli & Norkin 2001 ). et al 1 987). The function o f the TMT joints i s t o continue the move­ ments of the transverse tarsal joint when needed, while retaining ground contact of the forefoot. Levangie & Norkin (2001 ) note: As long as the transverse tarsal joint motion is adequate to compensate for the hindfoot position, TMT joint motion is not

524 CLINICAL APPLICATION OF NMT VOLUME 2 Box 1 4.6 The plantar vault The plantar vault is a structure which uses concepts of triangular AC equilibrium, with the anterior aspect of the triangle being a 'floating' component, which is bound somewhat at the posterior tarsus. The Figure 1 4. 1 9 The plantar vault from a medial perspective, with its vault provides a dynamic component to the gaiting foot while three support points occurring at the calcaneus and the first and functional arches act as elastic shock absorbers. Unless exercised fifth metatarsal heads (reproduced with permission from Kapandji on actual ground surfaces (beaches, rocky slopes), the ability of the 1 987). arches to 'hollow' and to adapt to ever-changing terrain is often lost to the town dweller, who almost always walks on even, firm ground. Talus Regarding the plantar vault, Kapandji (1 987) eloquently states: Navicular Cuneiform (medial) The plantar vault is an architectural structure which blends all the elements of the foot -joints, ligaments and muscles - into a unified 1 st Metatarsal system. Thanks to its changes of curvature and its elasticity, the vault can adapt itself to uneveness of the ground, and can transmit 12 C to the ground the forces exerted by the weight of the body and its Ab. H L Calcaneus movements. This it achieves with the best mechanical advantage under the most varied conditions. The plantar vault acts as a shock­ Figure 1 4.20 The medial longitudinal arch. A: first metatarsal absorber essential for the flexibility of the gait. Any pathological contact; C: calcaneal contact; PL: peroneus longus; TP: tibialis conditions, which exaggerate or flatten its curvatures, interfere posterior; FHL: flexor hallucis longus; Ab HL: abductor hallucis seriously with the support of the body on the ground and necessarily longus; 1 : plantar calcaneonavicular ligament; 2: talocalcanean with running, walking and the maintenance of the erect posture. ligament; 3: tibialis posterior attachment which blends with plantar ligaments (reproduced with permission from Kapandji 1 987). The plantar aponeurosis, which arises from the plantaris muscle (Cailliet 1 997), provides a substantial structural component for the plantar vault of the foot. Levangie & Norkin (2001 ) simplify this concept. The function of the aponeurosis has been likened to the function of a tie-rod on a truss. The truss and the tie-rod form a triangle; the two struts of the truss form the sides of the triangle, and the tie-rod is the bottom. The talus and calcaneus form the posterior strut and the anterior strut is formed by the remaining tarsal and the metatarsals. The plantar aponeurosis, as does the tie-rod, holds together the anterior and posterior struts when the body weight is loaded onto the triangle. The struts in weight-bearing are subjected to compression forces, while the tie-rod is subjected to tension forces. Increasing the load on the truss, or actually causing flattening of the triangle, will increase tension in the tie-rod. The functional anatomy of the foot is commonly described in terms of its longitudinal and transverse arches, which help compose the 'vault'. (Fig. 1 4. 1 9). The longitudinal arch (or curve) can be divided into medial and lateral constituents and is accompanied by a transverse curvature. The medial longitudinal ('spring') arch has bony components composed of the calcaneus, talus, navicular, the cuneiforms and the first three metatarsals (Fig. 1 4.20). This arch is designed to transmit and absorb force. Gray's anatomy (1 995) summarizes: [ The arch 's] summit is at the superior talar articular surface, taking the full thrust from the tibia and passing it backwards to the calcaneus, forwards through the navicular and cuneiforms to the metatarsals. When the foot is grounded these forces are transmitted through the three metatarsal heads and calcaneus (especially its tuberosity). The medial longitudinal arch is higher, more mobile and resilient than the lateral and as it flattens there is a progressive tightening of the plantar calcaneonavicular ligament and plantar fascia. Active support of the medial arch is primarily supplied by tibialis posterior, the tendon of which has attachments on the navicular, first cuneiform and the bases of the second, third and fourth metatarsals, the peroneus longus, flexor hallucis longus, flexor digitorum longus and abductor hallucis longus. The lateral longitudinal arch comprises the calcaneus, cuboid and the fourth and fifth metatarsals (Fig. 1 4. 2 1 ) . This arch is low, has limited mobility and is designed for transmission of force to the walking surface rather than for the absorption of weight and thrust (Gray's anatomy 1 995, Schiowitz 1 991 ). Muscles acting to tighten it include peroneus brevis, peroneus longus and abductor digiti minimi. (continued overleaf)