Clinical Applications of Neuromuscular Techniques The Lower Body Volume 2

THE LEG AND FOOT 525 Box 1 4.6 The plantar vault (cont'd) PB Arches 5th Metatarsal �nODACuneiforms UbOid_.._. �T_ ars:a:l _.!: -+'-+- --+--_-t 4::-- ,- Figure 1 4.21 The lateral longitudinal arch. B: fifth metatarsal Posterior contact; C: calcaneal contact; PL: peroneus longus; PB: peroneus metatarsal brevis; Ab 5: abductor digiti minimi; 4: long plantar ligament deep; 5: long plantar ligament superficial; 6: peroneal tubercle of --08- 00-8- Anterior calcaneus (reproduced with permission from Kapandji 1 987). The transverse arch is best described as an almost full-length Figure 1 4.22 The 'vaulted' appearance of the foot is i n part due transverse curvature of the tarsals and metatarsals, giving a to an almost full-length transverse curvature of the tarsals and 'vaulted' appearance to the foot. It can be examined at several metatarsals. The degree of transverse arching will vary at different locations along its length (Fig. 1 4.22). The flexible anterior aspect points of the foot, as shown here by considering the metatarsal includes the metatarsal heads. The fixed metatarsal arch includes heads, metatarsal bases and the tarsals (adapted from Cailliet the bases of the metatarsals. The fixed tarsal arch includes the 1 997). cuboid and the cuneiforms, resting on the ground only at the laterally placed cuboid while the neighboring navicular is 'slung above the Gray's anatomy ( 1 995) observes that: ground and overhangs the medial surface of the cuboid' (Kapandji 1 987). The muscular support for the transverse arch includes The human foot, alone among primates, is normally arched in its peroneus longus (which acts on all three components of the arch skeletal basis, usually with visible concavity in the sale. The word system), adductor hallucis running transversely and tibialis posterior 'arch' so applied has perhaps become too architectural, imposing which runs obliquely anterolaterally. rigidity on classical descriptions of curved pedal form and differences of interpretation more linguistic than factual. The word The intrinsic muscles are significant contributors to the muscular has several meanings and doubtless 'arches of the foot' has support of the arches. Their line of pull lies essentially in the long various implications. As a start, at simplest, the term implies little arch of the foot and perpendicular to the transverse tarsal joints; more than a curved form, concave on the plantar aspect. Such an thus they can exert considerable flexion force on the forefoot and arch should not be compared with static masonry, with pediments are also the principal stabilizers of the transverse tarsal jOint. on terra firma and an intermediate keystone structure. The pedal arch is dynamic; muscles and ligaments are functionally Regarding the arches, though there are some shared inseparable. Moreover, its heel is often off the ground. In this philosophies, there is little agreement, especially concerning the account, therefore, 'arch ' denotes no more than curved form, just 'transverse arch'. as the back is merely curved when 'arched'. • Schiowitz ( 1 991 ) suggests that although: 'many authors It should be borne i n mind that the plantar vault, whether describe a number of transverse arches, with the exception of the considered as a twisted osteoligamentous plate (Gray's anatomy metatarsal heads, these arches do not transmit force to the ground'. 1 995, Levangie & Norkin 200 1 ) or as an architectural wonder, is an integral component of whole-body health, its influences being felt • Gray's anatomy ( 1 995), in partial agreement with Schiowitz, both locally and throughout the body. The health and integrity of states that: 'Apart from the metatarsal heads and to some degree this dynamic system should be a priority component of most along the lateral border, the transverse arches cannot transmit therapeutic interventions. forces, though subjacent soft tissues do; medially, only the metatarsal heads can do so'. • Regarding the anterior metatarsal transverse arch comprising the five metatarsal heads, Greenman ( 1 996) suggests that: 'The metatarsal arch is not a true arch, but refers to the relation of the heads of the five metatarsals'. He notes that restrictions of the metatarsal heads are usually secondary to dysfunctional patterns involving the other arches of the foot and are likely to be associated with soft tissue changes, especially involving the plantar fascia (see below). Joint play here includes dorsal and plantar glide, as well as rotation (Greenman 1 996) . If restriction is noted it is commonly between the second and third metatarsals, with associated tenderness in the interosseous musculature.

526 CLINICAL APPLICATION OF NMT VOLUME 2 Evidence suggests that flat feet protect against meta­ tarsal stress fractures but the feet offer poor shock absorption with regard to the lower back, leading to a higher incidence of low back pain. In contrast, a cavus foot (high arch) may actually be somewhat protective of stress-rela ted low back pain (Ogon 1 999). It is important to distinguish between flexible flat foot and rigid (or spastic) flat foot. Surgical intervention is only called for if there is a rigid flat foot (seldom in flexible flat foot) and only when pain, deformity (midfoot breakdown) or severe contracture are factors. A small number of flexible flat feet do not correct with growth and eventually become rigid due to adaptive changes (Lau & Daniels 1 998). Conservative treatment Figure 1 4.23 The toes are stabilized against the supporting su rface as the resulting rigid lever rotates around the oblique metatarsal break Wenger et al ( 1 989) suggest that, since flexible flat foot is (MTP axis) (adapted from Levangie & Norkin 200 1 ) . generally a benign condition, it rarely requires treatment. If there are problems associated with heel cord shortening, contribute t o supination which creates a locking o f the stretching should be the main treatment. It is important hindfoot and midfoot. The resulting rigid lever rotates when stretching to ensure that the foot is supinated in around the oblique metatarsal break (MTP axis) (Fig. 14.23) order to avoid worsening midfoot collapse. as the toes are stabilized against the supporting surface. Levangie & Norkin (200 1 ) explain: Wenger et al suggest that in most cases orthotics do not change osseous relationships and are ineffective. They go If the body weight passed forward through the foot and the further and indicate that arch supports may actually foot lifted around a coronal MTP axis, an excessive amount of make the patient's symptoms worse, unless and until heel weight would be placed on the first metatarsal head, and on cord shortening is relieved. the long second metatarsal. These two toes would also require a disproportionately large extension range. The obliquity of It is also suggested that in some cases, patients with a the metatarsal break shifts the weight laterally, minimizing the calcaneovalgus deformity can normalize their weight­ large load on the first two digits. bearing pattern by using a medial heel wedge. This should be distinguished from calcaneovalgus dysfunction The phalanges are hinge joints and are limited to for which a heel wedge couId be detrimental. flexion and extension, with flexion being considerable and extension being limited. These movements are accompanied THE FOREFOOT by slight associated rotation (see Box 14. 1 1 for toe movements). The metatarsophalangeal (MTP) joints and the inter­ phalangeal OP) joints of the foot are identical to those The toes, though capable of grasping, are primarily found in the hand (Kapandji 1 987), descriptions of which used to 'dynamically balance the superimposed body can be found in Volume 1 of this text. Each MTP joint is weight' as it passes over them (Levangie & Norkin 2001 ). composed of a convex metatarsal head articulating with While the structure of the toes is very similar to that of a shallow phalangeal 'socket' which allows for flexion, the fingers, their functional design is geared toward (considerably more) extension and some abduction and pressing into the supporting surface during gaiting rather adduction. than grasping. The metatarsal length has an unusual arrangement, with the 2nd metatarsal being longest, followed by the 3rd, 1 st, 4th and 5th. This arrangement places the collec­ tive group of the joints on an oblique axis. As a group, the MTP joints allow a hinge-type motion of the foot across this oblique line (termed the metatarsal break) as the heel is raised from the supporting surface by active contraction of the plantarflexors. As these muscles contract, they

THE LEG AND FOOT 527 Sesamoid bones of the lower extremity Morton's neuroma is widely suggested to result from loss of the fat pad protecting the interdigital nerves of the Non-articular sesamoid bones or cartilages are frequently foot. H owever, Waldecker (200 1 ) used sonography to found in the lower limb and bursal arrangements may measure the plantar fat pad and found that neither the frequency nor intensity of metatarsalgia correlated with a also occur at such sites (Gray's anatomy 1 995) . Those decrease of the thickness of the plantar fat pad under the second metatarsal head. Low-grade repetitive trauma or muscles in the lower limb in which these minute bones improper footwear are more likely contributing factors. A are commonly found include: gradual persistent benign thickening and enlargement of the perineurium of one (or, less commonly, two or more) • peroneus longus at the cuboid bone of the interdigital nerves of the foot occurs. In the early • tibialis anterior at the medial cuneiform bone stages, patients may complain of only a mild ache in the • the tendon of tibialis posterior on the medial side of ball of the foot. Diagnosis is primarily based on the history and physical exam which should include associ­ the talar head ated trigger points which refer into this region. • lateral part of gastrocnemius posterior to the lateral Palpation of the plantar aspect of the metatarsal inter­ femoral condyle space (proximal to metatarsal heads) may cause tenderness • tendon of psoas major at its ilial contact and reproduce symptoms. Thumb pressure applied • tendon of gluteus maximus at the greater trochanter between the third and fourth metatarsal heads elicits • in tendons deflected by the malleoli. pain when a 'neuroma' is present. Symptoms may be aggravated by squeezing compression of the forefoot. In COMMON DISORDERS OF THE FORE FOOT a very few cases, the nerve enlargement is palpable. If the condition involves simple interdigital neuralgia (without Metatarsalgia a perineural fibrosis) it usually resolves fairly quickly with proper shoes and insoles (Merck 2001 ). This is a collective term used to describe pain in the region of the metatarsal heads. Since causes could be Alleviation of pain vascular, avascular, mechanical or neurogenic, a careful comprehensive evaluation is in order (Cailliet 1 997) . • Hamilton's (1994) advice to patients is 'don't do what Some of the most common causes include the following. hurts, until it doesn't hurt to do it any more' Mechanical • Wider shoes with lower heels to reduce metatarsal head pressure. Pronation of the foot which results in a valgus position of the hindfoot and a resultant splaying of the forefoot. This • Soft metatarsal pads to reduce forefoot pressure or places unacceptable degrees of pressure on the middle pads placed just proximal to the metatarsal heads. three metatarsal heads, ultimately causing the formation of calluses, which further aggravate the pressure site • Metatarsal bar to shift pressure proximally or rocker­ (Cailliet 1 997). bottom sole. Neurogenic • Stiff-soled shoes may decrease pain, due to limitation of MTP extension during the toe-off phase. Morton's neuroma (Frey 1 994, Hamilton 1 994, Johnson 1 994) is a neuralgia of an interdigital nerve resulting from • Total-contact orthosis helps to transfer pressure into compression by a metatarsophalangeal joint. Also known the longitudinal and metatarsal arches. as interdigital perineural fibrosis or interdigital nerve pain, this condition, which is most common in middle­ Treatment A variety of surgical approaches are used aged women, is not, as it is often termed, a neuroma but to treat Morton's neuroma, with approximately 80% of a perineural fibrosis associated with a type of nerve com­ results considered 'successful' and about 20% producing pression syndrome involving the common digital nerves very poor outcomes (Johnson 1 994) . Contraindications of the lesser toes, most often the third (80-85%) and less (as with most forms of foot surgery) include poor circu­ often the second ( 15-20%) interspace (interdigital neuromas latory status, diabetes mellitus, reflex sympathetic do not occur in the first and fourth web spaces). Symp­ dystrophy, atypical symptoms and hysterical personality. toms include burning and tingling down the interspace of the involved toes, made worse by walking in high­ Morton's syndrome heeled shoes and relieved by rest and removing the shoe. In some cases the pain will radiate to the toes or vague Morton's syndrome, as described by Dudley Morton, is pains may radiate up the leg. not to be confused with Morton's neuroma (see above), as described by Thomas G Morton (Cailliet 1 997). Morton's syndrome is due to the presence of a short first metatarsal which results in excessive weight bearing by the second

528 CLIN ICAL APPLICATION OF NMT VOLUME 2 metatarsal. Cailliet (1 997) describes this condition as ' ( 1 ) Gout an excessively short first metatarsal, which is hyper­ mobile at its base where it articulates with the second Gout is a disorder of purine metabolism, characterized by metatarsal and the cuneiform; (2) posterior displacement raised blood uric acid levels which result in deposition of of the sesamoids; and (3) a thickening of the second crystals of sodium urate in connective tissues and articular metatarsal shaft'. Because of stress on the ligaments, cartilage. Severe recurrent acute arthritis often presents capsules and muscles that bind the second metatarsal as pain in the first metatarsal. with the cuneiform, its base also becomes hypermobile. Travel! & Simons (1 992) note extensive compensational Hallux rigidus patterns associated with a long second metatarsal and describe an examination for its presence as well as patterns See also notes on functional hallux Iimitus (FHL) below of callus development associated with the condition. (Mulier 1 999, Shefeff & Baumhauer 1 998) . Hallux valgus Hallux rigidus results from degenerative changes at the first MTP joint. Hallux valgus describes a deviation of the tip of the great toe toward the outer or lateral side of the foot. The bursa • There is limitation of motion and pain at the MTP which is located on the medial aspect of the first meta­ joint of the great toe, secondary to repetitive trauma tarsal head may become inflamed (usually due to rubbing and degenerative changes involving new growth of on the shoe), resulting in the formation of a bunion. There bone around the dorsal articular surface of the first may be pain, crepitus and either restrictive or excessive metatarsal head. mobility, which ultima tely affects gaiting mechanics. • Because the great toe has limited dorsiflexion, push­ Bunion off during ambulation can be painful. A bunion is a painful bursa, which has responded to • Examination demonstrates decreased ROM, repeated pressure and friction by forming a thickening of especially involving dorsiflexion. its wall. Treatment should include removal of pressure by correction of deviant foot mechanics which led to its • X-ray shows joint degeneration. formation. Although bunions most commonly occur at • Surgical treatment may involve removal of bone the first metatarsophalangeal joint, a tailor's bunion may be noted at the fifth metatarsal, often associated with spurs although this is seldom sufficient for pain pressure created on the lateral aspect of the foot by relief. crossing of the ankles. • More commonly, cheilectomy is performed in which not only the dorsal spur but also the dorsal third of Calluses and corns the metatarsal head is removed. This is claimed to give long-term pain relief in most patients. If this fails Calluses and corns are natural responses of the skin to arthrodesis is suggested (Mulier 1 999). external pressure applied against an underlying bony • Surgeons suggest that mobilization of the toe should surface. Abnormal foot mechanics are usually the cause be initiated soon after surgery. of the conditions and must be addressed if treatment is to • Non-operative treatment includes the use of molded be successful. Neurovascular corns may be very tender stiff inserts with a rigid bar or rocker-bottom shoe. and painful and are best addressed by a podiatric specialist. The widespread negative influences of FHL (see immedi­ Plantar warts ately below) suggest that additional musculoskeletal symptoms of patients with hallux rigidus may benefit Plantar warts are not usually found over bony pro­ from any functional improvement it may be possible to minences and do not usually develop from pressure. deliver for this structure, via surgery or any other means. Their cause is consid ered to be viral and treatment varies depending upon the type of wart. Since they may be Functional hallux limitus (FHL) contagious, gloves are recommended during examin­ ation of a foot which has a suspicious wart-like growth. FHL describes limitation in dorsiflexion of the first MTP joint during walking, despite normal function of this joint when non-weight bearing (Dananberg 1 986). The wide­ spread adaptive and dysfunctional patterns which flow from FHL demonstrate how imbalances in foot mechanics can affect the rest of the body (see discussion in Chapter 3 regarding FHL and bodywide postural and functional problems and also below). These potentials may emerge just as effectively from hallux rigidus as from FHL.

FHL limits the rocker phase, since first MTP joint THE LEG AND FOOT 529 dorsiflexion promotes plantarflexion of the foot. If plantarflexion fails to occur, there will be early knee joint Box 14.7 Assessment of functional hallux limitus (FHL) flexion prior to the heel lift of the swing limb, which also reduces hip joint extension of that leg. 'The reduced hip • The patient is seated. extension converts the stance limb into a dead weight for • The practitioner places her right thumb directly beneath the swing, which is exacerbated by hip flexor activity . . . resulting in ipsilateral rotation of the spine, stressing the right first metatarsal head. intervertebral discs' (Prior 1 999). • Pressure is applied toward the dorsal aspect of the foot, Vleeming et al ( 1 997) note that: 'FH L . . . because of its mimicking floor pressure when standing. asymptomatic nature and remote location, has hidden • The practitioner places her left thumb directly beneath the itself as an etiological source of postural degeneration'. They also observe that: 'FHL is a unifying concept in right great toe interphalangeal joint (see Fig. 3. 1 5) and understanding the relationship between foot mechanics attempts to passively dorsiflex the toe. and postural form . . . identifying and treating this can • A failure of dorsiflexion of between 20° and 25° suggests have a profound influence on the chronic lower back pain FHL. patient' (see Fig. 3 . 1 3 as well as Table 3.3). and/or Assessment and treatment protocols for FHL are to be found in Chapter 3. For a summary see Box 1 4. 7. • The patient stands with weight predominantly on the side being examined. • The practitioner makes an attempt to dorsiflex the great toe at the first metatarsal joint. • Failure to dorsiflex to 20-25° suggests FHL. Treatment of FHL Treatment options for FHL may include stretching of associated muscles and gait training, as well as deactivation of associated trigger points. However, Dananberg ( 1 997) suggests that wearing custom-made foot orthotic devices is the most effective approach. Box 1 4.8 Diabetes and the foot Because of the very poor circulatory status, there is a great risk of amplification since this can be subtle and unrecognized by the complications affecting the lower extremity in diabetics (Harrelson uninformed and uneducated patient'. 1 989). In diabetes mellitus, foot infections, cellulitis and diabetic ulcers (a result of the poor circulatory status) are not uncommon Cailliet ( 1 997) further notes that, though not yet fully understood, and can lead to bone infections such as osteomyelitis. Such the considered causes of diabetic neuropathy might include retained metabolites, vascular factors and nutritional deficiencies. conditions are often also associated with polyneuritis. If infection spreads from ulcerated soft tissues (if the ulcer perforates, for There are now five pathological processes considered pertinent: example) a condition resembling Charcot's joints occurs, involving 1 . Ischemia caused by atherosclerosis or diabetic microangiopathy swelling associated with marked degeneration but commonly 2. Accumulation-inhibitory defect with lipid accumulation of fatty without pain (initially) or heat. This often affects the tarsal and material in the Schwann cells that interferes with their activity metatarsal bones and sometimes the ankle and knee joints. Once 3. Cofactor deficiency, enzymatic inhibition, or enzymic deficit, they are infected, ulcers may require debridement and aggressive antibiotic treatment. Cailliet (1 997) states that the leading medical which affects the transportation of lipids and proteins. cause of amputation of the lower limb is diabetes and that 'Ninety 4. Accumulation of sugar alcohols and glycogen, causing osmotic percent of diabetic patients who undergo amputation also smoke'. damage to the nerves. Protection of the feet and early diagnosis and treatment of any 5. Resultant thickening of the Schwann cell basal lamina and ulcerations, blisters or other lesions, particularly those developing at pressure sites, are of critical importance for the diabetic foot. alteration of the nodes of Ranvier. McCormack & Leith ( 1 998) reported a 42% complication rate in Cailliet also remarks that, though there is probably not a single the treatment of diabetic ankle fractures, as against no cause for peripheral damage, trauma affects this metabolic complications in a matched series of ankle fracture patients without process. 'Impaired sensation, as well as pain and paresthesias, presents a major factor in the management of diabetically caused diabetes. Nineteen of the diabetic patients were treated surgically foot problems.' and six developed major complications, with two requiring The manual practitioner should conclude from this summation amputation. These researchers concluded that diabetic patients that, although the foot of the diabetic patient might be painful, extreme caution must be exercised in application of therapy not to with displaced ankle fractures treated non-operatively showed a induce even minor trauma to the diabetic foot by inappropriate high incidence of failure of bony union, although few symptoms amounts of pressure, forceful ranges of motion, residual moisture resulted. Because of such results non-surgical approaches are (especially left between toes where cracking of the skin may occur) commonly recommended for diabetic patients. or application of excessive heat. Loss of sensation in the diabetic foot might allow the practitioner to use detrimental degrees of Attention should be paid to any signs of ill-fitting shoes or other pressure or extreme temperatures in thermal therapy as, due to deviations from the appearance of a 'normal' foot, as the patient loss of sensation, the patient might find it difficult to judge what is may not often make a close inspection of his feet. This is 'too much'. Encouragement to control blood sugar levels is particularly true if painful lower back, hip, knee or other physical extremely important, as well as early detection and treatment of problems prevent the foot from being lifted close enough for the any lesions, pressure sites or (minor or major) traumas, which might lead to progressive deterioration of the tissues of the foot. patient to see it well. Cailliet (1 997) observes: 'Trauma, often minor, results in cutaneous injury with slow poor healing, ultimate ulceration, and possible infection. The term trauma needs

530 CLINICAL APPLICATION OF NMT VOLUME 2 NEU ROMUSCU LOSKELETAL arising outside the foot to act upon it) or intrinsic (those ASSESSMENT OF THE FOOT arising within the foot structure itself), which has merit when organizing a treatment approach. They could also Petty & Moore ( 1 998) have described a comprehensive be classified by innervation as to dorsal and ventral sequence for evaluating foot function, which follows a divisions of the plexus. However, the best way to classify logical progression involving: the muscles of the leg and foot is by location (Platzer 1 992) since the leg is conveniently divided into three • formal observation (posture, muscle form, soft tissue compartments and the foot into dorsal and plantar changes, gait) surfaces. • joint tests: integrity tests (are the joints stable?), active In the next section, the extrinsic muscles (those arising and passive (ROM) movements of the foot and ankle in the leg) will be considered first within their three (including accessory movements) and associated compartments (anterior, lateral and posterior), followed joints. Where appropriate, overpressure is used in by the dorsal and plantar intrinsic muscles of the foot. these tests (see notes on overpressure in Chapter 13, Box 1 3.8) The leg can be conveniently divided into three compartments - anterior, posterior and lateral - although • muscle t�sts for strength (including dorsiflexors, some authors offer only anterior and posterior by includ­ plantarflexors, foot inverters, evertors, as well as toe ing the peroneal muscles in the posterior compartment flexors, extensors, abductors, adductors) and (Fig. 14.24). shortness (postural muscles such as tibialis posterior, gastrocnemius and soleus) • The anterior compartment contains the dorsiflexors: tibialis anterior, extensor hallucis longus, extensor • neurological examination (light touch and pain digitorum longus and peroneus tertius. sensations, tests for motor loss, reflexes such as knee and ankle jerk tests, neural mobility tests) • The lateral compartment contains peroneus longus and brevis. • vascular tests (pulses, special tests for DVT) • alignment tests (leg with heel; forefoot with heel; • The posterior compartment can be subdivided into two layers: superficial layer, which includes the tibial torsion) triceps surae (gastrocnemius and soleus) and • proprioception (see discussion relating to balance and plantaris; and the deep layer which includes tibialis posterior, flexor hallucis longus and flexor digitorum disequilibrium, including tests and rehabilitation longus. Although popliteus could certainly be strategies, in Chapter 2 as well as Box 1 4.2) included in the deep layer of the leg, since it does not • palpation for temperature, effusion, skin moisture, act upon the foot directly, it is rightfully grouped mobility and feel of superficial tissues, muscle spasm, with the knee on p. 492. tenderness, asymmetry of structures, pain responses. The extrinsic muscles are discussed first in the following It is not within the scope of this book to cover in detail all section, organized by their compartmental location. The these assessment protocols. In this chapter, thus far, intrinsic muscles are then discussed more briefly and additional evaluation procedures have been outlined organized as to dorsal or plantar location. Although the relating to special circumstances (such as for functional discussion of the intrinsic muscles may be brief, this in no hallux limitus - see Box 14.7). In the remainder of this way diminishes the tremendously important role they chapter additional assessment methods will be presented, play in maintaining the integrity of the foot. some immediately below and some in the context of the discussion of specific muscles. In particular, evaluation MUSCLES OF THE LEG for the presence of myofascial trigger points will be highlighted, where appropriate, in the clinical appli­ The muscles of the leg surround and control the strut-like cations segment. Additional active and passive tests for tibia and fibula, to provide the stance leg with stability as the multiple joints and structures of the foot are described the swinging contralateral limb and, therefore, the entire by Petty & Moore (1 998), which is recommended by the body moves forward. With the exception of popliteus, all authors. the muscles in the leg are extrinsic muscles of the foot and cross the ankle mortise to provide dorsiflexion, Muscles of the leg and foot plantarflexion, supination, pronation (inversion, eversion), adduction and abduction of the foot and / or movement The muscles of the leg and foot can be functionally of the toes. All these muscles of the ankle and foot act on classified into those which primarily flex, extend, invert a t least two joints or joint complexes, with none acting on and evert the ankle and subtalar joint and those which act one joint alone (Levangie & Norkin 2001 ) . upon the toes. Many of these muscles perform several functions and would appear in several categories. They could certainly be classified as being extrinsic (those

THE LEG AND FOOT 531 Tibia Interosseous membrane Deep peroneal nerve and anterior tibial vessels Tibialis posterior Flexor digitorum longus Tibialis anterior Extensor hallucis longus I ntermuscular septum --Ifi-).-;-f�j ,;:-�\":'- -- --\\T�<\\-- Extensor digitorum longus and peroneus tertius /,.B*\"A\\-\" - Superficial peroneal nerve --\\-=' Peroneus brevis Tibial nerve and posterior tibial vessels -j'f+*---'-�: _,\",�. \\-\\+-t Fibu la Plantaris tendon -m'-�,.'- ����fl;Jfll Peroneus longus Flexor hallucis longus Peroneal vessels Gastrocnemius aponeurosis Soleus Figure 1 4.24 Transverse section of the right leg (adapted with permission from Travell & Simons 1 992). Posterior compartment of the leg 5ynergists: For plantarflexion: soleus, plantaris, peroneus The muscles in the posterior compartment of the leg form longus and brevis, flexor hallucis brevis, flexor hallucis superficial and deep groups, separated by the deep trans­ longus, tibialis posterior verse fascia. They are all plantarflexors as well as inverters of the foot, some offering medial stabilization to the ankle, For supination: tibialis posterior and anterior, extensor especially important on rough terrain. hallucis longus, flexor hallucis longus, flexor digitorum Muscles of the superficial layer of the posterior leg longus, soleus, plantaris The superficial layer of the posterior leg is composed of For knee flexion: hamstring group, sartorius, gracilis and gastrocnemius, plantaris and soleus, which together form the bulk of the calf (Fig. 1 4.25). They constitute a power­ plantaris ful muscular mass, with their large size associated with 'one of the most characteristic features of the musculature Antagonists: To plantarflexion: extensor digitorum longus, of man, being related directly to his upright stance and peroneus tertius, extensor hallucis longus, tibialis mode of progression' (Gray' anatomy 1 995). Gastrocnemius anterior and plantaris act on both the knee and foot positioning, To supination: peroneus longus, brevis and tertius and while the soleus acts only on the foot. extensor digitorum longus Gastrocnemius (Fig. 14.26) To knee flexion: quadriceps group Attachments: Two heads, one each from the lateral and medial condyles, the surface of the femur and capsule Indications for treatment of the knee to merge distally with the soleus to form the tendo calcaneus (Achilles or calcaneal tendon) • Calf cramps (especially nocturnal) which attaches to the posterior surface of the calcaneus • Intermittent claudication • Pain in posterior knee or instep of foot Innervation: Tibial nerve (51, 52) Muscle type: Postural, prone to shortening under stress Soleus (Fig. 1 4.27) Function: Plantarflexes, inverts the foot, contributes very Attachments: From proximal third of the shaft of the weakly to knee flexion and, more likely, to stabilization fibula and the posterior surface of the fibular head and of the knee from the soleal line and the middle third of the medial border of the tibia and from a fibrous arch between the tibia and fibula to merge distally with the gastrocnemius to form the tendo calcaneus (Achilles or calcaneal tendon) which attaches to the posterior surface of the calcaneus Innervation: Tibial nerve (51 , 52)

532 CLIN ICAL APPLI CATION OF NMT VOLUME 2 Semitendinosus --+-tl- -I-- Biceps femoris TrP, -lI--\\ Plantaris Semimembranosus -1-+11'- G racilis Gastrocnemius --+-- Gastrocnemius lateral head medial head ---f Flexor digitorum Peroneus brevis Figure 1 4.26 Trigger point target zone for gastrocnemius. Other longus ---t\"f' 11f-- Peroneus longus trigger points in this muscle also refer to the medial and lateral posterior knee (not shown) (adapted with permission from Travel! & Calcanean tendon ---It,if Simons 1 992). Calcaneus Antagonists: To plantarflexion: extensor digitorum longus, Figure 14.25 Muscles of the superficial layer of the posterior peroneus tertius, extensor hallucis longus, tibialis compartment of the right leg (reproduced with permission, from Gray's anterior anatomy 1 995) . To supination: peroneus longus, brevis and tertius and Muscle type: Postural, prone t o shortening under stress Function: Plantarflexes, inverts the foot at the ankle extensor digitorum longus Synergists: For plantarflexion: gastrocnemius, plantaris, Indications for treatment peroneus longus and brevis, flexor hallucis brevis, • Restricted dorsiflexion flexor hallucis longus, tibialis posterior • Heel pain • Pain in uphill walking or stair climbing (usually For supination: tibialis posterior and anterior, extensor severe) hallucis longus, flexor hallucis longus, flexor digitorum • 'Growing pains' longus, gastrocnemius, plantaris • Edema of the foot and ankle • Low back pain • 'Shin splints' • Posterior compartment syndrome Special notes The triceps surae, composed of the gastrocnemius and the deeper placed soleus, is the strongest supinator of the foot and is 'simply the plantarflexor par excellence' (Platzer 1 992). The two muscles arise independent from each other proximally but merge into the tendo calcaneus (Achilles or calcaneal tendon) which attaches to the posterior heel. This tendon is often the site of painful and dysfunctional conditions, such as tendinitis, bursitis or tendon rupture. The more superficial gastrocnemius arises by two heads with the fleshy part of the muscle extending to about

THE LEG AND FOOT 533 -+--- Femur the medial head. Anterior to the tendon of the medial head lies a bursa, which sometimes communicates with Gastrocnemius -+t-- Gastrocnemius the knee joint. A fibrocartilaginous or bony sesamoid may medial head (cut) --'-OM?\" be contained in the lateral head overlying the lateral lateral head (cut) Plantaris --\\-----+ Head of fibula femoral condyle; one may also be present in the tendon of IL--+ Soleus canal the medial head (Gray's anatomy 1 995). Soleus Trigger points within gastrocnemius refer pain to the lower posterior thigh, posterior leg, posterior knee and to the arch of the foot (Travell & Simons 1 992). Some of these trigger points are associated with nocturnal calf cramps (restless leg), although mineral imbalances (especially potassium) can be responsible for this disturbing condition (Travell & Simons 1 992). Immediately deep to the gastrocnemius is the broad, flat soleus muscle. While the gastrocnemius covers the muscle proximally, at about mid-calf the soleus is exposed and accessible on each side of the overlying tendon. Additionally, when the knee is flexed, the gastrocnemius can often be displaced slightly on each side to expose more of the underlying tissues. @�����H--- Gastrocnemius Venous pumping tendon Travell & Simons ( 1 992) describe the venous pumping Plantaris tendon (cut and reflected) action of the soleus muscle. Fibula The soleus provides a major pumping action to return blood from the lower limb toward the heart. Venous sinuses in the Tibia soleus muscle are compressed by the muscle's strong Achilles tendon --.=f-?+ contractions so that its venous blood is forced upward toward the heart. This pumping action (the body's second heart) Calcaneus depends on competent valves in the popliteal veins. Valves in the veins to prevent reflux of the blood are most numerous in Figure 1 4.27 Soleus and plantaris with gastrocnemius reflected the veins of the lower limbs where the vessels must return (adapted with permission from Travel l & Simons 1 992). blood against high hydrostatic pressure. The popliteal vein usually contains four valves. Deeper veins that are subject to mid-calf. Its medial head is thicker and longer than the the pumping action of muscle contraction are more richly lateral one with the two heads remaining separate until provided with valves. the distal muscle fibers insert into a broad aponeurosis which gradually narrows and merges with the soleus Travell & Simons further note that when seated for long tendon. Occasionally the lateral head, and sometimes the periods of time, such as when traveling, 'spontaneous' whole muscle, may be missing or a third head, arising thrombosis can occur in the deep veins of the legs. The pumping action of the soleus can be employed (using the from the popliteal surface, may be present (Gray's pedal exercise) to prevent this occurrence, as mentioned anatomy 1 995). The tendon of biceps femoris partially in Chapter 4 and illustrated in Fig. 4.9. covers the lateral head while semimembranosus overlays Since the blood vessels which serve the leg and the tibial nerve must course deep to the soleus, the soleus canal, formed by a tendinous arc at the proximal end of the muscle, provides a passageway. Travell & Simons ( 1 992) suggest that entrapment of these structures is possible by the plantaris muscle belly or by taut bands of myofascial tissues which are often associated with trigger points. 'Obstruction affects mainly the soft-walled veins, causing edema of the foot and ankle'. Trigger points in the soleus muscle primarily refer to the heel, Achilles tendon and ipsilateral sacroiliac joint

534 CLINICAL APPLICATION OF NMT VOLUME 2 Deep vein thrombosis their strength is most obvious when one is standing on the toes. CAUTION: Deep vein thrombophlebitis is a serious condition to which applications of massage, and other Regarding the postural roles of the triceps surae, Gray's forms of soft tissue manipulation, are contraindicated. anatomy ( 1 995) notes: Symptoms include constant pain even when the muscles are Gastrocnemius provides force for propulsion in walking, not active, warmth and redness but these symptoms are not running and leaping. Soleus is said to be more concerned with always present. A positive Homan's sign is noted, in which pain steadying the leg on the foot in standing. This postural role is is elicited when the foot of the fully extended leg is placed also suggested by its high content of slow, fatigue-resistant forcibly in dorsiflexion, especially when accompanied by (Type 1) muscle fibres; in the soleus muscle of many adult tenderness on deep palpation of the calf (Hoppenfeld 1 976). mammals the proportion of this type of fibre approaches Difficulty arises in achieving an accurate diagnosis from these 1 00%. In man, at least, such a rigid separation of functional last two symptoms alone, since these may also be roles seems unlikely; soleus probably [also] participates in characteristic of myofascial dysfunction. Travell & Simons locomotion and gastrocnemius in posture. Nevertheless, the ( 1 992) further note that 'clinical examination alone is unreliable talotibial joint is loose-packed in the erect posture, and since for detection of thrombophlebitis' and that 'contrast venography the weight of the body acts through a vertical line that passes remains the standard'. anterior to the ankle joint, a strong brace is required behind the joint to maintain stability. Electromyography shows that e +-t-- these forces are supplied mainly by soleus: during symmetrical standing, soleus is continuously active, whereas r1U.--TrP3 gastrocnemius is recruited only intermittently (Joseph et al IO-f-- TrP 1 1 955; Joseph 1 960). The relative contributions of soleus and gastrocnemius to phasic activity of the triceps surae in Figure 14.28 Trigger point target zones for soleus. A rare trigger walking has yet to be analysed satisfactorily. point in soleus refers to the face and jaw (not illustrated) (adapted with permission from Travell & Simons 1 992). In normal walking, gastrocnemius restrains the tibia from rotating on the talus as the weight is shifted from the heel (Fig. 1 4.28). Additionally, a rare and 'exceptional' trigger to the ball of the foot during stance phase (Travell & point (not illustrated) is known to refer to the ipsilateral Simons 1 992). It is effective in plantarflexion of the foot face and jaw, possibly altering occlusion of the teeth when the foot is free to move and since plantarflexion (Travell & Simons 1 992). forces applied to the calcaneus are transmitted through the cuboid to the 4th and 5th metatarsals, supination While both muscles of triceps surae produce plantar­ simultaneously occurs with plantarflexion movements flexion when the knee is extended, as the knee is pro­ (Travell & Simons 1 992). Its flexion forces on the knee are gressively flexed the gastrocnemius becomes less effective weak when the knee is extended, resulting in a strong and the soleus becomes successively more responsible for plantarflexion force instead. plantarflexion. The force created by these two muscles can lift the body during gaiting as well as during stance, Achilles tendon The Achilles tendon is the thickest and strongest tendon in the human body, beginning near the middle of the calf, receiving additional fibers almost to its lower end and attaching to the posterior surface of the calcaneus at its mid-level. A bursa usually separates the tendon from the bony surface of the tibia and another separates the tendon from the skin (Cailliet 1 997). The tendon spirals as it descends so that the gastrocnemius tendinous fibers insert on the lateral calcaneus and the soleus fibers more medially. Gray's anatomy (1 995) notes that: 'T11e tendon plays an important part in reducing the energy cost of locomotion by storing energy elastically and releasing it at a subsequent point in the gait cycle'. Plantaris (see Fig. 14.27) Attachments: From the lower part of the lateral supra­ condylar line of the femur and the oblique popliteal ligament to cross obliquely between gastrocnemius and soleus and course distally along the medial aspect

THE LEG AND FOOT 535 of soleus to fuse with or insert next to the tendo calcaneus \" \" NMT for superficial layer of on the posterior calcaneus posterior leg Innervation: Tibial nerve (51, 52) • The patient is prone and the foot is resting on a Muscle type: Not established cushion. Function: Plantarflexes, inverts the foot and contributes • The practitioner stands at the level of the foot and very weakly to knee flexion faces the patient's torso. Synergists: For plantarflexion: gastrocnemius, soleus, Gastrocnemius peroneus longus and brevis, flexor hallucis longus and • Lubricated gliding strokes are applied to the most brevis, tibialis posterior lateral segment of the gastrocnemius 7-8 times. For supination: tibialis posterior and anterior, extensor • The thumbs are moved medially 1-2 inches and the hallucls longus, flexor hallucis longus, flexor digitorum gliding strokes repeated on the next section of longus, gastrocnemius, soleus muscle. • The gliding strokes are repeated in sections until the For knee flexion: hamstring group, sartorius, gracilis entire posterior surface of the leg has been treated. • As the thumbs glide over the tissues, attention is and (weakly) gastrocnemius focused on the consistency and quality of the tissues being palpated. There should be a pliable and Antagonists: To plantarflexion: extensor digitorum longus, somewhat elastic quality and they should have no taut bands or thick or fibrotic congestion. peroneus tertius, extensor hallucis longus, tibialis • If dense or taut tissues are found, repetitive gliding, anterior trigger point pressure release (as described in To supination: peroneus longus, brevis and tertius and Chapter 9) and myofascial release teclmiques may be extensor digitorum longus applied to reduce ischemia and enhance blood flow and lymphatic drainage of the region. To knee flexion: quadriceps group • The gastrocnemius can often be lifted in a pincer-type grasp as each head is examined by rolling or Indications for treatment compressing it between the fingers and thumb. This may be accomplished more easily if the knee is flexed Pain in back of knee or upper calf (note caution above regarding DVT). to at least 45-90° (Fig. 1 4.29). Special notes • During this type of examination, nodules associated with trigger points may be revealed and assessment Plantaris has a small, delicate muscle belly and a very can easily turn into treatment, as applied long, slender tendon. The belly lies obliquely across the compression is used to release the taut bands. posterior knee (see Fig. 14.27) while its tendon courses • Stretching of the tissues housing trigger points is recommended after their release as well as home distally between the gastrocnemius and soleus on the application of the stretching techniques to help medial aspect of the leg. Its tendon sometimes merges prevent reoccurrence. with the fascia of the leg or with the flexor retinaculum Soleus (Gray's anatomy 1 995) and often it is embedded distally in the medial aspect of the calcaneal tendon (Platzer 1 992). • Deeper pressure applied with gliding strokes or static Plantaris may be absent about 10% of the time (Gray's compression, if appropriate, may influence the soleus anatomy 1995) and is sometimes double (Platzer 1 992). which lies deep to the gastrocnemius. The soleus may also be treated by displacing the gastrocnemius Regarding plantaris, Gray's anatomy notes that it: medially and laterally to gain access to a part of its . . . is the lower limb's equivalent of palmaris longus: in many belly on each side (Fig. 1 4.30). mammals it is well developed and inserts directly or indirectly into the plantar aponeurosis. In man the muscle is almost • To treat the medial and lateral aspects of the soleus vestigial and normally inserts well short of the plantar simultaneously, the practitioner places one thumb on aponeurosis, usually into the calcaneus. It is therefore the medial side of the exposed portion near the distal presumed to act with gastrocnemius. end and the other thumb on the lateral side of the It weakly assists knee flexion (in a loading situation), plantarflexion and supination of the foot. The trigger point target zone for plantaris is to the posterior knee and radiating to the mid-calf region. Travell & Simons (1 992) note that: 'A TrP in the vicinity of the plantaris refers pain to the ball of the foot and base of the big toe. However, it is not clear whether this pain arises from TrPs in the plantaris muscle or in the fibers of the lateral head of the gastrocnemius' .

536 CLINICAL APPLICATION OF NMT VOLUM E 2 Figure 14.30 The gastrocnemius can often be displaced so that a portion of the underlying tissues may be palpated on each side of the leg. Figure 14.29 The gastrocnemius can often be lifted and Plantaris (and gastrocnemius attachments) compressed between the thumb and fingers as its fibers are examined for taut bands or ischemia. • The medial thumb will also be treating the long tendon of the plantaris muscle. A similar compressive exposed portion. The thumbs will be deep to the 'double thumb' glide can also be applied to the tendon of gastrocnemius and opposite each other on gastrocnemius. the sides of the leg (Fig. 14.31). • The knee is now supported at 70-90° of passive • With lubrication, the practitioner glides the thumbs flexion, to relax the hamstring tendons. Palpation of proximally, while simultaneously pressing them the attachments of plantaris and the lateral head of toward each other. This 'double thumb' technique gastrocnemius is sometimes possible by placing a will entrap the soleus between the thumbs as thumb between the biceps femoris tendon and the pressure is applied . iliotibial band and directly onto the lateral condyle of • Mild tension can also be applied to the triceps surae the femur (Fig. 14.32). by bracing the foot against the practitioner 's abdomen or hip in such a way as to create slight • The procedure can be repeated for the medial head of dorsiflexion, which will tighten the gastrocnemius gastrocnemius by working either between the and lift it slightly from the soleus. Since this semimembranosus and semitendinosus tendons or movement will also stretch the soleus, care should be around them (in the medial edge of the popliteal taken to avoid excessive stretch and / or excessive space) on the medial epicondyle of the femur. thumb pressure on the tissues while repeating the gliding process (from the distal end to the knee) • Palpation may reveal a tender attachment but plantarflexion of the foot to assess muscular 7-8 times. contraction of the tendon will not produce the desired effect, since these two muscles only plantarflex the foot when the knee is extended . Caution must be

THE LEG AND FOOT 537 Figure 1 4.32 Palpation for the lateral attachment of gastrocnemius as well as the attachment of plantaris. Figure 1 4.31 The medial and lateral portions of the soleus are , 00 / pressed toward each other while a gliding stroke is applied with both I thumbs simultaneously. Fig u re 1 4.33 Transverse snapping palpation can be precisely exercised to avoid pressing into the mid-portion of applied to the belly of plantaris. the popliteal fossa due to the course of a neurovascular bundle. • The plantaris muscle belly can sometimes be palpated just medial to the lateral head of gastrocnemius. This is best and most safely accomplished with the knee flexed to 90°. The practitioner stands beside the knee and wraps her caudad arm around the medial aspect of the leg so as to 'cradle' the leg with the tibia resting on her forearm (not shown in illustration). The thumb of that wrapping arm is placed diagonally across the back of the knee so that it lies directly over the course of the plantaris muscle (see Fig. 14.33). • A short, transverse snapping stroke can be repeatedly applied to the belly of plantaris with that overlying thumb while caution is exercised to avoid intruding on the popliteal fossa, especially when applying strong compression for trigger point pressure release, due to the neurovascular structures. When positioned correctly and if the plantaris is present, the thumb should 'flip' across the muscle when appropriate pressure is being used.

538 CLINICAL APPLICATION OF NMT VOLUME 2 \" f NMT for Achilles tendon Figure 1 4.35 The anterior surface of the Achilles tendon can be accessed with lateral and medial displacement. CAUTION: If evidence of bursitis or tendinitis is present, the following treatments should be postponed until the inflammation has been reduced. If partial tear of the tendon is suspected, a clear diagnosis should be sought before application of these or any other tech­ niques which may stress the possibly damaged tendon. All forms of strain (including stretching and possibly walking) which could further tear the tissue should be avoided until the extent of damage is known. • The practitioner is positioned at the foot of the table. A thumb is placed on each side of the lightly lubricated Achilles tendon. The thumbs are pressed toward each other, thereby entrapping the tendon between them, and a 'double thumb' gliding stroke applied from the calcaneus to the mid-calf region where the tendon becomes muscular. • The gliding process is repeated 8-10 times. Following the compressive strokes, slight pressure is applied to dorsiflex the foot which will stretch the tendon slightly. Compression of the posterior aspect can be applied by the (overlapped) thumbs as they are slid along the posterior surface (Fig. 1 4.34). • With the foot relaxed and supported by a cushion, the tendon may be displaced laterally to allow a finger to be hooked onto the anterior surface of the tendon. Tender points may be found on this 'hidden' portion of the tendon which may be the source of recurrent pain. The Figu re 1 4.34 Slight dorsiflexion of the foot will assist in maintaining tendon can also be displaced medially and examined in a tension on the Achilles tendon as gliding stokes are applied to the posterior surface. Without the applied dorsiflexion the tendon collapses similar manner (Fig. 1 4.35). under the thumbs. • The beveled pressure bar may be used on the lightly lubricated calcaneus and on the plantar surface of the heel, with short scraping movements (Fig. 14.36). When heel spurs have been diagnosed (see notes earlier in this chapter), chronic tightness of the Achilles tendon and its contributing muscles should be addressed. Loss of integrity of the plantar vault and the resultant pronation of the foot, 'splay foot' and other conditions which place tension on the plantar fascia should also be assessed. The muscles of the posterior compartment of the leg, as well as the intrinsic muscles of the foot, should be addressed, as well as proprioceptive retraining incorporated for the muscles of the feet (see Box 1 4.2). \" f MET assessment and treatment of tight gastrocnemius and soleus (Fig. 14.37) Assessment of tight gastrocnemius • The patient is supine with feet extending over the edge of the table.

THE LEG AND FOOT 539 A B Figure 1 4.37 A: Gastrocnemius assessment position. B: Soleus assessment position (adapted from Chaitow 200 1 ) . Figure 1 4.36 Unless inflammation is present, the fascia of the heel soleus. Further screening i s required t o identify as well as the plantar fascia can be treated with a 'scraping' movement precisely which (see soleus test below). applied with the beveled pressure bar. • It is possible to use the right hand, which has removed slack from the muscles via traction, to • For right leg examination the practitioner 's right palpate the tissues with which it is in contact for a hand grasps the Achilles tendon just above the heel, sense of bind, as the foot is dorsiflexed. avoiding pressure on the tendon. • The leg should remain resting on the table all the while and the left hand holding/palpating the • The heel lies in the palm of the hand, fingers curving muscular insertion and the heel should be so oriented round it. that it is a virtual extension of the leg, avoiding any upward (toward the ceiling) pull, when stretch is • The left hand is placed so that the fingers rest on the introduced. dorsum of the foot (these are not active and do not apply any pulling stretch), with the thumb on the Assessment of tight soleus sole, lying along the medial margin. The method described above assesses both gastrocnemius • This position is important as it is a mistake to place and soleus. the thumb too near the center of the sole of the foot. • To assess only the soleus, precisely the same • Stretch is introduced by pulling on the heel with the procedure is adopted, with the knee passively flexed. right hand, taking out the slack of the muscle, while at the same time the left hand maintains cephalad • If the sole of the foot cannot easily achieve a 90° pressure via the thumb (along its entire length). angle with the leg, without force, once slack has been taken out of the tissues via traction through the long • A range of movement should be achieved which axis of the calf, soleus. is considered short. takes the sole of the foot to a 90° angle to the leg without any force being applied. • If the test in which the leg is straight indicates shortness of gastrocnemius or soleus and the test in • If this is not possible, i.e. force is required to achieve which the knee is flexed is normal, then the 90° angle between the sole of the foot and the leg, gastrocnemius alone is short. there is shortness in either gastrocnemius and / or

540 CLINICAL APPLICATION OF NMT VOLUME 2 A screening test for soleus involves the patient being agonists (the muscles being treated) for the asked to squat, with the trunk in slight flexion and feet contraction, the antagonists to the shortened muscles placed shoulder width apart, so that the buttocks rest can be used, by introducing resisted dorsiflexion with between the legs (legs should face forward, rather than the muscle at its barrier or short of it (acute/chronic), outward). If the soleus muscles are normal then it should followed by painless stretch to the new barrier (acute) be possible to go fully into this squat position, with the or beyond it (chronic), during an exhalation. heels remaining flat on the floor. If the heels rise from the • Use of antagonists in this (reciprocal inhibition) way floor as the squat is performed, the soleus muscles are is less effective than use of agonist, but may be a probably shortened. useful strategy if trauma has taken place or pain is noted on contraction of the agonist. Treatment of shortened gastrocnemius and soleus An alternative treatment position for gastrocnemius, which (see Fig. 14.37) can also be used for assessment, involves the practitioner using the forearm to stabilize the sale of the foot as the • The same position is adopted for treatment as for heel is cradled in the palm of the hand. Flexion of the testing, with the knee flexed over a rolled towel or knee (rolled towel under the knee) would allow this posi­ cushion if soleus is being treated and the knee tion to be used for assessing and / or treating soleus (Fig. extended (straight) if gastrocnemius is being treated. 14.38). • If the condition is acute (defined as a P RT for gastrocnemius and soleus dysfunctionl injury of less than 3 weeks' duration or • The patient is prone, with the affected leg straight or inflamed or acutely painful) the area is treated with flexed at the knee, depending upon whether the foot dorsiflexed to the first sign of a restriction gastrocnemius or soleus is being treated. barrier. • If it is a chronic problem (longer duration than • Effectively the treatment protocol is identical, with just this one variable (knee extended or flexed) . 3 weeks) the barrier is assessed and the muscle Figure 1 4.38 Alternative position for treatment of gastrocnemius treated in a position of ease, in its mid-range, away and/or soleus (adapted from Chaitow 2001 ). from the restriction barrier. (See notes on MET in Volume 1, Chapter 1 0, for discussion of acute and chronic variations of MET.) • Starting from the appropriate position, at the restriction barrier or just short of it, based on the degree of acuteness or chronicity, the patient is asked to exert a small, painless effort (no more than 20% of available strength) toward plantarflexion, against unyielding resistance. • This effort isometrically contracts either gastrocnemius or soleus (depending on whether the knee is unflexed or flexed). This contraction is held for 7-1 0 seconds (up to 1 5 seconds if the condition is chronic). • On slow release, on an exhalation, the foot/ankle is dorsiflexed (the whole foot should be flexed, not just the toes) to its new restriction barrier, if acute or slightly and painlessly beyond the new barrier if chronic, with the patient's assistance. • If chronic, the tissues should be held in slight stretch for 1 5-30 seconds (longer would be better) in order to allow a slow lengthening of tissues. (See Volume 1 , Chapter 2 , for discussion o f viscoelastic and viscoplastic qualities of the soft tissues.) • This pattern is repeated until no further gain is achieved (backing off to mid-range for the next contraction, if chronic, and commencing the next contraction from the new resistance barrier, if acute). • Alternatively if there is undue discomfort using the

THE LEG AND FOOT 541 • A tender point is located in one or other of the tion (being housed between the two bones) as well as the muscles, usually in the area of the belly or on the overlying neurovascular structures which forbid intrusion Achilles (calcaneal) tendon. into its belly. • Sufficient digital pressure is applied to the located Flexor hallucis longus tender point to allow a score of '10' to be attributed to it by the patient. Attachments: From the distal two-thirds of the posterior surface of the fibula, interosseous membrane, posterior • The other hand grasps calcaneus and introduces intermuscular septa and from the fascia covering tibialis plantarflexion, until there is some reduction in the posterior to attach to the plantar surface of the base of reported pain 'score'. the distal phalanx of the great toe • Fine tuning is achieved by means of rotation, Innervation: Tibial nerve (LS, Sl, S2) eversion or inversion of the calcaneus to achieve a Muscle type: Not established position of ease in which the score has reduced to '3' Function: Plantarflexes the great toe, assists plantar­ or less. flexion and supination of the foot • This may be further assisted by means of long-axis Synergists: For toe flexion: flexor hallucis brevis compression of the calcaneus toward the knee. For plantarflexion offoot: gastrocnemius, soleus, plantaris, • The position of ease is held for not less than 90 peroneus longus and brevis, flexor digitorum longus seconds, before a slow release and return to a neutral and tibialis posterior position. For supination: tibialis posterior and anterior, extensor hallucis longus, flexor digitorum longus, gastrocnemius, Note: These maneuvers are performed with the knee in soleus, plantaris flexion or in extension, depending on whether soleus or Antagonists: To toe flexion: extensor hallucis longus and gastrocnemius is being treated. brevis To plantarflexion of the foot: extensor digitorum longus, Muscles of the deep layer of the posterior leg peroneus tertius, extensor hallucis longus, tibialis anterior Between the superficial and deep muscles of the calf lies To supination: peroneus longus, brevis and tertius and the deep transverse fascia of the leg. It extends from the extensor digitorum longus medial margin of the tibia to the posterior border of the fibula. It is thick and dense proximally and is continuous Flexor digito rum longus with fascia covering popliteus and receives an expansion from the tendon of semimembranosus. It is thin at inter­ Attachments: From the posterior surface of the middle mediate levels and thick again at the distal end, where it three-fifths of the tibia and from the fascia covering is continuous with the flexor and superior peroneal tibialis posterior to divide into tendons and attach on retinacula (Gray's anatomy 1 995). the plantar surfaces of the bases of the distal phalanges of the four lesser toes The deep flexors of the calf include flexor hallucis longus, which courses along the posterior shaft of the Innervation: Tibial nerve (LS, Sl, S2) fibula, flexor digitorum longus, which lies on the posterior Muscle type: Not established shaft of the tibia and tibialis posterior, which lies between Function: Plantarflexes the four lesser toes, plantarflexes the two bones, directly superficial to the interosseous membrane (Fig. 14.39). and supinates the foot Synergists: For toe flexion: flexor digitorum brevis Popliteus, which only acts on the knee joint, lies across the posterior aspect of that joint capsule and wraps For plantarflexion of the foot: gastrocnemius, soleus, around to the lateral surface of the lateral femoral plantaris, peroneus brevis and longus, flexor hallucis condyle. A portion of the popliteus can be treated at its longus, tibialis posterior attachment on the upper 3-4 inches of the posteromedial For supination: tibialis posterior and anterior, extensor shaft of the tibia when the flexor digitorum longus is hallucis longus, flexor hallucis longus, gastrocnemius, addressed . soleus, plantaris Antagonists: To toe flexion: extensor digitorum longus The deep layer is separated from the superficial layer and brevis by the deep transverse fascia and an interposing sub­ To plantarflexion of the foot: extensor digitorum longus, stantial neurovascular complex which serves the leg and peroneus tertius, extensor hallucis longus, tibialis foot and from the anterior compartment by the interosseous anterior membrane. A portion of the toe flexors can be reached on To supination: peroneus longus, brevis and tertius and the posterior shafts of the bones but little of the tibialis extensor digitorum longus posterior is available to palpation due to its central loca-

542 CLINICAL APPLICATION OF NMT VOLUM E 2 Sem itendinosus ----=i=. -!f1-:-'! --;J-, :-:--:i ----- Biceps tendon Sartorius ---�+ --->,- -='\"- ,-______ Gastrocnemius, lateral head Semimembranosus ---+.-r1-:-:1-H- -=--;-'-;-- -::-:+--- ---- Plantaris '_--:c'-.,�:.-=,; Popliteus Gracilis -----E� .\"fJ,-:-'\"- \"--'\" t'=:-:------ Soleus Gastrocnemius, medial head -----3fC.- f-fTf- +-:--- ---- Peroneus longus Tibialis posterior -------':-- +T-,-c ,- --''-'.-' :;.: -_____ Flexor hallucis longus Flexor digitorum longus ---'rt; -r.:::--- ---- Peroneus longus +=+------,-- Peroneus brevis +.-______ Superior peroneal retinaculam Flexor retinaculum ---1:. Figure 1 4.39 Muscles of the deep layer of the posterior compartment of the right leg (reproduced with permission from Gray's anatomy 1 995). Indications for treatment (FHL) plantarflexes the great toe (and sometimes others), while flexor digitorum longus (FDL) flexes the four lesser • Feet which hurt when walking toes. Both of these muscles act as supinators of the foot • Pain in the great toe (flexor hallucis longus) or lesser and FDL also supports the medial arch. toes (flexor digitorum longus) or bottom of foot FHL courses down the posterior surface of the tibia, • Cramping toes (check also intrinsic foot muscles) then through a series of grooves on the surface of the • Claw toes or hammer toes talus and the inferior surface of the sustentaculum tali of • Valgus position of great toe (FHL) the calcaneus. These grooves are then converted into a canal by fibrous bands, which is lined by a synovial Special notes sheath, FHL crosses FDL (being connected at that point by a fibrous slip) and then crosses the lateral part of flexor The flexor muscles of the toes stabilize the foot and ankle hallucis brevis (FHB) to reach the head of the first during walking, while they contribute to plantarflexion metatarsal between the sesamoid bones of FHB. It then of the foot and the resultant forward transfer of weight continues through an osseo-aponeurotic tunnel to attach onto the forefoot. Additionally, flexor hallucis longus to the plantar aspect of the base of the distal phalanx.

THE LEG AND FOOT 543 FHL may also offer connections to the second, third and Flexor digitorum sometimes fourth digit. longus trigger point FDL has a similar course down the lower half of the Flexor hallucis fibula and crosses the posterior ankle and tibialis posterior. longus trigger point It passes behind the medial malleolus and shares a groove with tibialis posterior, being divided from tibialis From FHL posterior by a fibrous septum which separates each tendon in its own synovial-lined compartment. FDL courses Figure 1 4.40 Trigger point target zones for flexor digitorum longus obliquely forward and laterally as it enters the sole of the and flexor hallucis longus (adapted with permission from Travell & foot. The quadratus plantae and the lumbricals radiate Simons 1 992). into the tendon complex of FDL. Antagonists: To plantarfIexion of the foot: extensor digitorum Though gastrocnemius and soleus are considerably stronger plantarflexors, FHL and FDL certainly make a longus, peroneus tertius, extensor hallucis longus, contribution to this movement. Both muscles flex the tibialis anterior phalanges of the toes, acting primarily on these when the To supination: peroneus longus, brevis and tertius and foot is off the ground. Gray's anatomy (1 995) notes: extensor digitorum longus When the foot is on the ground and under load, they act synergistically with the small muscles of the foot and Indications for treatment especially in the case of flexor d igitorum longus with the lumbricals and interossei to maintain the pads of the toes in • Pain in the sole of the gaiting foot (especially on firm contact with the ground, enlarging the weight-bearing uneven ground) area and helping to stabilize the heads of the metatarsal bones, which form the fulcrum on which the body is propelled • Pain in arch of foot, calcaneal tendon, heel, toes and forwards. Activity in the long digital flexors is minimal during calf quiet standing, so they apparently contribute little to the static maintenance of the longitudinal arch, but during toe-off and • 'Shin splints' tip-toe movements they become very active. • Posterior compartment syndrome • Posterior tibial tenosynovitis (or rupture) Trigger points in FHL refer pain and tenderness to the plantar surface of the first metatarsal and great toe, while Special notes FDL refers to the plantar surface of the middle of the forefoot and sometimes into the lesser toes. FDL may also Tibialis posterior is the most deeply placed muscle of the radiate pain into the calf and medial ankle, while the FHL posterior compartment (see Box 14.10 regarding compart­ referred pain is confined to the foot (Fig. 1 4.40). Over­ ment syndromes). It lies on the posterior surface of the activity of these toe flexor muscles contributes to the interosseous membrane, which separates it from the development of hammer toes, claw toes and other deform­ anterior compartment. Distally, the tendon of flexor ing foot conditions as they attempt to stabilize the foot digitorum longus lies just superficial to it and they share (Travell & Simons 1 992) (see Box 1 4. 1 1 ) . a groove behind the medial malleolus, although they have separate synovial sheaths. In the foot, it lies inferior Tibialis posterior to the plantar calcaneonavicular ligament, where it contains a sesamoid fibrocartilage. The tendon then divides Attachments: From the medial surface of the fibula, lateral to attach to all tarsal bones except the talus (to which no portion of posterior tibia, interosseous membrane, intermuscular septa and deep fascia to attach to the plantar surfaces of the navicular bone, sustentaculum tali of the calcaneus, to all three cuneiform bones, the cuboid and the bases of the second, third and fourth metatarsals Innervation: Tibial nerve (L4, L5) Muscle type: Not established Function: Plantarflexes and inverts the foot at the ankle Synergists: For plantarflexion of the foot: gastrocnemius, soleus, plantaris, peroneus brevis and longus, flexor hallucis longus, flexor digitorum longus For supination: tibialis anterior, extensor hallucis longus, flexor hallucis longus, gastrocnemius, soleus, plantaris

544 CLINICAL APPLICATION OF NMT VOLUME 2 muscles attach) and the bases of the middle three procedures in a home-care program, reduction in pain metatarsals. from these trigger points is likely. Although the tibialis posterior may assist in plantar­ NMT for deep layer of posterior leg flexion, its primary role is as the principal supinator of the foot and it assists in elevating the longitudinal arch of • The patient is prone with the knee passively flexed to about 70-90° and supported by the practitioner 's the foot, although it is quiescent in standing (Gray's anatomy caudad hand. 1 995). Gray's anatomy notes: • The practitioner stands so that she is slightly distal It is phasically active in walking, during which it probably acts to the flexed leg and faces the patient's torso. With the with the intrinsic foot musculature and the lateral calf muscles muscles of the leg as relaxed as possible, the practi­ to control the degree of pronation of the foot and the tioner's cephalad thumb is placed on the posterior aspect distribution of weight through the metatarsal heads. It is said of the shaft of the fibula, just proximal to the lateral that when the body is supported on one leg, the supinator malleolus and with the tip pointing toward the knee (the action of tibialis posterior, exerted from below, helps to practitioner's elbow may need to be elevated to achieve maintain balance by resisting any tendency to sway laterally. this position) (Fig. 1 4.42). However, any act of balancing demands the co-operation of many muscles, including groups acting on the hip joints and • If the thumb points toward the mid-line instead or if vertebral column. the fingers are substituted, the fingernails will most definitely intrude into the tissues and very likely scratch Trigger points in tibialis posterior produce pain from the the skin. If properly placed, the pad of the thumb will calf through the plantar surface of the foot, with a overlie the posterior fibula and, with the ensuing gliding particularly strong referral into the Achilles tendon (Fig. stroke, will address all tissues which attach to it, includ­ 1 4.41 ). This muscle's trigger points are particularly ing peroneus brevis distally, flexor hallucis longus on the difficult to treat with massage techniques, or injections, middle third and a portion of soleus on the proximal due to the overlying muscles and interposed neuro­ third as the thumb slides proximally along the posterior vascular structures. The authors have found spray (or ice shaft of the fibula. This gliding stroke is stopped about stripping) and stretch techniques, as described by Travell 2 inches distal to the head of the fibula to avoid & Simons (1 992), to be an effective treatment. If, in compressing the peroneal nerve which courses around add ition to correction of associated muscular and skeletal the fibula and is vulnerable in this location. conditions, such methods are coupled with PRT and MET • A similar gliding stroke is applied to the posterior Fig u re 1 4.41 Trigger point target zones for tibialis posterior (adapted Figure 1 4.42 Treatment of the posterior shaft of the fibula will with permission from Travell & Simons 1 992) . address (from distal to proximal) peroneus brevis, flexor hallucis longus and a portion of soleus. Caution should be exercised to avoid compressing the peroneal nerve near the fibular head.

THE LEG AND FOOT 545 • The practitioner applies digital pressure toward the tibia with sufficient force to create discomfort registered by the patient as '10'. • The positioning of the leg to produce ease requires the patient to lie prone, with knee passively flexed, with the foot held by the practitioner at the heel. • The practitioner introduces plantarflexion and inversion of the foot and applies long-axis compression toward the knee, until pain in the tender point is reduced by at least 70% . • This i s held for 9 0 seconds before a slow return o f the leg to neutral. Figure 1 4.43 Treatment of the posterior shaft of the tibia will address Tibialis posterior flexor digitorum longus and the attachment of popliteus. • The tender point for tibialis posterior is found on the shaft of the tibia on the medial aspect of the leg, to posterior surface of the calf, inferior to the head of address the flexor digitorum longus. In this region it is the fibula, between the tibia and the fibula, between important that the thumb be placed anterior to the bulk the bellies of gastrocnemius while avoiding blood of the soleus to avoid pressing through its thick medial vessels. mass (Fig. 14.43). • The practitioner applies digital pressure anteriorly • On the proximal aspect of the posterior tibial shaft, with sufficient force to create discomfort registered the attachment of popliteus will be addressed. This area by the patient as ' 1 0'. is often abruptly tender when the gliding thumb encounters the popliteus attachment. Again, it is important that the • The positioning of the leg to produce ease requires thumb is anterior to the soleus to avoid attempting to the patient to lie prone, with knee passively flexed, treat the tissues through this bulky muscle. with the foot held by the practitioner at the heel. It is doubtful whether any portion of tibialis posterior is • The practitioner introduces maximal plantarflexion available to direct examination. From an anterior per­ and inversion of the foot and applies long-axis spective it is inaccessible because of the interosseous compression toward the knee, until pain in the tender membrane and from a posterior perspective it lies deeply point is reduced by at least 70% . placed between the tibia and fibula with flexor muscles and soleus overlying it. Tenderness from its trigger points • This i s held for 9 0 seconds before a slow return o f the might possibly be elicited through the overlying muscles leg to neutral. but the vascular structures course along the mid-line of the calf and deep pressure into this region is certainly not Lateral compartment of the leg (Fig. 1 4.44) advisable. At best, the tendon of tibialis posterior is palpable near the medial malleolus but caution should be Peroneus longus exercised in this region as well, due to the course of the posterior tibial artery. This muscle is best addressed with Attachments: From the head and proximal two-thirds of spray (or ice strip) and stretch, MET or other stretching the lateral shaft of the fibula, the deep surface of the methods. crural fascia, the anterior and posterior intermuscular septa (and sometimes a few fibers from the lateral PRT for deep layer of posterior leg condyle of the tibia) to attach by two slips to the base of the first metatarsal and medial clmeiform (sometimes Flexor digitorum longus a third slip is extended to the base of the second meta­ tarsal) (see details of tendon course below) • The tender point for FDL is found posterior to the medial aspect of the tibia, in the belly of FDL. Innervation: Deep peroneal nerve (L5, 51 ) Muscle type: Phasic (type 2), with a tendency to weakening and lengthening (Lewit 1999) Function: Plantarflexes and pronates the foot Synergists: For plantarfIexion: gastrocnemius, soleus, plantaris, peroneus brevis, flexor hallucis brevis, flexor hallucis longus, tibialis posterior For pronation: peroneus brevis and tertius and extensor digitorum longus

546 CLINICAL APPLICATION OF NMT VOLUME 2 Peroneus longus, Synergists: For pLantarflexion: gastrocnemius, soleus, cut and reflected ---/tI plantaris, peroneus longus, flexor hallucis brevis, flexor hallucis longus, tibialis posterior For pronation: peroneus longus and tertius and extensor digitorum longus Antagonists: To pLantarflexion: extensor digitorum longus, peroneus tertius, extensor hallucis longus, tibialis anterior To pronation: tibialis anterior and posterior, extensor hallucis longus, flexor hallucis longus, gastrocnemius, soleus, plantaris Fibula \",.-fl-+-+ I ntermuscular septum Indications for treatment Peroneus brevis Extensor digitorum longus • Weak and / or painful ankles • Frequent ankle sprains Peroneus longus, -+I-I Peroneus tertius • Foot drop cut and I nferior extensor retinaculum • Peroneal nerve entrapment reflected Peroneus tertius tendon • Residual pain from ankle fractures Inferior peroneal Peroneus brevis Special notes retinaculum tendon 5th metatarsal bone Peroneus longus is the more superficial and is the longer of the two lateral compartment muscles which lie on the Figure 1 4.44 The peroneal muscles with peroneus longus reflected lateral shaft of the fibula. The longus attaches to the upper (adapted with permission from Travell & Simons 1 992). half of the bone and the brevis to the lower half, with their tendons coursing together through a common groove Antagonists: To pLantarfLexion: extensor digitorum longus, posterior to the lateral malleolus, being contained there in a common synovial sheath. The shorter peroneus brevis peroneus tertius, extensor hallucis longus, tibialis attaches to a tuberosity on the fifth metatarsal, shortly anterior distal to where the longus alters its course to run under the cuboid and through a canal created by the long plantar To pronation: tibialis anterior and posterior, extensor ligament. Peroneus longus attaches on the medial aspect of the foot at the base of the first metatarsal and medial hallucis longus, flexor hallucis longus, gastrocnemius, cuneiform bone, lateral to the attachment of tibialis anterior soleus, plantaris on the same bones. Gray's anatomy (1 995) notes that a Peroneus brevis third slip sometimes extends to the base of the second Attachments: From the distal two-thirds of the lateral metatarsal, while additional tendinous slips may run to surface of the fibula, anterior and deep to peroneus the third, fourth or fifth metatarsals. 'Fusion of peroneus longus, and the anterior and posterior intermuscular longus and brevis can occur, but is rare' . septa to attach to a tuberosity on the lateral surface of the base of the fifth metatarsal Near the head of the fibula, there is a gap beneath the peroneus longus through which the common peroneal Innervation: Deep peroneal nerve (L5, Sl ) nerve passes. Manual techniques used in this region must Muscle type : Phasic ( type 2), with a tendency to be applied with caution to avoid compression of the nerve against the bony surface of the fibula, with possible weakening and lengthening (Lewit 1 999) resultant neural irritation. On the other hand, it is Function: Plantarflexes and pronates the foot important that when symptoms of neural entrapment of the peroneal nerves are present, peroneus longus be examined and treated due to its ability to compress the neural structures (Travell & Simons 1 992) . Compression of the peroneal nerve can result in various neural deficiencies (such as neurapraxia or nerve palsy) and functional impairment, such as toe drop if motor or numb­ ness in the foot if sensory (see Box 1 4.9).

THE LEG AND FOOT 547 Box 1 4.9 Neural impingement and neurodynamic testing • A positive tension test is one in which the patient's symptoms are reproduced by the test procedure and where these Note: See Volume 1 , Box 1 3. 1 1 , pp. 369-370 for additional symptoms can be altered by variations in what are termed information regarding the background to neural impingement. 'sensitizing maneuvers', which are used to 'add weight to', and confirm, the initial finding of AMT. Korr ( 1 970, 1 981 ) demonstrated that nerves transport vital biochemical substances throughout the body, constantly. The rate • Adding dorsiflexion during SLR is an example of a sensitizing of axonal transport of such substances varies from 1 mm/day to maneuver. several hundred mm/day, with 'different cargoes being carried at different rates'.The motor powers (for the waves of transportation) • Precise symptom reproduction may not be possible, but the test are provided by the axon itself'. Transportation is a two-way traffic, is still possibly relevant if other abnormal symptoms are with retrograde transportation, 'a fundamental means of produced during the test and its accompanying sensitizing communication between neurons and between neurons and non­ procedures. Comparison with the test findings on an opposite neuronal cells'. limb, for example, may indicate an abnormality worth exploring. Korr ( 1 98 1 ) believes this process to have an important role in • Altered range of movement is another indicator of abnormality, maintenance of 'the plasticity of the nervous system, serving to whether this is noted during the initial test position or during keep motor-neurons and muscle cells, or two synapsing neurons, sensitizing additions. mutually adapted to each other and responsive to each other's changing circumstances'. The trophic influence of neural structures Variations of passive motion of the nervous system during on the structural and functional characteristics of the soft tissues examination and treatment they supply can be shown to be vulnerable to disturbance. Korr ( 1 98 1 ) explains: 1 . An increase in tension can be produced in the interneural component, where tension is being applied from both ends, so Any factor which causes derangement of transport mechanisms in to speak, as in the 'slump' test (Fig. 1 4.45). the axon, or that chronically alters the quality or quantity of the axonally transported substances, could cause the trophic 2. I ncreased tension can be produced in the extraneural influences to become detrimental. This alteration in turn would component, which then produces the maximum movement of the nerve in relation to its mechanical interface (such as in straight produce aberrations of structure, function, and metabolism, leg raising) with the likelihood of restrictions showing up at 'tension points'. thereby contributing to dysfunction and disease. 3. Movement of extraneural tissues in another plane can be Among the negative influences frequently operating on these engineered. transport mechanisms, Korr informs us, are deformations of nerves and roots, such as compression, stretching, angulation and torsion. CAUTION : General precautions and contraindications Nerves are particularly vulnerable in their passage over highly mobile joints, through bony canals, intervertebral foramina, fascial • Care should be taken of the spine during the 'slump test' if layers and tonically contracted muscles (for example, posterior rami disc problems are involved or if the neck is sensitive (or the of spinal nerves and spinal extensor muscles). patient is prone to dizziness). Neurodynamic testing for and the treatment of 'tensions' in neural • If any area is sensitive, care should be taken not to structures offer a means of dealing with some forms of pain and aggravate existing conditions during performance of tests. dysfu nction. • If obvious neurological problems exist, special care should Maitland ( 1 986) suggested that assessment and treatment of be taken to avoid exacerbation which vigorous or strong 'adverse mechanical tension' (AMT) in the nervous system should stretching might provoke. be seen as a form of 'mobilization'. • Similar precautions apply to diabetic, MS or recent surgical Any pathology in the mechanical interface (MI) between nerves patients or where the area being tested is affected by and their surrounding tissues can produce abnormalities in nerve Circulatory deficit. movement, resulting in tension on neural structures. Examples of MI dysfunction are nerve impingement by disc protrusion, • Tests of the sort described below should be avoided if there osteophyte contact or carpal tunnel constriction. These problems has been recent onset or worsening of neurological signs may be regarded as mechanical in origin and symptoms will more or if there is any cauda equina or cord lesion. easily be provoked by movement rather than passive testing. Straight leg raising (SLR) test Chemical or inflammatory causes of neural tension can also occur, resulting in 'interneural fibrosis', which leads to reduced Note: See text relating to hamstring tests (for shortness) in elasticity and increased 'tension', which would become obvious Chapters 1 0 and 1 2. See Figure 1 2.49 in particular. In Chapter 1 0 with tension testing of these structures (see the discussion of Box 1 0.5, see discussion under the subheading: Protocol for Morton's neuroma on p. 527). The pathophysiological changes assessment of symptoms caused by nerve root or peripheral nerve resulting from inflammation, or from chemical damage (i.e. toxicity) dysfunction (p. 240). lead to internal mechanical restrictions of neural structures, which are quite different from externally applied mechanical causes, such The leg is raised in the sagittal plane, knee extended. as would be produced by a disc lesion, for example. It is suggested that this test should be used in all vertebral disorders, all lower limb disorders (and some upper limb disorders) When a neurodynamic test (see below) is positive (i.e. pain is to establish the possibility of abnormal mechanical tension in the produced by one or another element of the test - initial position nervous system in the lower back or limb. alone or with 'sensitizing' additions) it indicates only that AMT exists somewhere in the nervous system and not that this is Sensitizing additions to SLR necessarily at the site of reported pain. • Ankle dorsiflexion (this stresses the tibial component of the Petty & Moore ( 1 998) suggest that: 'in order to ascertain the sciatic nerve). degree to which neural tissue is responsible for the production of the patient's [ankle and foot) symptoms' the tests which should be • Ankle plantarflexion plus inversion (this stresses the common carried out are passive neck flexion, straight leg raising, passive peroneal nerve, which may be useful with anterior shin and knee flexion and 'slump'. These tests are described below, with the dorsal foot symptoms). (continued overleaf) exception of passive neck flexion which is self-explanatory.

548 CLINICAL APPLICATION OF NMT VOLUME 2 Box 14.9 Neural impingement and neurodynamic testing (cont'd) • Passive neck flexion. • Increased medial hip rotation. • Increased hip adduction. • Altered spinal position (for example, left SLR may be 'sensitized' by lateral flexion to the right of the spine). The SLR test should be performed with the addition, one at a time, of each sensitizing maneuver, in order to assess changes in symptoms, new symptoms, restrictions, etc. The question being asked is: 'Can the leg be raised as far, and as easily, without force, and without symptoms (new or old) appearing, when the sensitizing additions are i ncorporated?' Notes on SLR test Figure 14.45 The slump test places the entire neural network, from pons to the feet, under tension. Note the movement pattern of • During the SLR test there is caudad movement of the nerve roots and dura mater as indicated by the arrows. Also note lumbosacral nerve roots in relation to interfacing tissue (which is that as the knee moves from flexion to extension the tibial nerve why there is a 'positive' indication of pain and limitation of leg­ moves in two directions in relation to the tibia and femur. The raising potential when SLR is performed in the presence of a peroneal tension pOint is at the head of the fibula. No neural prolapsed intervertebral disc). movement occurs behind the knee or at levels C6, T6 or L4 (Butler 1 994). • The tibial nerve, proximal to the knee, moves caudad (in relation to the mechanical interface) during SLR, whereas distal to the The test involves the seated patient introducing the following knee it moves cranially. There is no movement of the tibial nerve sequence of movements: behind the knee itself, which is therefore known as a 'tension point'. • thoracic and then lumbar flexion, followed by • cervical flexion • The common peroneal nerve is attached firmly to the head of • knee extension the fibula (another 'tension point'). • ankle dorsiflexion • sometimes also hip flexion (produced by either bringing the trunk Prone knee bend test (PKB) forward on the hips or by increasing SLR). • The patient is prone and the knee is flexed, taking the heel toward the buttock to assess reproduction of existing symptoms, Additional sensitizing movements during slump testing are or other abnormal symptoms, or altered range of movement achieved by changes in the terminal positions of joints. Butler (heel should approximate buttock easily). See Figure 1 2. 1 9 for ( 1 994) gives examples. positioning in prone position. • If the test reproduces (for example) lumbar and radiating thigh • During the test, the knee of the prone patient is flexed while the pain , a change in head position - say into slight extension - hip and thigh are stabilized, which moves the nerves and roots could result in total relief of these symptoms (desensitizing). from L2, L3, L4 and, particularly, the femoral nerve and its branches. • A change in ankle and knee positions could significantlY'change cervical, thoracic or head pain produced by the test. • If, however, the test is conducted with the patient sidelying, the hip should be maintained in extension during the test (this • In both instances this would confirm that AMT was operating, alternative position is thought more appropriate for identifying although the site would remain obscure. entrapped lateral femoral cutaneous nerve problems). • Trunk sidebending and rotation or even extension, hip adduction, It is obvious that the PKB test stretches rectus femoris and rotates abduction or rotation and varying neck positions are all the pelvis anteriorly, thus extending the lumbar spine, which can sensitizing movements. confuse interpretation of nerve impingement symptoms. Care should be taken to avoid this by stabilizing the pelvis or by Cadaver studies demonstrate that neuromeningeal movement placement of a pillow under the abdomen to support the lumbar occurs in various directions, with C6, T6 and L4 intervertebral spine. A bodyCushionTM would most ideally achieve this goal. levels being regions of constant state (i.e. no movement, therefore 'tension points'). Butler ( 1 994) reports that many restrictions Sensitizing maneuvers include (in either prone or sidelying use identified during the slump test may only be corrected by of the test): appropriate spinal manipulation. (continued overleaf) • introduction of cervical flexion • adopting the 'slump' position (below) - but only in the sidelying variation of the test • hip abduction, adduction, or rotation. The 'slump test' Butler ( 1 994) regards this as the most important test in this series. It links neural and connective tissue components from the pons to the feet and requires care in performance and interpretation (Fig. 1 4.45). The slump test is suggested for all spinal disorders, most lower l imb disorders and some upper limb disorders (those which seem to involve the nervous system).

THE LEG AND FOOT 549 Box 1 4.9 Neural impingement and neurodynamic testing (cont'd) It is possible for SLR to be positive (e.g. symptoms are Butler ( 1 994) suggests that in treating adverse mechanical reproduced) and the slump test negative (no symptom tensions in the nervous system, initial stretching of the tissues reproduction) and vice versa, so both should always be performed. associated with neural restrictions should commence well away The following findings have been reported in research using the from the site of pain in sensitive individuals and conditions. It is not slump test. Mid-thoracic to T9 are painful on trunk and neck flexion within the scope of this text to detail methods for releasing in 50% of 'normal' individuals. The following are considered normal abnormal tensions, except to suggest that the treatment positions responses if they are symmetrical. are commonly a replication of the test positions (as in shortened musculature, where MET is used). • Hamstring and posterior knee pain occurring with trunk and neck flexion, when the knees are extended and increasing further with We suggest that when the protocols outlined throughout the ankle dorsiflexion. clinical applications segments are diligently carried out, including identifying and releasing tense and shortened musculature, • Restrictions in ankle dorsiflexion during trunk/neck flexion while releasing tense, indurated, fibrotic myofascial structures using the knee is in extension. NMT or other deep tissue methods as well as deactivating trigger points, where appropriate, mobilizing joints, including those • There is a common decrease in pain noted on release of neck aspects of movement which are involuntary (joint play), there flexion and an increase in range of knee extension or ankle will almost always be an improvement in abnormal neural dorsiflexion on release of neck flexion. restrictions. If the patient's symptoms are reproduced by the slump position, Retesting restricted tissues regularly during treatment is altered or aggravated by sensitizing movements and can be important, in order to see whether gains in range of motion or relieved by desensitizing maneuvers, the test is regarded as lessening of pain noted during AMT testing are being achieved. positive. Regarding the actions of peroneus longus, Gray's surface of the calcaneus and to the cuboid (Platzer 1 992), anatoll1Y (1 995) notes: while an even rarer peroneus digiti minimi (2%) courses from the distal fibula to the extensor aponeurosis of the There is little doubt that peroneus longus can evert and fifth toe (Travell & Simons 1 992). plantar-flex the foot and possibly act on the leg from its distal attachments. The oblique direction of its tendon across the sole NMT for lateral compartment of leg would also enable it to support the longitudinal and transverse arches of the foot. How are these potentialities • The patient is placed in a sidelying position, with the actually deployed in movement? With the foot off the ground, lowermost limb extended (straight) and the uppermost eversion is visually and palpably associated with increased leg flexed at the hip and knee, with the knee and leg sup­ prominence of both tendon and muscle. It is not clear to what ported on a cushion. The foot bolster of the bodyCushionTM extent this helps to maintain plantigrade contact of the foot in is ideal for this step as it is flat and wide and supports the standing, but electromyographic records show little or no leg without rolling, which roun d bolsters have a peroneal activity under these conditions. On the other hand, tendency to do. peroneus longus and brevis come strongly into action to maintain the concavity of the foot during toe-off and tip­ • In this position, the lateral surface of the leg is avail­ toeing. If the subject deliberately sways to one side, the able for palpation and, by supporting the leg, stress is peronei contract on that side, but their involvement in avoided in the knee, hip or lower back region. postural activity between the foot and leg remains uncertain. • The practitioner positions herself to comfortably Trigger point target zones for peroneus longus and brevis address the lateral surface of the leg, from the lateral project around the lateral malleolus ( 'above, behind and malleolus to near the head of the fibula. This position can below it') and into the lateral foot and middle third of the be in front or in back of the patient or she may even sit on lateral leg (Travel & Simons 1 992) . Trigger points in these the edge of the examination table, as long as her body is muscles can be activated or perpetuated, by ankle sprain, comfortably placed, with no strain or lumbar twist prolonged immobilization (cast), by other trigger points occurring. which have the lateral leg as their target zone, the wear­ ing of high heels, tight elastic on the calf, by crossing the • Lubricated, gliding strokes are repetitively applied legs and by pronated feet or Morton's foot structure (see (8- 1 0 times) to the peroneal muscles which lie on the p. 527). lateral aspect of the shaft of the fibula, from the la teral malleolus to 1 -2 inches distal to the head of the fibu la Peroneus tertius is contained within the anterior compartment and is discussed in the next section. It shares (Fig. 1 4.46). eversion tasks with the other two peroneal muscles but is antagonistic to their plantarflexion movements due to its • The remaining tissues near the fibular head can be location anterior to the ankle joint. The 'rarely present' carefully treated as long as care is taken to avoid peroneus quartus ( 1 3 % according to Travell & Simons compressing the common peroneal nerve into the surface 1 992) arises from the fibula and attaches to the lateral of the fibula. Even gentle palpation may irritate this

550 CLINICAL APPLICATION OF NMT VOLUME 2 Figure 1 4.46 Treatment of the lateral shaft of the fibula will address Anterior compartment of the leg peroneus longus and brevis. Caution should be exercised to avoid compressing the peroneal nerve near the fibular head. The anterior compartment of the leg houses the primary dorsiflexors: anterior tibialis, extensor digitorum longus, Figure 1 4.47 Tendons of peroneus longus and brevis can be stroked extensor hallucis longus and peroneus tertius (Fig. 1 4.48). with the tip of the beveled pressure bar. Caution should be exercised This compartment is bordered on the medial aspect by following ankle sprains to ensure that swelling and inflammation in this the tibia and by unyielding fascial structures on the lateral region have subsided before these techniques are used. (anterior intermuscular septum) and posterior (interosseous membrane) aspects which separate it from the other two nerve and cause lasting discomfort, especially if it is compartments. The overlying dense fascia on the anterior already in a hyperirritable state. surface of the compartment, combined with the unyielding enclosures above, which should functionally offer support • The beveled pressure bar can be used to apply short and containment, may contribute to increased pressure gliding strokes on the tendon of the peroneus brevis to its within the compartment sufficient to occlude circulation insertion on the fifth metatarsal (Fig. 1 4.47). to the muscles contained within it, resulting in a patho­ logical (and serious) condition known as anterior • Resisted eversion of the foot will expose the tendon compartment syndrome (see Box 14. 1 0). visibly and / or palpably. The muscle should be relaxed before its tendon is treated. Tibialis anterior Note: The tendon of the peroneus longus crosses the foot Attachments: From the lateral condyle and proximal half to two-thirds of the lateral surface of the tibial shaft, to insert on the first metatarsal and medial cuneiform anterior surface of the interosseous membrane, deep bone. This tendon should always be checked when there surface of crural fascia and anterior intermuscular are formations of bunions on the first metatarsal or septum to attach to the medial and plantar surfaces of the instability of the arches. This tendon is treated with the medial cuneiform and base of the first metatarsal bone intrinsic muscles later in this chapter. Innervation: Deep peroneal nerve (L4-L5) Muscle type: Phasic (type 2), with a tendency to weakening and lengthening (Lewit 1 999) Function: Dorsiflexes and supinates (inverts and adducts) the foot; pulls the body forward over the fixed foot Synergists: For dorsiflexion: extensor digitorwn longus, peroneus tertius, extensor hallucis longus For supination: tibialis posterior, triceps surae, flexor hallucis longus, flexor digitorum longus and plantaris For forward pull of body: extensor digitorum longus, peroneus tertius, extensor hallucis longus Antagonists: To dorsiflexion: gastrocnemius, soleus, plantaris, peroneus longus and brevis, flexor hallucis brevis, flexor hallucis longus, tibialis posterior To supination: peroneus longus, brevis and tertius and extensor digitorum longus To forward pull of body: gastrocnemius, peroneus longus and brevis, tibialis posterior, soleus Indications for treatment • Pain in the great toe or anteromedial ankle • Functional toe drop, tripping over one's own feet • Weakness of dorsiflexion (especially when walking) Special notes Tibialis anterior dorsi flexes the foot and supinates it when it is free to move. When gaiting, its activity begins

THE LEG AND FOOT 551 Patellar ligament ---+_ Insertion of sartorius (quadriceps tendon) Gastrocnemius Soleus Peroneus longus Tibialis anterior Extensor digitorum longus Extensor hallucis longus ---l Superior extensor retinaculum l!-- Medial malleolus --r-t�i\\\";JdLateral malleolus --�- Inferior extensor retinaculum Extensor digitorum brevis Cl Utlft-- Tibialis anterior Extensor digito rum longus Peroneus tertius ---+¥J ��,..-'!J Extensor hallucis brevis H!!- Extensor hallucis longus Figure 1 4.48 Muscles of the right leg from anterior aspect (reproduced with permission from Gray's anatomy 1 995). just after toe-off as it lifts the foot, so that the foot and toes the leg forwards at the ankle. It has a role in supporting the clear the ground during the swing phase. At heel strike, medial longitudinal arch of the foot and although it prevents foot slap and then advances the tibia forward electromyographic activity is minimal during standing, it is over the talus. Regarding its role in standing postures, manifest during any movement which increases the arch, such as toe-off in walking and running. Gray's anatomy ( 1 995) states: Trigger points in tibialis anterior refer pain and tender­ The muscle is usually quiescent in a standing subject, since the ness from the mid-shin region to the distal end of the weight of the body acts through a vertical line that passes great toe, being strongest at the ankle and toe (Fig. 1 4.49). anterior to the ankle joints. Acting from below, it helps to These trigger points may be activated by ankle injuries or counteract any tendency to overbalance backwards by flexing

552 CLIN ICAL APPLICATION OF NMT VOLUM E 2 Box 1 4.10 'Shin splints' and compartment syndromes Shin splints is a term previously used to describe any exercise­ Figure 14.49 Trigger point referral pattern for tibialis anterior related chronic pain of the leg. It is important to establish and (adapted with permission from Travell & Simons 1 992). differentiate the source of pain, as the etiology of apparently identical symptoms can be substantially different, even though membrane to attach to the dorsal aspect of the base of the many are related to overuse and/or foot mechanics. The most distal phalanx of the hallux. The anterior tibial vessels common causes include the following. and deep peroneal nerve lie between it and tibialis anterior Stress fracture pain is usually located along the medial Innervation: Deep peroneal nerve (L5-S 1 ) aspect of the lower third of the tibia. It is usually localized in the Muscle type : Phasic (type 2 ) , with a tendency to bone itself, is uncomfortable to palpation of the bony surface weakening and lengthening (Lewit 1 999) surrounding the fracture site and may be accompanied by Function: Dorsiflexes (extends) the great toe and dorsi­ swelling and warmth. Though a bone scan may reveal a stress flexes and supinates (inverts and adducts) the foot; fracture within a few days, X-rays may not detect it for several pulls the body forward over the fixed foot; decelerates weeks. Treatment is usually rest and reduced weight-bearing the descent of the forefoot following heel strike stress. Synergists: For dorsiflexion of first toe: extensor hallucis Medial tibial stress syndrome (soleus syndrome, chronic periostalgia) is related to tension placed on the periosteum, brevis which can result in separation from the tibial cortex (Travell & Simons 1 992). The distal one-third to one-half of the medial For dorsiflexion of foot: extensor digitorum longus, aspect of the tibia exhibits localized and specific pain at the muscular insertion sites of the overstressed muscles. Pain peroneus tertius, tibialis anterior usually extends to a larger area than that found in stress fractures. Edwards & Myerson ( 1 996) note: 'In medial tibial For supination: tibialis posterior, triceps surae, flexor stress syndrome, local inflammation of the periosteum results in activity-related pain early in a bout of exercise, but the pain hallucis longus, flexor digitorum longus, plantaris and tends to abate as exercise continues, or with enhanced tibialis anterior conditioning'. Though X-rays do not usually reveal evidence, Edwards & Myerson point out that a bone scan 'will show a For forward pull of body: extensor digitorum longus, transverse linear pattern for stress fracture, and a longitudinal linear uptake in the cortex for medial tibial stress syndrome' peroneus tertius, extensor hallucis longus which is helpful in differential diagnosis. Antagonists: To dorsiflexion of first toe: flexor hallucis Exertional compartment syndrome (ECS) is a condition in which the tissues confined in an anatomical space (like the four longus and brevis compartments of the leg) are adversely influenced by increased pressure which effects circulation and threatens the function To dorsiflexion: gastrocnemius, soleus, plantaris, peroneus and viability of the tissues. Muscle swelling or increased osmotic pressure results in raised intracompartmental longus and brevis, flexor hallucis brevis, flexor hallucis pressures. Pain and swelling may be accompanied by sensory longus, tibialis posterior deficits or paresthesias and motor loss or weakness related to ischemic changes within the compartment (Edwards & Myerson To supination: peroneus longus, brevis and tertius and 1 996). Pressure on associated nerves within the compartment may result in sensory deficits in the areas of nerve distribution extensor digitorum longus as well as motor loss which, in severe cases, might result in foot drop. Onset is usually gradual and usually associated directly with the amount or i ntensity of exercise and is usually relieved by cessation of the exercise session. Physical exam should take place after the patient has exercised strenuously enough to reproduce symptoms. Symptoms will i nclude tenderness over the involved muscles, with muscle weakness and paresthesia to light touch in severe cases. Because serious complications may result from neural and arterial occlusion, referral to a physician for diagnosis is indicated prior to application of manual therapies, especially when using any modality which might increase pressure within the compartment. Though assorted tests may be given for differential diagnosis, measurement of intracompartmental pressure is necessary to confirm the diagnosis of ECS (Edwards & Myerson 1 996). overload, gross trauma or walking on sloped surfaces or rough terra in. Extensor hallucis longus Attachments: From the middle half of the medial surface of the fibu la and anterior surface of the interosseous

THE LEG AND FOOT 553 To forward pull of body: gastrocnemius, peroneus longus and brevis, tibialis posterior, soleus Extensor digitorum longus Extensor digitorum -+-\\+�- longus trigger point Attachments: From the lateral condyle of the tibia, proximal three-quarters (including the head) of the shaft of the rl++- Extensor hallucis fibula, the interosseous membrane, deep surface of the longus trigger point crural fascia, anterior intermuscular septum and the septum between EDL and tibialis anterior, distally From FHL dividing into four slips which attach to the dorsal surfaces of the bases of the middle and distal phalanges Figure 1 4.50 Trigger point referral pattern for extensor digitorum of the four lesser toes longus and extensor hallucis longus (adapted with permission from Travell & Simons 1 992). Innervation: Deep peroneal nerve (L5, 51 ) Muscle type : Phasic (type 2), with a tendency to the second toe and sometimes it merges with extensor weakening and lengthening (Lewit 1 999) digitorum longus (Gray's anatomy 1 995). Between tibialis Function: Dorsiflexes (extends) the four lesser toes, anterior and EHL lies the deep peroneal nerve and the dorsiflexes and pronates (everts and abducts) the foot; anterior tibial vessels. pulls the body forward over the fixed foot; decelerates the descent of the forefoot following heel strike Extensor digitorum longus (EDL) lies in the most lateral aspect of the anterior compartment. It courses over the Synergists: For dorsiflexion of lesser toes: extensor dorsal foot to attach to the four lesser toes, which it dorsi­ flexes. The tendons to the second and fifth toes may be digitorum brevis doubled and there may be accessory slips attached to For dorsiflexion of foot: extensor hallucis longus, metatarsals or to the great toe (Gray's anatomy 1 995). peroneus tertius, tibialis anterior Trigger points in the EHL refer across the dorsum of the foot and strongly into the first metatarsal and great For pronation: peroneus longus, brevis and tertius toe, while the EDL refers across the dorsum of the foot (or For forward pull of body: tibialis anterior, peroneus ankle) and into the lesser toes (Fig. 1 4.50). tertius, extensor hallucis longus Peroneus tertius Antagonists: To dorsiflexion of lesser toe: flexor digitorum Attachments: From the distal third of the anterior surface of the fibular shaft, interosseous membrane a nd longus and brevis intermuscular septum to attach by a tripartite anchor to the base of the fifth metatarsal and its medial shaft To dorsiflexion of the foot: gastrocnemius, soleus, plantaris, and to the base of the fourth metatarsal peroneus longus and brevis, flexor hallucis brevis, Innervation: Deep peroneal nerve (L5, 51 ) flexor hallucis longus, tibialis posterior Muscle type : Phasic ( type 2), with a tendency to To pronation: tibialis posterior, triceps surae, flexor hallucis weakening and lengthening (Lewit 1 999) Function: Dorsiflexes and pronates the foot longus, flexor d igitorum longus, tibialis anterior, plantaris Synergists: For dorsiflexion: extensor digitorum longus, To forward pull of body: gastrocnemius, peroneus longus extensor hallucis longus, tibialis anterior and brevis, tibialis posterior, soleus Indications for treatment • Pain on the top of the foot extending into the great toe (EHL) or the lesser toes (EDL) • Weakness of the foot during gaiting • Foot drop • Night cramps • 'Growing pains' Special notes Extensor hallucis longus (EHL) lies between tibialis anterior and extensor digitorum longus, being covered for the most part by the two. It courses over the dorsal surfaces of the foot to attach to the great toe, which it dorsiflexes. The muscle sometimes produces a slip onto

554 CLINICAL APPLICATION OF NMT VOLUME 2 For pronation: peroneus longus and brevis, extensor attention and application of massage to the affected area can increase the pressure within the compartment, with digitorum longus gastrocnemI. Us, soleu�, potentially serious repercussions. Antagonists: To dorsiflexion: plantaris, peroneus longus and brevis, flexor halluCls • The patient is supine with the leg resting straight on brevis, flexor hallucis longus, tibialis posterior the table and a small cushion placed under the knee. To pronation: tibialis posterior, lotnrigceups,sti. bs�ilarl�ise,anftleen�oorr • The practitioner stands at the level of the foot on the hallucis longus, flexor digitorum side to be treated and faces the patient's head. Indications for treatment • The thumbs are used to apply lubricated, gliding • Weak and /or painful ankles strokes to the tibialis anterior just lateral to the tibia • Frequent ankle sprains • Foot drop from the anterior ankle to the proximal end of the • Peroneal nerve entrapment • Residual pain from ankle fractures tibia. These gliding strokes are repeated 7-8 times, while simultaneously examining for dense or thickened tissue associated with ischemia. • The thumbs are then moved laterally onto the next section of the tibialis anterior and the gliding strokes Special notes repeated. examm. ed If taut bands Although peroneus tertius is often considered to be an • are discovered, they can be additional component of the extensor digitorum longus more precisely for the presence of trigger points. (Platzer 1 992), Travell & Simons ( 1 992) note that it is • Localized nodules, tenderness and associated referred 'usually anatomically distinct' from EDL, despite its pain offer evidence of their presence. Tri�ger poi�t pressure release can be applied to each tngge� pomt, anatomical and functional differences from the other as well as localized MFR, followed by stretchmg of peroneals. It is a dorsiflexor (the other two are plantar­ the tissues. flexors), housed in the anterior compartment of the leg • A flat-tipped pressure bar (in this case, never the (the others in the lateraD and separated from brevis and beveled one!) can be substituted for the thumbs when longus by an intermuscular septum. They also note that the tibialis anterior is very large or very thick. This is it is 'usually as large or larger than extensor digitorum a particular problem in the athletic leg, as application longus'. of sufficient pressure to be effective can be highly The peroneus cteormtipulsetiselhyigabhslyenvtaorinalbylein, Gar?aoyu's�a4n.�at%om?yf stressful to the practitioner's thumbs. noting that it is • The pressure bar should be supported by the web cases while Travell & Simons ( 1 992) report It mlssmg m 7.1 -8.2%. Other variations (peroneus digiti minimi and between the thumb and index finger (creating a peroneus quartus) are noted as being sometimes present stabilizing 'V'), to assist in controlling the tip and (see p. 549). preventing it from sliding off the rounded surface of Like the other peroneals, the tertius can actively evert the anterior leg (Fig. 1 4.51 ). the foot and stabilize it laterally at the ankle. It helps the • The thumbs are now moved again laterally which toes clear the ground in the swing phase and levels the places them onto the toe extensors. The tableside foot as necessary. Gray's anatomy (1 995) notes: 'Peroneus hand is used to displace the tibialis anterior medially, tertius is not active during stance phase, a finding that while the thumb of the other hand presses the contradicts suggestions that it acts primarily to support extensor muscles posteriorly against the anterior the lateral longitudinal arch or to transfer the foot's center aspect of the shaft of the fibu la (Fig. 1 4.52). of pressure medially'. • When performed correctly, the thumbs will feel a Trigger points in peroneus tertius refer to the antero­ natural 'groove' between the tibialis anterior al�d extensors and the stroke will produce an effective lateral ankle and project posteriorly to the lateral malleolus compression of the muscles against the fibula. and into the heel (Travell & Simons 1 992). These trigger points are not activated and perpetuated by the �ame • The tendons of the muscles of the anterior activities that influence the other peroneals, due to differ­ compartment are treated with the intrinsic muscles of ences in location as well as function. the foot in the following section. NMT for anterior compartment of leg PRT for tibialis anterior CAUTION: The following steps are contraindicated • The tender point is found in a depression on the when anterior compartment syndrome is suspected (see talus, just medial to the tibialis anterior tendon, anterior and slightly caudal to the medial malleolus. Box 14.10). This condition requires immediate medical

THE LEG AND FOOT 555 Figure 1 4.51 A flat pressure bar can be substituted for the practitioner's thumbs when the tibialis anterior is too thick to be treated effectively by the hands alone. In most cases, however, the thumbs are sufficient. Figure 1 4.53 The position of ease for the tibialis anterior tender point. Figure 1 4.52 A double-thumb technique is used to simultaneously digital pressure is applied to this to allow the patient displace the tibialis anterior (TA) while compressing the extensor to assign a score of '10' to it. muscles against the shaft of the fibula. • The practitioner holds the foot and initiates strong dorsiflexion, while simultaneously applying long-axis • The prone patient's ipsilateral knee is flexed and the compression from the sole of foot toward the knee, in foot, held at the calcaneus, is inverted and the ankle order to reduce the palpated discomfort by 70% or internally rotated to fine tune, until reported more. sensitivity in the palpated tender point reduces by at • Fine tuning may involve slight variations in the least 70% . degree of dorsiflexion or the introduction of minor rotational positioning of the foot. • Additional ease may be achieved by long-axis • The final position of ease is held for 90 seconds and compression toward the knee from the calcaneus. the foot is then returned to neutral. • This is held for 90 seconds before slowly returning MUSCLES OF T H E FOOT the leg to neutral (Fig 1 4.53). The intrinsic muscles of the foot control movements of PRT for extensor digitorum longus the toes and also act on other joints to offer support to the plantar vault (arches) of the foot. Since none of them • The tender point for EDL lies in the belly of the crosses the ankle joint, they are not involved with gross muscle, anywhere from a few inches (4-5 cm) below movements of the foot but are extremely important to the the head of the fibula, to just proximal to the ankle. structural integrity of the foot and how it behaves when loaded. Hence, they are indirectly highly influential in • The patient is supine and the most sensitive point in determining how the extrinsic muscles must function in the belly of EDL is located by palpation and sufficient those gross movements, as well as being responsive to them. There are two dorsal and 11 plantar intrinsic muscles. Some of these are sets (seven interossei and four lumbricals) and are considered as one muscle in this COW1t. None of these muscles acts on one joint alone and most of them act on several joints.

556 CLINICAL APPLICATION OF NMT VOLUM E 2 The intrinsic muscles of the foot strongly resemble which foot mechanics have upon gaiting, maintenance of those of the hand and (as in the hand and forearm) only functional arches and the elastic components of move­ the tendons (not bellies) of the extrinsic muscles extend ment, which are reflected up through the body to the into the foot, some being influenced directly or assisted knee, pelvis, arms and head, their importance becomes by intrinsic muscles which attach to them. evident. When adaptation occurs in response to mech­ anical impairment, resulting in foundational instability, • Those on the dorsal surface are innervated by the compensational rotations of the ankle joint, leg or hip deep peroneal nerve (51-2). automatically alter the length and /or quality of the stride. 5uch compensational changes are seldom localized events • Those on the plantar surface are innervated by the but are commonly reflected throughout the body, due to plantar nerve: flexor digitorum brevis, flexor hallucis the ways each region builds upon and interfaces with the brevis, abductor hallucis and the portion of the others. lumbrical serving the great toe are all innervated by the medial plantar nerve (L5-5 1 ), while all others are Dorsal foot muscles (Fig. 14.58) innervated by the lateral plantar nerve (52-3). • Extensor hallucis brevis (EHB) and extensor Movements of the toes are achieved by a complex digitorum brevis (EDB) arise together from a common coordination of extrinsic and intrinsic muscles, the under­ attachment on the calcaneus (entrance to the sinus tarsi) standing of which is especially applicable to conditions and the inferior extensor retinaculum. They cross the such as claw toe, hammer toe and hallux rigidis (see Box dorsum of the foot deep to the tendons of the extensor 14.1 1 ). At first glance it would appear that such details digitorum longus and peroneus tertius. would not be significant in the picture of the body as a whole but when one considers the far-reaching influences Box 1 4.1 1 Movements of the toes Figure 1 4.54 Lumbrical and interossei produce plantarflexion of the metatarsophalangeal joints (reproduced with permission from The tendinous arrangement of the toes is similar to that of the Kapandji 1 987). hand as are the digital joints. Like the hand, the tendon of the extensor digitorum longus (EDL) forms a dorsal aponeurosis into Figure 14.55 Curling of the toes into full plantarflexion relies on which the extensor digitorum brevis, the lumbricals and long and short toe flexors (reproduced with permission from (sometimes) the interossei merge. The primary functional Kapandji 1 987). difference between these associated foot and hand structures is that flexion exceeds extension in metacarpophalangeal joints whereas extension exceeds flexion in the metatarsophalangeal (MTP) joints. In the foot, this difference is extremely important in the final phase of gaiting when dorsiflexion (extension) of the MTP joints reaches or exceeds 90° (Kapandji 1 987). A closer examination of the tendinous arrangement of the toe muscles as well as the mechanics of their movement may assist in understanding the development of dysfunctional deformities, such as hammer toes, claw toes and mallet toes. The following pertains to the lesser toes, which have a higher occurrence of flexion deformity than the great toe, which only has two phalanges instead of three. • The lumbricals (L) attach to the base of the proximal phalanx and also merge into the tendon of the EDL on the dorsal surface of the toes. The interossei (Ix) may have a similar attachment into the dorsal aponeurosis of EDL but anatomical variations exist. When EDL is relaxed, contraction of lumbricals and interossei (if they indeed insert into the tendon complex) produces plantarflexion of the MTP joints (Fig. 1 4.54). • On the plantar surface, the flexor digitorum brevis (FDB) splits near its distal attachment at the middle phalanx, forming a tunnel through which the flexor digitorum longus (FDL) courses to attach to the distal phalanx. When FDB and FDL simultaneously contract, they plantarflex the interproximal and distal interphalangeal joints, respectively (Fig. 1 4.55). Assistance from the interossei and lumbricals will result in plantarflexion of all the toe joints, causing a plantarward curling of the toes. • On the dorsal aspect, extensor digitorum brevis (EDB) merges into the tendons of EDL and serves to extend all three phalanges of the lesser toes except the fifth, which is usually extended by EDL only. (continued overleaf)

THE LEG AND FOOT 557 Box 1 4.1 1 Movements of the toes (cont'd) FDL FOB • The tendon complex of EDL forms an elaborate dorsal aponeurosis into which the EDB, the lumbricals and (sometimes) Figure 1 4.56 Dysfunctional muscular imbalances can produce the interossei merge. As mentioned previously, when EDL is 'claw toe' positioning (reproduced with permission from Kapandji relaxed and the flexors contract, the lumbricals and interossei can 1 987). assist plantarflexion of the MTP joints. However, when EDL contracts and the flexors relax, the lumbricals and (sometimes) Extensors i nterossei will assist extension (dorsiflexion) of the MTP joints instead (Fig. 1 4.56). and capsule -r;�; �... These muscles work together to press the toes into the ground Stretched when weight is borne onto the ball of the foot to stabilize the Callus Contracted tendon and capsule forefoot and to provide rigidity to the toes, while also allowing the forefoot rocker to function. Like so many foot muscles, these Figure 1 4.57 Hammer toes (adapted from Cailliet 1 997). muscles adjust the foot to instantaneously changing terrain, 'grabbing' the ground as necessary to provide balance to the gaiting foot. When substitution and muscular imbalance occur, resulting digital contracture can produce deformities of toe position. A common result is the development of hammer toe (Fig. 1 4.57) which is a fixed-flexion deformity of the interphalangeal joint in which capsules and tendons of the toe shorten and calluses develop in areas which bear excessive pressure or which rub on the shoe. Claw toe or mallet toe can develop in a similar manner, the evolution of which simply depends upon which joints are held in flexion or extension. I n any of these positional deformities of the toes, evaluation of the toe joints, hypertonicity of musculature, trigger points in these muscles, as well as those whose target zones include these muscles, gait patterning, static postural alignment and the shoes which the patient wears will provide clues as to the possible cause as well as assist in formulating a treatment plan. Treatment might include the manual techniques described within this text, orthoses which assist in correction of structural problems and, when the condition is disabling or severe, surgical correction. Extensor hallucis brevis which anchors to the middle and distal phalanges and Extensor digitorum brevis possibly to the proximal one as well, allowing extension of all three phalanges of these toes (Travell & Simons Figure 1 4.58 Dorsal intrinsic foot muscles (adapted from Travell & 1 992). Variations of this muscle include attachments to Simons 1 992). the fifth toe or absence of portions or all of the EDB muscle (Platzer 1 992). • EHB attaches to the dorsal surface of the proximal phalanx of the great toe, often uniting with the tendon of Trigger points in these muscles target the area imme­ EHL, and extending the great toe at the MTP joint (Travell diately surrounding (and including) their bellies and may & Simons 1 992) . be associated with trigger points in the corresponding long toe extensors. Trigger points should be sought in • EDB attaches to the second through fourth toes by these muscles when structural deviations exist which merging into the EDL, to form an extensor apparatus might be influenced by chronic toe extension, such as hammer toes or claw toes. t \" NMT for dorsal intrinsic muscles of the foot The patient is supine with the knee supported by a cushion while the practitioner stands or is seated at the level of the foot on the side to be treated. Extensor digitorum brevis and extensor hallucis brevis are palpated anteromedial to the lateral malleolus, just

558 CLINICAL APPLICATION OF NMT VOLUME 2 Figure 14.59 Palpation of extensor hallucis brevis and extensor Digital vessels digitorum brevis at the base of the sinus tarsi. Practitioner resistance and nerves against dorsiflexion of the lesser toes will assist in locating the muscles. Digital bands f-;f-, Transverse bands �;f-- Medial plantar artery anterior to the palpable indentation of the sinus tarsi. �+-- Abductor hallucis Their location is more evident if resisted extension of the H-- Central part of great toe (for EHB) or the lesser toes (for EOB) is applied plantar aponeurosis with one hand while the other palpates this region (Fig. 1 4.59). �'+-- Abductor minimi digiti Once the muscle bellies are located, short gliding strokes, -4-N.f+-- Lateral calcanean transverse gliding or static compression can be used to vessels treat these muscles. Additionally, the beveled pressure bar can be used to assess each tendon with short, scrap­ VH�-- Medial calcanean ing strokes or the thumb can be used in a gliding vessels assessment. Figure 14.61 Plantar aponeurosis of the right foot (reproduced with The dorsal interossei are discussed with the plantar permission from Gray's anatomy 1 995). muscles since they are innervated by the plantar nerve. However, they may be best accessed here with the dorsal Plantar foot muscles muscles. The beveled tip of the pressure bar can be wedged between the metatarsal bones, from the dorsal The plantar aponeurosis (deep fascia) is orientated surface, to examine and treat these small muscles, which mainly longitudinally but it also has some transverse lie deeply placed between the bony surfaces (Fig. 14.60). components (Fig. 1 4.61 ). It is considerably denser, stronger While the finger tip can be substituted, the authors find and thicker centrally, where it overlies the long and short that the beveled tip of the pressure bar is a better fit and digital flexors. Running from the calcaneus to the meta­ can be angled more effectively than the finger tip. tarsal heads, it divides into five bands, each attaching to a single toe. It broadens and thins distally and is united Figure 14.60 The beveled tip of the pressure bar can be wedged by transverse fibers. between the metatarsals to examine the dorsal interossei. It should be borne in mind that applications of manual massage techniques to the plantar surfaces of the foot will be applied through this plantar fascia. The integrity of this fascia is important to the arch system of the foot and overenthusiastic applications to 'loosen' it could be detrimental. As noted on p. 524, the plantar aponeurosis is tensionally loaded and in this way helps retain the plantar vault. When abused by structural stress (which might include prolonged standing or loss of the integrity of the arch through overload or repetitious strain), this

THE LEG AND FOOT 559 tissue may develop inflammation which is commonly �-- Flexor digitorum termed plantar fascitis (Cailliet 1 997). longus The plantar muscles, which lie deep to the plantar 1�t\"i'H\\+--+',¥ Flexor digitorum fascia, can be grouped in two ways. First, they can be dis­ brevis cussed according to where they longitudinally lie on the foot. This has merit since, for the most part, those which 11i-f-1� Sheath removed serve the great toe lie in the medial column of the foot, those which serve the fifth digit lie in a lateral column ��:-- Fibrous flexor and those which lie in between these two groups serve sheath the middle digits (except adductor hallucis which lies transversely across the forefoot). In clinical application it Flexor hallucis allows all muscles associated with a particular toe or longus group of toes, to be assessed at once. Alternatively, after the removal of the plantar fascia, they can be considered Abductor digiti in four layers. This is particularly useful in anatomy minimi studies, as cadaver dissection is often performed in this manner. It is also useful in the application of manual --- Abductor hallucis techniques, since superficial layers need to be addressed before underlying tissues are palpated. In the following '--l�;If Calcaneus discussion of anatomy details, the second style is employed, although the first can be easily substituted in Figure 14.62 Su perficial plantar muscles of the right foot. clinical application once the reader is familiar with the (reproduced with permission from Gray's anatomy 1 995). anatomy. foot and the taut bands associated with trigger points in Travell & Simons ( 1 992) note that trigger points in the this muscle may be responsible for tarsal tunnel syndrome plantar intrinsic muscles are activated or aggravated by, (Travell & Simons 1 992). the wearing of tight, poorly designed or ill-fitting shoes, ankle and foot injuries, structural inadequacies of the Flexor digitorum brevis (FOB) attaches to the medial foot, articular dysfunction or loss of structural integrity process of the calcaneal tuberosity, from the central part of the joints of the foot, walking on sandy or sloped of the plantar aponeurosis and from the intramuscular surfaces, conditions which allow the feet to get chilled septa. It courses distally through the longitudinal center and systemic conditions (especially those which affect of the foot, dividing distally into four tendons, which the feet, such as gout). insert into the four lesser toes, accompanied through their tendon sheaths by the tendons of flexor digitorum First layer longus. At the base of each proximal phalanx, the corre­ sponding FOB tendon divides, forming a tunnel through The superficial layer of plantar muscles includes which the tendon of FOL passes, to attach to the distal abductor hallucis on the medial side of the foot, abductor phalanx, while FOB attaches to both sides of the shaft of digiti minimi on the lateral side, while flexor digitorum the middle phalanx. Because it is 'perforated' by FOL, the brevis lies between them (Fig. 1 4.62). brevis is sometimes called perforatus (Platzer 1 992). Abductor hallucis (AbH) attaches proximally to the Gray's anatomy ( 1 995) notes: 'The way in which the flexor retinaculum, medial process of the calcaneal tuberosity, the plantar aponeurosis and the intermuscular tendons of flexor digitorurn brevis divide and attach to the septum which separate it from flexor digitorum brevis. phalanges is identical to that of the tendons of flexor Its distal tendon attaches to the medial side of the base (or medial side or plantar surface) of the proximal phalanx of the great toe. Sometimes fibers attach to the medial sesamoid bone of the great toe (Gray's anatomy 1 995). I t abducts and / or weakly flexes the proximal phalanx of the great toe (Platzer 1 992) and is a 'particularly efficient tightener' of the arch (Kapandji 1 987). AbH crosses the entrance of the plantar vessels and nerves which serve the sole of the foot and it may entrap these nerves against the medial tarsal bones (Travell & Simons 1 992). Trigger points in AbH refer to the medial aspect of the heel and

560 CLINICAL APPLICATION OF NMT VOLUME 2 digitorum superficialis in the hand' . It also states that and may form a separate muscle, abductor ossis metatarsi variations of FOB include second, supernumerary slips, digiti quinti. An accessory slip from the base of the fifth that a tendon may be absent or it may be that a small metatarsal is not infrequent. muscular slip from the FOL, or from quadratus plantae, may be substituted. FOB flexes the middle phalanges on ADM abducts the fifth toe and also flexes it. Kapandji the proximal ones. Trigger points in FOB refer to the ( 1 987) mentions that it also 'assists in the maintenance of plantar surface of the foot, primarily to the region of the the lateral arch'. Trigger points in ADM primarily target heads of the four lesser metatarsals. They may be the plantar surface of the fifth metatarsal head and the associated with trigger points found in FOL (Travell & adjacent tissues. Simons 1 992). Second layer Abductor digiti minimi (quintO (ADM) attaches to both processes of the calcaneal tuberosity and to the bone The second layer of plantar intrinsic muscles consists of between them, to the plantar aponeurosis and to the quadratus plantae and the four lumbrical muscles (Fig. intermuscular septum. It attaches to the lateral side of the 1 4.63). The flexor digitorum longus tendons accompany this layer and are intimately associated with these muscles. base of the proximal phalanx of the fifth toe. Gray's anatomy (1 995) notes: Quadratus plantae (QP) is also known as flexor digitorum accessorius or the plantar head of FOL. It Some of the fibres arising from the lateral calcaneal process attaches to the calcaneus by two heads, proximately usually reach the tip of the tuberosity of the fifth metatarsal Flexor digitorum brevis ;��]1 st Lumbricals Third plantar interosseus +--,,-_- ___ 4th Flexor digiti minimi brevis --�- Tendon of flexor hallucis longus Flexor hallucis brevis Abductor digiti minimi ________¥.!� �-- Tendon of flexor digitorum longus [Flexor d.lgl.torum accessor.ius Medial part �-- Abductor hallucis Lateral part ---�F Medial plantar nerve Flexor digitorum brevis ______�-\".\"!=! = Lateral plantar nerve Plantar aponeurosis Figure 14.63 First and second layer of plantar muscles of the right foot (reproduced with permission from Grays anatomy 1 995).

THE LEG AND FOOT 561 separated by the long plantar ligament. The medial head Adductor hallucis, --,�=:\"-­. Flexor attaches to the medial concave surface of the calcaneus, transverse part hallucis below the groove for the tendon of FHL, while the lateral I nterossei brevis attaches distal to the lateral process of the tuberosity and to the long plantar ligament. The larger medial head is Flexor digiti ':\"-�\"! Adductor more fleshy, while the flat lateral head is tendinous. They minimi brevis hallucis, both join the lateral border of the tendon of FDL, either to oblique the common tendon or into the divided tendons, varying Fibrous tunnel ---!­\"l'� part as to the number it supplies. The muscle is sometimes lor peroneus longus +-- Tibialis absent altogether (Gray's anatomy 1 995). QP assists in Peroneus ---t­ posterior tendon flexion of the four lesser toes by compensating for the longus tendon obliquity of the FDL tendon by centering the line of pull on the tendon. It also serves as a stabilizer for the Long plantar �_____ lumbricals which attach to the distal side of the same ligament tendon unit. The trigger point target zone for QP is strongly into the plantar surface of the heel. Figure 1 4.64 Third layer of plantar muscles of the right loot (reproduced with permission from Gray's anatomy 1 995). The lumbrical muscles are four small muscles which arise from the FDL tendons as far back as their angles of oblique head attaches to the bases of the second through separation. Each lumbrical attaches to the sides of two fourth metatarsal bones and from the fibrous sheath of adjacent tendons, except for the first which arises only the tendon of peroneus longus, and courses to the base of from the medial border of the tendon of the second toe. the proximal phalanx of the great toe, blending with the They attach distally on the medial sides of the dorsal tendon of FHB and its lateral sesamoid bone. The trans­ digital expansions, on their associated proximal phalanx; verse head attaches to the plantar metatarsophalangeal one or more may be missing. They serve as an accessory ligaments of the third through fifth toes and the deep to the tendons of FDL by assisting flexion of the transverse metatarsal ligaments, and blends with the metatarsophalangeal joints of the lesser toes, as well as tendons of the oblique head which attach to the base of extension of the interphalangeal joints. Travell & Simons (1 992) note that their trigger point patterns are likely to the proximal phalanx of the great toe. Gray's anatomy be similar to the interossei, although the patterns have not been confirmed. ( 1 995) notes: 'Part of the muscle may be attached to the first metatarsal, constituting an opponens hallucis. A slip T hird layer may a lso extend to the proximal phalanx of the second toe' . AdH adducts the great toe (toward the mid-line of The third layer of plantar intrinsic muscles consists of the foot), assists in flexion of the proximal phalanx of the flexor hallucis brevis, adductor hallucis and flexor digiti great toe ,and aids in maintaining transverse stability of minimi brevis (Fig. 1 4.64). the forefoot (Travell & Simons 1 992) and in stabilizing the great toe (Kapandji 1 987). Flexor hallucis brevis (FHB) attaches to the medial part of the plantar surface of the cuboid, to the lateral cuneiform Flexor digiti minimi (quinti) brevis (FDMB) attaches to and to the tendon of tibialis posterior. The belly of the the base of the fifth metatarsal and the sheath of peroneus muscle divides and attaches to the medial and lateral longus and courses to the base of the proximal phalanx of sides of the base of the proximal phalanx of the great toe, with a sesamoid bone present in each tendon, near its attachment. The medial tendon blends with abductor hallucis and the lateral with adductor hallucis. An additional slip may extend to the proximal phalanx of the second toe (Travell & Simons 1 992). FHB flexes the metatarsophalangeal joint of the great toe and the medial and lateral heads abduct and adduct the proximal phalanx of the great toe, respectively (Travell & Simons 1 992). Trigger points in FHB refer to both the plantar and dorsal surface of the head of the first metatarsal and sometimes include the entire great toe and the second toe. (Travell & Simons 1 992). Adductor hallucis (AdH) arises by two heads. The

562 CLINICAL APPLICATION OF NMT VOLUME 2 the fifth toe, usually blending with abductor digiti Box 1 4. 1 1 Movements of the toes). The interossei act to minimi. 'Occasionally some of its deeper fibres extend to stabilize the foot in rough (varying) terrain and stabilize the lateral part of the distal half of the fifth metatarsal the toes during gaiting. See PI below for trigger point bone, constituting what may be described as a distinct details. muscle, opponens digiti minimi' (Gray's anatomy 1 995). The three plantar interossei (PI) lie on the plantar surfaces of metatarsal bones of the last three toes, with FDMB flexes the proximal phalanx of the fifth toe at the each being connected to only one metatarsal. Each metatarsophalangeal joint. Its trigger point referral pattern attaches individually to the base and medial side of its has not been established but Travell & Simons ( 1 992) corresponding metatarsal and courses distally to the suggest it would be similar to ADM. medial side of the base of the proximal phalanx of the same toe and into its dorsal digital expansion. The PI Fourth layer adduct the last three lesser toes toward the mid-line of The fourth layer of plantar muscles consists of the plantar the foot (second toe) and assist in plantarflexion of the and dorsal interossei (Fig. 1 4.65). Gray's anatomy ( 1 995) proximal phalanx or hold it in dorsiflexion when dys­ notes: functional. Trigger points in dorsal and plantar interossei target the region of the digit they serve: the dorsal and They resemble their counterparts in the hand, but they are plantar surface of the associated toe and the plantar arranged relative to an axis through the second digit and not surface of its metatarsal. Travell & Simons ( 1 992) add that the third, as in the hand, the second being the least mobile of ' .. .TrPs in the first dorsal interosseous muscle may the metatarsal bones. produce tingling in the great toe; the disturbance of The four dorsal interossei (DI) are situated between the sensation can include the dorsum of the foot and the metatarsal bones. They each arise by two bipennate heads, lower shin' . from the sides of adjacent metatarsal bones and course distally to attach to the bases of the proximal phalanges Actions of the intrinsic muscles of the foot and debate exists as to their possible attachment to the dorsal digital expansions (Platzer 1 992, Travel & Simons In the above dissection, we have noted the various indi­ 1 992). The first inserts into the medial side of the second vidual movements which each intrinsic muscle produces toe, while the other three pass to the lateral sides of the when isolated. However, when the foot is gaiting, these first three lesser toes. The DI abduct the second through muscles do not work in isolation; they work in a complex fourth toes away from the mid-line of the foot (second coordinated manner in which instantaneous adjustments toe) and assist in plantarflexion of the proximal phalanx are made to the foot, to the leg and to the rest of the body, or hold it in dorsiflexion when dysfunctional (see based on a barrage of constant input received from a variety of proprioceptive sources. B Gray's anatomy (1 995) eloquently describes the com­ Figure 1 4.65 Fourth layer of plantar muscles of the right fool. A: Dorsal interossei viewed from dorsal aspecl. B: Plantar interossei plexity of predicting the various muscular responses to viewed from plantar aspect (reproduced with permission from Gray's this vital input. anatomy 1 995). The main intrinsic muscle mass of the foot consists of abductor hallucis, adductor hallucis, flexor d igitorum brevis, flexor hallucis brevis and abductor digiti minimi. These muscles are particularly difficult to study by the normal methods of investigation . . . The geometry of a muscle, and its attachments, may suggest its potential actions - and this is the basis for the names applied to some of them - but such deductions must take account not only of the influence of other muscles, but also of the modifying effects of contact with the ground. When a subject is standing quietly, with the feet flat on the ground, the feet serve as platforms for the d istribution of weight, the center of gravity of the body being maintained above them by suitable adjustment of tension and length in muscles of the leg and trunk. Under these conditions, the skeleton of the foot - with interosseous and deep plantar ligaments only - is capable of supporting several times body weight without failure (Walker 1 991 ). The intrinsic muscles show no electrical activity other than sporadic bursts at intervals of 5 to 10 seconds associated with postural adjustment.

THE LEG AND FOOT 563 When the heel lifts clear of the ground in beginning to take a The plantar surface of the foot is most easily examined step, whether in walking or running, the whole of the weight with the patient prone but he could also be supine or and muscular thrust is transferred to the forefoot region of the sidelying. In the illustrations offered here, the patient is metatarsal heads and the pads of the toes. This shifts the role supine so that the foot is in the same position as the of the foot from platform to lever and intensifies the forces anatomy illustrations presented in this chapter. Any posi­ acting on the fore part of the foot, especially in running and tion can be used, however, provided both the patient and jumping. There has been so much argument about the nature the practitioner are comfortable. and behavior of the 'arches' of the foot and the muscles and ligaments that act as 'tie-beams' or trusses across them, that The practitioner stands or is seated at the end of the the essential role of the foot as a lever is often overlooked. At treatment table in a comfortable manner. She can be first sight it appears ill-suited to act as a lever, being composed seated on the table, as long as she can easily approach the of a series of links, although there are good mechanical foot without postural strain. precedents for its curved or arched form. As the heel lifts, the concavity of the sole is accentuated, at which point available In the following palpation examination, assessment of electromyographic evidence indicates that the intrinsic the tissues can easily turn into treatment applica tion when muscles become strongly active. This would slacken the a tender tissue is located or reprod uction of a referred plantar aponeurosis, but dorsiflexion of the toes tightens it up. pattern is noted. Sustained pressure, circular massage or The foot is also supinated and the position of close-packing short gliding strokes can be employed as needed to treat of the intertarsal joints is reached as the foot takes the full trigger points or taut bands of ischemia within these small effects of leverage. The toes are held extended at the foot muscles. metatarsophalangeal and interphalangeal joints. In this position the foot loses all its pliancy and so becomes effective as a lever. • Examination of the foot begins with light palpation with the thumbs pressing into the superficially placed The intrinsic muscles are the main contributors to the plantar fascia. This tissue covers the entire plantar muscular support of the arch. Their line of pull lies essentially surface of the foot but is denser at the mid-line of the foot. in the long arch of the foot and perpendicular to the transverse It should feel elastic and 'springy' and should be non­ tarsal joints; thus they can exert considerable flexion force on tender even when moderate pressure is placed on it. The the fore part of the foot and are also the principal stabilizers of practitioner 's thumbs can be used, starting just anterior the transverse tarsal joint. (This includes the abductors of the to the plantar surface of the calcaneus, to examine small hallux and minimus, since both act as flexors and probably sections of this fascia by pressing the thumbs into the have little abductor effect.) The pronated or flat-foot, requires tissues with mild, then moderate (if appropriate) pressure greater activity in the intrinsic muscles to stabilize the along the course of the fascia (see Fig. 1 4.61 ) . If tissue is midtarsal and subtalar joint than does the normal foot (Suzuki non-tender, lubricated gliding strokes can be applied in 1972). This can be shown in walking. In a subject with a small segments to the entire surface of the foot, from the normal foot, activity in the intrinsic muscles begins at distal metatarsal heads to the calcaneus. Pressure can be approximately 30% of the gait cycle and increases at the time increased to begin penetrating into the muscles which lie of toe-off. In an individual with flat feet, these muscles begin deep to the plantar fascia to increase blood flow and to to function much earlier, at approximately 1 5 % of the cycle prepare the tissues for deeper palpation. and their action ceases when the arch again drops at toe-off ( Mann & Inman 1 964). • To assess the muscles of the medial column, the practitioner 's thumbs are placed just anterior to the NMT for the plantar intrinsic calcaneus on the medial side of the foot (Fig. 1 4.66). muscles of the foot Pressure into this location will entrap the lateral half of abductor hallucis against the underlying bones near its For the NMT clinical application discussion below, first proximal attachment. The thumbs are moved distally one the medial column of the foot is addressed, followed by thumb width and pressure applied again into the belly of the lateral colunm and finally the middle section (the AH. The examination continues in a similar manner until order is arbitrary). Variations in pressure and the angulation the MTP joint is reached, with only the tendon being of the palpating digit will influence which tissue is being assessed in the distal half of this strip. Sometimes this treated. Though some of these muscles are easily dis­ muscle can be lifted between the thumb and fingers, in a tinguishable one from the other, some are less identifiable pincer compression, for assessment or for treatment. by palpation and knowledge of anatomy and referral patterns for trigger points will offer assistance in deter­ • The thumbs are moved medially a thumb's width mining which tissue is tender. and pressure applied just distal to the calcaneus and onto the medial half of abductor hallucis. In a similar manner, CAUTION: If there is evidence of foot fungus or plantar the second section of the medial column is examined. As the thumbs progress distally, they will encounter the warts, the practitioner's hands should be protected with flexor digitorum brevis (Fig. 14.67). gloves as these conditions can be contagious. If signs of infection are present (for instance, with an ingrown toe­ naiD, immediate medical attention is warranted prior to the application of manual techniques.

564 CLINICAL APPLICATION OF NMT VOLUME 2 Figure 1 4.66 Palpation of abductor halluc is. Practitioner resistance Figure 1 4.68 Palpation of lateral column muscles. Palpation of the to the patient's attempts to abduct the great toe will help ensure fibers while the patient abducts the last toe against resistance will help correct placement. ensure location of the abductor digiti minimi. Figure 1 4.67 Palpation of flexor hallucis brevis. Palpation of the • Approximately halfway between the tip of the toe fibers while the patient adducts the great toe against resistance will and the tip of the heel on the medial column is the attach­ help ensure correct placement. ment site of anterior tibialis (medially) and peroneus longus (laterally) tendons on the plantar aspect of the first metatarsal and medial cuneiform bones. These sites may be tender when palpated. • The palpation/ treatment is repeated in a similar manner to the lateral column of the foot to assess the abductor digiti minimi, flexor digiti minimi and flexor digiti minimi brevis (Fig. 1 4.68). Pincer compression can usually be readily applied to the more lateral of these muscles. • The thumbs are now placed just anterior to the calcaneus at the middle of the foot. The most superficial muscle (deep to the thick portion of the plantar fascia) is flexor digitorum brevis (Fig. 1 4.69). Deep to it lies the quadratus plantae posteriorly, the flexor digitorum longus tendon obliquely across the mid-foot and the lumbricals on the anterior side of the FDL tendon. Variations in pressure will influence the different muscles which are layered upon each other. Sustained compression, short gliding strokes, transverse friction or circular massage can be used as needed as assessment shifts to treatment and back to assessment of these tissues.

THE LEG AND FOOT 565 Figure 1 4.69 Pressure applied through the plantar fascia will Figure 1 4.70 The beveled pressure bar can be used to penetrate to penetrate to the flexor digitorum brevis and (deep to that) quadratus the interossei as long as the overlying muscles are not too tender. plantae. culations and structures, the usefulness of PRT is parti­ • The entire remaining middle aspect of the foot can cularly evident. The insightful observations of Goodheart, be examined in a similar manner. The adductor hallux is as described in Box 1 4 . 1 2, help to make PRT an invalu­ located deep to the lumbricals in the region of the able clinical management tool for the foot. metatarsal heads. Mulligan's MWM and compression • If the overlying tissues are not excessively tender, methods for the foot the plantar interossei may be best influenced by applying pressure with the beveled tip of the pressure bar (held so The usefulness of simple translationj glide movements as the tip is parallel with the metatarsals (Fig. 14.70). the patient introduces active movement has been described elsewhere in this text (see Chapter 9 in this text and Goodheart's positional release Volume 1, Chapter 1 0) . Mulligan ( 1 999) has created a protocols model which is particularly helpful in dealing with small joints (although, as noted in Chapters 1 0, 1 1 , 12 and 1 3, While PRT can be effectively utilized in treatment of pain there are excellent MWM methods for larger joints as and dysfunction of any part of the body (Chaitow 2001, well). In addition, he has developed (based on earlier O'Ambrogio & Roth 1 997, Oeig 200 1 ), because o f the descriptions by Maitland 1 98 1 ) what he terms compression complexity and size of the foot, with its multiple arti- protocols for some foot dysfunctions and these are described in Box 1 4 . 1 3 .

566 CLIN ICAL APPLICATION OF NMT VOLUME 2 Box 1 4.1 2 Goodheart's PRT guidelines increase his pain (or which are restricted) the search sites for tender areas are easily decided. Goodheart ( 1 984) has described a means of utilizing PRT which simplifies the practitioner's task of identifying the tender point site. Exercise i n use of Goodheart's guidelines He suggests that a suitable tender point be searched for in the tissues/structures which perform the opposite function to that being • Identify a movement of the foot or ankle which is restricted or performed when pain or restriction is observed or reported. The uncomfortable/painful (say, dorsiflexion). antagonist muscles to those operating at the time pain is noted (or restriction is observed or reported by the patient) will be those that • Determine which action would produce precisely the opposite house the tender point(s). These are usually in shortened rather movement (plantarflexion, in this example). than lengthened/stretched structures. The suspect tissues are palpated and the most sensitive localized area selected to act as a • A clinically useful method in localizing where palpation should monitor during the performance of PRT (see Chapter 9). initially be focused is to restrain the area, as the patient actively attempts to move the foot (in this example) in the direction This 'tender point' is probed sufficiently firmly to create a pain opposite that which was restricted or painful. score of '1 0'. The patient then reports on the perceived 'score' as the tissues are carefully repositioned. The most beneficial • As this brief (few seconds only) period of isometric restraint is directions of movements toward an 'ease' or 'comfort' state, where maintained, a rapid, superficial scan of the tissues can often the reported pain will drop markedly, usually involve a further identify abnormally tense or shortened structures which, shortening ('crowding') of already short structures (Chaitow 2001 ). following release of the contraction, should be palpated, using either skin drag (discussed briefly in Chapters 1 and 9 of this Goodheart also suggests a simple test to identify whether a volume and in more detail in Volume 1 , Chapter 6, p. 81 ; see tender point, identified as described above, is likely to benefit from also Figure 6.5 in Volume 1 ) or NMT or other methods. the application of PRT. He states that if the muscle in which the tender point lies tests as weak, following a maximal 3-second • Once a suitably sensitive, localized, tender point has been contraction, after first initially testing strong, it will most probably identified, this should be pressed sufficiently firmly for the patient benefit from positional release (Walther 1 988). to register a pain score of ' 1 0'. Goodheart suggests that the neuromuscular function of muscles • The foot should then be positioned, most probably into pure can be improved using SCS, even if no pain is present. plantarflexion (in this example), and gently 'fine tuned', until the score in the tender point has reduced by at least 70%. Walther ( 1 988) reports Goodheart's suggestion that antagonistic muscles may fail to return to neurological equilibrium following • This position is held for 90 seconds, theoretically allowing acute or chronic strain. When this happens, an abnormal spindle cell resetting and enhancement of local Circulation, neuromuscular pattern is established which can benefit from following which a slow release and return to neutral is carried positional release treatment. The muscles which were shortened in out (Chaitow 200 1 ) . the process of strain and not those stretched (where pain is commonly sited) are the tissues which should be utilized in the • I f there was previously restriction, this should have reduced process of rebalancing. 'Understanding that the cause of the appreciably and pain may have also declined. Pain noted on continued pain one suffers in a strain/counterstrain condition is movement commonly eases slowly over a period of hours, usually not at the location of pain, but in an antagonistic muscle, is following such treatment, rather than vanishing dramatically the most important step in solving the problem,' says Walther. quickly. Function, however, usually improves immediately, albeit for brief periods only in chronic situations or where underlying The tender point might lie in muscle, tendon, or ligament and the etiological features have not been addressed. perpetuating factor is the imbalance in the spindle cell mechanisms. • Any restriction or pain, noted on movement, can be treated this way, usually offering rapid 'first aid' relief and sometimes lasting Since the patient can usually describe which movements benefit Box 14.13 M u lligan's MWM and compression methods for the foot The general principles of Mulligan's methods, mobilization with • The practitioner holds the head of the third metatarsal between movement (MWM), have been described elsewhere in this text (see Volume 1 , Chapter 1 0, and Chapter 9 of this volume) the thumb and index finger of one hand and with the other hand (Mulligan 1 999). holds the head of the second metatarsal. • The third metatarsal head is translated (glided) distally, against Several examples of MWM have been described earlier in this chapter, in relation to treatment of fibula head dysfunction, the second, and held in this pOSition as the patient is asked to restricted talotibiofibular joint and postinversion and eversion slowly flex the toes. sprains. An example of the familiar MWM protocol, relating to foot • If this proves painful the glide is reversed, with the second dysfunction (metatarsalgia), is described below, as well as a metatarsal head being translated distally against the head of variation involving compression. the third, as the patient slowly performs toe flexion. • When the toe can be painlessly flexed during one or other of MWM in treatment of anterior metatarsalgia these translations this action (flexion during translation) is repeated approximately 10 times. Mulligan writes: 'If pain under the heads of the middle metatarsals • 'Then have the patient flex the toes without [translation] can be reproduced with toe flexion or extension, this could be due assistance to reassess. After several sets he should feel much to a metatarsal head positional fault, and a MWM should be tried' . better.' • The patient lies supine and the practitioner sits or stands distally, MWM compression approach at the foot of the table, facing the foot. Mulligan pays tribute to Maitland ( 1 98 1 ) for the introduction of • In this example it is assumed that the pain is located under the head of the third metatarsal and is aggravated by toe flexion. compression methodology (continued overleaf)

THE LEG AND FOOT 567 Box 1 4.13 Mulligan's MWM and compression methods for the foot (cont'd) When assessing extremity joints you should try a compression test • With the other hand 'you now passively flex and extend the big to see if this produces pain. To do this the joint is placed in a toe [while maintaining compression]. If pain is produced with this biomechanical resting position, where all the structures movement then it is probably coming from the sesamoids, surrounding it are maximally relaxed. You now stabilise the proximal facet {of a metatarsophalangeal joint, for example} with particularly if it stops when the compression component is one hand, and apply a compressive force on the joint with the removed.' other {by easing the distal facet toward the unmoving proximal facet}. . . . While maintaining this compression, try a series of • Mulligan suggests that if pain is produced by a combination of {passive} joint movements to see if they produce pain. . . (flexion, extension, rotation and accessory {glide} movements). compression and passive movement, this strongly suggests that treatment should involve compression as part of the protocol. Compression approach for sesamoids beneath first MTP joint • 'If a combination of compression and movement causes pain, • The patient is supine and the practitioner stands facing the then repeat the combination for up to 20 seconds to see if the pain medial aspect of the affected foot. disappears. Ensure that the pressure on the articular surfaces remains constant. If the pain increases STOP immediately. Use no • 'Place the lateral border of the fully flexed index finger [of the more pressure than is needed to just produce the pain . . . If the pain caudal hand] beneath the sesamoids and the opposing thumb on disappears within 20 seconds [of commencing the compression top of the first metatarsophalangeal joint. Using the flexed index and passive jOint movement] then a compression treatment is finger provides a larger surface to place under these small bones indicated. This means that you repeat the movements, with the and ensures they do not escape the compression about to be same amount of compression. The pain should go again within 20 applied. By squeezing with the thumb and index finger so seconds. Further repetitions see a remarkable change in the positioned, the sesamoids cannot avoid the compression.' response. . .after several repetitions, the time for the pain to go drops rapidly. . .soon there is virtually no pain with the movement, • Mulligan cautions to avoid compression of the tendon of and this signals the end of the session.' extensor hallucis longus. • Compression is seldom applied at end-range where, if pain were experienced, this would most likely be a result of capsular or ligamentous tissues, rather than the articular surface which is being treated by these means. 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Appendix PATIENT SELF-HELP EXERCISES These sheets are designed for photocopying for patient use Patient self-help. PRT exercise • Sit in a chair and, using a finger, search around in the muscles • Do not treat more than five pain points on any one day as your of the side of your neck, just behind your jaw, directly below your body will need to adapt to these self-treatments. ear lobe about an inch. Most of us have painful muscles here. Find a place which is sensitive to pressure. • Expect improvement in function (ease of movement) fairly soon (minutes) after such self-treatment but reduction in pain may • Press just hard enough to hurt a little and grade this pain for take a day or so and you may actually feel a little stiff or achy in the previously painful area the next day. T his will soon pass. yourself as a '10' (where 0 = no pain at all). However, do not 10make it highly painful; the is simply a score you assign. • If intercostal muscle (between the ribs) tender points are being self-treated, in order to ease feelings of tightness or discomfort • While still pressing the point bend your neck forward, very in the chest, breathing should be felt to be easier and less slowly, so that your chin moves toward your chest. constricted after PRT self-treatment. Tender points to help release ribs are often found either very close to the sternum • Keep deciding what the 'score' is in the painful point. (breast bone) or between the ribs, either in line with the nipple • As soon as you feel it ease a little start turning your head a little (for the upper ribs) or in line with the front of the axilla (armpit) toward the side of the pain, until the pain drops some more. (for ribs lower than the 4th) (Fig. 7.1). • By 'fine tuning' your head position, with a little turning, • If you follow these instructions carefully, creating no new pain sidebending or bending forward some more, you should be able when finding your positions of ease and not pressing too hard, you cannot harm yourself and might release tense, tight and to get the score close to '0' or at least to a '3'. painful muscles. • When you find that position you have taken the pain point to its Figure 7.1 Positional release self-treatment for an upper rib 'position of ease' and if you were to stay in that position (you don't have to keep pressing the point) for up to a minute and a tender point (reproduced from Chaitow 2000). half, when you slowly return to sitting up straight the painful area should be less sensitive and the area will have been flushed with fresh oxygenated blood. • If this were truly a painful area and not an 'experimental' one, the pain would ease over the next day or so and the local tissues would become more relaxed. • You can do this to any pain point anywhere on the body, including a trigger point, which is a local area which is painful on pressure and which also refers a pain to an area some distance away or which radiates pain while being pressed. It may not cure the problem (sometimes it will) but it usually offers ease. The rules for self-application of PRT are as follows. • locate a painful point and press just hard enough to score '10'. • If the point is on the front of the body, bend forward to ease it and the further it is from the mid-line of your body, the more you should ease yourself toward that side (by slowly sidebending or rotating). • If the point is on the back of the body ease slightly backward until the 'score' drops a little and then turn away from the side of the pain, and then 'fine tune' to achieve ease. 30• Hold the 'position of ease' for not less than seconds (up to 90 seconds) and very slowly return to the neutral starting position. • Make sure that no pain is being produced elsewhere when you are fine tuning to find the position of ease. Chaitow l, Delany J 2002 Clinical Application of Neuromuscular Techniques. Vol 2: the lower Body © 2002, Elsevier Science Limited 569

570 APPENDIX Patient self-help. Prevention: flexion exercise Patient self-help. MET neck relaxation exercise Perform daily but not after a meal. Phase 1 • Sit on the floor with both legs straight out in front of you, toes pointing toward the ceiling. Bend forward as • Sit close to a table with your elbows on the table and far as is comfortable and grasp one leg with each rest your hands on each side of your face. hand. • Turn your head as far as you can comfortably turn it in • Hold this position for about 30 seconds - one direction, say to the right, letting your hands move approximately four slow deep breathing cycles. You with your face, until you reach your pain-free limit of should be aware of a stretch on the back of the legs rotation in that direction. and the back. Be sure to let your head hang down and relax into the stretch. You should feel no actual pain • Now use your left hand to resist as you try to turn and there should be no feeling of strain. your head back toward the left, using no more than a quarter of your strength and not allowing the head to • As you release the fourth breath ease yourself a little actually move. Start the turn slowly, building up force further down the legs and grasp again. Stay here for a which is matched by your resisting left hand, still further half minute or so before slowly returning to an upright position, which may need to be assisted by a using 25% or less of your strength. light supporting push upward by the hands. • Hold this push, with no movement at all taking place, • Bend one leg and place the sole of that foot against for about 7-10 seconds and then slowly stop trying to the inside of the other knee, with the bent knee lying turn your head left. as close to the floor as possible. • Now turn your head round to the right as far as is • Stretch forward down the straight leg and grasp it with comfortable. both hands. Hold for 30 seconds as before (while breathing in a similar manner) and then, on an • You should find that you can turn a good deal further exhalation, stretch further down the leg and hold for a than the first time you tried, before the isometric further 30 seconds (while continuing to breathe). contraction. You have been using MET to achieve what is called postisometric relaxation in tight muscles • Slowly return to an upright position and alter the legs which were restricting you. so that the straight one is now bent, and the bent one straight. Perform the same sequence as described Phase 2 above. • Your head should be turned as far as is comfortable to • Perform the same sequence with which you started, the right and both your hands should still be on the with both legs out straight. sides of your face. • Now use your right hand to resist your attempt to turn (using only 25% of strength again) even further to the right starting slowly, and maintaining the turn and the resistance for a full 7-10 seconds. • If you feel any pain you may be using too much strength and should reduce the contraction effort to a level where no pain at all is experienced. • When your effort slowly stops see if you can now go even further to the right than after your first two efforts. You have been using MET to achieve a different sort of release called reciprocal inhibition. Chaitow l, Delany J 2002 Clinical Application of Neuromuscular Techniques. Vol 2: the lower Body © 2002, Elsevier Science Limited

A P P ENDIX 571 Patient self-help. Prevention: extension exercises - whole body Excessive backward bending of the spine is not desirable producing pain, so that your back is slightly arched. Your and the 'prevention' exercises outlined are meant to be upper arm should rest along your side. performed very gently, without any force or discomfort at • Now take your head and shoulders backward to increase all. For some people, the expression 'no pain no gain' is the backward bending of your spine. Again, this should taken literally, but this is absolutely not the case where be done slowly and without pain, although you should be spinal mobilization exercises such as these are concerned. aware of a stretching sensation along the front of your If any pain at all is felt then stop doing the exercise. body and some 'crowding' in the middle of the back. • Hold this position for approximately 4 full slow breaths Repeat daily after flexion exercise. and then hold your breath for about 15 seconds. As you release this try to ease first your legs and then your • Lie on your side (either side will do) on a carpeted floor upper body into a little more backward bending. Hold this with a small cushion to support your head and neck. Your final position for about half a minute, breathing slowly and legs should be together, one on top of the other. deeply all the while. • Bring yourself back to a straight sidelying position before • Bend your knees as far as comfortably possible, bringing turning onto your back and resting. Then move into a your heels toward your backside. Now slowly take your seated position (still on the floor) for the rotation exercise. legs (still together and still with knees fully flexed) backward of your body as far as you can, without Patient self-help. Prevention: rotation exercises - whole body It is most important that when performing these exercises the whole exercise to the right, reversing all elements of no force is used, just take yourself to what is best described the instructions (i.e cross right leg over left, place left as an 'easy barrier' and never as far as you can force hand between knees, turn to right, etc.). yourself. The gains that are achieved by slowly pushing the barrier back, as you become more supple, arise over a Ideally, repeat the next exercise twice daily following the period of weeks or even months, not days, and at first you flexion and extension exercises and the previous rotation may feel a little stiff and achy in newly stretched muscles, exercise. especially the day after first performing them. This will soon pass and does not require treatment of any sort. • Lie face upward on a carpeted floor with a small pillow or book under your head. Repeat daily following the flexion and extension exercises. • Flex your knees so that your feet, which should be • Sit on a carpeted floor with legs outstretched. together, are flat on the floor. • Cross your left leg over your right leg at the knees. • Bring your right arm across your body and place your • Keep your shoulders in contact with the floor during the exercise. This is helped by having your arms out to the right hand over the uppermost leg and wedge it between side slightly, palms upward. your crossed knees, so locking the knees in position. • Your left hand should be taken behind your trunk and • Carefully allow your knees to fall to the right as far as placed on the floor about 12-15 cm behind your buttocks possible without pain - keeping your shoulders and your with your fingers pointing backwards. This twists your lower back in contact with the floor. You should feel a upper body to the left. tolerable twisting sensation, but not a pain, in the • Now turn your shoulders as far to the left as is muscles of the lower and middle parts of the back. comfortable, without pain. Then turn your head to look over your left shoulder, as far as possible, again making • Hold this position while you breathe deeply and slowly for sure that no pain is being produced, just stretch. about 30 seconds, as the weight of your legs 'drags' on • Stay in this position for five full, slow breaths after which, the rest of your body, which is stationary, so stretching a as you breathe out, turn your shoulders and your head a number of back muscles. little further to the left, to their new 'restriction barriers'. • Stay in this final position for a further five full, slow • On an exhalation slowly bring your knees back to the breaths before gently unwinding yourself and repeating mid-line and then repeat the process, in exactly the same manner, to the left side. • Repeat the exercise to both right and left one more time, before straightening out and resting for a few seconds. JChaitow l, Delany 2002 Clinical Application of Neuromuscular Techniques. Vol 2: the lower Body © 2002, Elsevier Science Limited

572 APPENDIX Patient self-help. Chair-based exercises for spinal flexibility These chair-based exercises are intended to be used when • Stay in this position for about 30 seconds (four slow deep back pain already exists or has recently been experienced. breaths). They should only be used if they produce no pain during their performance or if they offer significant relief from • On an exhalation, ease your left hand toward your right current symptoms. foot a little more and stay in this position for a further 30 seconds. Chair exercise to improve spinal flexion • On an exhalation, stop the left hand stretch and now • Sit in a straight chair so that your feet are about 20 cm ease your right hand toward the floor, just to the right of apart. your right foot, and hold this position for another 30 seconds. • The palms of your hands should rest on your knees so that the fingers are facing each other. • Slowly sit up again and turn a little to your left, bend forward so that this time your right arm hangs between • Lean forward so that the weight of your upper body is your legs. supported by the arms and allow the elbows to bend outward, as your head and chest come forward. Make • Make sure your neck is free so that your head hangs sure that your head is hanging freely forward. down. • Hold the position where you feel the first signs of a • Once again you should feel stretching between the stretch in your lower back and breathe in and out slowly shoulders and in the low back. and deeply, two or three times. • Stay in this position for about 30 seconds and on an • On an exhalation ease yourself further forward until you exhalation ease your right hand toward your left foot and feel a slightly increased, but not painful, stretch in the stay in this position for another 30 seconds. back and repeat the breathing. • On another exhalation stop this stretch with your right • After a few breaths, ease further forward. Repeat the hand and begin to stretch your left hand to the floor, just breathing and keep repeating the pattern until you cannot to the left of your left foot, and hold this position for go further without feeling discomfort. another 30 seconds. • When, and if, you can fully bend in this position you • Sit up slowly and rest for a minute or so before resuming should alter the exercise so that, sitting as described normal activities or doing the next exercise. above, you are leaning forward, your head between your legs, with the backs of your hands resting on the floor. To encourage spinal mobility in all directions • All other aspects of the exercise are the same, with you • Sit in an upright (four-legged) chair and lean sideways so easing forward and down, bit by bit, staying in each new that your right hand grasps the back right leg of the chair. position for 3-4 breaths, before allowing a little more flexion to take place. • On an exhalation slowly slide your hand down the leg as far as is comfortable and hold this position, partly • Never let the degree of stretch become painful. supporting yourself with your hand-hold. For spinal mobility • Stay in this position for two or three breaths before sitting up on an exhalation. • Sit in an upright chair with your feet about 20 cm apart. • Twist slightly to the right and bend forward as far as • Now ease yourself forward and grasp the front right chair leg with your right hand and repeat the exercise as comfortably possible, so that your left arm hangs described above. between your legs. • Make sure your neck is free so that your head hangs • Follow this by holding on to the left front leg and finally down. the left back leg with your left hand and repeating all the • You should feel stretching between the shoulders and in elements as described. the low back. • Make two or three 'circuits' of the chair in this way to slowly increase your range of movement. Chaitow l, Delany J 2002 Clinical Application of Neuromuscular Techniques. Vol 2: the lower Body © 2002, Elsevier Science Limited

APPENDIX 573 Patient self-help. For abdominal muscle tone • This strengthens the oblique abdominal muscles. Do up to 10 cycles of this exercise daily. For low back tightness and abdominal weakness To tone lower abdominal muscles • Lie on your back on a carpeted floor, with a pillow under your head. • Bend one knee and hip and hold the knee with both hands. Inhale • Lie on the floor with knees bent and arms lying alongside the body. • Tighten the lower abdominal muscle to curl your pubic bone (groin deeply and as you exhale, draw that knee to the same side shoulder (not your chest), as far is is comfortably possible. Repeat this twice area) toward your navel. Avoid tightening your buttock muscles. more. • Keep your shoulders, spine and (at this point) pelvis on the floor by • Rest that leg on the floor and perform the same sequence with the other leg. just tightening the lower abdominal muscles but without actually • Replace this on the floor and now bend both legs, at both the knee raising the pelvis. Breathe in as you tighten. and hip, and clasp one knee with each hand. • Continue breathing in as you hold the contraction for 5 seconds and, • Hold the knees comfortably (shoulder width) apart and draw the as you exhale, slowly relax all tight muscles. knees toward your shoulders - not your chest. When you have • Do this up to 10 times to strengthen the lower abdominal muscles. reached a point where a slight stretch is felt in the low back, inhale • When you can do this easily, add a variation in which the pelvis curls deeply and hold the breath and the position for 10 seconds, before toward the navel and the buttocks lift from the floor in a slow curling slowly releasing the breath and, as you do so, easing the knees a manner. Be sure to use the lower abdominal muscles to create this little closer toward your shoulders. movement and do not press up with the legs or contract the buttocks • Repeat the inhalation and held breath sequence, followed by the instead. easing of the knees closer to the shoulders, a further four times (five • When this movement is comfortable and easy to do, the procedure times altogether). can be altered so that (while inhaling) the pelvis curls up to a slow • After the fifth stretch to the shoulders stay in the final position for count of 4-5, then is held in a contraction for a slow count of 4-5 about half a minute while breathing deeply and slowly. while the inhale is held, then slowly uncurled to a slow count of 4-5 • This exercise effectively stretches many of the lower and middle while exhaling. T his can be repeated 10 times or more to strengthen muscles of the back and this helps to restore tone to the abdominal lower abdominals and buttocks. muscles, which the back muscle tightness may have weakened. 'Dead-bug' abdominal stabilizer exercise For low back and pelvic muscles • Lie on your back and hollow your abdomen by drawing your navel • Lie on the floor on your back with a pillow under your head and with toward your spine. your legs straight. • When you can hold this position, abdomen drawn in, spine toward • Keep your low back flat to the floor throughout the exercise. the floor, and can keep breathing at the same time, raise both arms • As you exhale, draw your right hip upward toward your shoulder - as into the air and, if possible, also raise your legs into the air (knees can be bent), so that you resemble a 'dead bug' lying on its back. though you are 'shrugging' it (the hip, not the shoulder) - while at the same time stretch your left foot (push the heel away, not the pOinted • Hold this for 10-15 seconds and slowly lower your limbs to the floor toe) away from you, trying to make the leg longer while making and relax. certain that your back stays flat to the floor throughout. • Hold this position for a few seconds before inhaling again and • This tones and increases stamina in the transverse muscles of the relaxing both efforts. abdomen which help to stabilize the spine. Repeat daily at the end of • Repeat in the same way on the other side, drawing the left leg (hip) other abdominal exercises. up and stretching the right leg down. • Repeat the sequence five times altogether on each side. Releasing exercise for the low back muscles ('cat and camel') • This exercise stretches and tones the muscles just above the pelvis and is very useful following a period of inactivity due to back • Warm up the low back muscles first by getting on to all fours, problems. supported by your knees (directly under hips) and hands (directly under shoulders). For abdominal muscles and pelvis • Slowly arch your back toward the ceiling (like a camel), with your • Lie on your back on a carpeted floor, no pillow, knees bent, arms head hanging down, and then slowly let your back arch downward, so folded over abdomen. that it hollows as your head tilts up and back (like a cat). • Inhale and hold your breath, while at the same time pulling your • Repeat 5-10 times. abdomen in ('as though you are trying to staple your navel to your spine'). 'Superman' pose to give stamina to back and abdominal muscles • Tilt the pelvis by flattening your back to the floor. • First do the 'cat and camel' exercise and then, still on all fours, make • Squeeze your buttocks tightly together and at the same time, lift your your back as straight as possible, with no arch to your neck. hips toward the ceiling a little. • Raise one leg behind you, knee straight, until the leg is in line with • Hold this combined contraction for a slow count of five before the rest of your body. exhaling and relaxing onto the floor for a further cycle of breathing. • Try to keep your stomach muscles in and back muscles tight • Repeat 5-10 times. throughout and keep your neck level with the rest of the back, so that you are looking at the floor. To tone upper abdominal muscles • Hold this pose for a few seconds, then lower the leg again, repeating • Lie on the floor with knees bent and arms folded across your chest. the raising and lowering a few times more. • Push your low back toward the floor and tighten your buttock muscles • When, after a week or so of doing this daily, you can repeat the leg and as you inhale, raise your head, neck and, if possible, your raise 10 times (either leg at first, but each leg eventually), raise one shoulders from the floor - even if it is only a small amount. leg as before and also raise the oppOSite arm and stretch this out • Hold this for 5 seconds and, as you exhale, relax all tight muscles straight ahead of you ('superman' pose) and hold this for a few and lie on the floor for a full cycle of relaxed breathing before seconds. repeating. • Do this up to 10 times to strengthen the upper abdominal muscles. • If you feel discomfort, stop the pose and repeat the 'cat and camel' a • When you can do this easily add a variation in which, as you lift few times to stretch the muscles. yourself from the floor, you ease your right elbow toward your left knee. Hold as above and then relax. • Eventually, by repetition, you should build up enough stamina to hold • The next lift should take the left elbow toward the right knee. the pose, with either left leg/right arm or right leg/left arm, and eventually both combinations, for 10 seconds each without strain and your back and abdominal muscles will be able to more efficiently provide automatic support for the spine. Chaitow l, Delany J 2002 Clinical Application of Neuromuscular Techniques. Vol 2: the lower Body © 2002, Elsevier Science Limited

574 APPENDIX Patient self-help. Brugger relief position • Ease the sternum forward and upward slightly. • With your arms hanging at your sides, rotate the arms Brugger (1960) devised a simple postural exercise known as the 'relief position' which achieves a reduction of the outward so that the palms face forward. slumped, rounded back (kyphotic) posture which often • Separate the fingers so that the thumbs face backward results from poor sitting and so eases the stresses which contribute to neck and back pain (see also Box 4.4, p. 118, slightly. where this exercise is illustrated). • Draw the chin in slightly. • Remain in this posture as you breathe slowly and deeply • Perch on the edge of a chair. • Place your feet directly below the knees and then into the abdomen, then exhale fully and slowly. • Repeat the breathing 3-4 times. separate them slightly and turn them slightly outward, • Repeat the process several times each hour if you are comfortably. • Roll the pelvis slightly forward to lightly arch the low back sedentary. Patient self-help. Cold ('warming') compress This is a simple but effective method involving a piece of • One thickness of woolen or flannel material (toweling will cold, wet cotton material well wrung out in cold water and do but is not as effective) larger than the cotton material then applied to a painful or inflamed area after which it is so that it can cover it completely with no edges immediately covered (usually with something woolen) in a protruding way that insulates it. This allows your body heat to warm the cold material. Plastic can be used to prevent the damp • Plastic material of the same size as the woolen material from spreading and to insulate the material. The effect is for • Safety pins a reflex stimulus to take place when the cold material first • Cold water touches the skin, leading to a flushing away of congested blood followed by a return of fresh blood. As the compress Method slowly warms there is a relaxing effect and a reduction of pain. Wring out the cotton material in cold water so that it is damp but not dripping wet. Place this over the painful area This is an ideal method for self-treatment or first aid for and immediately cover it with the woolen or flannel material, any of the following: and also the plastic material if used, and pin the covering snugly in place. The compress should be firm enough to • painful joints ensure that no air can get in to cool it but not so tight as to • mastitis impede circulation. The cold material should rapidly warm • sore throat (compress on the throat from ear to ear and and feel comfortable and after few hours it should be dry. supported over the top of the head) Wash the material before reusing it as it will absorb acid • backache (ideally the compress should cover the wastes from the body. abdomen and the back) Use a compress up to four times daily for at least an hour • sore tight chest from bronchitis. each time if it is found to be helpful for any of the conditions listed above. Ideally, leave it on overnight. Materials Caution • A single or double piece of cotton sheeting large enough to cover the area to be treated (double for people with If for any reason the compress is still cold after 20 minutes, good circulation and vitality, single thickness for people the compress may be too wet or too loose or the vitality with only moderate circulation and vitality) may not be adequate to the task of warming it. In this case, remove it and give the area a brisk rub with a towel. Chaitow l, Delany J 2002 Clinical Application of Neuromuscular Techniques. Vol 2: the lower Body © 2002, Elsevier Science Limited