PNF in Practice-An Illustrated Guide - 3rd Edition

214 Chapter 11 · Mat Activities 1 2 3 4 5 6 b a 7 . Fig. 11.25a,b. Standing up from half-kneeling 8 11.5.7 From Hands-and-Feet Position b (Arched Position on All Fours) 9 to Standing Position and back to Hands-and-Feet Position 10 (. Fig. 11.26) 11 The people who use this activity for function are most often those whose knees are maintained in extension. For example, patients wearing bilateral 12 long leg braces (KAFOs) or those with bilateral above-knee prostheses can go from standing to the 13 floor or from the floor to standing. Use of this posi- tion requires full hamstring muscle length. 14 15 16 17 18 19 ac 20 . Fig. 11.26. Moving to the floor and back up again. a, b Resistance at the pelvis; c guidance at the pelvis, patient with ampu- tation of left leg

11.5 · Mat Activities 11215 11.5.8 Exercise in a Sitting Position 5 Assuming the position – From side-sitting Long-Sitting – From supine This position is functional for bed activities such 5 Balancing with and without upper extremity as eating and dressing. Use all the stabilizing tech- support (. Fig. 11.27 a) niques to increase the patient’s balance in this posi- tion. Because the patient can sit on the floor mats, 5 Pushing up exercises this is a safe position for independent balance work. – Resistance at the pelvis and shoulders Long-sitting is also a good position for exercises to (. Fig. 11.27 b–d) increase arm and trunk strength. All the strength- – Resistance at the legs (. Fig. 11.27 e–h) ening exercises are appropriate here. Patients can practice all the lifts used for transfers. 5 Scooting forward (. Fig. 11.27 i) and backward ab cd . Fig. 11.27. Exercises in long-sitting. a Stabilization; b–c pushing up, resistance at pelvis; d pushing up, resistance at scapulae

216 Chapter 11 · Mat Activities 1 2 3 4 5e f 6 7 8 9 10 g h 11 12 . Fig. 11.27. Exercises in long-sitting. e, f pushing up, resist- ance at the legs; g, h pushing up, resistance to reciprocal leg patterns; i scooting forward 13 14 15 i 16 Short-Sitting tient’s trunk and hip stability. Dynamic exercises 17 To use their arms for other activities, patients need will increase trunk and hip motion. Resisting the as much trunk control as possible. To reach for dis- patient’s strong arms will provide irradiation to fa- tant objects they need to combine trunk stability cilitate weaker trunk and hip muscles. Combin- 18 with trunk, hip, and arm motion. Those patients ing static and dynamic techniques facilitate the pa- with spinal problems can learn to stabilize their tient’s ability to combine balance and motion. 19 back while moving at the hip when reaching with 5 Assuming the position from side-lying their arms. (. Fig. 11.28) Patients need to exercise while sitting on the – Resist the patient’s concentric contractions while they move into sitting. 20 side of the bed and in a chair as well as on the mats. Static exercises in short-sitting will increase the pa- – Resist the eccentric control as they lie down.

11.5 · Mat Activities 11217 a b . Fig. 11.28a,b. Moving from side-lying to short-sitting 5 Balancing Use Stabilizing Reversals or Rhythmic Stabili- zation to increase trunk stability. Resist at the shoulders, pelvis, and head (. Fig. 11.29). – With and without upper extremity support – With and without lower extremity support a b . Fig. 11.29. Stabilization in short-sitting ; c Stabilization on a Pezzi ball

218 Chapter 11 · Mat Activities 1 2 3 4 5 6 7 8 9 a 10 c . Fig. 11.29. c Stabilization on a Pezzi ball 11 5 Trunk exercises Use Dynamic Reversals (Slow Reversals) and 12 Combination of Isotonics to increase the pa- tient’s trunk strength and coordination. Resist 13 at the scapula (. Fig. 11.30 a, b) or use chop- ping (. Fig. 11.30 d) and lifting combinations 14 to get added irradiation. – Trunk flexion (. Fig. 11.30 c) and extension – Reaching forward and to the side with re- 15 turn: this requires hip flexion, extension, lateral motion, and rotation with the trunk 16 remaining stable 5 Moving 17 These activities teach mobility in sitting and b exercise pelvic and hip muscles. – Forward and back (. Fig. 11.30 e) . Fig. 11.30. Trunk exercise in short-sitting. a, b Resistance at scapula 18 – From side to side 19 20

11.5 · Mat Activities 11219 c d e . Fig. 11.30. Trunk exercise in short-sitting. c flexion with traction through arms; d chopping; e moving forward with resist- ance at pelvis

220 Chapter 11 · Mat Activities 11.5.9 Bridging 1 In the hook-lying position the patient exercises 2 with weight-bearing through the feet but without danger of falling. Lifting the pelvis from the sup- 3 porting surface makes it easier for a person to move and dress in bed. Working in the hook-lying position requires 4 some selective control of the lower trunk flexors and the leg muscles. Patients must keep their knees 5 flexed while extending their hips and pushing with their feet. When patients push against the mats 6 with their arms, their upper trunk, neck, and up- b per extremity muscles are exercised. Resist concen- tric, eccentric, and stabilizing contractions to in- 7 crease strength and stability in the trunk and low- er extremity. 8 5 Assuming the hook lying position If the patient is unable to assume this position independently: 9 – Move from a side-lying position with hips and knees flexed. Facilitate at the knees, 10 pelvis or a combination of these – From supine, guide and resist the bilateral 11 pattern of hip flexion with knee flexion 5 Stabilizing (. Fig. 11.31 a) – With approximation from the distal femurs b 12 into the pelvis combined with stabilizing resistance . Fig. 11.31. Hook lying: a stabilization; b lower trunk rota- 13 – With approximation from the distal femurs tion into the feet combined with stabilizing re- 14 sistance vis rotates, followed by the spine. The abdomi- – Stabilizing resistance without approxima- nal muscles prevent any increase in lumbar tion lordosis. The return to upright requires a re- verse timing of the motion. The lumbar spine 15 Use resistance with approximation at the legs to fa- must de-rotate first, then the pelvis, and then 16 cilitate lower extremity and trunk stability. Give the legs. Correct timing of this activity is im- the resistance in all directions. Resistance in diago- portant. Limit the distance that the legs de- 17 nals will recruit more trunk muscle activity. As the scend to the ability of the patient to control the patient gains strength, decrease the amount of ap- motion. . Fig. 11.31 b shows resistance to re- proximation. Resist the legs together and separate- turning to the upright leg position with lower 18 ly. Resist both legs in the same direction and in op- trunk rotation to the right. You can use Com- posite directions when working them separately. bination of Isotonics and Slow Reversals to 19 5 Lower trunk rotation in the hook-lying posi- teach and strengthen this activity. tion 5 Bridging The motion begins with the legs moving down – Stabilize the pelvis with resistance in all di- 20 diagonally (distally) toward the floor. When rections (. Fig. 11.32 a, b, resisting from be- the hips have completed their rotation, the pel- low; . Fig. 11.32 c, d resisting from above)

11.5 · Mat Activities 11221 ab c d . Fig.11.32a-d. Bridging on two legs in supine position – Lead with one side of the pelvis duction, the harder the supporting muscles – Resist static and dynamic rotation of the must work – Bridge while bearing weight on the arms pelvis (. Fig. 11.34–11.36) – Scoot the pelvis from side to side Use Combination of Isotonics to strengthen the pa- tient’s antigravity control. ! Caution Monitor and control the position of the patient’s lumbar spine while the pelvis is elevated. 5 Other bridging activities . Fig. 11.33. Bridging on one leg – Stepping in place – Walking the feet: apart, together, to the side, away from the body (into extension) and back – Bridge on one leg (. Fig. 11.33). The ab- dominal muscles maintain the pelvis lev- el and the hip muscles on the supporting side work to prevent lateral sway. The more the lifted leg moves into extension or ab-

222 Chapter 11 · Mat Activities 1 2 3 4 5 b b 6a b . Fig.11.34a,b. Bridging on the hands 7 8 9 10 11 12 13 a 14 . Fig. 11.35a,b. Bridging on the elbows 15 16 17 18 19 20 a . Fig. 11.36a,b. Bridging on the arms and one leg

11.6 · Patient Cases in Mat Activities 11223 11.6 Patient Cases in Mat Activities Patient I: Limited range of motion in the right shoulder (. Fig. 11.37) b a c . Fig. 11.37. a Demonstrating the limited range of motion in the right shoulder. b Contract-relax for the short shoulder exten- sor and posterior adductor muscles, resistance to the arm pattern of extension-abduction-internal rotation with fixation of the scapula. c Mobilization of the right shoulder using indirect treatment: the lower trunk rolls against a fixed right shoulder

224 Chapter 11 · Mat Activities 1 2 3 4 5 6d e 7 8 9 10 11 f 12 13 14 15 g 16 17 . Fig. 11.37. Patient I. Limited range of motion in the right shoulder. d Indirect mobilization of the shoulder into flexion by mov- ing the pelvis back and down. e Weight-bearing activity of the right shoulder: resistance to the left arm provides irradiation into the involved shoulder. f Mobilization of the right shoulder. g Strengthening and mobilization of the shoulder in a standing po- sition 18 19 20

11.6 · Patient Cases in Mat Activities 11225 Patient II: Incomplete paraplegia in the post-acute phase (. Fig. 11.38) a b . Fig. 11.38. a Rolling: irradiation into lower trunk and hip muscles. b Bridging

226 Chapter 11 · Mat Activities 1 2 3 4 5 6e 7 8 9c 10 11 f 12 13 14 15 16 17 g d 18 . Fig. 11.38. Patient II. Incomplete paraplegia in the post-acute phase. c, d Long-sitting: pushups and weight shift. e–g Trans- fer from floor into a chair and a wheelchair 19 20

11.6 · Patient Cases in Mat Activities 11227 Patient III: Ankylosing spondylitis . Fig. 11.39. a Bridging. b Bridging combined (Spondylitis ankylopoetica)1 (. Fig. 11.39) with lifting to the right. c Kneeling with lifting a b c 1 Ankylosing spondylitis: The form of rheumatoid arthritis affecting the spine. It occurs predominantly in young males and produces pain and stiffness as a result of inflammation of the sacroiliac, interverte- bral, and costovertebral joints. Aetiology is unknown. (On-line Medi- cal Dictionary (OMD), Academic Medical Publishing & Cancer WEB 1997–1998).

228 Chapter 11 · Mat Activities Patient IV: Incomplete tetraplegia with 1 brachial plexus lesion (. Fig. 11.40) 2 3 4 5 6 7 8 9 10 b d a 11 12 13 14 15 16 17 18 19 c 20 . Fig. 11.40. a, b Side-lying and side-sitting. c, d Trunk stabilization in sitting

11.6 · Patient Cases in Mat Activities 11229 ef gh . Fig. 11.40. Patient IV. Incomplete tetraplegia with brachial plex- us lesion. e–i Mat work i

230 Chapter 11 · Mat Activities 1 2 3 4 5 6 7 8 9j k 10 11 12 13 14 15 16 17 18 lm 19 . Fig. 11.40. Patient IV. Incomplete tetraplegia with brachial plexus lesion. j–m Standing and walking in parallel bars 20

11.6 · Patient Cases in Mat Activities 11231 Reference VanSant AF (1991) Life-span motor development. In: Contem- porary management of motor control problems. Proceed- ings of the II Step Conference. Foundation for Physical Therapy, Alexandria, VA Further Reading Portney LG, Sullivan PE, Schunk MC (1982) The EMG activity of trunk-lower extremity muscles in bilateral-unilateral bridging. Phys Ther 62:664 Schunk MC (1982) Electromyographic study of the perone- us longus muscle during bridging activities. Phys Ther 62:970–975 Sullivan PE, Portney LG, Rich CH, Langham TA (1982) The EMG activity of trunk and hip musculature during unresisted and resisted bridging. Phys Ther 62:662 Sullivan PE, Portney LG, Troy L, Markos PD (1982) The EMG activity of knee muscles during bridging with resistance applied at three joints. Phys Ther 62:648 Troy L, Markos PD, Sullivan PE, Portney LG (1982) The EMG activity of knee muscles during bilateral-unilateral bridg- ing at three knee angles. Phys Ther 62:662

8.1 · 8117 The Lower Extremity 8.1 Introduction and Basic Procedures – 118 8.2 Flexion – Abduction – Internal Rotation – 120 8.2.1 Flexion – Abduction – Internal Rotation with Knee Flexion – 122 8.2.2 Flexion – Abduction – Internal Rotation with Knee Extension – 124 8.3 Extension – Adduction – External Rotation – 126 8.3.1 Extension – Adduction – External Rotation with Knee Extension – 129 8.3.2 Extension – Adduction – External Rotation with Knee Flexion – 132 8.4 Flexion – Adduction – External Rotation – 133 8.4.1 Flexion – Adduction – External Rotation with Knee Flexion – 135 8.4.2 Flexion – Adduction – External Rotation with Knee Extension – 137 8.5 Extension – Abduction – Internal Rotation – 139 8.5.1 Extension – Abduction – Internal Rotation with Knee Extension – 141 8.5.2 Extension – Abduction – Internal Rotation with Knee Flexion – 143 8.6 Bilateral Leg Patterns – 144 8.7 Changing the Patient’s Position – 147 8.7.1 Leg Patterns in a Sitting Position – 147 8.7.2 Leg Patterns in a Prone Position – 149 8.7.3 Leg Patterns in a Side Lying Position – 151 8.7.4 Leg Patterns in a Quadruped Position – 151 8.7.5 Leg Patterns in the Standing Position – 154

118 Chapter 8 · The Lower Extremity 8.1 Introduction and Basic Diagonal Motion The lower extremity has two diagonals: 1 Procedures 5 Flexion–abduction–internal rotation and ex- 2 Lower extremity patterns are used to treat dysfunc- tension–adduction–external rotation tions in the pelvis and leg caused by muscular weak- 5 Flexion–adduction–external rotation and ex- 3 ness, incoordination, and joint restrictions. We can tension–abduction–internal rotation use these leg patterns for treatment of functional problems in walking and climbing up and down The hip and the ankle-foot complex are tied togeth- 4 stairs, with activities such as rolling, and moving in er in the pattern synergy. The knee is free to move bed. Your imagination can supply other examples. into flexion, move into extension, or remain mo- 5 The leg patterns are also used to exercise the trunk. tionless. The leg moves through the diagonals in a Resistance to strong leg muscles produces irradia- straight line with the rotation occurring smooth- 6 tion into weaker muscles elsewhere in the body. ly throughout the motion. In the normal timing of We can use all the techniques with the leg pat- the pattern, the toes, foot, and ankle move first, the terns. The choice of individual techniques or com- other joints then move through their ranges togeth- 7 binations of techniques will depend on the patient’s er. condition and the treatment goals. You can, for in- The basic patterns of the left leg with the sub- 8 stance, combine Dynamic Reversals with Combi- ject supine are shown. All descriptions refer to nation of Isotonics, Repeated Contractions with this arrangement. To work with the right leg just 9 Dynamic Reversals or Contract-Relax or Hold-Re- change the word “left” to “right” in the instructions. lax with Combination of Isotonics and Dynamic We can exercise leg patterns in different positions: Reversals. prone, supine, side lying, quadruped, long sitting, 10 11 Flex.-Add.- ER Flex.-Abd.- IR . Fig. 8.1. Lower extremity 12 Dorsiflexion Dorsiflexion diagonals (Courtesy of V. Jung): Supination Pronation with all four patterns, the knee Inversion Eversion can flex, extend or maintain a Toe extension Toe extension position 13 14 15 16 17 18 Ext.-Add.- ER Ext.-Abd.- IR 19 Plantar flexion Plantar flexion 20 Supination Pronation Inversion Eversion Toe flexion Toe flexion

8.1 · Introduction and Basic Procedures 8119 side-sitting and in standing. Choose the position Resistance depending on the abilities of the patient, the treat- The direction of the resistance is in an arc back to- ment-goals, the influence of gravity, etc. Variations ward the starting position. The angle of the thera- of position are shown later in the chapter. pist’s hands and arms giving the resistance changes as the limb moves through the pattern. Patient Position – Note Traction and Approximation Traction and approximation are an important part Position the patient close to the edge of the table. of the resistance. Use traction at the beginning of the motion in both flexion and extension. Use ap- The patient’s spine should be in a neutral position proximation to stabilize the limb when it is in ex- without side-bending or rotation. Before beginning tension and traction to stabilize the limb in flex- a lower extremity pattern, visualize the patient’s leg ion. in a middle position where the lines of the two di- agonals cross. Starting with the hip in neutral rota- Normal Timing and Timing for Emphasis tion, move the extremity into the elongated range Normal Timing of the pattern with the proper rotation, beginning The foot and ankle (distal component) begin the with the foot and ankle. pattern by moving through their full range. Rota- tion at the hip and knee accompanies the rotation Therapist Position (eversion or inversion) of the foot. After the distal – Note movement is completed, the hip or hip and knee move jointly through their range. The therapist stands on the left side of the table with his or her pelvis facing the line of the diago- Timing for Emphasis nal, arms and hands aligned with the motion. In the sections on timing for emphasis we offer some suggestions for exercising components of the All grips described in the first part of each section patterns. Any of the techniques may be used. We assume that you are in this position. We first give have found that Repeated Stretch (Repeated Con- the basic position and body mechanics for exercis- tractions) and Combination of Isotonics work well. ing the straight leg pattern. When we describe var- Do not limit yourself to the exercises we suggest in iations in the patterns we identify any changes in this section, use your imagination. position or body mechanics. Some of these varia- tions are pictured at the end of the chapter. Grips Stretch The grips follow the basic procedures for manu- As with some other basic principles, you only use al contact, that is, opposite the direction of move- the stretch with a specific therapeutic goal. It is not ment. The first part of this chapter (7 Sect. 8.2) de- necessary to use this basic procedure each time, and scribes the two-handed grip used when the thera- in some cases it is a contraindication to use it. Use pist stands next to the moving lower extremity. The it only when it is needed to facilitate a movement. basic grip is described for each straight leg pattern. In the leg patterns we can use the stretch-stimu- The grips are modified when the therapist’s or pa- lus with or without the stretch-reflex to facilitate an tient’s position is changed. The grips also change easier or stronger movement, or to start the motion. when the therapist uses only one hand while the When stretching a pattern it is important to start other hand controls another part of the body. with elongation of the distal component. Maintain the ankle and foot in its stretched position while you The grip on the foot contacts the active surface, elongate the rest of the synergistic muscles. dorsal or plantar, and holds the sides of the foot to resist the rotary components. Using the lumbrical Repeated Stretch (Repeated Contractions) dur- grip will prevent squeezing or pinching the patient’s ing the motion facilitates a stronger motion or foot. Remember, pain inhibits effective motion. guides the motion into the desired direction. Re-

120 Chapter 8 · The Lower Extremity peated Stretch at the beginning of the pattern is Irradiation and Reinforcement 1 used when the patient has difficulty initiating the We can use strong leg patterns (single or bilateral) motion and to guide the direction of the motion. to get irradiation into all other parts of our body. 2 To get the stretch-reflex the therapist must elongate The patient’s position in combination with the both the distal and proximal components. Be sure amount of resistance will control the amount of ir- 3 you do not overstretch a muscle or put too much radiation. We can use this irradiation to strengthen tension on joint structure. This is particularly im- or mobilize other parts of our body, to relax mus- portant when the hip is extended with the knee cle chains, or to facilitate a functional activity such 4 flexed. as rolling. 5 8.2 Flexion – Abduction – Internal Rotation (. Fig. 8.2) 6 Movement Muscles: principal components Joint Flexion, abduction, internal rotation (Kendall and McCreary 1993) Extended (position unchanged) 7 Tensor fascia lata, rectus femoris, gluteus medius Hip (anterior), gluteus minimus 8 Knee Quadriceps 9 Ankle/foot Dorsiflexion, eversion Peroneus tertius 10 Toes Extension, lateral deviation Extensor hallucis, extensor digitorum 11 Grip midline, and the left side of the trunk elongates. If Distal Hand there is restriction in the range of hip adduction or Your left hand grips the dorsum of the patient’s external rotation the patient’s pelvis will move to- 12 foot. Your fingers are on the lateral border and your ward the right. If the hip extension is restricted, the thumb gives counter-pressure on the medial bor- pelvis will move into anterior tilt. 13 der. Hold the sides of the foot but don’t put any contact on the plantar surface. To avoid blocking Therapist’s Position and Body Mechanics 14 toe motion, keep your grip proximal to the meta- Stand in a stride position by the patient’s left hip tarsal-phalangeal joints. Do not squeeze or pinch with your right foot behind. Face toward the pa- the foot. tient’s foot and align your body with the line of mo- tion of the pattern. Start with the weight on your 15 front foot and let the motion of the patient’s leg Proximal Hand 16 Place your right hand on the anterior-lateral sur- push you back over your right leg. If the patient’s face of the thigh just proximal to the knee. The fin- leg is long, you may have to step back with your 17 gers are on the top, the thumb on the lateral sur- left foot as your weight shifts farther back. Conti- face. nue facing the line of motion. 18 Elongated Position Alternative Position Traction the entire limb while you move the foot in- You may stand on the right side of the table facing 19 to plantar flexion and inversion. Continue the trac- up toward the patient’s left hip. If you choose this tion and maintain the external rotation as you place position, move the patient to the right side of the 20 the hip into extension (touching the table) and ad- table. Your right hand is on the patient’s foot, your duction. Elongate the leg parallel to the table, don’t left hand on the thigh. Stand in a stride with your push the leg into the table. The thigh crosses the right leg forward. As the patient’s leg moves up in-

8.2 · Flexion – Abduction – Internal Rotation 8121 Movement The toes extend as the foot and ankle move into dorsiflexion and eversion. The eversion promotes the hip internal rotation, and these motions occur almost simultaneously. The fifth metatarsal leads as the hip moves into flexion with abduction and in- ternal rotation. Continuation of this motion pro- duces trunk flexion with left side-bending. Resistance Your distal hand combines resistance to eversion with traction through the dorsiflexed foot. The re- a sistance to the hip abduction and internal rotation comes from resisting eversion. The traction resists both the dorsiflexion and hip flexion. Your proxi- mal hand combines traction through the line of the femur with a rotary force that resists the inter- nal rotation and abduction. Maintaining the trac- tion force will guide your resistance in the prop- er arc. Too much resistance to the leg does not al- low the pelvis to move in the proper direction. Too much resistance to the leg does not allow the pelvis to move freely in the proper direction. b ! Caution . Fig. 8.2a,b. Flexion–abduction–internal rotation Too much resistance to hip flexion may result in strain on the spine. End Position The foot is in dorsiflexion with eversion. The knee is in full extension and the hip in full flexion with enough abduction and internal rotation to align the knee and heel approximately with the lateral border of the left shoulder. to flexion, step forward with your left leg. This po- ! Caution sition makes it easier to get a good elongation at the The length of the hamstring muscles or other pos- beginning of the pattern. See . Fig. 8.3 for an illus- terior structures may limit the hip motion. Do not tration of the alternative position. allow the pelvis to move into a posterior tilt. Stretch Timing for Emphasis The response to the stretch comes from a rapid Prevent motion in the beginning range of hip flex- elongation and rotation of the ankle, foot, and hip, ion and exercise the foot and toes. by both hands simultaneously. Command “Foot up, lift your leg up and out.” “Lift up!”

122 Chapter 8 · The Lower Extremity 1 Points to Remember 5 Internal rotation of the hip is necessary, don’t 5 Start with good elongation of the leg, the 2 thigh must start across mid-line move only the foot 5 Continuation of the elongation will lengthen 5 Give traction to the femur during the motion 3 the trunk lateral flexors 5 The lumbar spine must remain in neutral 4 5 8.2.1 Flexion – Abduction – Internal Rotation with Knee Flexion (. Fig. 8.3) 6 Movement Muscles: principal components Joint Flexion, abduction, internal rotation (Kendall and McCreary 1993) Flexion 7 Tensor fascia lata, rectus femoris, gluteus medius Hip (anterior), gluteus minimus 8 Knee Hamstrings, gracilis, gastrocnemius 9 Ankle/foot Dorsiflexion, eversion Peroneus tertius 10 Toes Extension, lateral deviation Extensor hallucis, extensor digitorum 11 Grip Command Your distal and proximal grips remain the same as “Foot up, bend your knee up and out.” “Bend up!” they were for the straight leg pattern. Movement The foot and ankle dorsiflex and evert. The hip 12 Elongated Position 13 Position the limb as you did for the straight leg pat- and knee motions begin next and both joints reach tern. their end ranges at the same time. Continuation of 14 Body Mechanics this motion also causes trunk flexion with lateral flexion to the left. Stand in the same stride position by the patient’s 15 hip as for the straight leg pattern. Again, allow the Resistance patient’s motion to shift your weight from the front Give traction with your proximal hand through the 16 to the back foot. Face the line of motion. line of the femur, adding a rotary force, to resist the hip motion. Resist the foot and ankle motion as be- 17 Alternative Positions fore with your distal hand. Resist the knee flexion You may use the same alternative position, stand- by applying traction through the tibia toward the ing on the opposite side of the table, as you used for starting position. The resistance to knee flexion is 18 the straight leg pattern (. Fig. 8.3 c, d). crucial to successful use of this combination for strengthening the hip and trunk. 19 Stretch Use the same motions for the stretch that you used End Position 20 with the straight leg pattern. Traction with the dis- The foot is in dorsiflexion with eversion. The hip tal hand will facilitate the knee flexors. and knee are in full flexion with the heel close to the

8.2 · Flexion – Abduction – Internal Rotation 8123 ab c d . Fig. 8.3. Flexion–abduction–internal rotation with knee flexion. a, b Usual position of the therapist; c, d alternative position on the opposite side of the table

124 Chapter 8 · The Lower Extremity lateral border of the buttock. The knee and heel are When exercising the patient’s foot, move your 1 aligned with each other and lined up approximately proximal hand to a position on the tibia and give with the lateral border of the left shoulder. resistance to the hip and knee with that hand. Your 2 distal hand is now free to give appropriate resist- – Note ance to the foot and ankle motions. To avoid fatigue 3 If you extend the patient’s knee the position is the of the hip allow the heel to rest on the table. same as the straight leg pattern. Points to Remember 4 Timing for Emphasis 5 End the pattern with maximal flexion in With three moving segments, hip, knee, and foot, the knee joint 5 you may lock in any two and exercise the third. 5 Resist the knee flexion with your distal With the knee bent it is easy to exercise the internal hand throughout the range of motion 6 rotation separately from the other hip motions. Do 5 The foot should not move lateral to the these exercises where the strength of the hip flexion knee is greatest. You may work through the full range of 7 hip internal rotation during these exercises, but re- turn to the groove before finishing the pattern. 8 9 8.2.2 Flexion – Abduction – Internal Rotation with Knee Extension (. Fig. 8.4) 10 Joint Movement Muscles: principal components (Kendall and McCreary 1993) 11 Hip Flexion, abduction, internal Tensor fascia lata, rectus femoris, gluteus medius (anterior), 12 rotation gluteus minimus Knee Ankle/foot Extension Quadriceps Dorsiflexion, eversion Peroneus tertius 13 Toes Extension, lateral deviation Extensor hallucis, extensor digitorum 14 Position at Start may restrict full hip extension–adduction. Keep For this combination place the patient toward the the thigh in the diagonal and flex the knee only as 15 end of the table so the knee can be flexed as ful- much as is possible without pain. ly as possible. 16 Grip ! Caution Do not allow the pelvis to move to the right or go 17 Your distal and proximal grips remain the same as into anterior tilt. they were for the straight leg pattern. To protect the patient’s back, flex the right hip and 18 Elongated Position rest the foot on the end of the table or another sup- Traction the entire limb as before, while you move port. 19 the foot into plantar flexion and inversion. Contin- ue the traction while you flex the knee over the end Body Mechanics 20 of the table and position the hip in extension with Stand in a stride position by the patient’s knee. adduction and external rotation. Tightness in the Bend from the hips as you reach down and flex the anterior muscles that cross the hip and knee joints patient’s knee. As the patient lifts his leg with the

8.2 · Flexion – Abduction – Internal Rotation 8125 ab d c . Fig. 8.4. Flexion–abduction–internal rotation with knee extension. a, b Usual position of the therapist; c, d alternative posi- tion at the end of the table

126 Chapter 8 · The Lower Extremity knee extending your weight shifts back and then Resistance 1 you step back. Your distal hand resists the foot and ankle motion with a rotary push. Using the stable foot as a han- 2 Alternative Positions dle, resist the knee extension with a traction force Stand at the end of the table facing up toward the toward the starting position of knee flexion. The ro- 3 patient’s left shoulder. Lean back so that your body tary resistance at the foot resists the knee and hip weight helps with the stretch of the hip. As the leg rotation as well. moves into flexion, step forward with your back Your proximal hand combines traction through 4 foot (. Fig. 8.4 c, d). the line of the femur with a twist to resist internal rotation. 5 Stretch Apply the stretch to the foot, hip, and knee simul- – Note 6 taneously. Stretch the hip with the proximal hand, The knee takes more resistance than the hip. Your using rapid traction and rotation. Stretch the foot two hands must work separately. and ankle with your distal hand, using elongation 7 and rotation. Stretch the knee very gently by apply- End Position ing only traction with your distal hand along the The end position is the same as the straight leg pat- 8 line of the tibia. tern. Command Timing for Emphasis 9 “Foot up, bend your hip up and straighten your The emphasis here is to teach the patient to com- knee as you go.” bine hip flexion with knee extension in a smooth motion. 10 Movement 11 The foot and ankle dorsiflex and evert. The hip mo- Points to Remember tion begins next. When the hip has moved through 5 Good elongation and rotation in the hip about 5 ° of flexion the knee begins to extend. It is are necessary to facilitate the hip motion 12 important that the hip and knee reach their end 5 Do not cause pain with the stretch of the knee ranges at the same time. 5 The hip and knee motions occur together, 13 the end position is a straight leg 14 15 8.3 Extension – Adduction – External Rotation (. Fig. 8.5) 16 17 Joint Movement Muscles: principal components 18 (Kendall and McCreary 1993) 19 Hip Extension, adduction, external rotation 20 Adductor magnus, gluteus maximus, hamstrings, Knee Extended (positions unchanged) lateral rotators Ankle Plantar-flexion, inversion Toes Flexion, medial deviation Quadriceps Gastrocnemius, soleus, tibialis posterior Flexor hallucis, flexor digitorum

8.3 · Extension – Adduction – External Rotation 8127 Grip Stretch Hold the plantar surface of the foot with the palm Your proximal hand stretches the hip by giving a of your left hand. Your thumb is at the base of the quick traction to the thigh. Use the forearm of your toes to facilitate toe flexion. Be careful not to block distal hand to traction up through the shin while the flexion of the toes. Your fingers hold the me- you stretch the patient’s foot farther into dorsiflex- dial border of the foot, the heel of your hand gives ion and eversion. counter-pressure along the lateral border. ! Caution ! Caution Do not force the hip into more flexion. Do not squeeze or pinch the foot. Command Proximal Hand “Point your toes, push your foot down and kick Your right hand comes underneath the thigh from down and in.” “Push!” lateral to medial to hold on the posteromedial side. Movement Elongated Position The toes flex and the foot and ankle plantar flex and Traction the entire leg while moving the foot in- invert. The inversion promotes the hip external ro- to dorsiflexion and eversion. Continue the traction tation, and these motions occur at the same time. and maintain the internal rotation as you lift the leg The fifth metatarsal leads as the thigh moves down into flexion and abduction. If the patient has just into extension and adduction maintaining the ex- completed the antagonistic motion (flexion–ab- ternal rotation. Continuation of this motion caus- duction–internal rotation), begin at the end of that es extension with elongation of the left side of the pattern. trunk. ! Caution Resistance Do not try to push the hip past the limitation imposed by hamstring length. Do not allow the Your distal hand combines resistance to inversion pelvis to move into a posterior tilt. with approximation through the bottom of the foot. The approximation resists both the plantar flexion Body Mechanics and the hip extension. Resisting inversion results in Stand in a stride position by the patient’s left shoul- resistance to the hip adduction and external rota- der facing toward the lower right corner of the ta- tion as well. Your proximal hand lifts the thigh back ble. Your inner foot (closest to the table) is in front. toward the starting position. The lift resists the hip Your weight is on the back foot. Allow the patient’s extension and adduction. The placement of your motion to pull you forward onto your front foot. hand, coming from lateral to medial, gives resist- When your weight has shifted over the front foot, ance to the external rotation. step forward with your rear foot and continue the weight shift forward. As the hip approaches full extension, continue to give approximation through the foot with your Alternative Position distal hand and approximate through the thigh You may stand on the right side of the table fac- with your proximal hand. ing up toward the left hip. Your right hand is on the plantar surface of the patient’s foot, your left hand End Position on the posterior thigh. Stand in a stride and allow the patient to push your weight back as the leg kicks The foot is in plantar flexion with inversion and the down (. Fig. 8.5 d, e). toes are flexed. The knee remains in full extension. The hip is in extension (touching the table) and ad- duction while maintaining external rotation. The thigh has crossed to the right side of the midline.

128 Chapter 8 · The Lower Extremity b . Fig. 8.5. Extension–adduction–external rota- 1 tion. a, b Therapist standing on the same side of 2 the table; c same pattern with the patient’s other 3 leg flexed; d, e therapist standing on the opposite 4 side of the table 5 6a e 7 8 9 10 11 12 c 13 14 15 16 17 18 19 20 d

8.3 · Extension – Adduction – External Rotation 8129 Timing for Emphasis Lock in the hip at the end of the range and exercise the foot and toes. Points to Remember 5 The therapist’s proximal hand comes from 5 End position: the thigh crosses mid-line and the lateral side of the thigh to the posterior- the lumbar spine remains in neutral tilt and medial surface side bend 5 Normal timing: to get the proper direct 5 The hip maintains external rotation as well as movement into the pattern, instead of an adduction arcing movement, the foot must move into its position first 8.3.1 Extension – Adduction – External Rotation with Knee Extension (. Fig. 8.6) Joint Movement Musclcs: principal components (Kendall and McCreary 1993) Hip Extension, adduction, external rotation Adductor magnus, gluteus maximus, hamstrings, Knee Extension lateral rotators Ankle Plantar-flexion, inversion Toes Flexion, medial deviation Quadriceps Gastrocnemius, soleus, tibialis posterior Flexor hallucis, flexor digitorum Grip Body Mechanics Your distal and proximal grips are the same as the Your body mechanics are the same as for the ones used for the straight leg pattern. straight leg pattern. Elongated Position Alternative Position The foot is in dorsiflexion with eversion. The hip You may stand on the opposite side of the table fac- and knee are in full flexion with the heel close to ing up toward the left hip (. Fig. 8.6 c, d). the lateral border of the buttock. The knee and heel are aligned with each other and lined up approxi- Stretch mately with the lateral border of the left shoulder. The hip has the same amount of rotation as it did Apply the stretch to the hip, knee, and foot simul- in the straight leg pattern. Straighten the knee to taneously. With your proximal (right) hand com- check the rotation. bine traction of the hip through the line of the fe- mur with a rotary motion to stretch the external rotation. Your distal (left) hand stretches the foot farther into dorsiflexion and eversion and stretch- es the knee extension by bringing the patient’s heel closer to his buttock.

130 Chapter 8 · The Lower Extremity b 1 . Fig. 8.6. Extension–adduction–external rota- 2 tion with knee extension. a, b Usual position of 3 the therapist; c, d alternative position on the oth- 4 er side of the table 5 6 7 8a 9 10 11 12 13 14 c 15 16 17 18 19 20 d

8.3 · Extension – Adduction – External Rotation 8131 ! Caution Timing for Emphasis Don’t over-rotate the hip by pulling the foot more Prevent knee extension at the beginning of the lateral than the knee. range and exercise the hip motions. Lock in hip ex- tension in mid-range and exercise the knee exten- Command sion. Lock in the knee before it is fully extended and exercise the hip extension. “Push your foot down and kick down and in.” “Kick!” Points to Remember Movement 5 Don’t over-rotate the hip at the beginning of the movement The foot and ankle plantar flex and invert. The hip motion begins next. When the hip extension has 5 Resist the knee extension with your distal completed about 5 ° of motion the knee begins to hand throughout the range extend. It is important that the hip and knee reach their end ranges at the same time. 5 Resistance with your distal hand to the knee extension at the beginning of the Resistance motion will prevent over rotation of the hip Your distal hand resists the foot and ankle motion with a rotary push. The rotary resistance at the foot 5 The movement ends with external rota- also resists the rotation at the knee and hip. Us- tion in the hip, not just inversion of the ing the foot as a handle, resist the knee extension foot by pushing the patient’s heel back toward the but- tock. The angle of this resistance will change as the knee moves further into extension. The resistance to the knee extension motion continues in the same direction (toward the patient’s buttock) when the knee is fully extended. Your proximal hand pulls the thigh back to- ward the starting position. The pull resists the hip extension and adduction. The placement of your hand, coming from lateral to medial, supplies the resistance to the external rotation. As the hip and knee approach full extension, give approximation through the foot with your distal hand and approx- imate through the thigh with your proximal hand. – Note The knee takes more resistance than the hip. Your two hands must work separately. End Position The end position is the same as the straight leg pat- tern.

132 Chapter 8 · The Lower Extremity 8.3.2 Extension – Adduction – External Rotation with Knee Flexion (. Fig. 8.7) 1 Joint Movement Muscles: principal components (Kendall and McCreary 1993) 2 Hip Extension, adduction, external rotation Adductor magnus, gluteus maximus, lateral rotators Flexion Hamstrings, gracilis 3 Knee 4 Ankle Plantar-flexion, inversion Gastrocnemius, soleus, tibialis posterior Toes Flexion, medial deviation Flexor hallucis, flexor digitorum 5 Position at Start Body Mechanics 6 For this combination place the patient toward the Use the same body mechanics as for the straight end of the table so that the knee can flex as fully as leg pattern. As the pattern nears end range, bend at 7 possible. This is the same placement you used to be- your hips as you reach down to continue resisting gin the pattern of flexion–abduction–internal rota- the knee flexion. 8 tion with knee extension (7 Sect. 8.2.2). To protect the patient’s back flex the right hip and rest the foot Stretch 9 on the end of the table or another support. The stretch comes from the rapid elongation and Grip rotation of the hip, ankle, and foot by both hands simultaneously. With your distal hand you can give 10 Your distal and proximal grips are the same as those increased traction to stretch the knee flexor mus- used for the straight leg pattern. cles. 11 Elongated Position Command Position the limb as you did for the straight leg pat- “Push your foot and toes down; push your hip 12 tern. down and bend your knee as you go.” 13 14 15 16 17 18 19 20 a b . Fig. 8.7a,b. Extension–adduction–external rotation with knee flexion

8.4 · Flexion – Adduction – External Rotation 8133 Movement ! Caution The foot and ankle plantar flex and invert. The hip Do not allow the pelvis to move to the right or go motion begins next. When the hip extension has into anterior tilt. completed about 5 ° of motion the knee begins to flex. It is important that the hip and knee reach Timing for Emphasis their end ranges at the same time. Lock in the hip extension at any point in the range and exercise the knee flexion. Do not let the hip ac- Resistance tion change from extension to flexion. Teach the Your distal hand uses the resistance to the plantar patient to combine hip extension with knee flexion flexion and inversion to resist the knee flexion as in a smooth motion. well. The pull is back toward the starting position of knee extension and foot eversion. Your prox- Points to Remember imal hand resists the hip motion as it did for the straight leg pattern. As the hip approaches full ex- 5 Resist the flexion of the knee as well as the tension approximate through the thigh with your extension of the hip proximal hand. 5 Normal timing: the knee flexes smoothly End Position during the entire motion The hip is extended with adduction and external rotation. The knee is flexed over the end of the table 5 Give traction to the femur during the and the foot is in plantar flexion with inversion. motion 8.4 Flexion – Adduction – External Rotation (. Fig. 8.8) Joint Movement Muscles: principal components (Kendall and McCreary 1993) Hip Flexion, adduction, External rotation Psoas major, iliacus, adductor muscles, sartorius, Knee Extended (position unchanged) pectineus, rectus femoris Ankle/foot Dorsiflexion, inversion Toes Extension, medial deviation Quadriceps Tibialis anterior Extensor hallucis, extensor digitorum Grip Proximal Hand Distal Hand Place your right hand on the anterior-medial sur- face of the thigh just proximal to the knee. Your left hand grips the patient’s foot with the fin- gers on the medial border and the thumb giving Elongated Position counter-pressure on the lateral border. Hold the Traction the entire limb while you move the foot sides of the foot but do not put any contact on the into plantar flexion and eversion. Continue the plantar surface. To avoid blocking toe motion, keep traction and maintain the internal rotation as your grip proximal to the metatarsal-phalangeal you place the hip into hyperextension and abduc- joints. Do not squeeze or pinch the foot. tion. The trunk elongates diagonally from right to left.

134 Chapter 8 · The Lower Extremity 1 2 3 4 5 6 7 b a 8 . Fig. 8.8a,b. Flexion–adduction–external rotation 9 ! Caution Movement If the hip extension is restricted, the pelvis will The toes extend as the foot and ankle move into 10 move into anterior tilt. If the abduction is restrict- dorsiflexion and inversion. The inversion promotes ed, the pelvis will move to the left. the hip external rotation, so these motions occur 11 Body Mechanics simultaneously. The big toe leads as the hip moves into flexion with adduction and external rotation. Stand in a stride position with your inner foot (clos- Continuation of this motion produces trunk flex- 12 est to the table) behind and your outer foot (farthest ion to the right. from the table) in front. Face toward the patient’s 13 right shoulder with your body aligned with the pat- Resistance tern’s line of motion. Shift your weight from your Your distal hand combines resistance to inversion 14 front foot to your back foot as you stretch. As the with traction through the dorsiflexed foot. The re- patient moves, let the resistance shift your weight sistance to the hip adduction and external rotation forward over your front foot. If the patient’s leg is comes from resisting the inversion. The traction 15 long, you may have to take a step as your weight resists both the dorsiflexion and hip flexion. Your shifts farther forward. Continue facing the line of proximal hand combines traction through the line 16 motion. of the femur with a rotary force to resist the exter- nal rotation and adduction. Maintaining the trac- 17 Stretch tion force will guide your resistance in the prop- The response to the stretch comes from a rapid er arc. elongation and rotation of the hip, ankle, and foot 18 by both hands simultaneously. ! Caution 19 Command Too much resistance to hip flexion may result in “Foot up, lift your leg up and in.” “Lift up!” strain on the patient’s spine. 20 End Position The foot is in dorsiflexion with inversion. The knee is in full extension. The hip is in full flexion with

8.4 · Flexion – Adduction – External Rotation 8135 enough adduction and external rotation to place Points to Remember the knee and heel in a diagonal line with the right shoulder. 5 Continuation of the lower extremity elon- gation will tighten the trunk flexors in the ! Caution same diagonal direction The length of the hamstring muscles or other pos- terior structures may limit the hip motion. Do not 5 The therapist’s body position remains fac- allow the pelvis to move into a posterior tilt. ing the line of motion Timing for Emphasis You may prevent motion in the beginning range of hip flexion and exercise the foot and toes. 8.4.1 Flexion – Adduction – External Rotation with Knee Flexion (. Fig. 8.9) Joint Movement Muscles: principal components (Kendall and McCreary 1993) Hip Flexion, adduction, external rotation Psoas major, iliacus, adductor muscles, sartorius, Knee Flexion pectineus, rectus femoris Ankle/foot Dorsiflexion, inversion Toes Extension, medial deviation Hamstrings, gracilis, gastrocnemius Tibialis anterior Extensor hallucis, extensor digitorum Grip Command Your grips are the same as those for the straight leg “Foot up, bend your leg up and across.” “Bend up!” pattern. Movement Elongated Position The toes extend and the foot and ankle dorsiflex Position the limb as you did for the straight leg pat- and invert. The hip and knee flexion begin next, tern. and both joints reach their end ranges at the same time. Continuation of this motion also causes trunk Body Mechanics flexion to the right. Stand in the same stride position by the patient’s foot as for the straight leg pattern. Again allow the – Note patient to shift your weight from the back to the Be sure that the knee flexes smoothly and con- front foot. Face the line of motion. tinuously as the hip flexes. Stretch Resistance The response to the stretch comes from a rapid Give traction with your proximal hand through the elongation and rotation of the ankle and foot and line of the femur, adding a rotary force, to resist the hip by both hands simultaneously. Traction the hip motion. The resistance given by your dis- with the distal hand facilitates the knee flexors. tal hand to the dorsiflexion and inversion will al- so resist the hip adduction and external rotation. Your distal hand now resists the knee flexion by ap-

136 Chapter 8 · The Lower Extremity 1 2 3 4 5 6 7 8a b 9 10 11 12 13 14 15 16 c 17 . Fig. 8.9a–c. Flexion–adduction–external rotation with knee flexion 18 plying traction through the tibia toward the start- End Position ing position. The foot is in dorsiflexion with inversion, the hip 19 – Note and knee are in full flexion. The adduction and ex- ternal rotation cause the heel and knee to line up 20 The resistance to knee flexion is crucial to success- with each other and with the left shoulder. ful use of this combination for strengthening the hip and trunk.

8.4 · Flexion – Adduction – External Rotation 8137 – Note When exercising the foot, move your proxi- An anteroposterior plane bisecting the foot mal hand to a position on the tibia and give resist- should also bisect the knee. If you extend the ance to the hip and knee with that hand. Your distal patient’s knee, the position is the same as the hand is now free to give appropriate resistance to straight leg pattern. the foot and ankle motions. To avoid fatigue of the hip allow the heel to rest on the table. Timing for Emphasis Points to Remember With three moving segments, hip, knee and foot, you may lock in any two and exercise the third. 5 Normal timing: the knee flexion matches the hip flexion throughout the motion With the knee bent it is easy to exercise the ex- ternal rotation separately from the other hip mo- 5 There is full flexion of the knee in the end tions. Do these exercises where the strength of the position hip flexion is greatest. You may work through the full range of hip external rotation during these ex- 5 The direction of resistance to the knee ercises. Return to the groove before finishing the flexion is back toward the starting position pattern. 5 The resistance with the distal hand con- trols the hip rotation 8.4.2 Flexion – Adduction – External Rotation with Knee Extension (. Fig. 8.10) Joint Movement Muscles: principal components (Kendall and McCreary 1993) Hip Flexion, adduction, External rotation Psoas major, iliacus, adductor muscles, sartorius, Knee Extension pectineus, rectus femoris Ankle/foot Dorsiflexion, inversion Toes Extension, medial deviation Quadriceps Tibialis anterior Extensor hallucis, extensor digitorum Position at Start Elongated Position For this combination place the patient closer to the Traction the entire limb as before, while you move side of the table (. Fig. 8.10). An alternative place- the foot into plantar flexion and eversion. Continue ment is toward the end of the table so that the knee the traction on the femur and flex the knee over the can flex as fully as possible. This is the same place- side of the table as you position the hip in exten- ment you used to begin the pattern of flexion–ab- sion with abduction and internal rotation. Tight- duction–internal rotation with knee extension ness in the anterior muscles that cross the hip and (7 Sect. 8.2.2). To protect the patient’s back flex the knee joints may restrict full hip extension–abduc- right hip and rest the foot on the end of the table or tion. Keep the thigh in the diagonal and flex the another support. knee as much as possible. Grip ! Caution Do not allow the pelvis to move into anterior tilt. Your grips remain the same as those for the straight To protect the patient’s back flex the right hip and leg pattern. rest the foot on the table or another support.

138 Chapter 8 · The Lower Extremity kle and foot with your distal hand using elongation 1 and rotation. Stretch the knee very gently by apply- ing only traction with your distal hand along the 2 line of the tibia. 3 ! Caution 4 Stretch for the knee is traction only. Do not push 5 the knee into more flexion. 6a 7 Command 8 “Foot up, bend your hip up and straighten your knee as you go.” Movement The foot and ankle dorsiflex and invert. The hip mo- tion begins next. When the hip has moved through about 5° of flexion the knee begins to extend. It is important that the hip and knee reach their end ranges at the same time. 9 Resistance Your distal hand resists the foot and ankle motion 10 with a rotary force. Using the stable foot as a han- dle, resist the knee extension with a traction force 11 toward the starting position of knee flexion. The ro- tary resistance at the foot resists the knee and hip rotation as well. 12 Your proximal hand combines traction through the line of the femur with a twist to resist the exter- 13 nal rotation and adduction. 14 b – Note 15 The knee takes more resistance than the hip. Your . Fig. 8.10a,b. Flexion–adduction–external rotation with two hands must work separately. knee extension End Position 16 Body Mechanics The end position is the same as the straight leg pat- Stand in a stride position by the patient’s knee fac- tern. 17 ing the foot of the table. Bend from the hips to Timing for Emphasis reach down and flex the patient’s knee. Your weight The emphasis here is to teach the patient to com- bine hip flexion with knee extension in a smooth shifts forward, and then you turn to face the line of motion. 18 the pattern. Step forward as the patient lifts his leg with the knee extending. 19 Stretch 20 Apply the stretch to the hip, knee, and foot simul- taneously. Stretch the hip with the proximal hand using rapid traction and rotation. Stretch the an-

8.5 · Extension – Abduction – Internal Rotation 8139 Points to Remember 5 The hip and knee motions occur together 5 The end position is a straight leg with adduc- 5 Elongation in the hip is necessary to facilitate the hip motion tion and external rotation 5 Do not cause pain with stretch of the knee 8.5 Extension – Abduction – Internal Rotation (. Fig. 8.11) Joint Movement Muscles: principal components Hip Extension, abduction, internal rotation (Kendall and McCreary 1993) Knee Extended (positions unchanged) Ankle Plantar-flexion, eversion Gluteus medius, gluteus maximus (upper), Toes Flexion, lateral deviation hamstrings Quadriceps Gastrocnemius, solcus, peroneus longus and brevis Flexor hallucis, flexor digitorum Grip ! Caution Distal Hand Do not try to push the hip past the limitation imposed by hamstring length. Do not allow the Hold the foot with the palm of your left hand along pelvis to move into a posterior tilt. the plantar surface. Your thumb is at the base of the toes to facilitate toe flexion. Your fingers hold If the patient has just completed the antagonistic the medial border of the foot while the heel of your motion (flexion–adduction–external rotation), be- hand gives counter pressure along the lateral bor- gin at the end of that pattern. der. ! Caution Body Mechanics Do not squeeze or pinch the foot. Stand in a stride position facing the patient’s right Proximal Hand shoulder. Your weight is on the front foot. Allow the Your right hand holds the posterior lateral side of patient to push you back onto your rear foot, then the thigh. step back and continue to shift your weight back- ward. Keep your elbows close to your sides so you Elongated Position can give the resistance with your body and legs. Traction the entire leg while moving the foot into dorsiflexion and inversion. Continue the traction Stretch and maintain the external rotation as you lift the leg into flexion and adduction. The proximal hand gives a stretch by rapid traction of the thigh. Use the forearm of your distal hand to traction up through the shin while you stretch the patient’s foot farther into dorsiflexion and in- version.

140 Chapter 8 · The Lower Extremity 1 2 3 4 5 6a b 7 8 9 10 11 12 c 13 . Fig. 8.11a–c. Extension–abduction–internal rotation 14 ! Caution Resistance Your distal hand combines resistance to eversion 15 Do not force the hip into more flexion. with approximation through the bottom of the foot. 16 Command The approximation resists both the plantar flexion “Point your toes, push your foot down and kick and the hip extension. The resistance to the hip ab- 17 down and out.” “Push!” duction and internal rotation comes from the re- sisted eversion. Your proximal hand lifts the thigh Movement back toward the starting position. The lift resists 18 The toes flex and the foot and ankle plantar flex and the hip extension and abduction. The placement of evert. The eversion promotes the hip internal ro- your hand, coming from lateral to posterior, gives 19 tation; these motions occur at the same time. The resistance to the internal rotation. thigh moves down into extension and abduction, As the hip approaches full extension, continue 20 maintaining the internal rotation. Continuation of to give approximation through the foot with your this motion causes extension with left side bending distal hand and approximate through the thigh of the trunk. with your proximal hand.

8.5 · Extension – Abduction – Internal Rotation 8141 End Position tension hip motion. Lock in the hip at the end of The foot is in plantar flexion with inversion and the the range and exercise the foot and toes. toes are flexed. The knee remains in full extension. The hip is in as much hyperextension as possible Points to Remember while maintaining the abduction and internal ro- tation. 5 Resist the hip extension all the way through the motion Timing for Emphasis Use approximation with Repeated Contractions or 5 The lumbar spine remains in neutral tilt Combination of Isotonics to exercise the hyperex- and side-bend 8.5.1 Extension – Abduction – Internal Rotation with Knee Extension (. Fig. 8.12) Joint Movement Muscles: principal components (Kendall and McCreary 1993) Hip Extension, abduction, internal rotation Gluteus medius, gluteus maximus (upper), hamstrings Knee Extension Quadriceps Ankle Plantar-flexion, eversion Gastrocnemius, soleus, peroneus longus and brevis Toes Flexion, lateral deviation Flexor hallucis, flexor digitorum Grip Command Your grips are the same as for the straight leg pat- “Push your foot down and kick down and out.” tern. “Kick!” Elongated Position Movement The foot is in dorsiflexion with inversion. The hip The foot and ankle plantar flex and evert. The hip and knee are in full flexion with the heel close to motion begins next. When the hip extension has the right buttock. The knee and heel are aligned completed about 5° of motion the knee begins to with each other and lined up approximately with extend. It is important that the hip and knee reach the right shoulder. their end ranges at the same time. Body Mechanics Resistance Your body mechanics are the same as for the Your distal hand resists the foot and ankle motion straight leg pattern. with a rotary push. Using the foot as a handle, re- sist the knee extension by pushing the patient’s heel Stretch back toward the buttock. The angle of this resist- Apply the stretch to the hip, knee, and foot simul- ance will change as the knee moves further into ex- taneously. With your proximal hand combine trac- tension. The rotary resistance at the foot resists the tion of the hip through the line of the femur with a knee and hip rotation as well. rotary motion to stretch the internal rotation. Your distal hand stretches the foot farther into dorsiflex- – Note ion and inversion as you stretch the knee extension The resistance to the knee extension motion by bringing the patient’s heel closer to the buttock. continues in the same direction when the knee is full extended.

142 Chapter 8 · The Lower Extremity 1 2 3 4 5 6 7 b a 8 . Fig. 8.12a,b. Extension–abduction–internal rotation with knee extension 9 Points to Remember Your proximal hand lifts the thigh back toward the 5 Timing: The hip extends at the same rate as the knee 10 starting position. The lift resists the hip extension and abduction. The placement of the hand from lat- 5 Your distal hand resists the extension of the knee by pushing the heel toward the 11 eral to posterior gives resistance to the internal rota- buttock tion. As the hip and knee approaches full extension, give approximation through the foot with your dis- 5 Resistance with your distal hand to the knee extension at the beginning of the 12 tal hand and approximate through the thigh with motion will prevent over rotation of the hip your proximal hand. 13 – Note 14 The knee takes more resistance than the hip. Your two hands must work separately. 15 End Position The end position is the same as the straight leg pat- 16 tern. Timing for Emphasis 17 Prevent knee extension at the beginning of the range and exercise the hip motions. Lock in hip ex- 18 tension in mid-range and exercise knee extension. Lock in the knee before it is fully extended and ex- 19 ercise the hip extension. 20

8.5 · Extension – Abduction – Internal Rotation 8143 8.5.2 Extension – Abduction – Internal Rotation with Knee Flexion (. Fig. 8.13) Joint Movement Muscles: principal components (Kendall and McCreary 1993) Hip Extension, abduction, internal rotation Gluteus medius, gluteus maximus (upper) Knee Flexion Hamstrings, gracilis Ankle Plantar-flexion, eversion Soleus, peroneus longus and brevis Toes Flexion, lateral deviation Flexor hallucis, flexor digitorum Position at Start Elongated Position For this combination place the patient closer to the Position the limb as you did for the straight leg pat- side of the table. This is the same position you used tern. to begin the pattern of flexion–adduction–exter- nal rotation with knee extension. To protect the pa- Body Mechanics tient’s back flex the right hip and rest the foot on Use the same body mechanics as for the straight the table. leg pattern. As the pattern nears end range, bend at your hips as you reach down to continue resist- Grip ing the knee flexion. You may turn your body to Your grips are the same as those for the straight leg face toward the foot of the table as the knee and hip pattern. reach their end range. a b . Fig. 8.13a,b. Extension–abduction–internal rotation with knee flexion

144 Chapter 8 · The Lower Extremity Stretch Points to Remember 1 The response to the stretch comes from the rapid 5 Timing: The foot moves first, then the knee and hip move together elongation and rotation of the hip, ankle, and foot 5 End the movement with full hip exten- 2 by both hands simultaneously. You can give a lit- sion and as much knee flexion as possible tle extra traction movement to the knee with your without causing lumbar hyperextension 3 distal hand to elongate the knee flexor muscles fur- ther. 4 Command “Push your foot and toes down, push your hip 5 down, and bend your knee as you go.” 8.6 Bilateral Leg Patterns 6 Movement When you exercise both legs at the same time there The foot and ankle plantar flex and evert. The hip is always more demand on the trunk muscles than motion begins next. When the hip extension has when only one leg is exercising. To exercise the 7 completed about 5° of motion the knee begins to trunk specifically you hold both the legs together. flex. It is important that the hip and knee reach The leg patterns for trunk exercise are discussed in 8 their end ranges at the same time. 7 Chapter 10. When you hold the legs separately the emphasis 9 Resistance of the exercise is on the legs. Bilateral leg work al- Your distal hand resists the plantar flexion and ever- lows you to use irradiation from the patient’s strong sion and uses that force to resist the knee flexion as leg to facilitate weak motions or muscles in the in- 10 well. The force is back toward the starting position volved leg. You can use any combination of patterns of knee extension and foot inversion. Your prox- and techniques in any position. Work with those 11 imal hand resists the hip motion as it did for the patterns, techniques and positions that give you straight leg pattern. As the hip approaches full ex- and the patient the greatest advantage in strength tension, approximate through the thigh with your and control. 12 proximal hand. The most common positions for doing bilater- al leg patterns are supine, prone, and sitting. In sit- 13 End Position ting we show two possible combinations. The first The hip is extended with abduction and internal ro- is a bilateral symmetrical combination, flexion– 14 tation. The knee is flexed over the side of the table abduction with knee extension (. Fig. 8.14), and and the foot is in plantar flexion with eversion. the second is a reciprocal asymmetrical combina- 15 ! Caution tion, left leg flexion–abduction with knee extension combined with right leg extension–abduction with Do not allow the pelvis to go into anterior tilt. knee flexion (. Fig. 8.15). In a supine position, the 16 Timing for Emphasis symmetrical straight leg combinations of flexion– abduction (. Fig. 8.16 a, b) and extension–adduc- 17 Lock in the hip extension at any point in the range tion (. Fig. 8.16 c, d), the reciprocal combination of and exercise the knee flexion. left leg extension–abduction with right leg flexion– abduction (. Fig. 8.17), and the asymmetrical pat- 18 ! Caution tern of hip extension with knee flexion (. Fig. 8.18) Do not let the hip action change from extension are shown. In the prone position we show hip ex- 19 to flexion. tension with knee flexion (. Fig. 8.19). 20 Teach the patient to combine hip extension with knee flexion in a smooth motion.

8.6 · Bilateral Leg Patterns 8145 ab . Fig. 8.14a,b. Bilateral symmetrical pattern combination of flexion–abduction with knee extension in sitting ab . Fig. 8.15a,b. Bilateral asymmetrical patterns, flexion–abduction with knee extension on the left, extension–abduction with knee flexion on the right a b . Fig. 8.16. Bilateral symmetrical combinations in a supine position. a, b Flexion– abduction

146 Chapter 8 · The Lower Extremity 1 2 3 4 5 d c 6 . Fig. 8.16. Bilateral symmetrical combinations in a supine position. c, d extension–adduction 7 8 9 10 11 12 b a 13 . Fig. 8.17a,b. Bilateral asymmetrical reciprocal combination of left leg extension–abduction with right leg flexion–abduction 14 15 16 17 18 19 a b 20 . Fig. 8.18a,b. Bilateral asymmetrical combination of hip extension with knee flexion, left leg in abduction and right leg in ad- duction

8.7 · Changing the Patient’s Position 8147 a b . Fig. 8.19a,b. Prone bilateral symmetrical combination, hip extension–adduction with knee flexion Points to Remember 8.7.1 Leg Patterns in a Sitting Position 5 Bilateral straight leg patterns have treat- The sitting position allows the therapist to work ment goals on the structural level, such as with the legs when hip extension is restricted by an strengthening leg or trunk muscles. outside force. This position lets the patient see the foot and knee while exercising. In addition, work- 8.7 Changing the Patient’s ing in this position challenges the patient’s sitting Position balance and stability. Using timing for emphasis, this is an easy way to stabilize one leg and exercise There are many advantages to exercising the patient the other with reciprocal motions. The number of in a variety of positions. These include the patient’s lower extremity exercises that you can do with your ability to see his or her leg, adding or eliminating patient in sitting is limited only by the patient’s abil- the effect of gravity from a motion, and putting ities and your imagination. We have pictured three two-joint muscles on stretch. There are also disad- examples in . Fig. 8.20. vantages for each position. Choose the positions that give the most advantages with the fewest draw- backs. We illustrate four of these positions.

148 Chapter 8 · The Lower Extremity 1 2 3 4 5 6a 7 8 b d 9 10 11 12 c 13 14 15 16 . Fig. 8.20. Leg patterns in sitting. a, b Extension–adduction 17 with knee flexion; c, d extension–abduction with knee flexion 18 19 20