Flexion Adduction External Rotation d

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Joint

Movement

Muscles: principal components (Kendall and McCreary 1993)

Hip

Flexion, adduction, External rotation

Psoas major, iliacus, adductor muscles, sartorius, pectineus, rectus femoris

Knee

Extended (position unchanged)

Quadriceps

Ankle/foot

Dorsiflexion, inversion

Tibialis anterior

Toes

Extension, medial deviation

Extensor hallucis, extensor digitorum

Grip

Distal Hand

Your left hand grips the patient's foot with the fingers on the medial border and the thumb giving counter-pressure on the lateral border. Hold the sides of the foot but do not put any contact on the plantar surface. To avoid blocking toe motion, keep your grip proximal to the metatarsal-phalangeal joints. Do not squeeze or pinch the foot.

Proximal Hand

Place your right hand on the anterior-medial surface of the thigh just proximal to the knee.

Elongated Position

Traction the entire limb while you move the foot into plantar flexion and eversion. Continue the traction and maintain the internal rotation as you place the hip into hyperextension and abduction. The trunk elongates diagonally from right to left.

Traction And Internal Rotation

Fig. 8.8a,b. Flexion-adduction-external rotation

Fig. 8.8a,b. Flexion-adduction-external rotation

! Caution

If the hip extension is restricted, the pelvis will move into anterior tilt. If the abduction is restricted, the pelvis will move to the left.

Body Mechanics

Stand in a stride position with your inner foot (closest to the table) behind and your outer foot (farthest from the table) in front. Face toward the patient's right shoulder with your body aligned with the pattern's line of motion. Shift your weight from your front foot to your back foot as you stretch. As the patient moves, let the resistance shift your weight forward over your front foot. If the patient's leg is long, you may have to take a step as your weight shifts farther forward. Continue facing the line of motion.

Stretch

The response to the stretch comes from a rapid elongation and rotation of the hip, ankle, and foot by both hands simultaneously.

Command

"Foot up, lift your leg up and in." "Lift up!"

Movement

The toes extend as the foot and ankle move into dorsiflexion and inversion. The inversion promotes the hip external rotation, so these motions occur simultaneously. The big toe leads as the hip moves into flexion with adduction and external rotation. Continuation of this motion produces trunk flexion to the right.

Resistance

Your distal hand combines resistance to inversion with traction through the dorsiflexed foot. The resistance to the hip adduction and external rotation comes from resisting the inversion. The traction resists both the dorsiflexion and hip flexion. Your proximal hand combines traction through the line of the femur with a rotary force to resist the external rotation and adduction. Maintaining the traction force will guide your resistance in the proper arc.

! Caution

Too much resistance to hip flexion may result in strain on the patient's spine.

End Position

The foot is in dorsiflexion with inversion. The knee is in full extension. The hip is in full flexion with b a enough adduction and external rotation to place the knee and heel in a diagonal line with the right shoulder.

! Caution

The length of the hamstring muscles or other posterior structures may limit the hip motion. Do not allow the pelvis to move into a posterior tilt.

Timing for Emphasis

You may prevent motion in the beginning range of hip flexion and exercise the foot and toes.

Points to Remember

Continuation of the lower extremity elongation will tighten the trunk flexors in the same diagonal direction The therapist's body position remains facing the line of motion

8.4.1 Flexion - Adduction - External Rotation with Knee Flexion (o Fig. 8.9)

Joint

Movement

Muscles: principal components (Kendall and McCreary 1993)

Hip

Flexion, adduction, external rotation

Psoas major, iliacus, adductor muscles, sartorius, pectineus, rectus femoris

Knee

Flexion

Hamstrings, gracilis, gastrocnemius

Ankle/foot

Dorsiflexion, inversion

Tibialis anterior

Toes

Extension, medial deviation

Extensor hallucis, extensor digitorum

Grip

Your grips are the same as those for the straight leg pattern.

Elongated Position

Position the limb as you did for the straight leg pattern.

Body Mechanics

Stand in the same stride position by the patient's foot as for the straight leg pattern. Again allow the patient to shift your weight from the back to the front foot. Face the line of motion.

Stretch

The response to the stretch comes from a rapid elongation and rotation of the ankle and foot and the hip by both hands simultaneously. Traction with the distal hand facilitates the knee flexors.

Command

"Foot up, bend your leg up and across." "Bend up!" Movement

The toes extend and the foot and ankle dorsiflex and invert. The hip and knee flexion begin next, and both joints reach their end ranges at the same time. Continuation of this motion also causes trunk flexion to the right.

Be sure that the knee flexes smoothly and continuously as the hip flexes.

Resistance

Give traction with your proximal hand through the line of the femur, adding a rotary force, to resist the hip motion. The resistance given by your distal hand to the dorsiflexion and inversion will also resist the hip adduction and external rotation. Your distal hand now resists the knee flexion by ap-

Trunk Flexion Range Motion

Fig. 8.9a-c. Flexion-adduction-external rotation with knee flexion

Fig. 8.9a-c. Flexion-adduction-external rotation with knee flexion plying traction through the tibia toward the starting position.

End Position

The foot is in dorsiflexion with inversion, the hip and knee are in full flexion. The adduction and external rotation cause the heel and knee to line up

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.

An anteroposterior plane bisecting the foot should also bisect the knee. If you extend the patient's knee, the position is the same as the straight leg pattern.

Timing for Emphasis

With three moving segments, hip, knee and foot, you may lock in any two and exercise the third.

With the knee bent it is easy to exercise the external rotation separately from the other hip motions. Do these exercises where the strength of the hip flexion is greatest. You may work through the full range of hip external rotation during these exercises. Return to the groove before finishing the pattern.

When exercising the foot, move your proximal hand to a position on the tibia and give resistance to the hip and knee with that hand. Your distal hand is now free to give appropriate resistance to the foot and ankle motions. To avoid fatigue of the hip allow the heel to rest on the table.

Points to Remember

Normal timing: the knee flexion matches the hip flexion throughout the motion There is full flexion of the knee in the end position

The direction of resistance to the knee flexion is back toward the starting position The resistance with the distal hand controls the hip rotation

8.4.2 Flexion - Adduction - External Rotation with Knee Extension (O Fig. 8.10)

Joint

Movement

Muscles: principal components (Kendall and McCreary 1993)

Hip

Flexion, adduction, External rotation

Psoas major, iliacus, adductor muscles, sartorius, pectineus, rectus femoris

Knee

Extension

Quadriceps

Ankle/foot

Dorsiflexion, inversion

Tibialis anterior

Toes

Extension, medial deviation

Extensor hallucis, extensor digitorum

Position at Start

For this combination place the patient closer to the side of the table (O Fig. 8.10). An alternative placement is toward the end of the table so that the knee can flex as fully as possible. This is the same placement you used to begin the pattern of flexion-abduction-internal rotation with knee extension (7 Sect. 8.2.2). To protect the patient's back flex the right hip and rest the foot on the end of the table or another support.

Grip

Your grips remain the same as those for the straight leg pattern.

Elongated Position

Traction the entire limb as before, while you move the foot into plantar flexion and eversion. Continue the traction on the femur and flex the knee over the side of the table as you position the hip in extension with abduction and internal rotation. Tightness in the anterior muscles that cross the hip and knee joints may restrict full hip extension-abduction. Keep the thigh in the diagonal and flex the knee as much as possible.

! Caution

Do not allow the pelvis to move into anterior tilt. To protect the patient's back flex the right hip and rest the foot on the table or another support.

D Fig. 8.10a,b. Flexion-adduction-external rotation with knee extension

Body Mechanics

Stand in a stride position by the patient's knee facing the foot of the table. Bend from the hips to reach down and flex the patient's knee. Your weight shifts forward, and then you turn to face the line of the pattern. Step forward as the patient lifts his leg with the knee extending.

Stretch

Apply the stretch to the hip, knee, and foot simultaneously. Stretch the hip with the proximal hand using rapid traction and rotation. Stretch the an kle and foot with your distal hand using elongation and rotation. Stretch the knee very gently by applying only traction with your distal hand along the line of the tibia.

! Caution

Stretch for the knee is traction only. Do not push the knee into more flexion.

Command

"Foot up, bend your hip up and straighten your knee as you go."

Movement

The foot and ankle dorsiflex and invert. The hip motion 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.

Resistance

Your distal hand resists the foot and ankle motion with a rotary force. Using the stable foot as a handle, resist the knee extension with a traction force toward the starting position of knee flexion. The rotary resistance at the foot resists the knee and hip rotation as well.

Your proximal hand combines traction through the line of the femur with a twist to resist the external rotation and adduction.

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 pattern.

Timing for Emphasis

The emphasis here is to teach the patient to combine hip flexion with knee extension in a smooth motion.

Points to Remember

Elongation in the hip is necessary to facilitate the hip motion

Do not cause pain with stretch of the knee

The hip and knee motions occur together The end position is a straight leg with adduction and external rotation

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