Introduction and Basic Procedures

Lower extremity patterns are used to treat dysfunctions in the pelvis and leg caused by muscular weakness, incoordination, and joint restrictions. We can use these leg patterns for treatment of functional problems in walking and climbing up and down stairs, with activities such as rolling, and moving in bed. Your imagination can supply other examples. The leg patterns are also used to exercise the trunk. Resistance to strong leg muscles produces irradiation into weaker muscles elsewhere in the body.

We can use all the techniques with the leg patterns. The choice of individual techniques or combinations of techniques will depend on the patient's condition and the treatment goals. You can, for instance, combine Dynamic Reversals with Combination of Isotonics, Repeated Contractions with Dynamic Reversals or Contract-Relax or Hold-Relax with Combination of Isotonics and Dynamic Reversals.

Diagonal Motion

The lower extremity has two diagonals:

— Flexion-abduction-internal rotation and extension-adduction-external rotation

— Flexion-adduction-external rotation and extension-abduction-internal rotation

The hip and the ankle-foot complex are tied together in the pattern synergy. The knee is free to move into flexion, move into extension, or remain motionless. The leg moves through the diagonals in a straight line with the rotation occurring smoothly throughout the motion. In the normal timing of the pattern, the toes, foot, and ankle move first, the other joints then move through their ranges together.

The basic patterns of the left leg with the subject supine are shown. All descriptions refer to this arrangement. To work with the right leg just change the word "left" to "right" in the instructions. We can exercise leg patterns in different positions: prone, supine, side lying, quadruped, long sitting,

Dorsiflexion Supination Inversion Toe extension

Plantar flexion Supination Inversion Toe flexion

Dorsiflexion Pronation Eversion Toe extension

Plantar flexion Pronation Eversion Toe flexion

Dorsiflexion Pronation Eversion Toe extension

D Fig. 8.1. Lower extremity diagonals (Courtesy of V. Jung): with all four patterns, the knee can flex, extend or maintain a position

Plantar flexion Pronation Eversion Toe flexion side-sitting and in standing. Choose the position depending on the abilities of the patient, the treatment-goals, the influence of gravity, etc. Variations of position are shown later in the chapter.

Patient Position

Position the patient close to the edge of the table.

The patient's spine should be in a neutral position without side-bending or rotation. Before beginning a lower extremity pattern, visualize the patient's leg in a middle position where the lines of the two diagonals cross. Starting with the hip in neutral rotation, move the extremity into the elongated range of the pattern with the proper rotation, beginning with the foot and ankle.

Therapist Position

The therapist stands on the left side of the table with his or her pelvis facing the line of the diagonal, arms and hands aligned with the motion.

All grips described in the first part of each section assume that you are in this position. We first give the basic position and body mechanics for exercising the straight leg pattern. When we describe variations in the patterns we identify any changes in position or body mechanics. Some of these variations are pictured at the end of the chapter.

Grips

The grips follow the basic procedures for manual contact, that is, opposite the direction of movement. The first part of this chapter (7 Sect. 8.2) describes the two-handed grip used when the therapist stands next to the moving lower extremity. The basic grip is described for each straight leg pattern. The grips are modified when the therapist's or patient's position is changed. The grips also change when the therapist uses only one hand while the other hand controls another part of the body.

The grip on the foot contacts the active surface, dorsal or plantar, and holds the sides of the foot to resist the rotary components. Using the lumbrical grip will prevent squeezing or pinching the patient's foot. Remember, pain inhibits effective motion.

Resistance

The direction of the resistance is in an arc back toward the starting position. The angle of the therapist's hands and arms giving the resistance changes as the limb moves through the pattern.

Traction and Approximation

Traction and approximation are an important part of the resistance. Use traction at the beginning of the motion in both flexion and extension. Use approximation to stabilize the limb when it is in extension and traction to stabilize the limb in flexion.

Normal Timing and Timing for Emphasis Normal Timing

The foot and ankle (distal component) begin the pattern by moving through their full range. Rotation at the hip and knee accompanies the rotation (eversion or inversion) of the foot. After the distal movement is completed, the hip or hip and knee move jointly through their range.

Timing for Emphasis

In the sections on timing for emphasis we offer some suggestions for exercising components of the patterns. Any of the techniques may be used. We have found that Repeated Stretch (Repeated Contractions) and Combination of Isotonics work well. Do not limit yourself to the exercises we suggest in this section, use your imagination.

Stretch

As with some other basic principles, you only use the stretch with a specific therapeutic goal. It is not necessary to use this basic procedure each time, and in some cases it is a contraindication to use it. Use it only when it is needed to facilitate a movement. In the leg patterns we can use the stretch-stimulus with or without the stretch-reflex to facilitate an easier or stronger movement, or to start the motion. When stretching a pattern it is important to start with elongation of the distal component. Maintain the ankle and foot in its stretched position while you elongate the rest of the synergistic muscles.

Repeated Stretch (Repeated Contractions) during the motion facilitates a stronger motion or guides the motion into the desired direction. Re peated Stretch at the beginning of the pattern is used when the patient has difficulty initiating the motion and to guide the direction of the motion. To get the stretch-reflex the therapist must elongate both the distal and proximal components. Be sure you do not overstretch a muscle or put too much tension on joint structure. This is particularly important when the hip is extended with the knee flexed.

Grip

Distal Hand

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

Proximal Hand

Place your right hand on the anterior-lateral surface of the thigh just proximal to the knee. The fingers are on the top, the thumb on the lateral surface.

Elongated Position

Traction the entire limb while you move the foot into plantar flexion and inversion. Continue the traction and maintain the external rotation as you place the hip into extension (touching the table) and adduction. Elongate the leg parallel to the table, don't push the leg into the table. The thigh crosses the

We can use strong leg patterns (single or bilateral) to get irradiation into all other parts of our body. The patient's position in combination with the amount of resistance will control the amount of irradiation. We can use this irradiation to strengthen or mobilize other parts of our body, to relax muscle chains, or to facilitate a functional activity such as rolling.

midline, and the left side of the trunk elongates. If there is restriction in the range of hip adduction or external rotation the patient's pelvis will move toward the right. If the hip extension is restricted, the pelvis will move into anterior tilt.

Therapist's Position and Body Mechanics

Stand in a stride position by the patient's left hip with your right foot behind. Face toward the patient's foot and align your body with the line of motion of the pattern. Start with the weight on your front foot and let the motion of the patient's leg push you back over your right leg. If the patient's leg is long, you may have to step back with your left foot as your weight shifts farther back. Continue facing the line of motion.

Alternative Position

You may stand on the right side of the table facing up toward the patient's left hip. If you choose this position, move the patient to the right side of the table. Your right hand is on the patient's foot, your left hand on the thigh. Stand in a stride with your right leg forward. As the patient's leg moves up in-

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