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MODULE 1: Introduction to the

Examination of the human Body


Session 2: Specific examination of the
lower extremities

INDEX
1.

OBJECTIVES ........................................................................ 3

2.

SPECIFIC EXAMINATION OF THE LOWER EXTREMITIES ............. 4

3.

SPECIFIC PALPATION OF THE KNEE AREA ............................... 8

4.

SPECIFIC PALPATION OF THE LOWER LEG AND FOOT AREA .... 10

5.
LOCOMOTIVE AND MUSCULAR STRENGTH EXAMINATION
OF THE LOWER EXTREMITIES ....................................................... 14
BIBLIOGRAPHY ........................................................................... 25

Module 1 Session 2 ___ 3/25

1. OBJECTIVES
The main objectives which must be attained by the students during this work session
are:

Familiarise himself with the descriptive and functional anatomy of the lower
limb

Know the specific techniques for examining the lower extremities of the human
body

Become familiarised with the nomenclature of the most relevant movements of


the extremities

Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions

4/25 ___ Module 1 Session 2

2. SPECIFIC EXAMINATION OF THE LOWER EXTREMITIES


Before inspection, palpation or motion and strength examinations can be carried out,
the pedorthist should study and familiarise himself with the descriptive and functional
anatomy of the areas of the human body to be examined.
There is no point wanting to perform examination techniques if you dont know what
to expect.

SPECIFIC PALPATION OF THE PELVIC AND UPPER LEG AREA


The skeleton
Both anterior superior iliac spines are important for determining the pelvic position in
the frontal plane. These can be palpated. When palpating from the upper leg muscles
to proximal, these will be the first epicondyle that the investigator will feel.
The investigator can also palpate from the crista iliaca (iliac crest) to anterior and
distal.
The last epicondyle before the investigators finger turns into the stomach from the
iliac crest is the anterior superior iliac spine.
The investigator can easily place his hands on both iliac crests from the lateral sides
and in so doing get an idea of the position of the pelvic girdle in the F-plane.
Dorsally both iliac crests end in the spinae iliacae posteriores superiores (posterior
superior iliac spines). At the location of these spines there are normally two dips,
because the skin attaches directly to these nodes. By comparing the depth of both
dips, the investigator can (in a third way) get an idea of the position of the pelvic
girdle in the F-plane.
Then, we can found a bone prominence in the lateral zone of the hip. It is situated
between iliac crest and the upper leg. It is the femur greater trochanter.

Muscles
M. tensor fasciae latae
Get the patient to lie on his back on an examination table.
Ask him to anteflex his extended leg in the hip joint and to endorotate a little.
The muscle belly of the m. tensor fasciae latae can now be palpated laterally from the
anterior superior iliac spine to distally from the trochanter major (greater trochanter),
after which the muscle turns into the tractus iliotibialis (vertical fibrous reinforcement
of the upper leg connective tissue-membrane between iliac crest and lateral upper
side of the tibia).
The palpation technique is best conducted with two fingers of the same hand, as
shown in Figure 1.

ONLINE TRAINING

Module 1 Session 2 ___ 5/25

Figure 1. M. tensor fasciae latae palpation

While palpating in the manner described above the fingers move in the longitudinal
direction of the muscle belly to distal and shifting downwards, the fingers apply
varying force. This is also called the alternating finger palpation technique.

M. sartorius (tailors muscle)


Get the patients to sit on an examination table with his legs dangling down.
Get the patient to make a light anteflexion, exorotation and abduction motion in the
hip joint.
Now the leg should be almost entirely extended in the knee, so as to make the load
arm of the leg in relation to the hip joint greater.
The m. sartorius can be inspected in this position and can be palpated from origin
almost to the insertion.
The alternating finger palpation technique can also be used here.

M. rectus femoris (straight thigh muscle)


The patient sits on an examination table with his legs dangling down.
We are going to palpate the m. rectus femoris of the right leg.
The right leg should be slightly anteflexed in the hip joint and extended in the knee.
You can now palpate the boundary with the laterally situated m. vastus lateralis
(exterior broad thigh muscle) with the left hand practically in the midline of the upper
leg.
Now you can use the right hand to palpate distally in the upper leg the boundary with
the m. vastus medialis (interior broad thigh muscle) and more proximally the
boundary with the m. sartorius.
Now two hands are used for the palpation, whereby the fingers have as much contact
as possible with the patients leg.
The fingers also apply more varying pressure against the muscle now.
This palpation method is called the two-handed palpation technique (Figure 2. ).

Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions

6/25 ___ Module 1 Session 2

Figure 2. M. rectus femoris palpation

M. vastus medialis (interior broad thigh muscle)


The area where the m. vastus medialis lies superficially can best be determined, using
the above-mentioned method, by palpating the distal parts of the m. sartorius and m.
rectus femoris.
If the investigator wishes to palpate the m. vastus medialis in contracted state, the
patient should sit on an examination table with legs dangling and one leg extended.
The m. vastus medialis is primarily visible in the final phase of this active stretching.
It is possible to palpate the muscle belly from distal to proximal using the twohanded palpation technique.
M. vastus lateralis (exterior broad thigh muscle)
The boundaries between which this muscle lies can be palpated. In the case of m.
rectus femoris we have already described how to find the anterior boundary of the m.
vastus lateralis with the m. rectus femoris.
The posterior boundary of the m. vastus lateralis is the limit with the m. biceps
femoris (two-headed thigh muscle).
To localise this border, the investigator should get the patient to lie on his stomach.
The leg is bent a little at the knee until it meets resistance (try to keep resistance as
low as possible). The tendon from the m. biceps femoris can be palpated from the
caput fibulae (head of the fibula). The investigator can use one hand to localise the
lateral boundary of the m. biceps femoris by applying sideways pressure to this
contracted muscle. This is also the way to find the posterior boundary of the m. vastus
lateralis.
M. biceps femoris (two-headed thigh muscle)
The patient lies on his stomach on an examination table, and the leg is then bent at
the knee a little until it meets resistance. It is best to palpate the muscle from its
insertion tendon, laterally from the head of the fibula, to proximal-medial, in the
direction of the tuber ischiadicum (sitz bone). The last proximal part of the muscle is
located under the m. gluteus maximus (large buttock muscle).
It is often possible to distinguish distally the caput breve (short head) from the caput
longum (long head). Either the 'alternating finger' or the 'two-handed palpation'
technique can be used.

ONLINE TRAINING

Module 1 Session 2 ___ 7/25

M. semitendinosus (semi-sinuous muscle)


When the patient is lying on his stomach on the examination table, with the leg bent
at a 90 angle with slight resistance, it is possible to inspect and palpate medially in
the knee hollow the round insertion tendon of the m. semitendinosus.
The tendon and muscle belly can be palpated to proximal with the alternating finger
palpation technique.
By placing a finger in the longitudinal direction of the muscle on both sides of the
tendon or the muscle belly, the muscle can be palpated almost as far as the origin.
M. semimembranosus (semi-membranous muscle)
This muscle can be palpated distal on both sides of and deeper than the m.
semitendinosus.
The patient lies on his stomach for this too, but this time the leg is only bent a little in
the knee, against resistance.
The m. semimembranosus can be partially palpated lateral from the tendon of the m.
semitendinosus in the knee hollow.
The muscle can be medially palpated along its entire length.
M. adductor longus (long adductor muscle)
When the patient is lying on his back on the examination table and if his leg is bent
completely at the knee and laid to one side, the m. adductor longus can be stretched.
On the medial side of the leg the tightly contracted muscle can be palpated from the
os pubis (pubic bone) to approximately halfway up the upper leg.
M. gracilis (slim thigh muscle)
As the only adductor this muscle also runs over the knee joint; this can be used when
palpating.
The patient lies on his back on the examination table, bends the leg at the knee and
lays the leg to one side. The back side of the calcaneus (the heel-bone) is now placed
against the edge of the examination table and the heel presses against this edge. The
patient now makes a knee flexion against resistance. The gracilis can be palpated from
its thin insertion tendon along the entire medial length of the upper leg up to and
including the origin tendon in the pubic bone.
M. gluteus maximus (large buttock muscle)
This muscle gives the round contour to the buttocks. When the patient lies on his
stomach and retroflexes his leg, the muscle contracts.
The upper edge of the muscle is situated at the line between the superior posterior
iliac spine and the upper side of the greater trochanter.
The lower edge of the muscle runs more distal than the buttock fold.

Groin artery A. femoralis (thigh bone artery)


This major artery can be palpated in the middle of the groin fold. Palpation is easiest
when the patient is lying on his back on the examination table.

Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions

8/25 ___ Module 1 Session 2

3. SPECIFIC PALPATION OF THE KNEE AREA


FRONT SIDE KNEE
Patella (kneecap)
The kneecap can be palpated. It is particularly easy to move the patella freely when
the knee is passively extended or stretched out in relaxed mode on an examination
table.
The edges of the kneecap can now be palpated.
Lig. Patellae (kneecap tendon).
Distal from the patella the ligament can easily be palpated on both sides.
There the ligament is flanked by two joint dips.
To the distal the ligament can be palpated up to the node mid proximal on the tibia,
the tuberositas tibiae (anterior tibial spine).
Tuberositas tibiae (tibial tuberosity)
To localise the distal start of the tibial tuberosity, the superior part of the tibia is
palpated to proximal. The knee should be stretched out in relaxed mode on an
examination table for this purpose.
Where the tibia starts to form a node that is where the tuberositas tibiae begins.
Palpate over the tuberositas to proximal; the tuberositas stops where the lig. patellae
can be pressed in. The proximal boundary of the tuberositas is usually located about
2 cm under the joint space of the knee joint.
The medial and lateral boundary can be found using sideways palpation.

LATERAL SIDE KNEE


Lateral joint space
This is found by shifting the palpating finger to lateral when the knee is bent, from the
projection situated lateral of the lig. patellae.
In order to ensure that the joint space is palpated, the investigator can passively
endo- and exorotate the knee so as to feel the lateral femoral condyle move in relation
to the lateral tibial plateau.
Caput fibulae (head of the fibula)
The head of the fibula can be found by following the insertion tendon of the m. biceps
femoris. Palpation can also be carried out from the lateral middle of the lower leg to
proximal. The first bone structure that you come across is the caput fibulae.
Lig. collaterale laterale (exterior knee ligament)
If the patient sits, and lays the distal section of the lower leg, with the knee to be
examined, on the distal section of the other upper leg, the ligament is easy to palpate.
It feels like a contracted round rope on the lateral side of the knee.

ONLINE TRAINING

Module 1 Session 2 ___ 9/25

Tractus iliotibialis (vertical fibrous reinforcement of the upper leg connective


tissue membrane between iliac crest and lateral upper side of the tibia)
Lateral, just proximal of the knee joint space is the best place for palpating the
tractus.
For the tractus in the upper leg, proximal palpation can be conducted; for the insertion
at the tibia distal palpation must be performed.
N. peroneus communis (common peroneal nerve)
The n. peroneus communis can be palpated just medial of the insertion tendon of the
m. biceps femoris like a thin round string.
The nerve just dorso-distal of the fibula head can also be palpated.

MEDIAL SIDE KNEE


Medial joint space
This is found by shifting the palpating finger to medial when the knee is bent, from the
dip situated medial of the lig. patellae.
In order to ensure that the joint space is palpated, the investigator can passively
endo- and exorotate the knee so as to feel the lateral femoral condyle move in relation
to the lateral tibial plateau.
Lig. collaterale mediale (interior knee ligament)
If a finger palpates the medial joint space deep while shifting from anterior to
posterior and while the knee is bent, a gradual rise is felt. This is a thickening in the
cap, the anterior border of the medial collateral ligament.
The posterior border is not palpable.
Insertion tendons
The tendon of the m. semitendinosus is best located in the hollow of the knee.
The fibres of the m. semimenbranosus are palpable on both sides of this tendon and
situated a little deeper. The medial edge of this muscle makes quite a sharp
impression, but cannot easily be confused with the round tendon of the m. gracilis.
The palpation of the tendon of the m. gracilis takes place just medial and anterior of
the medial part of the m. semimembranosus. Proceeding further to anterior, the
investigator will come to the m. sartorius, which feels more like a flat muscle.
The pes anserinus superficialis can often been seen just medial of the tuberositas
tibiae.
The tuberculum adductorium can be palpated proximal to the medial femoral condyle.
This is the insertion of the tendon of the m. adductor magnus.
This tendon can be palpated towards proximal.

Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions

10/25 __ Module 1 Session 2

DORSAL SIDE KNEE


N. tibialis (tibial nerve)
The n. tibialis, a rope-like structure, can be felt structurally central in the hollow of
the knee.
The nerve can be palpated by laying the patient on his back with the knee and hip in
90 flexion and the foot in maximum dorsiflexion.
A. poplitea (artery in the hollow of the knee)
This artery can be palpated medial and deeper in relation to the n. tibialis.
The patient should sit on an examination table with his legs bent and dangling.
If this doesnt work, the patient can lie on his stomach while the investigator bends his
knee and supports the lower leg.

4. SPECIFIC PALPATION OF THE LOWER LEG AND FOOT AREA


MUSCLES
M. tibialis anterior (anterior tibial muscle)
If the foot is put in dorsiflexion and supination, it should be possible to see the
anterior tibial muscle. With alternating contraction the muscle can best be palpated
from the insertion tendon, from the medial side of the foot.
The medial side of the muscle borders on the tibia.
The lateral border is more difficult to localise. By alternately bending and stretching
the toes, the lateral boundary with the m. extensor digitorum longus probably can be
better seen and felt.
The muscle ends proximal under the lateral tibial plateau.
M. extensor digitorum longus
The insertion tendons of this muscle can best be seen and felt to the second up to and
including the fifth toe while stretching the toes and dorsiflexion and pronation of the
foot.
The common tendon at the ankle joint can also be seen and palpated.
This muscle often has an extra lateral insertion tendon at the fifth metatarsal, the m.
peroneus tertius (third peroneal muscle).
The muscle belly of the m. extensor digitorum longus is so narrow that this is difficult
to palpate in most people.

ONLINE TRAINING

Module 1 Session 2 __ 11/25

M. extensor hallucis longus


The insertion tendon can only be inspected and palpated across the dorsum of the foot
with dorsiflexion of the foot and by stretching the hallux (first toe).
M. peroneus longus (long peroneal muscle)
It is useful first to localise the peroneus loge (the area where the peroneus muscles
are situated). Get the patient to sit on the examination table with relaxed dangling
legs, hold the whole calf in one hand from dorsal and push it to lateral.
Repeat this at various levels of the lower leg.
The two connective tissue partitions, between which the peroneus muscles are
situated, are demarcated as two grooves in the skin.
Let the feet pronate and plantarflex. The muscle belly of the m. peroneus longus is
demarcated from under the fibula head up to about half way up the lower leg, where a
'projection' appears on the lateral side of the lower leg.
That's where the tendon of the m. peroneus longus appears, which can be seen and
felt as a round structure just proximal to the lateral malleolus (exterior ankle) and
dorsal of the lateral malleolus.
About 1-2 cm distal of the lateral malleolus the tendon runs through and then
disappears under the heel bone to medial, ending under the first metatarsal head.
M. peroneus brevis (short peroneal muscle)
The muscle belly of the m. peroneus brevis begins approximately from the projection
on the lateral side of the lower leg, with pronation and plantarflexion of the foot.
Palpation of this muscle belly is a little easier if done just above the lateral malleolus,
because the muscle belly can be palpated there on both sides of the tendon of the m.
peroneus longus.
The tendon of the m. peroneus brevis usually runs at the height of the lateral
malleolus under that of the m. peroneus longus.
The insertion tendon of the m. peroneus brevis can only be seen and felt distal of the
lateral malleolus in the direction of the tuberositas ossis metatarsalis V (projection on
the basis of the fifth metatarsal).
M. gastrocnemius (calf muscle) and m. soleus (soleus muscle)
When the patient stands on the ball of his foot with extended knee, the two heads of
the m. gastrocnemius can be seen and felt from dorsal; their function is knee flexion
and plantar flexion of the foot.
The insertion tendon, the Achilles tendon, can also be inspected and palpated.
The m. soleus comes to the surface at the medial and lateral side of the m.
Gastrocnemius; its function only is plantar flexion of foot.
In order to differentiate between both muscles, the patient should lightly go through
the knees while standing on the ball of his foot. This will emphasise the m. soleus
more and this muscle can then be palpated with the alternating finger palpation
technique.
The narrow muscle belly of the m. soleus runs through till under the fibula head.
The muscle belly of the soleus muscle is usually palpated a little proximal of the
middle of the lower leg.

Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions

12/25 __ Module 1 Session 2

M. tibialis posterior (posterior tibial muscle)


Only the tendon insertion can be palpated (and often inspected too) at the medial
malleolus and distal from the medial malleolus.
The foot should then be moved in supination and plantarflexion.
This muscle is the principal stand of plantar arch.
M. flexor digitorum longus
The distal part of the muscle belly of the m. flexor digitorum longus can be palpated
proximal of the medial malleolus and dorsal of the tibia with alternating flexing of the
toes.
In this region, while flexing the toes, you can often see the skin move a little inwards
at the distal part of the muscle belly of the m. flexor digitorum longus.
M. flexor hallucis longus
A small part of the insertion tendon of the m. hallucis longus can be palpated distal
deep of the m. tibialis posterior and the m. flexor digitorum longus when the hallux is
bent.

SKELETON
MEDIAL
Tibia (shin bone)
The distal end of the tibia looks like a node, the malleolus medialis (inner ankle).
When palpating the foot should be moved passively in the ankle joint, so as to
properly feel the boundaries with the talus.
Calcaneus (heel bone)
The medial part of the tuber calcanei (heel bone node) can be palpated.
Whenever palpating is done from the foot sole, right under the medial malleolus, in
the direction of the medial malleolus, the first bone piece that is felt is the
sustentaculum tali.
This is the medial table-shaped projection of the heel bone which partly supports the
talus.
Talus (astragalus bone)
If palpation is performed from the sustentaculum tali forwards in the direction of the
os naviculare (navicular bone), the anterior edge of the caput tali (head of the talus)
can often be palpated at a dip.
This edge can be better felt when the foot is passively pronated, and in so doing the
os naviculare of the caput tali is moved.
Os naviculare (navicular bone)
On the medial side of the foot at the os naviculare, there is a node to be palpated, the
tuberositas ossis navicularis (projection on the navicular bone).

ONLINE TRAINING

Module 1 Session 2 __ 13/25

If the investigator is in doubt (as to whether he/she is palpating the talus head), the
foot should be passively supinated.
During this movement the tuberositas ossis navicularis can be felt, while the caput tali
disappears because the os naviculare revolves around it.
Os cuneiforme mediale (medial cuneiform bone)
Distal of the os naviculare, the medial part of the os cuneiforme mediale can be
palpated, and the dorsal side of this bone piece can also be felt.
Os metatarsale I (first metatarsal)
The first metatarsal can be palpated along its entire length on its medial (and dorsal)
side, from the base to the head.
Art. metatarsophalangele I (joint between the first metatarsal and the base
phalanx of the big toe or hallux)
The joint space between first phalanx and first metatarsal can be palpated, both on
the medial and dorsal side. Its principal deformity is hallux abductus valgus.

LATERAL
Fibula (calf bone)
The distal end of the fibula looks like a node, the malleolus lateralis; which is more
fallen than the malleolus medialis.
When palpating the foot should be moved passively in the ankle joint, so as to
properly feel the boundaries with the talus.
Calcaneus (heel bone)
The lateral part of the tuber calcanei can be palpated.
About 1.5 cm under the malleolus lateralis and situated a little more to anterior than
the point of the malleolus there is a lateral thickening on the calcaneus, between the
tendons of the mm. perone, called the trochlea peronealis.
Sinus tarsi (groove between talus and heel bone)
This is the groove between talus and calcaneus, in which the inferior talus joint can be
partially palpated.
The lateral opening of the groove can be inspected as the space between the lateral
tendon of the m. extensor digitorum longus and the malleolus lateralis.
Os cuboideum (cuboid bone)
The lower edge of the cuboid bone can usually be palpated.
It feels like an indentation, directly proximal and mainly dorsal of the tuberositas
ossis metatarsalis V.
Tuberositas metatarsalis V (projection at the base of the fifth metatarsal)
If the lateral foot edge is palpated from the calcaneus forwards, approximately
halfway on the foot the finger bounces on an obvious node, which can usually be
inspected, the tuberositas metatarsalis V, the projection at the base of the fifth
metatarsal).

Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions

14/25 __ Module 1 Session 2

Os metatarsale V (fifth metatarsal)


The fifth metatarsal can be palpated along its entire length on its lateral (and dorsal)
side, from the base to the head.
Art. metatarsophalageale V (joint between the fifth metatarsal and the fifth
toe)
The joint space between the fifth metatarsal and the fifth toe can be palpated, both on
the lateral and dorsal side.

PLANTAR SIDE OF THE FOOT


Ossa sesamoidea (sesamoid bones)
At the caput ossis metatarsalis I there are usually two sesamoid bones in the tendon
of the m. flexor hallucis longus, that can be palpated.
The capita metatarsalia (metatarsal heads) can be palpated simultaneously from the
dorsal and plantar side.

FOOT ARTERIES
A. tibialis posterior (posterior tibial artery)
The pulsation of this artery can usually be felt behind the medial malleolus.
A. dorsalis pedis (dorsal artery of foot)
The dorsal artery of the foot can be palpated between the medial tendon of the m.
extensor digitorum longus and the m. extensor hallucis longus.
This artery becomes the foot arch artery in the middle of the foot.

5. LOCOMOTIVE AND MUSCULAR STRENGTH EXAMINATION OF


THE LOWER EXTREMITIES
Locomotive and muscular strength usually take place in the pedorthists practice while
the patient is sitting on a chair. This means that some tests can be more difficult to
interpret, because in order to conduct a proper test an examination table should be
used in most cases.
Where possible an indication is given as to the difference between using a chair or a
table during the examination.
In the case of locomotive and muscular strength examinations the investigator should
always compare left and right!

HIP JOINT
The following tests are discussed bellow:
Active movements:
Anteflexion

ONLINE TRAINING

Module 1 Session 2 __ 15/25

Retroflexion
Abduction
Adduction
Passive movements:
Anteflexion
Retroflexion
Endorotation
Exorotation
Abduction
Adduction
Muscular strength:
Anteflexion
Retroflexion
Abduction
Adduction

Hip anteflexion or flexion


Active movement
Ask the patient, lying on his back on an examination table, to pull up his leg as far as
possible. Lay one hand under the lumbar spine to check whether or not this moves as
well.
If this test is carried out on a chair (which is usually the case in the pedorthists
consultation room), remember that when interpreting the test the starting position is
90 anteflexion in the hip joint.
Always take into account the position of the pelvis and the lumbar spine, in order to
be able to better interpret the range of motion in the hip.
Passive movement
The investigator pushes the leg in anteflexion with one hand, while using the other to
check whether the lumbar spine moves as well.
The average range of motion is approx. 125. Remember that age plays an important
part in range of motion. The end feel during this passive movement is soft.
If the passive locomotive test is performed on a chair, the investigator should not
forget to check the position of the pelvis and lumbar spine while he is anteflexing the
hip joint.
Muscular strength
If the patient, while lying on his back, actively anteflexes his hip joint, this implies
muscular strength 3 (moving against gravity). The investigator can apply counter
pressure to determine whether there is muscular strength 5 in anteflexion direction.

Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions

16/25 __ Module 1 Session 2

If the patient is sitting while the muscular strength is being tested in anteflexion
direction, remember that this starting position is not good for the m. iliopsoas. (Figure
3. )

Figure 3. Investigator applies counter pressure hip retroflexion

Hip retroflexion or extension


Active movement
While lying on his stomach on the examination table, the patient should retroflex his
outstretched leg. The investigator should also check that the pelvis remains in contact
with the examination table.
If there is no examination table, the active locomotive examination can be carried out
while the patient is standing.
The patient should bring the outstretched leg backwards as far as possible, while
standing upright. Remember that this movement is not against gravity now, so if this
movement can be made, it does not indicate muscular strength 3.
The investigator should check that pelvis and trunk do not move as well.
Passive movement
The investigator moves the outstretched leg up away from the examination table.
While standing a passive movement is difficult to perform.
The average passive range of motion is approx. 15. The end feel is capsular.
Muscular strength
The investigator applies counter pressure to the retroflexed leg, if the patient is lying
on his stomach on the examination table.
If the investigator wants to perform the test, in particular for the m. gluteus maximus,
the patient should bend the leg at the knee and only then retroflex the upper leg. This
way the hamstrings work only slightly along with the retroflexion movement.
It is difficult to perform a muscular strength test in retroflexion direction while the
patient is standing.

ONLINE TRAINING

Module 1 Session 2 __ 17/25

If the patient is sitting on a chair, the investigator should ask him to anteflex slightly
in the leg with bent knee, whereafter the upper leg should be pushed forcefully
downwards while the investigator is applying counter pressure.
Remember that it can be difficult to interpret muscular strength because the
movement is done with gravity.

Hip abduction
Active movement
The patient can move the outstretched leg entirely outwards while lying on his back on
the examination table. The trunk and pelvis should not move.
The investigator must ensure that there is no accompanying movement of the pelvis
and trunk. The patient can also be asked to simultaneously move both extended legs
outwards.
If the patient is sitting on a chair, both legs can be simultaneously moved outwards.
Remember that in both situations movement is not against gravity, therefore these
are not tests for determining minimum muscular strength 3.
If the patient is sitting on a chair, the ligaments of the hip joints are more relaxed and
can therefore be abducted a little more compared to when the test is performed on an
examination table.
Passive movement
The investigator can simultaneously abduct both hip joints while the patient is on the
table or on a chair.
Passively there will be average 40 abduction when lying on the examination table.
This will probably be slightly more on in a chair. The end feel is capsular-muscular.
Muscular strength
The investigator applies counter pressure distal to the exterior of the upper legs if the
legs are partially abducted.
This test can be performed while the patient is lying on a table or sitting on a chair
(Figure 4. ).

Figure 4. Pressure distal to the exterior of the upper legs

Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions

18/25 __ Module 1 Session 2

The test for determining the presence of muscular strength 3 and higher is done when
the patient is lying on his side on an examination table and then tries to abduct the
outstretched leg. This is actually a movement against gravity.
To determine whether muscular strength is 4 or 5, the investigator can now apply
counter pressure to the distal exterior of the upper leg, while the patient applies force.

Hip adduction
Active movement
Ask the patient, while he/she is lying on his back, to adduct the leg entirely, while the
investigator moves the other leg high off the examination table, in order to allow
sufficient room for the adduction movement.
This can also be done when a patient is seated, except that the hip joints are standing
at 90, which might allow for greater movement.
Passive movement
The investigator brings the leg into adduction, while the other leg is placed bent over
the leg to be tested.
The leg can be moved passively approximately 25. The end feel is capsular-muscular.
Muscular strength
If the patient is lying on an examination table or sitting on a chair, he/she should be
asked to move the upper legs together simultaneously from a neutral position (0
adduction), while the investigator applies counter pressure to the distal interior of the
upper legs (Figure 5).

Figure 5. Move the upper legs together simultaneously

Hip endo- and exorotation


Passive movements
These passive movements can be tested if the patient is sitting on a chair. The
investigator moves the lower leg, with knee bent, outwards for testing the
endorotation and inwards for testing the exorotation in the hip joint.
The investigator should also check that there are no simultaneous movements at the
knee, of the pelvis and/or trunk.
The passive exorotation is slightly more than the passive endorotation.

ONLINE TRAINING

Module 1 Session 2 __ 19/25

Exorotation is on average approximately 50 and endorotation approximately 40.


The end feel is capsular.

KNEE JOINT
The following tests are discussed bellow:
Active movements:
Flexion
Extension
Passive movements:
Flexion
Extension
Muscular strength:
Flexion
Extension
Knee flexion
Active movement
When the patient is lying on the examination table on his stomach, he is asked to
bend the leg completely at the knee.
If the test is performed on a chair, the patient can be asked to bend the lower leg
under the chair.
Passive movement
While the patient is lying on his back on the examination table, the leg can be entirely
bent at the knee by the investigator. The end feel is soft and the range is about 130.
While the patient is sitting on a chair, the investigator can bend the leg completely
under the chair.
The chair must however be high enough and the patient should sit forward a little on
the seat.
Muscular strength
If the patient is lying on his stomach, he can be asked to bend the knee from a flexion
position of a little more than 90. The investigator also holds the upper leg firm with
one hand (on the posterior side) and uses the other hand to apply counter pressure to
the distal posterior side of the lower leg.
On a chair the patient can be asked to bend the knee further under the chair from a
flexion position of a little more than 90. The investigator puts pressure on the distal
end of the upper lower limb with one hand, to hold it in place, while the other hand
applies counter pressure to the distal posterior side of the lower leg.

Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions

20/25 __ Module 1 Session 2

Knee extension
Active movement
The patient is seated and is asked to extend the leg fully.
This also indicates a minimum muscular strength 3 if it can be done (Figure 6. ).

Figure 6. Extend the leg

Passive movement
When the patient is sitting down, or lying on his back, the investigator fully extends
the knee.
The end feel is hard.
Muscular strength
Lying on his stomach on an examination table the patient can be asked to extend the
knee with the knee joint at a little more than 90 flexion.
The investigator holds the hollow of the knee on the table with one hand and applies
counter pressure to the distal front side of the lower leg with the other hand.
On a chair the knee is held in approximately 135 extension starting position. The
patient is asked to extend his knee, while the investigator supports the hollow of the
knee with one hand and uses the other hand to apply counter pressure to the distal
front side of the lower leg (Figure 7. ).

Figure 7. Pressure to the distal front side of the lower leg

ONLINE TRAINING

Module 1 Session 2 __ 21/25

ANKLE JOINT
The following tests are discussed bellow:
Active movements:
Dorsiflexion
Plantar flexion
Passive movements:
Dorsiflexion
Plantar flexion
Muscular strength:
Dorsiflexion
Plantar flexion

Dorsiflexion of the foot


Active movement
The patient moves the foot upwards; this can be done unloaded with bent or extended
knee.
With extended knee the range of motion will be less, due to the greater tension on the
calf musculature.
Active dorsiflexion can also be tested under load, by asking the patient to stand on his
heels.
Passive movement
The investigator pushes the foot in dorsiflexion on the plantar side of the
tarsus/metatarsus. The other hand must be also stabilised the calcaneus on the dorsal
side, to prevent a tipping motion of the calcaneus in the F-plane (Figure 8. ).

Figure 8. Move the foot in dorsiflexion

This test can be done with a bent as well as an extended knee.


The test with the extended knee also provides information about the effect of the calf
musculature on the extent of dorsiflexion of the ankle joint. If the patient cannot do a

Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions

22/25 __ Module 1 Session 2

foot flexion with extended knee, but he can do this movement with flexion knee, it
shows a calf shortening.
Muscular strength
The patient, sitting on a chair or examination table, moves the foot upwards, and the
investigator lays his hand on the dorsum of the foot and applies counter pressure.
Plantar flexion of the foot
Active movement
The patient moves the foot downwards while sitting on a chair or examination table.
The movement can also be investigated under load, by asking the patient to stand 'on
tiptoe' (ball of the foot). In so doing the muscular strength can also be examined.
Passive movement
The investigator moves the foot downwards by applying pressure to the dorsum of the
foot, while the heel bone is stabilised in the F- plane.
Muscular strength
The patient moves the foot downwards while sitting on a chair or examination table.
The investigator applies counter pressure on the plantar side of tarsus/metatarsus.
The patient can also be asked to stand on tiptoe.

FOOT
The following tests are discussed bellow:
Active movements:
Supination
Pronation
Passive movements:
Supination
Pronation
Muscular strength:
Supination
Pronation

Supination of the foot


Active movements
The patient, while sitting on a chair or examination table, is asked to turn the foot
inwards. This is usually a difficult movement for the patient and it is therefore useful if
the investigator can demonstrate the move or guide the patient.
Passive movement

ONLINE TRAINING

Module 1 Session 2 __ 23/25

The patient tips the foot inwards. By separately stabilising calcaneus or metatarsus if
possible, the investigator can passively investigate the supination movement
possibilities of the foot on various levels.
Muscular strength
Once the patient has supinated the foot, the investigator applies counter pressure in
the direction of the pronation from the medio-dorsal side of the foot (Figure 9. ) while
the other hand supports the heel.

Figure 9. Move in supinated the foot

Pronation of the foot


Active movements
The patient, while sitting on a chair or examination table, is asked to turn the foot
outwards. This is usually a difficult movement for the patient and it is therefore useful
if the investigator can demonstrate the movement or guide the patient.
Passive movement
The patient tips the foot outwards. By separately stabilising calcaneus or metatarsus if
possible, the investigator can passively investigate the pronation movement
possibilities of the foot on various levels.
Muscular strength
Once the patient has pronated the foot, the investigator applies counter pressure from
the latero-dorsal side of the foot in the direction of supination.
The other hand supports the heel.

TOES
The following tests are discussed:
Active movements:
Extension (dorsiflexion)
Flexion (plantar flexion)
Passive movements:

Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions

24/25 __ Module 1 Session 2

Extension (dorsiflexion)
Flexion (plantar flexion)
Muscular strength:
Extension (dorsiflexion)
Flexion (plantar flexion)

Extension (dorsiflexion) of the toes


Active movement
The patient is asked to extend his toes, unloaded.
Passive movement
The investigator extends the toes while the patient is seated, to check whether there
are any rigid toes.
The investigator also extends the toes separately while the patient is standing, to
check whether there is any functional rigidity. When the hallux cannot do extension it
is called hallux limitus or rigidus (it depends on the pathology phase). (Figure 10. ).

Figure 10. Extend the toes

Muscular strength
When the patient extends his toes, the investigator applies counter pressure.

Flexion (plantar flexion) of the toes


Active movement
The patient is asked to bend his toes, unloaded.
Passive movement
The investigator bends the toes, while the patient is seated.
Muscular strength
When the patient bends his toes, the investigator applies counter pressure.

ONLINE TRAINING

Module 1 Session 2 __ 25/25

SUMMARY OF RANGE OF MOVEMENTS


Following table summarizes the normal range of movements of the different joints.
Values out of these ranges will be considered as pathologic.

JOINT

MOVEMENT

RANGE OF MOVEMENT

FLEXION OR ANTEFLEXION

125

EXTENSION OR RETROFLEXION

15

ABDUCTION

40

ADUCTION

25

ENDOROTATION

40

EXOROTATION

50

HIP

FLEXION

130

EXTENSION

180

KNEE

FLEXION OR DORSAL FLEXION

10-15

EXTENSION OR PLANTAR FLEXION

40-70

ANKLE
SUPINATION

20

PRONATION

10

FLEXION

45

EXTENSION

20

FIRST TOE

BIBLIOGRAPHY
NVOS-Orthobanda. ORTHOPEDISCHE
Uitgeverij De Dienst (2002)

SCHOENTECHNIEK.

Boek

2:

Orthopedie.

Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions