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INDEX
1.
OBJECTIVES ........................................................................ 3
2.
3.
4.
5.
LOCOMOTIVE AND MUSCULAR STRENGTH EXAMINATION
OF THE LOWER EXTREMITIES ....................................................... 14
BIBLIOGRAPHY ........................................................................... 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
Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions
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
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.
Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions
ONLINE TRAINING
Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions
ONLINE TRAINING
Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions
ONLINE TRAINING
Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions
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
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
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.
HIP JOINT
The following tests are discussed bellow:
Active movements:
Anteflexion
ONLINE TRAINING
Retroflexion
Abduction
Adduction
Passive movements:
Anteflexion
Retroflexion
Endorotation
Exorotation
Abduction
Adduction
Muscular strength:
Anteflexion
Retroflexion
Abduction
Adduction
Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions
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. )
ONLINE TRAINING
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. ).
Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions
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).
ONLINE TRAINING
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
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. ).
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. ).
ONLINE TRAINING
ANKLE JOINT
The following tests are discussed bellow:
Active movements:
Dorsiflexion
Plantar flexion
Passive movements:
Dorsiflexion
Plantar flexion
Muscular strength:
Dorsiflexion
Plantar flexion
Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions
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
ONLINE TRAINING
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.
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
Extension (dorsiflexion)
Flexion (plantar flexion)
Muscular strength:
Extension (dorsiflexion)
Flexion (plantar flexion)
Muscular strength
When the patient extends his toes, the investigator applies counter pressure.
ONLINE TRAINING
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
10-15
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