1. Hip flexion Muscles: Iliopsoas (psoas major + iliacus)

Transcription

1 Chap. 5 Testing the muscles of the Lower Extremity Part I. Manual Muscle Testing of the hip joint muscles 1. Hip flexion Muscles: Iliopsoas (psoas major + iliacus) Rectus femoris Sartorius Tensor fascia latae Pectineus Adductor brevis Adductor longus Addictpr magmis Gluteus medius(ant.fiber) Starting position: Short sitting Legs are off the plinth (G345). Substitution by sartorius: abduction with ext. rotation Substitution by tensor fascia latae: abduction with internal rotation G2: Lying on non-test side upper limb supported by PT PT stands behind of the pt. Resistance: distal thigh. Downward direction 1

2 Verbal command: Lift your leg off the table (against me) and don t let me push it down (G4 and G5) Lift your leg straight up off the table. (G3) Bring your knee up toward your chest. (GI,G2 or alternative method in supine position) 2. Hip flexion, abduction and external rotation with knee flexion Muscle: Sartorius Substitution by rectus femoris muscles ; Pure hip flexion without external rotation and abduction of hip Short sitting with legs off the table (G345) Supine (G2): caution! Supine is not 100% gravity eliminated position for sartorius Resistance: Hand at knee: Antero-lateral aspect of distal thigh (to prevent hip flexion and external rotation: down and inward direction) Hand at ankle: posterior aspect of ankle (to prevent hip external rotation and knee flexion: up and outward direction) Verbal command: Slide your right heel up the shin of your left leg against me. Don t let me straighten your leg. (G4 and G5) Slide your right heel up the shin of your left leg. (G3) slide your right heel up to your left knee (along with your left shin). (G2) 2

3 3. Hip extension Muscles: Gluteus maximus, semitendinosus, semitensinosus, biceps femoris long head Starting position: prone(g345). Side lying(g2) Verbal commands Lift your leg off the table as high as you can against me without bending your knee. (G45) Lift your leg off the table as high as you can without bending your knee. (G3) Bring your leg back toward me. (G2) Possible substitution: trunk extension Gluteus maximus isolated test Starting position(g345): Knee flexed prone position. Starting position(g2): Knee flexed side lying position. Test for patient with hip flexor muscle tightness (when pt. can not be in prone with hip neutral) Standing with the trunk flexed and thorax resting on the plinth. Hug the plinth. Not testing leg: closed to the table( hip and knee flexion) Testing leg: less hip flexion with extended knee Verbal command: Lift your foot off the floor as high as you can 3

4 3. Hip abduction Alternative test for hip extensor muscle strength in supine (for patient with prone contraindication) READ TEXTBOOK for details Press your leg down to the table. Do not let me lift you leg from the table. Keep your hip locked tight and your whole body rigid as a board Muscles: Gluteus medius, gluteus minimus Accessory muscles: gluteus maximus and tensor fascia latae PT stand behind the patient at the level of pelvis Starting position: side lying (testing leg up) Verbal commands Lift your leg up toward the ceiling. Hold it against me. Do not let me push it down (sidelying:g45) Verbal commands Lift your leg up toward the ceiling.. (sidelyingg3) 4. Hip abduction from flexed position Muscles: tensor fascia latae Accessory muscles: gluteus medius and minimus Starting position: side lying (testing leg up) testing hip flexed (20-45 ) Verbal commands Bring your leg out to the side. Keep your knee cap pointing to the ceiling (supine:g2) 4

5 Trendelenberg test Clinical test of hip abductor weakness G2: long sitting in semi reclined position with hands placed behind body on the table (hip flexion ) G1:palpation on the insertion of the tensor fascia later (on the iliotibial band) Gluteus medius of stance leg function to maintain a level pelvis during one leg standing. Standing leg abductor prevent the pelvis drop toward the swing leg. Trendelenberg positive sign (weak abductor): on one leg standing, pt s PSIS are not level (drop to unsupported leg), and compensatory trunk flexion to the standing leg. Trendelenberg negative sign (no abductor weakness): during one leg standing, pt s PSIS are level. 5. Hip adduction Starting position: -Side lying on the testing leg (test leg down) -Non testing leg: Daniel( 25 abduction); Clackson s (45 abduction) supported by PT s forearm and hand. -PT stands behind of the patient at knee level. Resistance on the medial aspect of the testing knee. (downward direction to prevent adduction) Muscles: adductor longus, adductor brevis, adductor magnus, pectineus, and gracilis End position: until the testing (lower) leg contacts the non testing (upper) leg. Verbal commands (G4,5): lift your bottom leg up to your top one. Hold it. Don t let me push it down. 5

6 Verbal commands (G3): lift your bottom leg up to your top one. Verbal commands (G2): Bring (pull) your left leg in toward the right leg. G2: starting position: supine with non-testing leg abduction. Support the testing leg and elevate slightly to decrease friction. G1: palpation on the adductor mass on the proximal medial thigh 6. Hip external rotation Muscles: Priformis Obturator externus Obturator internus Quadratus femoris* Gemellus superior* Gemellus inferior Gluteus maxius Starting position: Short sitting with legs off table. Hands are placed flat or fisted at sides (to support trunk) PT position: sit on a low stool beside of the testing leg. Resistance: Ankle: grasp the ankle just above the medial malleolus (outward direction Lateral aspect of knee: counter force on the lateral aspect of knee (inward direction) Substitutions: Hip flexion and abduction; ipsilateral trunk side flexion Verbal commands (G3): Bring your foot in and upward, and turn your knee outward. Grade 2 Starting position: supine with testing hip in partial internal rotation Verbal commands (G2): Roll (turn) your leg out Verbal commands (G4,5): Bring your foot in and upward. Don t let me turn your leg out. Demonstration and passive guide of this motion 6

7 7. Hip internal rotation Starting position: Short sitting with legs off table. Hands are placed flat or fisted at sides (to support trunk) PT position: sit on a low stool in front of the patient. Resistance: Ankle: grasp the ankle just above the lateral malleolus inward direction (apply resistance on the lateral side of ankle) Medial aspect of knee: counter force on the medial aspect of knee (outward direction) Muscles: Gluteus minimus (anterior fiber) Tensor fascia latae Gluteus medius Substitutions: pelvic elevation, contra lateral trunk side flexion, and hip adduction Verbal commands (G4,5): Bring your foot out and upward. Don t let me turn your leg in. Demonstration and passive guide of this motion Verbal commands (G3): Bring your foot out and upward, and turn your knee inward. Grade 2 Starting position: supine with testing hip in partial external rotation Verbal commands (G2): Roll (turn) your leg in Part II. MMT of the KNEE muslecs 7

8 1. Knee flexion Muscles: Biceps femoris Semimebranosus Semitendinosus Accessory muscles of knee flexion Gracilis Tensor fasciae latae Sartorius Popliteus Gastrocnemius Plantaris Starting position for 3,4,5: Prone in hip and knee in anatomical position (hip neutral and knee 0, hip and tibial neural rotation) Stabilization: on the hamstring Resistance: Post. Ankle (into extension direction) Verbal command(g4,5): Bend your knee(as hard as you can) against me. Hold it. Do not let me straighten your knee. Verbal command(g3): Bend your knee Verbal command for starting position: Please pointing your heel toward me and toe away from me. Verbal command for movement: Please bend your knee against me. 1.1.Medial hamstring MMT (Semimembranosus and Semitendinosus) Starting positions: Medial tibial rotation (usually combined with hip internal rotation) Direction of movement: toward the medial side of the ipsilateral buttock Resistance direction: extension and external rotation (Down and out) 8

9 1.2. Lateral hamstring MMT (Biceps femoris) Verbal command for starting position: Please pointing your toes toward me and heel away from me. Verbal command for movement: Please bend your knee against me. Starting potions: Lateral tibial rotation (usually combined with hip external rotation) Direction of movement: toward the lateral side of the ipsilateral buttock Resistance direction: extension and medial rotation (Down and in) 2. Knee Extension Prime Muscles: Rectus femoris Vastus intermedius Vastus lateralis Vastus medialis Longus Oblique Accessory Muscle: Tensor fascia lata Starting position: short sitting PT s proximal hand: support under the knee. (place a roll of towel under the knee) Resistance: ant. ankle ( flexion direction) Verbal command: Straighten your knee as hard as you can. Grade 2: side lying with testing leg supported (top), Lower leg is flexed for stability. Testing leg hip in neutral hip extension with knee 90 degree flexion Verbal command: straighten your knee, Grade 1: supine Verbal command: pull your knee cap toward your nose. or push your knee down onto the bed. 9

10 1. Ankle Plantar Flexion Part III. MMT of the Ankle and Foot Muscles Prime Muscles Gastrocnemius (medial & lateral heads) Soleus Accessory muscles Tibialis posterior Plantaris Peroneus longus Peroneus brevis Flexor digitorum longus Flexor hallucis longus Ankle Plantar Flexion 1. Prone test (Gastrocnemius + Soleus) 2. Prone test (Soleus only) 3. Standing test (Gastrocnemius + Soleus) 4. Standing test (Soleus only) 1. Prone test (Non Weigh Bearing test: Gastrocnemius + Soleus) Starting position: prone with the knee extension and feet are over the edge of the table. Testing ankle is dorsiflexed. Verbal command: Bring your sole up toward the ceiling (G3). Push your sole up against me toward the ceiling (G4,5). 10

11 Stabilization: at ankle Resistance (G5,4) : downward direction Clarkson s text book :on the posterior aspect of the calcaneus (not easy) Daniel s text book: against the plantar surface at the level of the metatarsal heads. 2. Prone test (Soleus) Starting position: Prone with the knee in 90 flexion (Gastrocnemius is in slacked position). Testing ankle is dorsiflexed. Stabilization: at ankle Verbal command: Point your toes up toward the ceiling (G3). Push your sole up against me toward the ceiling (G4,5). Resistance: Clarkson s text book :on the posterior aspect of the calcaneus (not easy) Daniel s text book: against the plantar surface at the level of the metatarsal heads G2 (gravity eliminated) for gastrocnemius and soleus Side lying with the knee extended G2 (gravity eliminated) for soleus Side lying with the 90 knee flexion 11

12 3. Standing test (Gastrocnemius + Soleus) Standing on the testing leg with knee extension To assist balance provide parallel bar, table, or hand support by PT. Do not allow weight bearing through these supports Verbal command: Stand on your right (or left) leg. And try to go up on your tiptoes. Lift your heel off the floor, and stand on your tiptoes. Now, bring your heel down. And repeat 6 times. Grading Clarkson s text book G5:more than 6 repetitions G4: 3-5 repetitions G3:maintaining the heel off the floor through 1 or 2 repetitions (decreased range) Daniel s text book G5:more than 20 repetitions G4: repetitions G3:1-9 repetitions (full range) G2+: just able to heel off floor but unable to stand on tiptoes Regardless of any resistance in a non-standing position for any reason, the patient must be given a grade of less than Standing test (Soleus) Procedures are same to standing test for both gastrocnemius and soleus except the starting position. Starting position; one leg standing on testing leg with slight knee flexion. 2. Ankle Dorsiflexion and Inversion Prime Muscle Tibialis anterior Accessory muscles Peroneus tertius Extensor digitorum longus Extensor hallucis longus 12

13 Starting position: Short sitting (or supine) with ankle plantar flexion. PT position: sitting and patient s heel resting on the therapist s thigh. Verbal command: Bring your foot up and in against me. Don t let me push your foot down. Resistance: On dorsomedial aspect of the foot. Down and out direction G2: Sitting (partial range) Side lying (full range) Palpation: anteromedial aspect of ankle (above the medial maleolus), Medial to the anterior border of the tibia. 3. Foot Inversion Prime Muscle: Tibialis posterior Accessory muscles: Tibialis anterior Flexor digitorum longus Flexor hallucis longus Soleus Extensor hallucis longus Starting position: Either in short sitting on a testing table or in side lying. Tibialis posterior function is mixed motion (inversion with some plantar flexion). Therefore, it is not easy to get a true gravity eliminated or a gravity against position for the tibialis posterior.) 13

14 Verbal command: Turn your foot down and in. Resistance: on the dorsomedial side of the foot at the level of the metatarsal head. Toward eversion (out) and slight dorsiflexion (up) direction. Palpation of tibialis posterior tendon: between the medial malleolus and navicular bone Substitution by flexor digitorum longus and/or flexor hallucis longus: Toe flexion. Therefore, toes should be relaxed during the inversion MMT. Prime muscles Peroneus longus Peroneus brevis Accessory muscles Peroneus tertius extensor digitorum longus 4. Foot Eversion (with plantar flexion) Starting position: Either in short sitting on a testing table or in side lying. Verbal command: Turn your foot out. Resistance: on the dorsolateral side of the foot at the level of the metatarsal head. Toward inversion (out) direction. 14

15 Please self-study toe muscle MMT in your text book. 15