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Pelvis tilted

Pelvis level

Hip joints neutral Right hip joint adducted high on right

Left hip joint abducted Right hip joint adducted Left hip joint abducted

Lateral rotation and medial rotation are movements about a longitudinal axis. Medial rotation is movement in which the anterior surface of the thigh turns toward the midsagittal plane. Lateral rotation is movement in which the anterior surface of the thigh moves away from the midsagittal plane. Rotation also may result from movement of the trunk on the femur. For example, when standing with die legs fixed, a counterclockwise rotation of the pelvis will result in a lateral rotation of the right hip joint and a medial rotation of the left.

HIP ADDUCTION: RANGE OF MOTION

GONIOMETER

Equipment: Protractor and caliper. The caliper consists of two long arms held together with a setscrew (2).

Starting Position: Supine, with the pelvis in a neutral position, like the anatomical position in standing. Place the left leg in a neutral position and the right leg in enough abduction to allow adduction of the left leg. The stationary arm is held firmly against the inferior surface of the anterior and superior iliac spines by the subject, as illustrated. The movable arm is set at a 90° angle (as the zero position) and placed in line with midline of the extremity. Alternatively, the movable arm may be set at an angle that coincides with the axis of the femur (i.e., some adduction), in which case a reading is taken before moving the leg into adduction and the number of degrees are then subtracted from the number measured at the completion of adduction.

Test: The movable arm of the caliper is held in line with the thigh as the left leg is passively and slowly moved into adduction without any rotation. At the moment the pelvis starts to move downward on the side of the ad-ducted leg, the movement of the leg in adduction is stopped, and the set-screw is tightened. The caliper is then transferred to the protractor for a reading.

Normal Range of Motion: Random testing has disclosed that adduction is often less than 10° and seldom more than 10° in the supine position unless the hip joint is in flexion by virtue of anterior pelvic tilt. (With the hip joint flexed, as in sitting, the range of adduction is about 20°.) With the thigh maintained in the coronal plane, as in the modified Ober test (see p. 392), 10° of adduction should be considered as normal.

JOINT MEASUREMENT CHART

Name Identification #.

Diagnosis Age

Onset Doctor.

I£WJR EXIEiMnY

Date

Motion*

Average Range

Date

!

Examiner

Examiner

Left Hip

Extension

10 125 135

Flexion

Range

55

Right Hip

-

Adduction

Range

Lateral Rotation

Ol Ol

Medial Rotation

Range

90

Left Knee

Extension

140

Right Knee

Flexion

Range

Left Ankle

Plantar Flexion

45 20

Right Ankle

Dorsillexion

Range

85

Foot

Inversion

Foot

Eversion

Range

60

•Use either anatomical or geometric basis for measurement. 180" is the plane of reference for the geometric basis of measurement. The zero pcston is the plane of reference for all the others. When a part moves in the direction of zero but fails to reach the zero position, the degrees designating the joint motion obtained are recorded with a minus sign and subtracted in computing the range of motion.

Notes:

| If muscle length is excessive, avoid stretching exercises and postural positions that maintain elongation of the already stretched muscles. Work to correct the faulty posture. Because the stretched muscles are usually weak, strengthening exercises are indicated. However, for active individuals, strength may improve simply through avoidance of overstretching.

Supports are indicated to prevent excessive range if the problem cannot be controlled through positioning and corrective exercise. For example, marked knee hyperextension, if unavoidable in weight bearing, should be prevented by an appropriate support to allow the posterior knee joint ligaments and muscles to shorten.

A low back that is excessively flexible will be stretched further if sitting in a "slumped" position, but it usually will not be stretched in the standing position. (See figures, p. 377.) Proper positioning and support by chairs may be adequate to prevent further stretching. However, the lack of proper support from many chairs and car seats requires the wearing of a back support with metal stays (see p. 226) when excessive flexion cannot be avoided and, particularly, if a painful condition has developed.

When muscle shortness exists and stretching exercises are indicated, they must be done with precision to insure that the tight muscles are the ones that are actually being stretched and to avoid adverse effects on other parts of the body.

TESTS FOR LENGTH OF ANKLE PLANTAR FLEXORS

ONE-JOINT PLANTAR FLEXORS

Soleus and Pophteus:

Action: Ankle plantar flexion

Length Test: Ankle dorsiflexion, with the knee in flexion.

Starting Position: Sitting or supine, with the hip and knee flexed.

Test Movement: With the knee flexed 90° or more to make the two-joint gastrocnemius and plantaris slack over the knee joint, dorsiflex the foot.

Normal Range: The foot can be dorsi flexed approximately 20°.

TWO-JOINT PLANTAR FLEXORS Gastrocnemius and Plantaris

Action: Ankle plantar flexion and knee flexion.

Length Test: Ankle dorsiflexion and knee extension.

Starting Position: Supine or sitting, with the knees extended unless hamstring tightness causes the knee to flex.

Test Movement: With the knee in extension to elongate the gastrocnemius and plantaris over the knee joint, dor-siflex the foot.

Normal Range: With the knee fully extended, the foot can be dorsiflexed approximately 10°.

Sit forward in a chair with knees bent and feet pulled back toward chair enough to raise the heels slightly from the floor. Press down on thigh to help force heel to the floor.

Stand erect on board inclined at a 10° angle, with feet in approximately 8° to 10° of out-toeing.

The psoas major, iliacus, pectineus, adductors longus and brevis, rectus femoris, tensor fasciae latae, and sar-torius compose the hip flexor group of muscles. The il-iacus, pectineus, and adductor longus and brevis are one-joint muscles. The psoas major and the iliacus (as the iliopsoas) act essentially as a one-joint muscle. The rectus femoris, tensor fasciae latae, and sartorius are two-joint muscles, crossing the knee joint as well as the hip joint. All three muscles flex the hip. However, the rectus femoris and, to some extent, the tensor extend the knee, whereas the sartorius flexes the knee.

The test for hip flexor length is often referred to as the Thomas test (see Glossary). Tests to distinguish between one-joint and two-joint hip flexor tightness were first described in Posture and Pain in 1952 (3).

Iliopsoas

Action: Hip flexion.

Length test: Hip extension, with the knee in extension. Rectus Femoris

Action: Hip flexion and knee extension Length test: Hip extension and knee flexion. Tensor Fasciae Latae

Action: Hip abduction, flexion, and internal rotation as well as knee extension.

Length test: See pp. 392-397.

Sartorius

Action: Hip flexion, abduction, and external rotation as well as knee flexion.

Length test: Hip extension, adduction, and internal rotation as well as knee extension. (See also p. 380.)

Equipment:

A table, with no soft padding, and stable so it will not tilt with the subject seated at one end. Goniometer and ruler. Chart for recording findings.

Starting Position: Seated at the end of the table, wth the thighs half off the table.* The examiner places ere hand behind the subject's back and the other hand under one knee, flexing the thigh toward the chest and giving assistance as the subject lies down. The subject then holds the thigh, pulling the knee toward the chest only enough to flatten the low back and sacrum on the table. {Do not bring both knees toward the chest, because that allows excessive posterior tilt, which results in apparent [not actual] hip flexor shortness; see facing page.)

Note: If testing for excessive hip flexor length, the hipjoint should be at the edge of the table, with the thigh off the table. (See pp. 379, 380.)

Test Movement: If the right knee is flexed toward the chest, the left thigh is allowed to drop toward the table, with the left knee flexed over the end of the table. Wih four muscles involved in the length test, variations occur that require interpretations as described on the following pages.

*The thighs are half off the table in sitting because the body posifbn shifts as the subject lies down and brings one knee toward the chest: The end position for the start of testing is with the other knee just a' the edge of the table so that the knee is free to flex and the thigh & full length on the table.

In Figure A, the pelvis is shown in neutral position, the lower back in a normal anterior curve, and the hip joint in zero position. Normal hip joint extension is considered to be approximately 10°.. Normal .length of hip flexors permits this range of motion in extension. The length may be demonstrated by moving the thigh in a posterior direction with the pelvis in a neutral position;

or by moving the pelvis in the direction of posterior tilt with the thigh in zero position.

In a subject with hip flexors of normal length, the low back will tend to flatten in the supine position. If the low back remains in a lordotic position. &' in Figure B, some hip flexor shortness usually 15 present.

CORRECT TEST

ERROR IN TESTING

The low back and sacrum are flat on the table. The thigh touches the table indicating normal length of the one-joint hip flexors. The angle of knee flexion indicates little or no tightness in the two-joint hip flexors. The photograph at the right shows an error in testing the same subject.

This subject has good postural alignment in standing. Examination of posture in standing does not, however, provide a clue regarding the extent of back flexibility in this subject.

This subject has excessive back flexibility (see figure, below right). When he pulls the knee too far toward the chest, the thigh comes up from the table, and the sacrum is no longer flat on the table. The result is that the one-joint hip flexors, which are normal in length, appear to be tight.

Excessive flexion of the low back is clearly demonstrated by the forward bending test, as illustrated above.

NORMAL LENGTH OF HIP FLEXORS

NORMAL LENGTH OF HIP FLEXORS

With the low back and sacrum flat on the table, the posterior thigh touches the table, and the knee passively flexes approximately 80°. In the figure above, the pelvis is shown in 10° of posterior tilt. This is equivalent to 10° of hip joint extension and, with the thigh touching the table, represents normal length of the one-joint hip flex ors. In addition, the knee flexion (about 80°) indicates that the rectus femoris is normal in length and that (he tensor fasciae latae probably is normal. To maintain the pelvis in posterior tilt with the low back and sacrum flat on the table, one thigh is held toward the chest while testing the length of the opposite hip flexors.

SHORTNESS OF BOTH ONE-JOINT AND TWO-JOINT HIP FLEXORS

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