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To test for tightness of the posterolateral iliotibial band, the hip is slightly flexed and medially rotated along with the adduction. Tightness of this band can be a factor in a straight-leg-raising test for hamstring length.

Three-fourths of the gluteus maximus inserts into the iliotibial band, but the fibers are oblique to the band and do not have the direct line of pull as does the tensor fasciae latae. Furthermore, the gluteus maximus is seldom tight.

OBER AND MODIFIED OBER TESTS

OBER TEST

Below is the description of the test (which Oner called "The Abduction Test") quoted directly from the 1937 article to provide the reader with the author's exact description: (5)

The Abduction Test

1. The patient lies on their side on a table, the shoulder and pelvis being perpendicular to the table.

2. The leg on which the patient is lying is flexed at the knee, and the hip is flexed and kept flexed to flatten the lumbar curve.

3. If the patient is on their left side, die examiner places their left hand over the patient's hip in the region of the trochanter to steady him.

4. The right leg is flexed to a right angle at the knee and is grasped just below the knee with die examiner's right hand, the leg and ankle being allowed to extend backward under this forearm and elbow.

5. The right thigh is abducted widely, then hyperextended in the abducted position, the lower part of the leg being kept level and care being taken to keep die hip joint in a neutral position as far as rotation is concerned.

6. The examiner slides his right hand backward along the leg until it grasps die ankle lightly but with enough tension to keep the hip from flexing.

7. The thigh is allowed to drop toward the table in this plane. (Caution: Do no bear down on the leg.) If the fascia lata and the iliotibial band are tight, the leg will remain more or less permanently abducted. If the hip is allowed to flex or internally rotate, the iliotibial band becomes relaxed and the leg falls from its own weight.

8. The same procedure for the opposite side is followed in every case.

MODIFIED OBER TEST

A modification of the Ober test was first recommended by the Kendalls in Posture and Pain (3). The reasons for modifying the test are valid, including less strain medially in the area of the knee joint, less tension on the patella, and less interference by a tight rectus femoris. Additionally, for a muscle with multiple actions, like the tensor fascia latae, it is not necessary to stretch in the reverse of all actions when testing for length.

Place the subject in a side-lying position, with the underneath leg flexed at the hip and knee to flatten the low back, thereby stabilizing the pelvis against anterior pelvic tilt. Anterior pelvic tilt is the equivalent of hip flexion and is to be avoided because it "gives in" to the tightness.

The pelvis must also be stabilized to prevent lateral pelvic tilt downward on the tested side. Downward lateral tilt is the equivalent of hip joint abduction, and such a movement of the pelvis would "give in" to a tight tensor. For most people, the lateral trunk will be in contact with the table in the side-lying position. People with wide hips and narrow waists will be the exceptions.

On the tested side, the examiner places one hand laterally on the subject's pelvis, just below the iliac crest, and pushes upward enough to stabilize the pelvis and keep the lateral trunk in contact with the table. The examiner does not externally rotate the thigh but, instead, keeps it from internally rotating and brings it back in extension. If the tensor is tight, it will be necessary to abduct the leg to bring it into extension. Keep the leg extended in line with the trunk (i.e., in the coronal plane), and allow the leg to drop in adduction toward the table.

Ober Test, Normal Length: With the knee maintained at a right angle, the thigh drops slightly below horizontal.

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In this figure, the pelvis is in neutral position, the hip is neutral between medial and lateral rotation, and the leg is in the coronal plane and allowed to drop in adduction. In this case, it drops 10° below the horizontal, which may be considered a normal length for the tensor fasciae latae.

BILATERAL TIGHTNESS OF TENSOR FASCIAE LATAE: POSITIVE OBER TEST

The range of motion in adduction may be considered as knee flexed 90°. This subject's thighs remain in marked normal if the thigh drops slightly below horizontal with abduction because of bilateral tightness of the tensor fas-the thigh in neutral rotation in the coronal plane and the ciae latae and iliotibial band.

BILATERAL TIGHTNESS OF TENSOR FASCIAE LATAE: MODIFIED OBER TEST (KNEE EXTENDED)

The range of motion in adduction may be considered as knee extended. In this test, this subject's legs do not drop normal if the leg drops 10° below the horizontal with the to the horizontal because of tightness in the tensor fasthigh in neutral rotation in the coronal plane and the ciae latae and iliotibial band.

ERRORS IN TESTING FOR TIGHTNESS OF TENSOR FASCIAE LATAE AND ILIOTIBIAL BAND

According to one reference, the leg, with the knee bent, is maneuvered into the correct Ober test position and then released(4). As seen in the photographs above, the hip internally rotates and flexes when not controlled by the examiner. The thigh must be kept in the coronal plane and prevented from internally rotating to test accurately for tightness of the tensor fasciae latae and ili-otibial band.

Equipment: Treatment table. If the table is not padded, place a folded towel or thin pillow at the end of the table as a cushion. For this test, a table that can be raised or lowered is preferable to accommodate for the height of the subject.* Adjust the height of the table as needed for the subject to be able to place both feet on the floor with the knees slightly bent.

Starting Position: The subject stands at the end of the table, in contact with the table, and bends forward to rest the trunk prone on the table. For the trunk to rest fully on the table, the knees are bent, and the feet are placed forward under the table as much as necessary. The subject extends both arms overhead and grasps the sides of the table.

Reasons: With the trunk prone, the lower back will be flat; keeping the arms fully extended overhead tends to prevent any lateral tilting of the pelvis. This prone posi

•Except for this test, treatment tables that have thick padding and are hinged in the middle are not suitable for length and strength tests of most hip joint muscles and trunk muscles.

tion meets the requirements of the Ober test and is mote stable than the side-lying position.

Test Movement: To test for length of the left tensor fasciae latae and the iliotibial band, the examiner stands in position to grasp, with the left arm, the subject's left thigh and lower leg, holding the knee bent at a right angle. With the right hand, the examiner holds the pelvis firmly down on the table. Keeping the knee bent, the examiner moves the leg to the completion of hip abduction and then upward in extension. Maintaining the hip joint at the completion of extension, the examiner then moves it in the direction of adduction. (Reverse the instructions for testing the subject's right leg.)

Normal Range of Motion: Moving the thigh to a position of zero adduction (i.e., comparable to horizontal in the side-lying position). (If the hip cannot be fully extended, there will be slightly more adduction.)

•Except for this test, treatment tables that have thick padding and are hinged in the middle are not suitable for length and strength tests of most hip joint muscles and trunk muscles.

A tight one joint muscle will limit the range of motion in the direction opposite its action. A muscle that crosses two or more joints may exhibit tightness at only one joint if the other joint (or joints) are maintained in a position of normal elongation of the muscle.

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Figure 1. The subject is supine with the legs abducted. The low back is flat on the table i.e., normal flexion of the low back. The pelvis is in posterior tilt, and the hip joint is extended. There is no apparent hip flexor shortness.

Figure 2. The legs are in neutral position, neither adducted nor abducted. The low back is no longer flat on the table, the pelvis is in anterior tilt. Because of the anterior pelvic tilt, the hip joint is in flexion.

Figure 3. The subject is kneeling with the knees flexed about 90°, and the thighs are abducted.The pelvis and femur are in good alignment. Figure 4. The subject is kneeling with the thighs in neutral position (neither abducted nor adducted). The alignment of the trunk has shifted forward,The low back extension (arching) has increased providing evidence of hip flexor tightness.

Conclusion: The tightness is in the muscle that both flexes and abducts the hip joint, namely the Tensor Fasciae Latae.

DIFFERENTIAL DIAGNOSIS

Flexion of the hip joint may be performed by flexion of the thigh toward the pelvis, or by anterior tilting of the pelvis toward the thigh. Hip flexors (*) consist of the following:

1. The one-joint iliopsoas that flexes the hip joint.

2. The two-joint rectus femoris that flexes the hip joint and extends the knee joint.

3. The two-joint tensor fasciae latae that flexes, abducts and internally rotates the hip joint, and assists in extension of the knee.

Hip Flexor Length Tests

Below and on the facing page, photographs show tests for differential diagnosis of hip flexor tightness. The same subject and the same examiner appear in the both sets of tests.

The subject is also the same person as on the preceding page. The right column on this and the facing page shows the results of the first examination; the left column includes the same tests about five years later.

Figure 2 a

Figures 1, a and b: Starting position for hip flexor length tests. The low back is flat on the table and maintained in that position by holding the right knee toward the chest as the left leg is tested. There is evidence of left hip flexor shortness by the fact that the thigh does not touch the table.

Figure 2 b

Figures 2, a and b: The leg has been moved into a position of hip joint abduction. The thigh now touches the table, providing evidence that there is no tightness in the iliopsoas muscle. The degree of knee flexion indicates that there is little or no tightness in the rectus femoris.

(*) The sartorius is omitted here because it acts to flex and externally rotate the hip joint and flex the knee joint.

Figure 4a Figure 4 b

Figures 3, a and b: The thigh has been maintained in contact with the table (to keep the iliopsoas at its normal length). The pelvis has been stabilized to prevent any lateral movement of the pelvis as the leg has been moved back (against a fair amount of resistance by the tensor) from the abducted position to zero position.

Figures 4, a and b: Normal length of the tensor fasciae latae will permit knee flexion along with the hip extension and adduction. There is undeniable evidence of tightness in the tensor fasciae latae as exhibited by the extended position of the knees, especially evident at the time of the first test.

Tightness or even contracture of the iliotibial band is frequently seen. The relationship to painful conditions is discussed in Section IV (see p. 449). The following discussion concerns exercises to stretch the tensor fasciae latae and the anterolateral iliotibial band.

The tensor fasciae latae abducts, flexes, and internally rotates the hip joint, and it assists in knee extension. When a muscle has multiple actions, it is not necessary to elongate the muscle in all the directions opposite its actions to stretch it. An exercise may only need to include two or three movements in the direction of stretching. Most of all, it is important that the stretching be specifically directed to the area in need of stretch. Some commonly prescribed exercises are not meeting this requirement.

Standing with the legs crossed puts the hip joints in adduction. However, in this position, the hips are usually in internal rotation and in some degree of flexion by virtue of the pelvis being tilted anteriorly. If, besides standing in a position of adduction, the person sways sideways, toward a wall or a table, the stretch will often affect the posterior gluteus medius more than the tensor fasciae latae.

the left side of the pelvis will be elevated, and the left hip joint will also be in adduction (but without swaying sideways).

To stretch a tight left tensor and anterior iliotibial band, stand with a board, book, or magazine under the left foot; the thickness of such a raise should be determined by the amount tolerated. Keep the weight on both feet, and keep the feet and knees (i.e., femurs) in good alignment (i.e., the feet out-toeing approximately 8° to 10° on each side and the patellae facing straight ahead). Then, attempt to tilt the pelvis posteriorly. This posterior pelvic tilt results in extension of the hip joint. The range of motion will be slight, but the stretch should be felt very specifically in the area of the left tensor fasciae latae. The tensor will be stretched by adduction and extension of the hip joint without allowing internal rotation. Additionally, the stretching can be done by removing the right shoe (if the heel is not too high) instead of putting a lift under the left foot.

For bilateral tightness, place the lift alternately under the left and right, or alternately remove one shoe, and hold the stretch position for a comfortable length of time (e.g., 1-2 minutes).

AVOID

Crossing the legs places the hip io'tnt in flexion (by anterior pelvic tilt) and in internal rotation.

Swaying sideways, with the hip internally rotated and flexed, stretches the gluteus medius more than the tensor fasciae latae.

Standing with a raise under the left foot places the left hip joint in adduction. Posterior pelvic tilt adds hip joint extension, providing a stretch on the left tensor fasciae latae and iliotibial band. The subject makes an effort to control rotation, keeping the patellae facing straight ahead. Standing with slight out-toeing of the feet also helps to control rotation.

Better control and more precision in stretching can be obtained by moving the pelvis in relation to the femur. To understand this mechanism, however, it is necessary to describe the effect of pelvic tilt on the hip joints.

When the legs are of equal length and the pelvis is level in standing, both hip joints are neutral as far as adduction and abduction are concerned. If the person sways sideways, however, the position of the hip joints change. Swaying toward the left results in adduction of the left hip joint. Likewise, if a lift is placed under the left foot.

When tightness is unilateral, a lift (1/4-inch heel pad) in the shoe on the side of tightness will passively stretch the tensor. Make sure this lift is worn in all shoes and bedroom slippers and that the person avoids any bad habit of standing on the opposite leg. A lift will not do any good unless the person stands with the weight distributed evenly over both feet. (For assisted stretching of a tight tensor fasciae latae, see p. 450, and for treatment of a stretched tensor fasciae latae, see pp. 450, 451.)

Adductor hallucis trans head oblique head

Adductor hallucis trans head oblique head

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ABDUCTOR HALLUCIS

Origin: Medial process of tuberosity of the calcaneus, flexor retinaculum, plantar aponeurosis, and adjacent intermuscular septum.

Insertion: Medial side of the base of the proximal phalanx of the great toe. Some fibers are attached to the medial sesamoid bone, and a tendinous slip may extend to the base of the proximal phalanx of the great toe.

Action: Abducts and assists in flexion of the metatar-sophalangeal joint of the great toe, and assists with adduction of the forefoot.

Patient: Supine or sitting.

Fixation: The examiner grips the heel firmly.

Test: If possible, abduction of the big toe from the axial line of the foot. This is difficult for the average individual, and the action may be demonstrated by having the patient pull the forefoot in adduction against pressure by the examiner.

Pressure: Against the medial side of the first metatarsal and proximal phalanx. The muscle can be palpated and often seen along the medial border of the foot.

Weakness: Allows forefoot valgus, hallux valgus, and medial displacement of the navicular.

Contracture: Pulls the foot into forefoot varus, with the big toe abducted.

ADDUCTOR HALLUCIS Origin:

Oblique head: From the bases of the second through fourth metatarsal bones and the sheath of the tendon of the peroneus longus.

Transverse head: From the plantar metatarsophalangeal ligaments of the third through fifth digits and the deep transverse metatarsal ligament.

Insertion: Lateral side of the base of the proximal phalanx of the great toe.

Action: Adducts and assists in flexing the metatar-sophalangeal joint of the great toe.

Contracture: Adduction deformity of the great toe (i.e., hallux valgus).

Note: No test illustrated.

FLEXOR HALLUCIS BREVIS

Origin: Medial part of the plantar surface of the cuboid bone, adjacent part of the lateral cuneiform bone, and from prolongation of the tendon of the tibialis posterior.

Insertion: Medial and lateral sides of the base of the proximal phalanx of the great toe.

Action: Flexes the metatarsophalangeal joint of the great toe.

Nerve: Tibial, LA, 5, SI. Patient: Supine or sitting.

Fixation: The examiner stabilizes the foot proximal to the metatarsophalangeal joint and maintains a neutral position of the foot and ankle. (Plantar flexion of the foot may cause restriction of the test movement by tension of the opposing long toe extensor muscles.)

Test: Flexion of the metatarsophalangeal joint of the great toe.

Pressure: Against the plantar surface of the proximal phalanx, in the direction of extension.

Nolo: When the flexor hallucis longus is paralyzed and the brevis is active, the action of the brevis is clear because the toe flexes at the metatarsophalangeal joint without any flexion ofthe interphalangealjoint. When the flexor hallucis brevis is paralyzed and the longus is active, the metatarsophalangeal joint hyperextends, and the interphalangeal joint flexes.

Weakness: Allows a hammer-toe position of the great toe, and lessens stability of the longitudinal arch.

Contracture: The proximal phalanx is held in flexion.

402 FLEXOR HALLUCIS LONGUS

FLEXOR HALLUCIS LONGUS

Origin: Posterior surface of the distal 2/j of the fibula, interosseous membrane, and adjacent intermuscular septa and fascia.

Insertion: Base of the distal phalanx of the great toe, plantar surface.

Not©: The flexor hallucis longus is connected to the flexor digitorum longus by a strong tendinous slip.

Action: Flexes the interphalangeal joint of the great toe, and assists in flexion of the metatarsophalangeal joint, plantar flexion of the ankle joint, and inversion of the foot.

Nerve: Tibial, L5, SI, 2. Patient: Supine or sitting.

Fixation: The examiner stabilizes the metatarsopha-langeal joint in a neutral position and maintains the ankle joint approximately midway between dorsal and plantar flexion. (Full dorsiflexion may produce passive flexion of the interphalangeal joint, and full plantar flexion would allow the muscle to shorten too much to exert its maximum force.) If the flexor hallucis bre-vis is very strong and the flexor hallucis longus weak, it is necessary to restrict the tendency for the metatar-sophalangeal joint to flex by holding the proximal phalanx in slight extension.

Test: Flexion of the interphalangeal joint of the great toe.

Pressure: Against the plantar surface of the distal phalanx, in the direction of extension.

Weakness: Results in a tendency toward hyperextension of the interphalangeal joint and hammer-toe deformity of the great toe. Decreases the strength of inversion of the foot and plantar flexion of the ankle. In weight bearing, permits a tendency toward pronation of the foot.

Contracture: Claw-toe deformity of the great toe.

EXTENSOR HALLUCIS LONGUS

Origin: Middle two quarters of the anterior surface of the fibula and adjacent interosseous membrane.

Insertion: Base of the distal phalanx of the great toe.

Action: Extends the metatarsophalangeal and interpha-langeal joints of the great toe, and assists in inversion of the foot and dorsiflexion of the ankle joint.

EXTENSOR HALLUCIS BREVIS (MEDIAL SLIP OF EXTENSOR DIGITORUM BREVIS)

Origin: Distal part of the superior and lateral surfaces of the calcaneus, lateral talocalcaneal ligament, and apex of inferior extensor retinaculum. (See p. 408.)

Insertion: Dorsal surface of the base of the proximal phalanx of the great toe.

Action: Extends the metatarsophalangeal joint of the great toe.

Patient: Supine or sitting.

Fixation: The examiner stabilizes the foot in slight plantar flexion.

Test: Extension of the metatarsophalangeal and inter-phalangeal joints of the great toe.

Pressure: Against the dorsal surface of the distal and proximal phalanges of the great toe in the direction of flexion.

Weakness: Decreases the ability to extend the great toe, and allows a position of flexion. The ability to dorsiflex the ankle joint is decreased.

Contracture: Extension of the great toe, with the head of the first metatarsal driven downward.

Note: Paralysis of the extensor hallucis brevis (first slip of the extensor digitorum brevis) cannot be determined accurately in the presence of a strong extensor hallucis longus. In paralysis of the extensor hallucis longus, however, the action of the extensor hallucis brevis is clear. The distal phalanx does not extend, and the proximal phalanx extends in the direction of adduction (i.e., toward the axial line of the foot).

Flexor digitorum longus

Lumbrical

Lumbricales

Dorsal interossei

Origin: Bases and medial sides of the bodies of the third through fifth metatarsal bones.

Insertion: Medial sides of the bases of the proximal phalanges of the same digit.

Flexor digitorum longus

Lumbrical

Lumbricales

LUMBRICALES (FOUR)

Origin:

First: From the medial side of the first flexor digitorum longus tendon. Second: From the adjacent sides of the first and second flexor digitorum longus tendons.

Third: From the adjacent sides of second and third flexor digitorum longus tendons.

Fourth: From the adjacent sides of third and fourth flexor digitorum longus tendons.

Insertions: Medial side of the proximal phalanx and dorsal expansion of the extensor digitorum longus tendon of the second through fifth digits.

Actions: Flexes the metatarsophalangeal joints, and assists in extending the interphalangeal joints of the second through fifth digits.

Nerve to Lumbricalis I: Tibial, LA, 5, SI.

Nerve to Lumbricales II, II, and IV: Tibial, L(4), (5), SI, 2.

Dorsal interossei

PLANTAR INTEROSSEI (THREE)

Origin: Bases and medial sides of the bodies of the third through fifth metatarsal bones.

Insertion: Medial sides of the bases of the proximal phalanges of the same digit.

Action: Adduct the third, fourth, and fifth digits toward the axial line through the second digits. Assist in flexion of the metatarsophalangeal joints, and may assist in extension of interphalangeal joints, of the third, fourth, and fifth digit.

DORSAL INTEROSSEI (FOUR)

Origin: Each by two heads from the adjacent sides of the metatarsal bones.

Insertions: Side of the proximal phalanx and capsule of the metatarsophalangeal joint.

First: To the medial side of the second digit.

Second through fourth: To the lateral sides of the second through fourth digits.

Action: Abducts the second through fourth digits from the axial line through the second digit. Assists in flexion of the metatarsophalangeal joints, and may assist in extension of interphalangeal joints, of the second through fourth digits.

Patient: Supine or sitting.

Fixation: The examiner stabilizes the midtarsal region and maintains a neutral position of the foot and ankle.

Test: Flexion of the metatarsophalangeal joints of the second through fifth digits, with an effort to avoid flexion of the interphalangeal joints.

Pressure: Against the plantar surface of the proximal phalanges of the four lateral toes.

Weakness: When these muscles are weak and the flexor digitorum longus is active, hyperextension occurs at the metatarsophalangeal joints. The distal joints flex, causing a hammer-toe position of the four lateral toes. Muscular support of the transverse arch is decreased.

Patient: Supine or sitting.

Fixation: The examiner stabilizes the metatarsophalangeal joints and maintains the foot and ankle in approximately 20° to 30° of plantar flexion.

Test: Extension of the interphalangeal joints of the four lateral toes. (A separate test for adduction and abduction of the interossei is not practical, because most individuals cannot perform these movements of the toes.)

Pressure: Against the dorsal surface of the distal phalanges, in the direction of flexion.

Note: Testing for strength of the lumbricales is important in cases of hammer toe and of metatarsal arch strain.

DEFORMITIES OF FOOT AND ANKLE

In the following list, foot deformities are defined in terms of the positions of the involved joints. In severe deformities, the position of the joint is beyond the normal range of joint motion.

Talipes valgus: Foot everted and accompanied by flattening of the longitudinal arch.

Talipes varus: Foot inverted and accompanied by an increase in the height of the longitudinal arch.

Talipes equinus: Ankle joint plantar flexed.

Talipes equinovalgus: Ankle joint plantar flexed and foot everted.

Talipes equinovarus: Ankle joint plantar flexed and foot inverted (i.e., clubfoot).

Talipes calcaneus: Ankle joint dorsiflexed.

Talipes calcaneovalgus: Ankle joint dorsiflexed and foot everted.

Talipes calcaneovarus: Ankle joint dorsiflexed and foot inverted.

Talipes cavus: Ankle joint dorsiflexed and forefoot plantar flexed, resulting in a high longitudinal arch. With the change in position of the calca-neus, the posterior prominence of the heel tends to be obliterated, and weight bearing on the cal-caneus shifts posteriorly.

Flexor digitorum brevis

Flexor digitorum brevis

Flex digit brevis •Flex digit longus

FLEXOR D IG I TO RI U M BREVIS

Origin: Medial process of the tuberosity of the calcaneus, central part of the plantar aponeurosis, and adjacent intermuscular septa.

Insertion: Middle phalanx of the second through fifth digits.

Action: Flexes the proximal interphalangeal joints, and assists in flexion of the metatarsophalangeal joints of the second through fifth digits.

Patient: Supine or sitting.

Fixation: The examiner stabilizes the proximal phalanges and maintains a neutral position of the foot and ankle. If the gastrocnemius and soleus are paralyzed, the examiner must stabilize the calcaneus, which is the bone of origin, during the toe flexor test.

Test: Flexion of the proximal interphalangeal joints of the second through fifth digits.

Pressure: Against the plantar surface of the middle phalanx of the four toes, in the direction of extension.

Note: When the flexor digitorum longus is paralyzed and the brevis is active, the toes flex at the middle phalanx while the distal phalanx remains extended.

Weakness: The ability to flex the proximal interpha-langeal joints of the four lateral toes is decreased, and the muscular support of the longitudinal and transverse arches is diminished.

Contracture: Restriction of extension of the toes. The middle phalanges flex, and there is a tendency toward a cavus if the gastrocnemius and soleus are weak.

Not©: Testing for strength of the flexor digitorum brevis is important in cases of longitudinal arch strain. Often, a point of acute tenderness is found at the origin of this muscle on the calcaneus.

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