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With the low back and sacrum flat on the table, the posterior thigh does not touch the table, and the knee extends. The figure above shows shortness of both one-joint and two-joint muscles. If the hip remains in 15° of flexion with the knee extended, the one-joint hip flexors lack 15° of length. If the knee will flex to only 70°, the two-joint muscles lack 25° of length (15° at the hip plus 10° at the knee).

NORMAL LENGTH OF ONE-JOINT AND SHORTNESS OF TWO-JOINT HIP FLEXORS

With the low back and sacrum flat on the table and the knee in extension, the posterior thigh touches the table. Shortness of the two-joint muscles is determined by holding the thigh in contact with the table and allowing the knee to flex. The angle of knee flexion (i.e., number of degrees less than 80°) determines the degree of shortness. The photograph above shows a subject in whom the hip joint can be extended if the knee joint is allowed to extend. This means that the one-joint hip flexors are normal in length, but that the rectus femoris is short.

In standing, the subject does not have a lordosis. This indicates that the shortness is not in the one-joint hip flexors.

A kneeling position puts a stretch on the short rectus femoris and tensor fasciae latae over both the hip joints and knee joints, causing these muscles to pull the pelvis into anterior tilt and back into a lordotic position.

SHORTNESS OF ONE-JOINT AND NO SHORTNESS OF TWO-JOINT HIP FLEXORS

The posterior thigh does not touch the table, and the knee can be flexed as many degrees beyond 80° as the hip is flexed. In the figure above, the thigh is flexed 15° and the knee 95°.

EXCESSIVE HIP FLEXOR LENGTH

The subject is tested with the low back flat, hip joint at the end of the table, and knee straight. That the thigh drops below table level is evidence of excessive length in the one-joint hip flexors.

SHORTNESS OF TENSOR FASCIAE LATAE DURING HIP FLEXOR LENGTH TESTING

The following variations noted during hip flexor length testing indicate shortness of the tensor fasciae latae but do not constitute a length test for this muscle:

Abduction of the thigh as the hipjoint extends: Occasionally, the hip joint can be fully extended along with abduction. This finding indi* cates shortness of the tensor fasciae latae but not in the iliopsoas.

Lateral deviation of the patella: If the hip is not allowed to abduct during extension, there may be a strong lateral pull on the patella because of tensor fasciae latae shortness. It may also occur even if the hip abducts.

Extension of the knee if the thigh is prevented from abducting or is passively adducted as the hip is extended.

Internal rotation of the thigh.

External rotation of the leg on the femur.

SHORTNESS OF SARTORIUS

Shortness of Tensor Fasciae Latae and Sartorius: Similarities and Differences

Tensor Fasciae Latae

Joint

Sartorius

Abducts

Hip

Abducts

Flexes

Hip

Flexes

Internally rotates

Hip

Externally rotates

Extends

Knee

Flexes

Habitual Positions that Predispose to Bilateral Adaptive Shortening

Sitting in a "W" or reverse-tailor position favors tensor fasciae latae shortness; sitting in a tailor or yoga position favors sartorius shortening. The habit of sitting with one leg—and always the same one—in one of these positions is conducive to unilateral shortness. Changing postural habits is an important part of treatment.

During the hip flexor length test, a combination of three or more of the following indicate tightness of the sartorius: abduction of the hip, flexion of the hip, external rotation of the hip and flexion of the knee.

Begin in the supine position, with the low back held flat by keeping one knee toward the chest with the other leg extended. The subject should contract the gluteals to actively extend the hip joint, bringing the thigh down toward the table without arching the back. (Note: If no table is available, this is the only hip flexor stretching exercise that can be done in the supine position. The stretching will affect the one-joint hip flexors only.)

To stretch both one-joint and two-joint hip flexors, the test position may be used. If there is much tightness, take care to progress gradually with stretching. A little bit of stretching can cause soreness that may be felt more the next day. Also, remember that the psoas muscle is attached to the bodies, transverse processes, and intervertebral disks of the lumbar spine, and too vigorous stretching can create or aggravate a problem with the low back.

The prone position on a table is unsatisfactory for stretching hip flexors, because the low back, which is already in an anterior curve, cannot be held flat or controlled in any fixed position. If a table is available, the subject may lie with the trunk prone at the end of the table and the legs hanging down, with the knees bent as necessary and the feet on the floor. Have the subject raise one leg in hip extension, high enough to put a stretch on the hip flexors, with the knee straight for a one-joint stretch and the knee bent approximately 80° for a one-joint and two-joint stretch.

When two-joint hip flexors are short, avoid the kneeling lunge. (The kneeling lunge may be used to stretch the one-joint muscles, providing that the two-joint hip flexors are not tight.) Be cautious in use of the kneeling lunge because of potential strain on the sacroil-iac joint as well as on the low back.

When one-joint hip flexors are short, avoid the lunge. Because the low back is not stabilized, tight hip flexors pull it into a lordosis. In the supine position, the low back is held flat, and tightness appears at the hip joint.

Exercise to stretch the one-joint hip flexors. Contract the gluteus maximus to pull the thigh toward the table, maintaining the knee in extension and keeping the back flat.

To stretch the one-joint and two-joint hip flexors on the right, lie on the back with the right lower leg hanging over the end of the table. Pull the left knee toward the chest just enough to flatten the low back and sacrum on the table. With hip flexor tightness, the thigh will be up from the table. Keeping back flat and the knee bent, press the right thigh down toward the table by pulling with the buttock muscle. If stretching one-joint hip flexors only, passive extension of the knee is permitted. To stretch the left hip flexors, reverse the procedure. (To stretch two-joint hip flexors, see pp. 225 and 462.)

An effective stretch of one-joint hip flexors can be done standing by a door frame. Place one leg forward to help brace the body against the door frame, and place the other leg back to extend the hip joint. In the starting position (Figure A), the low back will be arched because of hip flexor tightness. Keep the hip extended, and pull upward and inward with the lower abdominal muscles to tilt the pelvis posteriorly and stretch the hip flexors (Figure B). This exercise requires a strong pull by the abdominals and is useful in building up the strength of these muscles, which are direct opponents of the hip flexors in standing.

There are only two variables in the forward bending hamstring length test: the knee joint and the hip joint. Movement at the knee is controlled by maintaining the knee in extension during the movement of hip flexion. Hip flexion is obtained by movement of the pelvis toward the thigh. This test is not valid when there is a significant difference in length between right and left hamstrings, in which case the straight-leg-raising test should be used.

There are three variables in the straight-leg-raising test: the low back, hip joint, and knee joint. The knee joint is controlled by maintaining it in extension. The pelvis is controlled by maintaining the low back and sacrum flat on the table. The position of the pelvis and low back must be controlled. If the pelvis is in anterior tilt and the low back is hyperextended, the hip joint is already in flexion. The hamstrings will appear shorter than they actually are when measured by the angle of the leg with the table because this measurement does not include the amount of hip joint flexion due to the anterior pelvic tilt.

Hip flexor shortness is the chief cause of anterior pelvic tilt in the supine position, and the degree of short ness varies from one individual to another. In order to stabilize the pelvis with the low back and sacrum flat on the table, one must "give in" to the tight hip flexors by passive flexion using pillows or a towel-roll under the knees, but only as much as is necessary to obtain the required position of the pelvis.

If the hip and knees are flexed to allow approximately 40 degrees of hip flexion, the position will assure that there will be no anterior pelvic tilt to interfere with testing, but it will not prevent excessive posterior tilting. Standardizing the hip and knee position will not ensure that the position of the low back and pelvis will be standardized.

The hamstrings will appear longer than their actual length are if the pelvis is in posterior tilt with the low back in excessive flexion. When the straight-leg-raising test is done starting with one knee and hip flexed and the foot resting on the table as the other leg is raised, the pelvis is free to move in the direction of posterior tilt. An individual with as little as 45 degrees of straight-leg-raising can appear to have as much as 90 degrees of length (see p. 388).

STRAIGHT-LEG RAISING

Equipment:

Table or floor.

Folded blanket may be used, but not soft padding. (The examiner cannot confirm that the low back and sacrum are flat if they are on a soft pad.)

Goniometer to measure the angle between the straight leg and the table.

Pillow or towel roll (in case of hip flexor shortness).

Chart to record findings.

Starting Position: Supine with the legs extended and the low back and sacrum flat on the table. (Standardization of the test requires that the knee be in extension, and that the low back and pelvis have a fixed position to control the variables created by excessive anterior or posterior pelvic tilt.) When the low back and sacrum are flat, hold one thigh firmly down, making use of passive restraint by the hip flexors to prevent excessive posterior pelvic tilt before starting to raise the other leg in the straight-leg-raising test.

Test Movement: With the low back and sacrum flat on the table and one leg held firmly down, have the subject raise the other leg with the knee straight and the foot relaxed.

Reasons: The knee is kept straight to control this variable. The foot is kept relaxed to avoid gastrocnemius involvement at the knee. (If the gastrocnemius is tight, dorsiflexion of the foot will cause the knee to flex, thereby interfering with the test of the hamstrings.) If the knee starts to bend, lower the leg slightly and have the subject fully extend the knee and again raise the leg until some restraint is felt and the subject feels slight discomfort.

FORWARD BENDING

Equipment:

Table (not padded) or floor.

Board (3 inches wide, 12 inches long, and approximately '/> inch thick) to place flat against the sacrum.

Goniometer to measure the angle between the sacrum and the table.

Chart to record findings.

Starting Position: Sitting with the hips flexed and the knees fully extended (long-sitting). Allow the feet to be relaxed, and avoid dorsiflexion.

Reasons: Keeping the knee straight maintains a fixed elongation of the hamstrings over the knee joint, eliminating movement at the knee as a variable. Avoiding dorsiflexion of the foot prevents the knee flexion that may occur if the gastrocnemius is tight.

lest Movement: Have the subject reach forward, as far as possible, in the direction of trying to touch the fingertips to the toes or beyond.

Reasons: The subject will tilt the pelvis forward, toward the thighs, flexing the hip joints to the limit allowed by the hamstring length.

Measuring Arc of Motion: Place the board with the 3-inch side on the table and the 12-inch side pressed against the sacrum when the hamstring length appears to be normal or excessive. Place the board with the 12-inch side on the table and the 3-inch side pressed against the sacrum when the hamstrings are tight. Measure the angle between the upright board and the table.

Normal Range of Motion: The pelvis flexes toward the thigh to the point that the angle between the sacrum and the table is approximately 80° (i.e., the same angle as that between the leg and the table in the straight-leg-raising test)

This straight-leg-raising test, with the lower back flat on the table, shows normal length of the hamstring muscles, which permits flexion of the thigh toward the pelvis (i.e., hip joint flexion) to an angle of approximately 80° up from the table.

In forward bending, normal hamstring length permits flexion of the pelvis toward the thigh (i.e., hip joint flexion) as illustrated.

NORMAL HAMSTRING LENGTH

NORMAL HAMSTRING LENGTH

No Hip Flexor Shortness: Straight-leg raising, with the subject in supine position, the low back and sacrum flat on the table, and the other leg either extended by the subject or held down by the examiner. An angle of approximately 80° between the table and the raised leg is considered to be a normal range of hamstring length.

EXCESSIVE HAMSTRING LENGTH

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