Lower extremity osteopathy

The lower extremity consists of the hip, thigh, knee, and popliteal fossa, as well as the leg (crus), ankle, and foot. The primary function of the lower extremity is ambulation. Therefore, it is important to evaluate the functional capacity by examining the lower extremities while standing, walking, and squatting. Dysfunction is typically present for any cardinal direction of each joint, as well as the fibular head and calcaneus. Moreover, dysfunction and even anatomical variations (e.g., short-leg syndrome) in this region often result in somatic dysfunctions of the pelvic girdle and vertebral column. Osteopathic treatment in this region consists of muscle energy and high-velocity low-amplitude.

Hip and knee

Bones

• Femur
• Patella
• Tibia
• Fibula
• For more information, see “The femur” in "Thigh, knee, and popliteal fossa" and “Bones and joints” in "The leg, ankle, and foot."

Muscles

• Hip
  • Gluteus maximus: primary hip extensor
  • Iliopsoas: primary hip flexor
  • Piriformis: external rotation of the lower limbs
• Knee
  • Quadriceps femoris (rectus femoris, vastus lateralis, vastus medialis, and vastus intermedius)
    • Primary knee extensors
    • Hip extensors
  • Hamstrings (semimembranosus, semitendinosus, and biceps femoris)
    • Primary knee flexors
    • Hip extensors
• For more information, see “Muscles of the thigh” in "Thigh, knee, and popliteal fossa."

Joints

• Hip
  • Hip joint (femoroacetabular joint)
  • Ball-and-socket joint
• Knee
  • Tibiofemoral joint
  • Patellofemoral joint
  • Tibiofibular joint
• For more information, see “Hip joint” in "Pelvis and hip joint" and “Bones and joints” in "The leg, ankle, and foot."

Ligaments

• Hip
  • Iliofemoral ligament
  • Ischiofemoral ligament
  • Pubofemoral ligament
  • Capitis femoris
• Knee
  • Cruciate ligaments: anterior cruciate ligament (ACL), posterior cruciate ligament (PCL)
  • Collateral ligaments: medial collateral ligament (MCL), lateral collateral ligament (LCL)
  • Menisci (medial meniscus, lateral meniscus)
• For more information, see “Hip joint” in "Pelvis and hip joint" and “The knee joint” in "Thigh, knee, and popliteal fossa."

Innervation

• Femoral nerve
• Sciatic nerve
• Tibial nerve
• Peroneal (common fibular) nerve
• For more information, see "Neurovasculature of the lower limbs."

Vasculature

• Femoral artery
• Common iliac arteries (external iliac artery, external iliac artery)
• Femoral circumflex arteries (medial, lateral)
• Popliteal artery
• Tibial arteries (anterior, posterior)
• Fibular artery

Anatomical landmarks of the hip and knee

• Femoral condyles
• Femoral epicondyles
• Patella
• Patellar tendon
• Medial and lateral joint line
• Tibial condyles
• Tibial tuberosity
• Pes anserinus
• Fibular head

Ankle and foot

Bones

• Ankle
  • Calcaneus bone
  • Talus bone
  • Cuboid bone
  • Navicular bone
  • Cuneiform bones (medial, middle, and lateral)
• Foot
  • Metatarsal bones (5)
  • Phalanges (14)
• For more information, “Bones and joints” in "The leg, ankle, and foot."

Arches of the foot

• Longitudinal arches
  • Medial longitudinal arch
    • Calcaneus
    • Talus
    • Navicular
    • 3 cuneiforms
    • Medial 3 metatarsals
  • Lateral longitudinal arch
    • Calcaneus
    • Cuboid
    • 4^th and 5^th metatarsals
• Transverse arch
  • Cuboid
  • 3 cuneiforms
  • Bases of the 5 metatarsals

The foot has one transverse and two longitudinal arches that help distribute body weight.

Muscles

• Gastrocnemius (primary plantar flexors and plantar extensor)
• Soleus and plantaris (plantar flexors)
• Anterior tibialis (primary dorsiflexion and foot inversion)
• Peroneus muscles (primary foot eversion)
• For more information, “Muscles” in "The leg, ankle, and foot."

Joints

• Ankle
  • Talocrural joint (tibiotalar joint)
  • Talocalcaneal joint (subtalar joint)
  • Talonavicular joint
• Foot
  • Metatarsophalangeal (MTP) joints
  • Interphalangeal (IP) joints
• For more information, “Bones and joints” in "The leg, ankle, and foot."

Ligaments

• Medial ligament (deltoid ligament)
  • Composed by the anterior tibiotalar ligament, tibiocalcaneal ligament, posterior tibiotalar ligament, and tibionavicular ligament
  • Prevents excessive ankle eversion (pronation)
• Lateral ligament
  • Composed by the anterior talofibular ligament, posterior talofibular ligament, and calcaneofibular ligament
  • Prevents excessive ankle inversion (supination)
  • Commonly injured in sports injuries (inversion injury)
• Plantar ligaments
  • Calcaneonavicular ligament (spring ligament)
  • Plantar fascia

In supination injuries, the Anterior TaloFibular ligament Always Tears First.

Innervation

• Tibial nerve
• Common fibular (peroneal) nerve
• For more information, see “Nerves” in "Neurovasculature of the lower limbs."

TIPPED = tibial nerve versus peroneal nerve
TIP = Tibial nerve Inverts and Plantarflexes the foot → cannot walk on TIPtoes when injured
PED = Peroneal nerve Everts and Dorsiflexes the foot → foot DROPs when injured

Vasculature

• Dorsalis pedis artery
• Plantar arterial arch
  
  

Anatomical landmarks of the ankle and foot

• Lateral malleolus (distal fibula)
• Medial malleolus (distal tibia)
• Achilles tendon
• Sustentacular tali

Hip

• Main motions
  • Flexion and extension
  • Abduction and adduction
  • Internal rotation and external rotation
• Minor motions
  • Anterior glide
  • Posterior glide
• Range of motion
  • Extension: 10–15°
  • Flexion: 130–140°
  • Abduction: 30–45°
  • Adduction: 20–30°
• For more information, see “Hip joint examination” in "Orthopedic examination."

Knee

• Main motions
  • Flexion and extension
  • Abduction and adduction
  • Rotation
• Range of motion
  • Extension: 0°
  • Flexion: 135°
• For more information, see “Knee joint examination” in "Orthopedic examination."

Tibiofibular joint

The movement of the fibular head, distal fibula, and foot are linked.

• The fibular head and distal fibula move reciprocally in opposite directions.
• In pronation of the foot, the fibular head glides anteriorly.
• In supination of the foot, the fibular head glides posteriorly.

Angulations of the hip and knee

• Caput-collum-diaphyseal angle (femoral neck-shaft angle)
  • The femoral head angle is measured by the intersection of 2 lines:
    • One line running along the femoral neck
    • The second line running along the femoral shaft
  • Normal angle: 120°–135°
• Quadriceps angle (Q angle)
  • The quadriceps angle is measured by the intersection of 2 lines:
    • One line running from the ASIS through the middle of the patella
    • The second line running from the tibial tubercle through the middle of the patella
  • Normal angle: 10°–12°

Ankle and foot

• Main motions
  • Pronation
    • Involves: dorsiflexion, eversion, and abduction
    • More stable motion
  • Supination
    • Involves: plantarflexion, inversion, adduction
    • Unstable motion
• Range of motion
  • Dorsiflexion: 20°
  • Plantarflexion: 50°
  • Subtalar eversion: 5°–10°
  • Subtalar inversion: 25°–30°
  • Forefoot abduction: 10°
  • Forefoot adduction: 20°

The ankle is more stable in pronation than supination.

Hip and knee

• Hip somatic dysfunctions
  • Hip internal rotation dysfunction
    • The hip is restricted in external rotation.
    • E.g., due to psoas or piriformis spasm
  • Hip external rotation dysfunction
    • The hip is restricted in internal rotation
    • E.g., due to internal rotator muscle spasms (gluteus minimus, adductor longus, adductor brevis, adductor magnus)
• Knee somatic dysfunctions
  • Knee flexion dysfunction: restricted knee extension
  • Knee extension dysfunction: restricted knee flexion
  • Fibular head dysfunctions (see “Fibular head dysfunctions” below)
• Femoral neck conditions
  • Coxa vara (femoral neck-shaft angle < 120°)
  • Coxa valga (femoral neck-shaft angle > 135°)
• Knee deformities
  • Genu varum (Q angle < 10°)
  • Genu valgum (Q angle > 12°)
• Other
  • Patellofemoral pain syndrome
  • Unhappy triad

Ankle and foot

• Foot somatic dysfunctions
  • Cuboid somatic dysfunction
    • The medial edge glides toward the plantar surface
    • Tenderness on palpation
  • Navicular somatic dysfunction
    • The lateral edge glides toward the plantar surface
    • Tenderness on palpation
  • Cuneiform somatic dysfunction
    • The second cuneiform glides downward and toward the plantar surface
    • Tenderness on palpation
• Ankle somatic dysfunctions
  • Plantar flexion somatic dysfunction (anterior talus somatic dysfunction)
    • Ankle dorsiflexion restriction
    • Tibia is posterior to the talus
  • Dorsiflexion somatic dysfunction (posterior talus somatic dysfunction)
    • Ankle plantarflexion restriction
    • Tibia is anterior to the talus
  • Calcaneal somatic dysfunction
    • Calcaneal eversion dysfunction: calcaneal inversion restriction
    • Calcaneal inversion dysfunction: calcaneal eversion restriction
• Ankle sprain
  • Type I: involves 1 ligament (anterior talofibular ligament)
  • Type II: involves 2 ligaments (anterior talofibular ligament, calcaneofibular ligament)
  • Type III: involves 3 ligaments (anterior talofibular ligament, posterior talofibular ligament, and calcaneofibular ligament)
  • For more information, see “Ankle sprain” in "Sports injuries."
• Other
  • Plantar fasciitis
  • Pes cavus
  • Pes planus

• Definition: trauma or strain of the piriformis muscle that manifests with buttock pain and paresthesia in the distribution of the sciatic nerve
• Pathophysiology: precipitating cause → hypertonicity or spasm of the piriformis muscle → shortening of the muscle → sciatic nerve impingement
• Clinical features
  • Pain in the deep gluteal region, exacerbated by sitting for prolonged periods
  • Pain and paresthesia in the distribution of the sciatic nerve (i.e., buttock pain that radiates down the leg)
  • Externally rotated lower extremity (restricted internal rotation)
• Diagnostics: mostly clinical diagnosis, based on history and physical examination
• Management
  • Osteopathic manipulative therapy
    • Counterstrain to the piriformis tender point
    • Muscle energy treatment
  • Physical therapy focuses on exercises that stretch and strengthen the piriformis muscle
  • See “Hip and knee treatment” below.

Overview

Anterior fibular head dysfunction (pronation dysfunction)

• The proximal fibular head glides anteriorly and resists glide posteriorly.
• The distal fibula glides posteriorly and resists to glide anteriorly.
• The foot is pronated, which involves dorsiflexion, eversion, and abduction.
• The talus is posterior.

Posterior fibular head dysfunction (supination dysfunction)

• The proximal fibular head glides posteriorly and resists glide anteriorly.
• The distal fibula glides anteriorly and resists to glide posteriorly.
• The foot is supinated, which involves plantarflexion, inversion, and adduction.
• The talus is anterior.

Hip

• Ober test
• FABER test (Patrick test)
• Thomas test
• Trendelenburg test
• For more information, see “Hip joint examination” in "Orthopedic examination."

Knee

• Ligaments
  • ACL: anterior drawer test, Lachman test
  • PCL: posterior drawer test
  • MCL: valgus stress test
  • LCL: varus stress test
• Menisci
  • McMurray test
  • Apley grind test
  • Steinman test
  • Patellar tap test
  • Bulge sign
  • Patellar grind test
• For more information, see “Knee joint examination” in "Orthopedic examination" and “Clinical features” in “Meniscus tear.”

Fibula

Bilateral spring test of the fibular head

• Function: assesses for fibular head dysfunction
• Position: seated with flexed knee; the foot should not touch the floor
• Procedure: pinch the fibular head between the index finger and thumb and spring (i.e., apply force) anteriorly and posteriorly
• Positive test: inability to spring or glide in one direction

Ankle and foot

Anterior drawer test of the ankle

• Function: assesses the integrity of the anterior talofibular ligament
• Position: Stabilize the leg with one hand and grab the heel with the other.
• Procedure: Apply a gentle anterior force on the heel.
• Positive test: pain or laxity

Thompson test (Achilles tendon)

• For more information, see “Thompson test” in “Achilles tendon rupture.”

Hip dysfunction

Muscle energy (Spencer technique)

• Position: supine, prone
• Procedure
  1. Flexion (supine)
     • Flex the patient's knee and hip.
     • Ask the patient to extend the hip against equal resistance.
  2. Extension (prone)
     • Flex the patient's knee and extend the hip.
     • Ask the patient to flex the hip against equal resistance.
  3. Circumduction with compression (supine)
     • Compress the foot toward the hip.
     • Circumduct from the foot to the hip.
  4. Circumduction with traction (supine)
     • Apply traction to the foot moving away from the hip.
     • Circumduct the hip, while holding the foot.
  5. Internal rotation (supine)
     • Flex the patient's knee and internally rotate the hip.
     • Ask the patient to externally rotate the leg against equal resistance.
  6. External rotation (supine)
     • Flex the patient's knee and externally rotate the hip.
     • Ask the patient to internally rotate the leg against equal resistance.
  7. Abduction (supine)
     • Abduct the leg.
     • Ask the patient to adduct the leg against equal resistance.
  8. Adduction (supine)
     • Adduct the leg.
     • Ask the patient to abduct the leg against equal resistance.

Piriformis syndrome

Muscle stretch

• Position: supine
• Procedure
  • Instruct patient to cross the ankle on the affected side over the opposite knee (figure 4 position).
  • Pull the opposite knee toward the chest.
    • E.g., for a left-sided piriformis stretch, cross the left ankle over the right knee and pull the right knee toward the chest.
• Position: prone
• Procedure
  • Instruct patient to lift the chest with the hands on the floor and keep the unaffected leg extended behind.
  • Bring the affected leg in front of the chest with the knee flexed and the hip abducted.

Muscle energy

• Position: prone
• Procedure
  • Ask the patient to flex the affected knee to 90°
  • Grasp the patient's ankle and push laterally to engage the restrictive barrier.
  • With the other hand, keep palpating the piriformis muscle.
  • Push the ankle into your hand to externally rotate the femur and hold the position for 3–5 seconds.
  • Relax for 5 seconds.
  • Re-engage barrier and repeat.
  • Reassess.

Knee flexion dysfunction

Muscle energy

• Position: prone
• Procedure
  1. Place knee into extension barrier.
  2. Ask the patient to flex against equal resistance for 3–5 seconds.
  3. Relax for 5 seconds.
  4. Re-engage barrier and repeat.
  5. Reassess.

Knee extension dysfunction

Muscle energy

• Position: prone
• Procedure
  1. Place knee into flexion barrier.
  2. Ask the patient to extend against equal resistance for 3–5 seconds.
  3. Relax for 5 seconds.
  4. Re-engage barrier and repeat.
  5. Reassess.

Anterior fibular head

Muscle energy

• Position: supine with knee slightly bent
• Procedure
  1. Grasp the fibular head with the index finger and thumb and apply posterior force.
  2. Place the ankle into plantarflexion, inversion, and internal rotation.
  3. Ask the patient to evert the foot against equal resistance for 3–5 seconds.
  4. Relax for 5 seconds.
  5. Re-engage barrier and repeat.
  6. Reassess.

High-velocity low-amplitude

• Position: supine
• Procedure
  1. Perform myofascial technique.
  2. Flex the patient's leg to ∼ 30 degrees.
  3. Place thenar eminence on the anterior aspect of the fibular head.
  4. Plantarflex, invert, and internally rotate the foot.
  5. Extend the knee and apply a posterior-medial thrust.
  6. Reassess.

Posterior fibular head

Muscle energy

• Position: supine with knee slightly bent
• Procedure
  1. Grasp the fibular head with the index finger and thumb and apply anterior force.
  2. Place the ankle into dorsiflexion, eversion, and external rotation.
  3. Ask the patient to invert the foot against equal resistance for 3–5 seconds.
  4. Relax for 5 seconds.
  5. Re-engage barrier and repeat.
  6. Reassess.

High-velocity low-amplitude

• Position: supine
• Procedure
  1. Perform myofascial technique.
  2. Flex the patient's hip and knee.
  3. Contact the posterior aspect of the fibular head with the hand hooked behind the popliteal fossa.
  4. Dorsiflex, evert, and externally rotate the foot.
  5. Apply an anterior thrust on the fibular head while rapidly flexing the knee.
  6. Reassess.

Plantar flexion dysfunction

Muscle energy

• Position: seated
• Procedure
  1. Place ankle into dorsiflexion restriction.
  2. Ask patient to plantarflex against equal resistance for 3–5 seconds.
  3. Relax for 5 seconds.
  4. Re-engage barrier and repeat.
  5. Reassess.

Dorsiflexion dysfunction

Muscle energy

• Position: seated
• Procedure
  1. Place foot into plantarflexion restriction.
  2. Ask patient to dorsiflex against equal resistance for 3–5 seconds.
  3. Relax for 5 seconds.
  4. Re-engage barrier and repeat.
  5. Reassess.

Calcaneal eversion dysfunction

Muscle energy

• Position: seated
• Procedure
  1. Grasp the forefoot.
  2. Place calcaneus into inversion barrier.
  3. Ask patient to move calcaneus laterally against equal resistance for 3–5 seconds.
  4. Relax for 5 seconds.
  5. Re-engage barrier and repeat.
  6. Reassess.

Calcaneal inversion dysfunction

Muscle energy

• Position: seated
• Procedure
  1. Grasp the forefoot.
  2. Place calcaneus into eversion barrier.
  3. Ask patient to move calcaneus medially against equal resistance for 3–5 seconds.
  4. Relax for 5 seconds.
  5. Re-engage barrier and repeat.
  6. Reassess.