Stretches for the Lower Extremity

1. Stretches for the Lower Extremity Chapter 4

2. Hip Extensors: Hamstrings and Gluteus Maximus • Anatomy: Chronically shortened hamstrings can contribute to these conditions: • Low back pain • Knee pain • Leg length differences • Restricted stride length • Overworked quadriceps • Gluteus maximus is a powerful hip extensor that can be involved in low back pain.

3. Hamstrings and Gluteus Maximus: Review Origins, Insertions, and Actions Adapted, by permission, from R.S. Behnke, 2005, Kinetic anatomy, 2nd ed. (Champaign, IL: Human Kinetics), 180.

4. Functional Assessment: Hip Flexion to 90 Degrees With the Knee Straight Is Ideal

5. Hip Rotators: Piriformis • One of six deep lateral hip rotators, all of which insert on some portion of the greater trochanter. • When these muscles are hypertonic, they contribute to a toe-out gait seen in dancers, and they restrict internal rotation of the hip. Stretching the piriformis also stretches the other lateral rotators. • Although the piriformis is considered a lateral rotator of the hip, it may be more of a postural muscle, stabilizing the spine and maintaining pelvic balance in conjunction with the psoas (Myers 1998).

6. Piriformis: Review Origin, Insertion, and Action

7. Functional Assessment (Piriformis): The Path of the Sciatic Nerve Through the Lateral Rotators

8. Hip Abductors • Primary abductors of the hip are the tensor fasciae latae (TFL) and the gluteus medius and minimus. • These muscles abduct the hip and also stabilize it during weight-bearing activities. • Tightness in these muscles can contribute to pelvic imbalances, which can cause pain in the hips, low back, and knees.

9. Hip Abductors: Review Origins, Insertions, and Actions

10. Hip Abductors: Functional Assessment Abductor tightness test (modified Ober’s test). Excessive tightness in the hip abductors prevents this position. Typical pain sites for iliotibial band syndrome. Fig. 4.14 (right): Adapted, by permission, from R.S. Behnke, 2005, Kinetic anatomy, 2nd ed. (Champaign, IL: Human Kinetics), 202.

11. Anatomy: Hip Adductors • When you bring your legs together (toward your midline), you use adductor muscles. • Adductor muscles can be divided into the short adductors (pectineus, adductor brevis, and adductor longus) and the long adductors (adductor magnus and gracilis). • We’ve provided one illustration showing all the adductors.

12. Hip Adductors: Review Origins, Insertions, and Actions Adapted, by permission, from R.S. Behnke, 2005, Kinetic anatomy, 2nd ed. (Champaign, IL: Human Kinetics), 183.

13. Hip Adductors: Functional Assessment Normal range of hip abduction is 45 to 50 degrees from the midline. Limited range is usually due to tight adductors. 50° 50°

14. Hip Flexors: Quadriceps Group • Quadriceps consist of four muscles and are powerful extensors of the knee. • One of the quads, the rectus femoris, also crosses the hip joint and acts as a hip flexor, assisting the psoas. • Chronically short quads can contribute to low back pain. The quadriceps are usually involved in any type of knee pain or instability.

15. Quadriceps Group: Review Origins, Insertions, and Actions Adapted, by permission, from R.S. Behnke, 2005, Kinetic anatomy, 2nd ed. (Champaign, IL: Human Kinetics), 198.

16. Quadriceps: Functional Assessment Normal range of knee extension. (a) The quadriceps should fully extend the knee. (b) The arc of motion should be smooth, with no hesitation or jerkiness.

17. Hip Flexors: Psoas and Iliacus • Iliopsoas is the primary hip flexor. • Because of its attachment along the lumbar spine, it affects the angle of the lumbar curve. A psoas that is too tight can cause an increase in the curve, which leads to swayback and low back pain. • However, sometimes a tight psoas will flatten the lumbar curve, which can also lead to low back pain. For a more detailed discussion of this seeming contradiction, see Tom Myers’ article “Poise: Psoas-Piriformis Balance” (1998).

18. Psoas and Iliacus: Review Origins, Insertions, and Actions Adapted, by permission, from R.S. Behnke, 2005, Kinetic anatomy, 2nd ed. (Champaign, IL: Human Kinetics), 178.

19. Psoas and Iliacus: Functional Assessment Normal range of (a) hip flexion and (b) hip extension. 120° a 30° b

20. Plantarflexors: Gastrocnemius and Soleus • Gastrocnemius-soleus muscles are also called the triceps surae. • They insert into the heel via the Achilles tendon, the strongest tendon in the body. The gastrocnemius is a two-headed muscle that gives the calf its shape. • The soleus muscle, which lies underneath the gastrocnemius, is more often the reason for calf tightness.

21. Gastrocnemius and Soleus: Review Origin, Insertion, and Action Adapted, by permission, from R.S. Behnke, 2005, Kinetic anatomy, 2nd ed. (Champaign, IL: Human Kinetics), 202.

22. Gastrocnemius and Soleus: Functional Assessment (a) Normal range of dorsiflexion at the ankle. (b) With the knee bent, the gastrocnemius is slack, and any limitation in dorsiflexion is probably due to a tight soleus. 20° a b

23. Gastrocnemius and Soleus: Functional Assessment (continued) Normal range of ankle plantarflexion is 50 degrees. 50°

24. Toe Flexors: Flexor Hallucis Longus, Flexor Digitorum Longus • We discuss only two of the six toe flexors (flexor hallucis and flexor digitorum longus). The muscle table lists all six toe flexors. • With the foot on the ground, flexor hallucis and digitorum longus assist in maintaining balance by keeping the toe pads on the ground. • Flexor hallucis longus helps support longitudinal arch and exerts a strong propulsion action during toe-off phase of gait.

25. Flexor Hallucis Longus and Flexor Digitorum Longus: Review Origins, Insertions, and Actions

26. Flexor Hallucis Longus and Flexor Digitorum Longus: Functional Assessment Normal range of motion of the great toe: 80 degrees of extension, 25 degrees of flexion.

27. Dorsiflexors: Tibialis Anterior • When the foot is free to move, tibialis anterior dorsiflexes and inverts it. • When the foot is on the ground, tibialis anterior assists in maintaining balance. • During walking or running, it helps prevent the foot from slapping onto the ground after heel strike and lifts the foot to clear the ground as the leg is swinging forward.

28. Tibialis Anterior: Review Origin, Insertion, and Action Adapted, by permission, from R.S. Behnke, 2005, Kinetic anatomy, 2nd ed. (Champaign, IL: Human Kinetics), 216.

29. Tibialis Anterior: Functional Assessment

30. Toe Extensors: Extensor Hallucis Longus, Extensor Digitorum Longus • We illustrate and discuss only two of the four toe extensors (extensor hallucis longus and extensor digitorum longus). The muscle table lists all four toe extensors. • Extensor hallucis longus and extensor digitorum longus help control the speed of descent of the forefoot to the ground following heel strike, preventing the foot from slapping onto the ground. • They also contribute to postural stability by controlling posterior sway. • With the foot anchored to the ground, they pull the leg forward at the ankle.

31. Extensor Hallucis Longus and Extensor Digitorum Longus: Review Origins, Insertions, and Actions

32. Extensor Hallucis Longus and Extensor Digitorum Longus: Functional Assessment Normal range of motion of the great toe: 80 degrees of extension, 25 degrees of flexion.

33. Evertors: Peroneal (Fibularis) GroupInvertors: Tibialis Anterior and Posterior • Eversion (pronation) and inversion (supination) of the foot occur with every step. • Proper function of evertors and invertors is critical for biomechanics and stability. • Invertors and evertors often control movement rather than initiate it. • Primary evertors are two of the three peroneal muscles (also known as fibularis muscles): peroneus longus and peroneus brevis. They make up the lateral compartment of the leg. The peroneus tertius is in the anterior compartment with the tibialis anterior. • Although peroneals are most often considered evertors, they also stabilize the foot, ankle, and leg. • Primary invertors are tibialis anterior and posterior. The tibialis posterior is the deepest muscle in the calf.

34. Evertors and Invertors: Review Origins, Insertions and Actions Adapted, by permission, from R.S. Behnke, 2005, Kinetic anatomy, 2nd ed. (Champaign, IL: Human Kinetics), 216, 217.

35. Evertors and Invertors: Functional Assessment Normal ROM for inversion (supination) is 45 degrees; for eversion (pronation) it is 20 degrees.

36. Spiral–Diagonal Patterns for the Lower Extremity • Not all spiral patterns for the leg lend themselves to stretching. Extension end of the D2 pattern is awkward. • Compared to single-plane stretches, the patterns require more concentration from both the stretcher and you. • Illustrate what you want the stretcher to do by taking him through the pattern passively. • You’re trying to improve ROM at the end of the pattern. Start with the stretcher at the end of his range in all three planes of motion. In isometric phase, stretcher attempts to move toward the opposite three planes (toward the shortened direction). • After isometric effort, stretching occurs as the stretcher moves farther in all three planes of motion toward lengthened direction.