Hip Knee Ankle
Hip Knee Ankle
Hip Knee Ankle
Anatomy
• 1. The hip joint is a synovial ball and socket joint.
• 6. The movements that take place at the hip joint are: flexion,
extension, abduction, adduction, lateral (external) rotation and
medial (internal) rotation.
Extensors
Table 1.2
Range of Movement
Extension
Starting position
Fig 1.1
Goniometric measurement of hip extension.
Stationary arm
This is parallel to the mid-axillary line of the trunk.
Moveable arm
This is parallel to the longitudinal axis of the femur, pointing towards the
lateral epicondyle of the femur.
Command to patient
‘Lift your leg backwards as far as you can.’
End position
The hip is extended to the limit of motion.
Trick movement
Extension of the lumbar spine.
CLINICAL TIP
The greater trochanter can be found by palpating the iliac crest – at its
mid-point, one hand span down should get you to the area of the greater
trochanter. You will feel movement at the greater trochanter on medial
and lateral rotation of the leg.
Flexion
Starting position
Fig 1.2
Goniometric measurement of hip flexion.
Stationary arm
This is parallel to the mid-axillary line of the trunk.
Moveable arm
This is parallel to the longitudinal axis of the femur, pointing towards the
lateral epicondyle of the femur.
Command to patient
‘Bend your knee up towards your chest as far as you can, sliding your
heel up the plinth.’
End position
The hip is flexed to the limit of motion. The heel is moved towards the
buttock to the limit of hip flexion.
Trick movement
Flexion of the lumbar spine.
Stationary arm
This is placed along a line between the two ASISs.
Moveable arm:
This is parallel to the longitudinal axis of the femur, pointing to the
middle of the patella.
Command to patient
‘Take your leg out sideways as far as you can. Keep your great toe
pointing towards the ceiling.’
End position
The hip is abducted to the limit of motion.
Trick movement
Lateral (external) rotation of the hip.
Adduction
Starting position
Fig 1.4
Goniometric measurement of adduction of the hip.
Goniometer axis
The goniometer axis is placed over the anterior superior iliac spine
(ASIS) of the innominate bone, on the side of the hip being measured.
Stationary arm
This is placed along a line between the two ASISs.
Moveable arm
This is parallel to the longitudinal axis of the femur, pointing to the
middle of the patella.
Command to patient
‘Bring your leg in towards your opposite leg as far as you can. Keep your
great toe pointing towards the ceiling.’
End position
The hip is adducted to the limit of motion.
Trick movement
Medial (internal) rotation of the hip.
Stationary arm
This is perpendicular to the floor.
Moveable arm
This is parallel to the anterior border of the tibia.
Command to patient
‘Turn your leg and foot in as far as you can.’
End position
The hip is laterally (externally) rotated to the limit of motion, so that the
leg and foot move in a medial direction.
CLINICAL TIP
This may seem a confusing movement: turning the foot in produces
lateral (external) rotation at the hip and turning the foot out produces
medial (internal) rotation. It may help if you think what would happen if a
nail was inserted anteriorly into the femoral shaft – it would move
laterally when the foot was turned in and medially when the foot was
turned out.
Medial (internal) rotation
Starting position
Fig 1.6
Goniometric measurement of medial rotation of the hip.
Stationary arm
This is perpendicular to the floor.
Moveable arm
This is parallel to the anterior border of the tibia.
Command to patient
‘Turn your leg and foot out as far as you can.’
End position
The hip is medially (internally) rotated to the limit of motion, so that the
leg and foot move in a lateral direction.
CLINICAL TIP
This may seem a confusing movement: turning the foot in produces
lateral (external) rotation at the hip and turning the foot out produces
medial (internal) rotation. It may help if you think what would happen if a
nail was inserted anteriorly into the femoral shaft – it would move
laterally when the foot was turned in and medially when the foot was
turned out.
Notes
Treatment record
Observational/reflective checklist
Observational/reflective checklist
Observation Y/N Comments
Introduction Was the treatment area properly prepared for
and the patient, e.g. pillow, blanket, safe
preparation environment, etc.?
for the skill
Did the therapist introduce him/herself?
Was the patient comfortable?
Was the patient adequately exposed/draped?
Was an explanation of the procedure given?
Was the explanation clear and succinct?
Was consent obtained?
Performing Was the plinth set at the correct height?
the skill
Was the therapist's posture compromised?
Did the therapist identify the joint and other
relevant bony landmarks?
Was the goniometer correctly aligned?
Was the reading of the joint range of
movement accurate?
Did the therapist compare both sides of the
body?
Safe and Was the procedure carried out with due care
effective and attention?
performance
of the
technique
How would Excellent
you rate the
proficiency in Very good
the overall Good
performance
of the skill? Satisfactory
Borderline
Fail
Muscle Bulk
Limb girth: thigh
Patient's position
Fig 1.7
Measurement of the girth of the thigh.
Repeat three times and produce an average reading, then repeat the
procedure on the other limb to compare the measurements.
Points to note:
Clinician's position
The clinician is standing by the patient, with both hands palpating the
gluteus maximus muscle.
Command to patient
‘Try and tighten your seat muscles.’
Clinical tip
Closely observing and feeling the muscle is essential in enabling the
clinician to pick up on even the smallest flicker of a contraction.
Clinical tip
The hip has to move through its full range of movement – full flexion to
full extension. The limb can be heavy, so the safe positioning of the
clinician is an essential part of this measurement technique.
Command to patient
‘Move your leg upwards as far as you can.’
The hip has to move through its full range of movement – full flexion to
full extension.
Clinical tip
You may have to commence with the hip in the neutral position, with the
patient lying prone on the plinth, especially for the less able patient.
Clinician's position
The clinician is standing at the foot of the plinth, applying a minimal
resistance to the patient's lower leg.
Command to patient
‘Push your leg upwards as far as you can against the minimal
resistance.’
The hip has to move through its full range of movement – full flexion to
full extension.
Clinical tip
Use the length of lever arm principle to make sure you can apply a
consistent resistance to the limb. Ask the patient to start slowly so they
can appreciate the amount of resistance.
Command to patient
‘Push your leg upwards as far as you can against the maximal
resistance.’
The hip has to move through its full range of movement – full flexion to
full extension.
Clinical tip
Use the length of lever arm principle to make sure you can apply a
consistent resistance to the limb. Ask the patient to start slowly so they
can appreciate the amount of resistance. Remember, the patient's hip
extensors (gluteus maximus) may be stronger than your applied
resistance; use a safe and mechanically advantageous position to
enable you to perform this technique safely and effectively.
Flexors
Grade 0 – ‘No contraction’ and Grade 1 – ‘Flicker of a contraction’
Patient's position
Fig 1.12
Oxford muscle grading for the hip flexors – Grades 0 and 1.
Command to patient
‘Try and tighten your thigh muscles.’/'Try and lift your leg up off the
plinth.’
Clinical tip
Closely observing and feeling the muscle is essential in enabling the
clinician to pick up on even the smallest flicker of a contraction.
Command to patient
‘Try and move your leg forwards as far as you can.’
The hip has to move through its full range of movement – full extension
to full flexion.
Clinical tip
The limb can be heavy, so the safe positioning of the clinician is an
essential part of this measurement technique.
The patient is positioned in supine lying on the plinth, with the right leg
over the edge of the plinth so that full extension of the hip/leg is
obtained.
Clinician's position
The clinician is standing at the side of the patient to observe the
movement.
Command to patient
‘Push your leg upwards as far as you can.’
The hip has to move through its full range of movement – full extension
to full flexion.
Clinician's position
The clinician is standing by the side of the patient, applying a minimal
resistance to the patient's upper leg.
Command to patient
‘Push your leg upwards as far as you can against the minimal
resistance.’
The hip has to move through its full range of movement – full extension
to full flexion.
Clinical tip
Use the length of lever arm principle to make sure you can apply a
consistent resistance to the limb. Ask the patient to start slowly so they
can appreciate the amount of resistance.
Fig 1.15
Oxford muscle grading for the hip flexors – Grades 4 and 5. The leg is
moving from full hip extension to full hip flexion (towards the ceiling).
Clinician's position
The clinician is standing by the side of the patient, applying a maximal
resistance to the patient's upper leg.
Command to patient
‘Push your leg upwards as far as you can against the maximal
resistance.’
The hip has to move through its full range of movement – full extension
to full flexion.
Clinical tip
Use the length of lever arm principle to make sure you can apply a
consistent resistance to the limb. Ask the patient to start slowly so they
can appreciate the amount of resistance. Remember, the patient's hip
flexors (iliopsoas and rectus femoris) may be stronger than your applied
resistance. Use a safe and mechanically advantageous position to
enable you to perform this technique safely and effectively.
Abductors
Grade 0 – ‘No contraction’ and Grade 1 – ‘Flicker of a contraction’
Patient's position
Fig 1.16
Oxford muscle grading for the hip abductors – Grades 0 and 1.
Command to patient
‘Try and push your leg out to the side.’
Clinical tip
Closely observing and feeling the muscles is essential in enabling the
clinician to pick up on even the smallest flicker of a contraction.
NB: Gluteus medius can be palpated between the iliac crest and the
greater trochanter, whereas gluteus minimus can be palpated between
the anterior superior iliac spine (ASIS) and the greater trochanter.
Command to patient
‘Try and push your leg out to the side as far as you can.’
The hip has to move through its full range of movement – full adduction
to full abduction.
Clinical tip
The limb can be heavy, so the safe positioning of the clinician is an
essential part of this measurement technique.
Patient's position
Fig 1.18
Oxford muscle grading for the hip abductors – Grade 3. The leg is
moving from hip adduction to full hip abduction (towards the ceiling).
The patient is positioned in side lying on the plinth or standing with the
support of the plinth.
Clinician's position
The clinician is standing by the side of the patient to observe the
movement.
Command to patient
If positioned in side lying – ‘Push upwards with your whole leg as far as
you can.’
The hip has to move through its full available range of movement –
adduction to full abduction.
If standing – ‘Push your leg out to the side as far as you can.’
Clinician's position
The clinician is standing at the foot of the patient, applying a minimal
resistance to the patient's lower leg.
Command to patient
‘Push your leg upwards as far as you can against the minimal
resistance.’
The hip has to move through its full available range of movement –
adduction to full abduction.
As the patient is positioned in side lying, the movement cannot start in
full hip adduction.
Clinical tip
Use the length of lever arm principle to make sure you can apply a
consistent resistance to the limb. Ask the patient to start slowly so they
can appreciate the amount of resistance.
Fig 1.19
Oxford muscle grading for the hip abductors – Grades 4 and 5. The leg
is moving from hip adduction to full hip abduction (towards the ceiling).
Clinician's position
The clinician is standing at the foot of the patient, applying a maximal
resistance to the patient's lower leg.
Command to patient
‘Push your leg upwards as far as you can against the maximal
resistance.’
The hip has to move through its full available range of movement –
adduction to full abduction.
Clinical tip
Use the length of lever arm principle to make sure you can apply a
consistent resistance to the limb. Ask the patient to start slowly so they
can appreciate the amount of resistance. Remember, the patient's hip
abductors (gluteus medius and minimus) may be stronger than your
applied resistance. Use a safe and mechanically advantageous position
to enable you to perform this technique safely and effectively.
Adductors
Grade 0 – ‘No contraction’ and Grade 1 – ‘Flicker of a contraction’
Patient's position
Fig 1.20
Oxford muscle grading for the hip adductors – Grades 0 and 1.
Command to patient
‘Try and brace your two legs together to tighten your muscles.’
Clinical tip
Closely observing and feeling the muscle is essential in enabling the
clinician to pick up on even the smallest flicker of a contraction. The
adductors may be felt high up on the inside of the thigh. Adductor
magnus can be palpated more easily just above the adductor tubercle of
the femur on the lower, medial aspect of the femur.
Command to patient
‘Try and push your leg inwards as far as you can.’
The hip has to move through its full range of movement – full abduction
to full adduction.
Clinical tip
The limb can be heavy, so the safe positioning of the clinician is an
essential part of this measurement technique.
Command to patient
‘Push your leg upwards as far as you can.’
The hip has to move through its full available range of movement –
abduction to full adduction.
Clinical tip
As the patient is positioned in side lying, the movement cannot start in
full hip abduction.
Clinician's position
The clinician is standing at the foot of the patient, applying a minimal
resistance to the patient's lower leg.
Command to patient
‘Push your leg upwards as far as you can against the minimal
resistance.’
The hip has to move through its full available range of movement –
abduction to full adduction.
Clinical tip
As the patient is positioned in side lying, the movement cannot start in
full hip abduction.
Clinical tip
Use the length of lever arm principle to make sure you can apply a
consistent resistance to the limb. Ask the patient to start slowly so they
can appreciate the amount of resistance.
Fig 1.23
Oxford muscle grading for the hip adductors – Grades 4 and 5. The leg
is moving from hip abduction to full hip adduction (towards the ceiling).
Clinician's position
The clinician is standing at the foot of the patient, applying a maximal
resistance to the patient's lower leg.
Command to patient
‘Push your leg upwards against the maximal resistance.’
The hip has to move through its full available range of movement –
abduction to full adduction.
Clinical tip
As the patient is positioned in side lying, the movement cannot start in
full hip abduction.
Clinical tip
Use the length of lever arm principle to make sure you can apply a
consistent resistance to the limb. Ask the patient to start slowly so they
can appreciate the amount of resistance. Remember, the patient's hip
adductors (adductors magnus, longus and brevis) may be stronger than
your applied resistance. Use a safe and mechanically advantageous
position to enable you to perform this technique safely and effectively.
Lateral (external) rotators
Grade 0 – ‘No contraction’ and Grade 1 – ‘Flicker of a contraction’
Patient's position
Fig 1.24
Oxford muscle grading for the hip lateral (external) rotators – Grades 0
and 1.
Command to patient
‘Try and tighten your seat muscles.’
Clinical tip
Closely observing and feeling the muscle is essential in enabling the
clinician to pick up on even the smallest flicker of a contraction. Only
gluteus maximus can be palpated as the other lateral rotators are too
deep.
The patient is positioned in supine lying on the plinth, their leg in full
medial rotation.
Clinician's position
The clinician is standing by the patient, whose leg is supported by the
plinth.
Command to patient
‘Try and turn your whole leg outwards as far as you can.’
The hip has to move through its full range of movement – full medial
(internal) rotation to full lateral (external) rotation.
Command to patient
‘Push your leg inwards and upwards as far as you can.’
The movement commences with the patient's leg in full medial (internal)
rotation and finishes in full lateral (external) rotation.
Clinician's position
The clinician is kneeling or standing by the side of the patient, applying a
minimal resistance to the patient's lower leg.
Command to patient
‘Push your leg inwards and upwards as far as you can against the
minimal resistance.’
The movement commences with the patient's leg in full medial (internal)
rotation and finishes in full lateral (external) rotation.
Clinical tip
Use the length of lever arm principle to make sure you can apply a
consistent resistance to the limb. Ask the patient to start slowly so they
can appreciate the amount of resistance.
Grade 5 – ‘Full ROM against maximal resistance’
Patient's position
The patient is positioned in sitting on the raised plinth, hip and knee in
90° of flexion. Their leg starts in full medial rotation (see Fig. 1.27 ).
Fig 1.27
Oxford muscle grading for the hip lateral (external) rotators – Grades 4
and 5. The leg has moved from full medial rotation to full lateral rotation.
Clinician's position
The clinician is kneeling or standing by the side of the patient, applying a
maximal resistance to the patient's lower leg.
Command to patient
‘Push your leg inwards and upwards as far as you can against the
maximal resistance.’
The movement commences with the patient's leg in full medial (internal)
rotation and finishes in full lateral (external) rotation.
Clinical tip
Use the length of lever arm principle to make sure you can apply a
consistent resistance to the limb. Ask the patient to start slowly so they
can appreciate the amount of resistance. Remember, the patient's hip
lateral rotators (gluteus maximus, piriformis, obturator internus, etc.) may
be stronger than your applied resistance. Use a safe and mechanically
advantageous position to enable you to perform this technique safely
and effectively.
Medial (internal) rotators
Grade 0 – ‘No contraction’ and Grade 1 – ‘Flicker of a contraction’
Patient's position
Fig 1.28
Oxford muscle grading for the hip medial (internal) rotators – Grades 0
and 1.
Command to patient
‘Try and turn your leg inwards.’
Clinical tip
Closely observing and feeling the muscles is essential in enabling the
clinician to pick up on even the smallest flicker of a contraction.
NB: Gluteus medius can be palpated between the iliac crest and the
greater trochanter. Gluteus minimus can be palpated between the
anterior superior iliac spine (ASIS) and the greater trochanter.
Command to patient
‘Try and turn your whole leg inwards as far as you can.’
The hip has to move through its full range of movement – full lateral
(external) rotation to full medial (internal) rotation.
Command to patient
‘Push your leg outwards and upwards far as you can.’
The movement commences with the patient's leg in full lateral (external)
rotation and finishes in full medial (internal) rotation.
Clinician's position
The clinician is kneeling or standing by the side of the patient, applying a
minimal resistance to the patient's lower leg.
Command to patient
‘Push your leg outwards and upwards as far as you can against the
minimal resistance.’
The hip has to move through its full range of movement – full lateral
(external) rotation to full medial (internal) rotation.
Clinical tip
Use the length of lever arm principle to make sure you can apply a
consistent resistance to the limb. Ask the patient to start slowly so they
can appreciate the amount of resistance.
Command to patient
‘Push your leg outwards and upwards as far as you can against the
maximal resistance.’
The hip has to move through its full range of movement – full lateral
(external) rotation to full medial (internal) rotation.
Clinical tip
Use the length of lever arm principle to make sure you can apply a
consistent resistance to the limb. Ask the patient to start slowly so they
can appreciate the amount of resistance. Remember, the patient's hip
lateral rotators (gluteus medius and minimus) may be stronger than your
applied resistance. Use a safe and mechanically advantageous position
to enable you to perform this technique safely and effectively.
Notes
Treatment record
Leg Length
True shortening of the lower limb may occur above or below the greater
trochanter, due to conditions such as coxa vara and malunion of a
fracture of the shaft of the femur. Apparent shortening is a result of
lateral tilting of the pelvis, secondary to conditions such as an abduction
deformity of the hip joint and lumbar scoliosis. Both apparent and true
discrepancies in limb length may be observed in standing, as a lateral
tilting of the pelvis. Lateral tilting, due to true shortening and deformity of
the hip, is eliminated if the patient sits on a hard seat, such as a
gymnastic stool or a plinth. Both the lateral tilt of the pelvis and the
scoliosis will still be observable if the patient has a lumbar scoliosis.
Fig 1.32
Measurement of limb length – greater trochanter of the femur to the
medial malleolus of the tibia.
Fig 1.33
Measurement of limb length – ASIS of the innominate bone to medial
malleolus of the tibia.
Fig 1.34
Measurement of limb length – xiphoid process to medial malleolus of the
tibia.
The proximal end of the tape measure should be placed distal to the
bony landmark, pushed up to it by the thumb, and held with the thumb.
The distal end of the tape is held in an inferior pincer grip so that the
index finger can be placed immediately distal to the medial malleolus of
the tibia and the reading can be read against the thumbnail.
Patient's position
The patient is positioned in supine lying on the plinth.
Method
The clinician palpates both ASISs to determine whether or not the pelvis
is set square with the lower limbs. If it is not, they must try to correct the
alignment so that the limbs are in neutral and similarly disposed to the
pelvis. If alignment cannot be corrected because one limb cannot be
placed in neutral, the other limb must be abducted or adducted through
a corresponding angle before the true length is measured.
Apparent shortening
If the pelvis cannot be set square with the limbs, measurements are
made from the xiphisternum to the medial malleolus of the tibia on each
side with the limbs parallel. Apparent discrepancy is always due to
sideways tilting of the pelvis as a result of either an abduction or an
adduction deformity of the hip joint or lumbar scoliosis. Measurements
from the ASIS of the innominate bone to the medial malleolus of the tibia
with the limbs parallel will also be unequal.
THE KNEE JOINT
Physiotherapist's Guide to Clinical Measurement, A, Chapter 2, 41-58
Anatomy
• 1. The knee joint is one of the largest and most complex joints of
the body.
• 6. All hinge joints have collateral ligaments. The knee joint has the
tibial (medial) and fibular (lateral) collateral ligaments.
• 8. The movements that take place at the knee joint are: extension
and flexion. When the knee is flexed, axial rotation of the leg can
be performed. These movements consist of lateral (external)
rotation of the tibia on the femur and medial (internal) rotation of
the tibia on the femur.
• The patella – anterior surface of the patella, and the apex of the
patella.
• The tibia – medial and lateral condyles, and the tibial tuberosity.
Table 2.1
Knee ligaments
The patient is positioned in half lying/supine lying on the plinth, their hip
in neutral and their knee in extension.
Goniometer axis:
The axis of the goniometer is placed over the lateral epicondyle of the
femur.
Stationary arm:
This is parallel to the longitudinal axis of the femur, pointing towards the
greater trochanter of the femur.
Moveable arm:
This is parallel to the longitudinal axis of the fibula, pointing towards the
lateral malleolus of the fibula.
Command to patient:
‘Straighten your leg as much as possible.’
End position:
The knee is extended to its limit of motion.
Flexion
Starting position:
Fig 2.2
Goniometric measurement of knee flexion.
The patient is positioned in half lying/supine lying on the plinth. Their hip
is in neutral and their knee is in extension.
Goniometer axis:
The axis of the goniometer is placed over the lateral epicondyle of the
femur.
Stationary arm:
This is parallel to the longitudinal axis of the femur, pointing towards the
greater trochanter of the femur.
Moveable arm:
This is parallel to the longitudinal axis of the fibula, pointing towards the
lateral malleolus of the fibula.
Command to patient:
‘Bend your knee up towards you so that your heel moves towards your
buttock as much as possible.’
End position:
The hip and knee are flexed to the limit of motion. The heel is moved
towards the buttock to the limit of knee flexion.
Points to note:
Repeat three times and produce an average reading, then repeat the
procedure on the other limb to compare the two measurements.
Points to note:
Points to note:
Clinician's position:
The clinician is standing by the patient, with both hands palpating the
quadriceps muscles (vastus medialis and vastus lateralis) for a
contraction.
Command to patient:
‘Try and tighten your thigh muscles.’
Clinical tip:
Fig 2.6
Oxford muscle grading for the knee extensors – Grades 0 and 1.
Clinician's position:
The clinician is standing by the patient, supporting the right limb, with
one hand under the thigh and the other supporting just below the knee.
Command to patient:
‘Try and straighten your leg as far as you can.’
The knee has to move through its full range of movement – full flexion to
full extension.
Clinical tip:
Fig 2.7
Oxford muscle grading for the knee extensors – Grade 2. The knee is
moving from full flexion to full extension (the leg is straightening).
Clinician's position:
The clinician is kneeling by the patient to observe the movement.
Command to patient:
‘Straighten your leg as far as you can.’
The knee has to move through its full range of movement – full flexion to
full extension.
Clinical tip:
Fig 2.8
Oxford muscle grading for the knee extensors – Grade 3. The knee is
moving from full flexion to full extension (the leg is straightening).
This position does compromise the movement from full flexion, because
of the effects of gravity; however, practically it is one of the most suitable
positions and allows easy progress to testing for Grades 4 and 5.
Grade 4 – ‘Full ROM against minimal resistance’
Patient's position:
The patient is positioned in sitting over the edge of the plinth so that full
flexion of the knee is obtained.
Clinician's position:
The clinician is kneeling in front of the patient, applying a minimal
resistance to the patient's lower leg.
Command to patient:
‘Straighten your leg as far as you can against the minimal resistance.’
The knee has to move through its full range of movement – full flexion to
full extension.
Clinical tip:
Use the length of lever arm principle to make sure you can apply a
consistent resistance to the limb. Ask the patient to start slowly so they
can appreciate the amount of resistance.
Command to patient:
‘Straighten your leg as far as you can against the maximal resistance.’
The knee has to move through its full range of movement – full flexion to
full extension.
Clinical tip:
Use the length of lever arm principle to make sure you can apply a
consistent resistance to the limb. Ask the patient to start slowly so they
can appreciate the amount of resistance. Remember, the patient's
quadriceps may be stronger than your applied resistance. Use a safe
and mechanically advantageous position to enable you to perform this
technique safely and effectively.
Flexors
Grade 0 – ‘No contraction’ and Grade 1 – ‘Flicker of a contraction’
Patient's position:
The patient is positioned in prone lying on the plinth.
Clinician's position:
The clinician is standing by the side of the patient with both hands
palpating the hamstring muscles (semimembranosus, semitendinosus,
biceps femoris) for a contraction.
Command to patient:
‘Try and tighten your posterior thigh muscles.’
Clinical tip:
Fig 2.10
Oxford muscle grading for the knee flexors – Grades 0 and 1.
Clinician's position:
The clinician is standing by the patient, supporting the right limb with one
hand under the thigh/ knee and the other supporting just above the
ankle.
Command to patient:
‘Try and bend your leg backwards as far as you can.’
The knee has to move through its full range of movement – full
extension to full flexion.
Clinical tip:
Fig 2.11
Oxford muscle grading for the knee flexors – Grade 2. The knee is
moving from full extension to full flexion (the heel is moving backwards
towards the buttock).
The limb can be heavy, so the safe positioning of the clinician is an
essential part of this measurement technique.
Grade 3 – ‘Full ROM against the effects of gravity’
Patient's position:
The patient is positioned in standing, using the plinth for support.
Clinician's position:
The clinician is standing by the patient to observe the movement.
Command to patient:
‘Bend your leg up as far as you can.’
The knee has to move through its full range of movement – full
extension to full flexion.
Clinical tip:
Fig 2.12
Oxford muscle grading for the knee flexors – Grade 3. The knee is
moving from full extension to full flexion (the heel is moving up towards
the buttock).
The more unstable patient may have to be positioned in prone lying on
the plinth. In this position full knee flexion will be completed with the
effects of gravity assisting the movement, i.e. after 90° of knee flexion
has been achieved.
Grade 4 – ‘Full ROM against minimal resistance’
Patient's position:
The patient is positioned in prone lying on the plinth with their right foot
over the end of the plinth so that full extension of the knee is obtained.
Clinician's position:
The clinician is standing to the side of the patient, applying a minimal
resistance to the patient's lower leg.
Command to patient:
‘Bend your leg up as far as you can against the minimal resistance.’
The knee has to move through its full range of movement – full
extension to full flexion.
Clinical tip:
Use the length of lever arm principle to make sure you can apply a
consistent resistance to the limb. Ask the patient to start slowly so they
can appreciate the amount of resistance.
Command to patient:
‘Bend your leg up as far as you can against the maximal resistance.’
The knee has to move through its full range of movement – full
extension to full flexion.
Clinical tip:
Use the length of lever arm principle to make sure you can apply a
consistent resistance to the limb. Ask the patient to start slowly so they
can appreciate the amount of resistance. Remember, the patient's
hamstrings may be stronger than your applied resistance. Use a safe
and mechanically advantageous position to enable you to perform this
technique safely and effectively.
Notes
Treatment record
THE ANKLE JOINT
Anatomy
• 1. The ankle joint is a synovial hinge joint.
• The foot – the head of the talus, the sustentaculum tali of the
calcaneus, the tuberosity of the navicular and the base of the 5th
metatarsal.
Ligaments
Table 3.1
Ankle ligaments
Evertors
Table 3.5
The evertors of the ankle
Muscle Origin Insertion Nerve Action(s)
supply
Peroneus Upper two-thirds Lateral Superficial Eversion of the
longus of the lateral surfaces of peroneal foot, and
surface of the medial nerve L5, plantarflexion of
fibula cuneiform and S1 the ankle
base of the first
metatarsal
Peroneus Lower two-thirds Base of the 5th Superficial Eversion of the
brevis of lateral surface metatarsal peroneal foot, and
of the fibula nerve L5, plantarflexion of
S1 the ankle
Peroneus Lower quarter of Base of the 5th Deep Eversion of the
tertius the fibula and the metatarsal peroneal foot, and
intermuscular nerve L5, dorsiflexion of
septum S1 the ankle
Measurement
Range of Movement
Dorsiflexion
Fig 3.1
Goniometric measurement of ankle dorsiflexion.
Starting position:
The patient is positioned in supine lying on the plinth, their knee is
slightly flexed and their foot is in neutral – 0°.
Goniometer axis:
The axis of the goniometer is placed 1.5 cm below the lateral malleolus
of the fibula.
Stationary arm:
This is parallel to the longitudinal axis of the fibula, in line with the head
of the fibula.
Moveable arm:
This is parallel to the longitudinal axis of the 5th metatarsal.
Command to patient:
‘Bend your foot up as far as you can’ (dorsiflexion).
End position:
The ankle is dorsiflexed to the limit of motion.
Starting position:
The patient is positioned in supine lying on the plinth, their knee is
slightly flexed and their foot is in neutral – 0°.
Goniometer axis:
The axis of the goniometer is placed 1.5 cm below the lateral malleolus
of the fibula.
Stationary arm:
This is parallel to the longitudinal axis of the fibula, in line with the head
of the fibula.
Moveable arm:
This is parallel to the longitudinal axis of the 5th metatarsal.
Command to patient:
‘Push your foot down as far as you can’ (plantarflexion).
End position:
The ankle is plantarflexed to the limit of motion.
Inversion
Fig 3.3
Measurement of the foot in neutral.
Starting position:
The patient is positioned in supine lying on the plinth; a roll is placed
under the knee. The ankle is in neutral – 0°.
A piece of paper is placed under the foot, a book is placed against the
sole of the foot, and a line is drawn parallel to the book.
Command to patient:
‘Turn your foot in as far as you can’ (inversion).
End position:
The foot has moved into inversion.
The book is placed against the full sole of the foot and a line is drawn
parallel to the book. This line should bisect the original line, making an
angle. This angle relates to the degree of inversion at the foot.
Fig 3.4
Measurement of foot inversion.
Eversion
Fig 3.5
Measurement of foot eversion.
Starting position:
The patient is positioned in supine lying on the plinth; a roll is placed
under the knee. The ankle is in neutral – 0°.
A piece of paper is placed under the foot, a book is placed against the
sole of the foot, and a line is drawn parallel to the book.
Command to patient:
‘Turn your foot out as far as you can’ (eversion).
End position:
The foot has moved into eversion.
The book is placed against the full sole of the foot and a line is drawn
parallel to the book. This line should bisect the original line, making an
angle. This angle relates to the degree of eversion at the foot.
Notes
Treatment record
Observational/reflective checklist
Observational/reflective checklist
Observation Y/N Comments
Introduction Was the treatment area properly prepared
and for the patient, e.g. pillow, blanket, safe
preparation environment, etc.?
for the skill
Did the therapist introduce him/herself?
Was the patient comfortable?
Was the patient adequately
exposed/draped?
Was an explanation of the procedure
given?
Was the explanation clear and succinct?
Was consent obtained?
Performing Was the plinth set at the correct height?
the skill
Was the therapist's posture compromised?
Did the therapist identify the joint and other
relevant bony landmarks?
Was the goniometer correctly aligned?
Was the reading of the joint range of
movement accurate?
Did the therapist compare both sides of the
body?
Safe and Was the procedure carried out with due
effective care and attention?
performance
of the
technique
How would Excellent
you rate the
proficiency Very good
in the Good
overall
performance Satisfactory
of the skill? Borderline
Fail
Joint Girth
Fig 3.6
Measurement of the girth of the ankle joint.
Patient's position:
The patient is positioned in half lying or supine lying on the plinth.
Method:
The ankle joint girth can be measured by taking a circumferential
measurement with a tape measure around the ankle joint line.
The ankle joint line can be recognized by identifying three points around
the ankle. Firstly, mark 1.5 cm above the medial malleolus of the tibia.
Secondly, mark 2 cm above the lateral malleolus of the fibula.
To confirm this position the clinician can move the ankle joint through
plantarflexion and dorsiflexion and feel the talus move against the
thumb. This enables confirmation of the anterior joint line of the ankle.
The joint is encircled with a tape measure around the joint line. The
circumferential measurement is then recorded.
Repeat the procedure on the other limb to compare the joint girth.
Points to note:
Patient's position:
The patient is positioned in long sitting or half lying on the plinth, well
supported. The knees are in passive extension so that the calf and thigh
muscles are relaxed.
Method:
Mark two or three points – 5 cm (2 inches), 10 cm (4 inches) and 15 cm
(6 inches) below the distal end of the tibial tuberosity. (If the patient is
small in stature, the measure at 15 cm (6 inches) may not be
necessary.)
The limb is encircled with a tape measure at each marked point. The
circumferential measurements are then recorded. Repeat the procedure
three times and produce an average reading. Repeat the procedure on
the other limb to compare the measurements.
Points to note:
Clinician's position:
The clinician is standing at the foot of the plinth with both hands
palpating the gastrocnemius muscle for a contraction.
Command to patient:
‘Try and tighten your calf muscles/try and move your foot up towards the
ceiling.’
Clinical tip:
Closely observing and feeling the muscle is essential in enabling the
clinician to pick up on even the smallest flicker of a contraction.
Fig 3.8
Oxford muscle grading for the ankle plantarflexors – Grades 0 and 1.
Clinician's position:
The clinician is standing by the patient, supporting the limb with one
hand just below the knee and the other supporting the foot.
Command to patient:
‘Try and push your foot away from your leg as far as you can.’
The ankle has to move through its full range of movement – full
dorsiflexion to full plantarflexion.
Clinical tip:
The limb can be heavy, so the safe positioning of the clinician is an
essential part of this measurement technique.
Fig 3.9
Oxford muscle grading for the ankle plantarflexors – Grade 2. The ankle
is moving from full dorsiflexion to full plantarflexion.
Grade 3 – ‘Full ROM against the effects of gravity’
Patient's position:
The patient is positioned in prone lying, with their feet over the end of the
plinth. The foot is in full dorsiflexion.
Clinician's position:
The clinician is standing at the foot of the plinth to observe the
movement.
Command to patient:
‘Move your foot upwards towards the ceiling as far as you can.’
The ankle has to move through its full range of movement – full
dorsiflexion to full plantarflexion.
Clinical tip:
Make sure the patient is in a fully plantarflexed position with the anterior
tibial muscles (tibialis anterior, extensor digitorum longus, extensor
hallucis longus) relaxed. This can be achieved by palpating the anterior
tibial muscles to assess muscle activity.
Fig 3.10
Oxford muscle grading for the ankle plantarflexors – Grade 3. The ankle
is moving from full dorsiflexion to full plantarflexion (the sole of the foot is
moving upwards).
Grade 4 – ‘Full ROM against minimal resistance’
Patient's position:
The patient is positioned in prone lying, with their feet over the end of the
plinth. Their foot is in full dorsiflexion.
Clinician's position:
The clinician is standing at the foot of the plinth, applying a minimal
resistance to the patient's foot.
Command to patient:
‘Push your foot up as far as you can against the minimal resistance.’
The ankle has to move through its full range of movement – full
dorsiflexion to full plantarflexion.
Clinical tip:
Use the length of lever arm principle to make sure you can apply a
consistent resistance to the limb. Ask the patient to start slowly so they
can appreciate the amount of resistance.
Command to patient:
‘Push your foot up as far as you can against the maximal resistance.’
The ankle has to move through its full range of movement – full
dorsiflexion to full plantarflexion.
Clinical tip:
Use the length of lever arm principle to make sure you can apply a
consistent resistance to the limb. Ask the patient to start slowly so they
can appreciate the amount of resistance. Remember, the patient's calf
muscles may be stronger than your applied resistance; use a safe and
mechanically advantageous position to enable you to perform this
technique safely and effectively.
Dorsiflexors
Grade 0 – ‘No contraction’ and Grade 1 – ‘Flicker of a contraction’
Patient's position:
The patient is positioned in prone lying or long sitting on the plinth, their
feet over the end of the plinth.
Clinician's position:
The clinician is standing at the foot of the plinth, with both hands
palpating the tibialis anterior muscle for a contraction
Command to patient:
‘Try and tighten the muscles on the front of your leg/pull your foot up
towards you.’
Clinical tip:
Closely observing and feeling the muscle is essential in enabling the
clinician to pick up on even the smallest flicker of a contraction.
Fig 3.12
Oxford muscle grading for the ankle dorsiflexors – Grades 0 and 1.
Clinician's position:
The clinician is standing by the patient, supporting the right limb with one
hand under the knee area and the other supporting the foot.
Command to patient:
‘Try and pull your foot up as far as you can.’
The ankle has to move through its full range of movement – full
plantarflexion to full dorsiflexion.
Clinical tip:
The limb can be heavy, so the safe positioning of the clinician is an
essential part of this measurement technique.
Fig 3.13
Oxford muscle grading for the ankle dorsiflexors – Grade 2. The ankle is
moving from full plantarflexion to full dorsiflexion (the dorsum of the foot
is moving towards the shin).
O
Grade 3 – ‘Full ROM against the effects of gravity’
Patient's position:
The patient is positioned in supine lying or long sitting on the plinth.
Their foot is hanging over the end of the plinth in full plantarflexion.
Clinician's position:
The clinician is standing at the foot of the plinth to observe the
movement.
Command to patient:
‘Pull your foot upwards as far as you can.’
The ankle has to move through its full range of movement – full
plantarflexion to full dorsiflexion.
Fig 3.14
Oxford muscle grading for the ankle dorsiflexors – Grade 3. The ankle is
moving from full plantarflexion to full dorsiflexion (the dorsum of the foot
is moving up towards the shin).
Grade 4 – ‘Full ROM against minimal resistance’
Patient's position:
The patient is positioned in supine lying or long sitting on the plinth.
Their foot is hanging over the end of the plinth in full plantarflexion.
Clinician's position:
The clinician is standing at the foot of the plinth, applying a minimal
resistance to the top of the patient's foot.
Command to patient:
‘Push your foot up as far as you can against the minimal resistance.’
The ankle has to move through its full range of movement – full
plantarflexion to full dorsiflexion.
Clinical tip:
Use the length of lever arm principle to make sure you can apply a
consistent resistance to the limb. Ask the patient to start slowly so they
can appreciate the amount of resistance.
Command to patient:
‘Push your foot up as far as you can against the maximal resistance.’
The ankle has to move through its full range of movement – full
plantarflexion to full dorsiflexion.
Clinical tip:
Use the length of lever arm principle to make sure you can apply a
consistent resistance to the limb. Ask the patient to start slowly so they
can appreciate the amount of resistance. Remember, the patient's
anterior tibial muscles may be stronger than your applied resistance.
You must use a safe and mechanically advantageous position to enable
you to perform this technique safely and effectively.
Evertors
Grade 0 – ‘No contraction’ and Grade 1 – ‘Flicker of a contraction’
Patient's position:
The patient is positioned in long sitting on the plinth, with their foot over
the end of the plinth.
Clinician's position:
The clinician is standing at the foot of the plinth with both hands
palpating the lateral aspect of the leg, over the peroneal muscles
(peroneus longus and brevis).
Command to patient:
‘Try and turn your foot outwards (by using the muscles on the side of
your leg).’
Clinical tip:
Closely observing and feeling the muscles is essential in enabling the
clinician to pick up on even the smallest flicker of a contraction.
Peroneus longus and brevis can be felt to contract on the lateral side of
the leg, below the head of the fibula. The tendons can be palpated as
they pass behind the lateral malleolus of the fibula.
Fig 3.16
Oxford muscle grading for the ankle evertors – Grades 0 and 1.
Clinician's position:
The clinician is standing at the foot of the plinth, supporting the
calcaneus and the foot.
Command to patient:
‘Try and turn your foot outwards as far as you can.’
The ankle has to move through its full range of movement – full inversion
to full eversion.
Clinical tip:
The leg and foot can be heavy, so the safe positioning of the clinician is
an essential part of this measurement technique. This has to be
balanced against being able to take the weight of the foot, but not
actually assisting the patient's efforts to evert the foot.
Fig 3.17
Oxford muscle grading for the ankle evertors – Grade 2. The ankle is
moving from full inversion to full eversion (the foot is moving from being
fully turned in to being fully turned out).
Clinician's position:
The clinician is standing at the foot of the plinth to observe the
movement.
Command to patient:
‘Try and turn the sole of your foot so that it is facing towards the ceiling.’
The ankle has to move through its full range of movement – full inversion
to full eversion.
Fig 3.18
Oxford muscle grading for the ankle evertors – Grade 3. The ankle is
moving from full inversion to full eversion (the sole of the foot is turning
up towards the ceiling).
Grade 4 – ‘Full ROM against minimal resistance’
Patient's position:
The patient is positioned in side lying on the plinth, their inverted foot
over the end of the plinth.
Clinician's position:
The clinician is standing at the foot of the plinth, applying a minimal
resistance to the lateral border of the foot.
Command to patient:
‘Try and turn the sole of your foot so that it is facing towards the ceiling
against the minimal resistance.’
The ankle has to move through its full range of movement – full inversion
to full eversion.
Command to patient:
‘Try and turn the sole of your foot so that it is facing towards the ceiling
against the maximal resistance.’
The ankle has to move through its full range of movement – full inversion
to full eversion.
Invertors
Grade 0 – ‘No contraction’ and Grade 1 – ‘Flicker of a contraction’
Patient's position:
The patient is positioned in long sitting on the plinth, their everted foot
over the end of the plinth.
Clinician's position:
The clinician is standing at the foot of the plinth with their hand palpating
the tendon of tibialis posterior on the medial aspect of the ankle joint.
Command to patient:
‘Try and turn your foot inwards by using the muscles on the inside of
your leg.’
Clinical tip:
Closely observing and feeling the tendon is essential in enabling the
clinician to pick up on even the smallest flicker of a contraction. Tibialis
posterior is a deep calf muscle, but it can be palpated behind the medial
malleolus of the tibia.
Fig 3.20
Oxford muscle grading for the ankle invertors – Grades 0 and 1.
Clinician's position:
The clinician is standing at the foot of the plinth, supporting the
calcaneus and the foot.
Command to patient:
‘Try and turn your foot inwards as far as you can.’
The ankle has to move through its full range of movement – full eversion
to full inversion.
Clinical tip:
The foot can be heavy, so the safe positioning of the clinician is an
essential part of this measurement technique. This has to be balanced
against being able to take the weight of the foot, but not actually
assisting the patient's efforts to invert the foot.
Fig 3.21
Oxford muscle grading for the ankle invertors – Grade 2. The ankle has
moved from full inversion to full eversion (the foot has moved from being
fully turned out to being fully turned in).
Grade 3 – ‘Full ROM against the effects of gravity’
Patient's position:
The patient is positioned in side lying on the plinth, their everted foot
over the end of the plinth.
Clinician's position:
The clinician is standing at the foot of the plinth observing the
movement.
Command to patient:
‘Try and turn the sole of your foot so that it is facing towards the ceiling.’
The ankle has to move through its full range of movement – full eversion
to full inversion.
Fig 3.22
Oxford muscle grading for the ankle invertors – Grade 3. The ankle has
moved from full eversion to full inversion (the foot has moved from being
fully turned out to being fully turned in).
Grade 4 – ‘Full ROM against minimal resistance’
Patient's position:
The patient is positioned in side lying on the plinth, their everted foot
over the end of the plinth.
Clinician's position:
The clinician is standing at the foot of the plinth, applying a minimal
resistance to the medial border of the foot.
Command to patient:
‘Try and turn the sole of your foot so that it is facing towards the ceiling
against the minimal resistance.’
The ankle has to move through its full range of movement – full eversion
to full inversion.
Command to patient:
‘Try and turn the sole of your foot so that it is facing towards the ceiling
against the maximal resistance.’
The ankle has to move through its full range of movement – full eversion
to full inversion.
Notes
Treatment record
Notes
Treatment record