Lower limb practical techniques review

Hip flexion goniometry (normal range and alignment)

Range: $0^\bot\text{--}125^\bot$. Axis: Lateral hip joint, anterior and superior to the greater trochanter. Stationary arm: Lateral midline of the trunk aligned with the greater trochanter. Moving arm: Lateral midline of the femur toward the lateral femoral epicondyle.

Hip extension and hyperextension goniometry (normal range and alignment)

Range: Return from flexion to $0^\bot$; hyperextension is $0^\bot\text{--}15^\bot$. Axis and arms: Identical to hip flexion. Patient positioned sidelying (opposite hip flexed to $90^\bot$) or prone with pelvis stabilized to prevent anterior pelvic tilt and lumbar extension.

Hip abduction goniometry (normal range and alignment)

Range: $0^\bot\text{--}45^\bot$. Axis: Anterior hip joint, in line with the greater trochanter. Stationary arm: Horizontal line parallel to and below the bilateral ASIS. Moving arm: Anterior midline of the femur directed toward the midline of the patella.

Hip adduction goniometry (normal range and alignment)

Range: $0^\bot\text{--}30^\bot$. Axis and arms: Identical to hip abduction. The non-tested extremity is abducted to allow clearance of the tested limb, with the pelvis stabilized against lateral tilting.

Hip medial and lateral rotation goniometry (normal range and alignment)

Range: $0^\bot\text{--}45^\bot$ each. Position: Supine or sitting with knee flexed $90^\bot$. Axis: Anterior mid-patella toward the femoral head. Stationary arm: Parallel to the table surface (or perpendicular to the floor). Moving arm: Anterior midline of the tibia toward the mid-malleolar point.

Thomas test (procedure and positive indication)

Patient is supine with knees brought to chest to flatten lumbar lordosis; the test thigh is lowered over the table edge while maintaining neutral rotation. A positive finding is failure of the posterior thigh to touch the table, indicating hip flexor contracture or shortness.

Ober test (procedure and positive indication)

Patient is sidelying with lower leg flexed; test hip is abducted, extended, and allowed to passively drop in adduction toward the table. A positive finding is failure of the thigh to drop to or below horizontal, indicating tensor fasciae latae and iliotibial band tightness.

Rectus femoris length assessment (modified Thomas position)

During hip extension over the table edge with the opposite knee held to chest, passive knee flexion is measured. Shortness is indicated if the knee involuntarily extends as the thigh is lowered or if knee flexion fails to reach approximately $80^\bot$.

Hamstring length test at the hip (straight leg raise)

In supine position with the pelvis neutral and opposite leg secured flat, the test hip is passively flexed with the knee kept straight until the sacrum begins to lift. Normal range is approximately $70^\bot\text{--}80^\bot$ of hip flexion.

Hip flexion MMT (primary muscle, AG position, and substitutions)

Primary muscle: Iliopsoas. AG Position: Seated with thighs supported, flexing the hip through available range while holding the table edge. Common substitutions: Sartorius (adds hip abduction and lateral rotation), TFL (adds hip abduction and medial rotation), and rectus femoris.

Resistance: on knee

Stabilisation: on the opposite (non-test) hip

Gluteus maximus MMT (AG position and key substitution)

AG Position: Standing with trunk bent over a table or prone with the knee flexed to $90^\bot$ to slacken the hamstrings, extending the hip against resistance applied at the posterior distal thigh. Key substitution: Hamstrings extending the hip.

Gluteus medius MMT (AG position, alignment, and substitutions)

AG Position: Sidelying with lower leg flexed; test hip is abducted slightly in extension with the knee straight and pelvis stabilized. Substitutions: Quadratus lumborum (pelvic hiking) or TFL if the hip accidentally flexes and internally rotates.

Sartorius MMT (combined motion and resistance points)

Motion: Simultaneous hip flexion, abduction, and lateral rotation with knee flexion (bringing heel toward contralateral knee). Resistance: Counter-force applied to the lateral distal thigh (toward extension/adduction) and at the medial malleolus (toward medial rotation).

Knee flexion and extension goniometry (normal ranges and alignment)

Flexion range: $0^\bot\text{--}130^\bot$; Extension range: Return to $0^\bot$. Axis: Lateral epicondyle of the femur. Stationary arm: Lateral midline of the femur toward the greater trochanter. Moving arm: Lateral midline of the fibula toward the lateral malleolus.

One-joint knee flexors length assessment (popliteus and short head of biceps femoris)

Prone with hips extended to slacken two-joint hamstrings and ankles off the table to slacken gastrocnemius; the knee is passively extended. Incomplete extension indicates tightness in the one-joint knee flexors.

Quadriceps vasti length assessment

Patient is sidelying or supine with the hip flexed to $90^\bot$ to eliminate rectus femoris passive tension; the knee is passively flexed. Normal reference value is approximately $125^\bot$ of knee flexion.

Hamstrings MMT (rotational biasing for medial vs. lateral heads)

Patient is prone, flexing the knee against resistance applied above the ankle. Biasing biceps femoris: Tibia positioned in lateral rotation. Biasing semitendinosus and semimembranosus: Tibia positioned in medial rotation.

Ankle dorsiflexion and plantarflexion goniometry (normal ranges and alignment)

Dorsiflexion: $0^\bot\text{--}20^\bot$ (knee flexed); Plantarflexion: $0^\bot\text{--}45^\bot$. Axis: Approximately $1\,\text{inch}$ distal to the lateral malleolus. Stationary arm: Lateral fibula toward the fibular head. Moving arm: Lateral calcaneus.

Gastrocnemius versus soleus muscle length differentiation

Passive ankle dorsiflexion is measured with the knee extended versus flexed $90^\bot$. Limited dorsiflexion with knee extended that normalizes with knee flexion indicates gastrocnemius tightness; restriction persisting in knee flexion indicates soleus or posterior capsular tightness.

Gastrocnemius standing functional MMT (grading criteria)

Single-leg standing heel raises through full range with knee extended: $1\,\text{rep} = \text{Fair (3)}$; $2\text{--}3\,\text{reps} = \text{Fair+ (3+)}$; $4\text{--}6\,\text{reps} = \text{Good (4)}$; $7\text{--}9\,\text{reps} = \text{Good+ (4+)}$; $10\,\text{reps} = \text{Normal (5)}$.

Soleus MMT (isolation rationale and test position)

Rationale: Knee flexion slackens the gastrocnemius, isolating soleus plantarflexion. AG Position: Prone with the knee flexed to $90^\bot$ (or single-leg standing with knee flexed), plantarflexing the ankle against resistance applied at the plantar rearfoot.

Tibialis anterior MMT (motion, resistance, and substitution)

Motion: Ankle dorsiflexion with inversion. Resistance: Medial dorsal forefoot pushing toward plantarflexion and eversion. Key substitution: Extensor hallucis longus (minimized by instructing the patient to keep the great toe relaxed or flexed).

Tibialis posterior MMT (motion, resistance, and tendon palpation)

Motion: Inversion with slight plantarflexion starting from neutral. Resistance: Medial forefoot pushing toward eversion and dorsiflexion. Palpation: Tendon directly posterior and inferior to the medial malleolus.

Peroneus longus and brevis MMT (motion, resistance, and substitutions)

Motion: Foot eversion while maintaining neutral plantarflexion/dorsiflexion. Resistance: Lateral forefoot pushing toward inversion. Substitutions: Extensor digitorum longus (causes dorsiflexion) and flexor digitorum longus (causes plantarflexion).