Knee and Thigh Anterior Structures PDF

KNEE AND THIGH: ANTERIOR STRUCTURES Patellar Tendon Patellar tendon Sartorius Gastrocnemius Tibialis anterior The patellar tendon, also known as the patellar ligament, is a continuation of the quadriceps tendon that encases the patella. The patellar tendon runs from the inferior pole of the pate...

KNEE AND THIGH: ANTERIOR STRUCTURES Patellar Tendon Patellar tendon Sartorius Gastrocnemius Tibialis anterior The patellar tendon, also known as the patellar ligament, is a continuation of the quadriceps tendon that encases the patella. The patellar tendon runs from the inferior pole of the patella to the tibial tuberosity, passing over the anterior joint line of the knee. Origin: Quadriceps tendon Extensor digitorum longus Soleus Superior extensor retinaculum Extensor hallucis longus Inferior peroneal retinaculum Insertion: Tibial tuberosity Action: Provides a mechanical advantage for knee extension and flexion as well as stability of the tibiofemoral joint Inferior extensor retinaculum Extensor hallucis brevis Extensor digitorum brevis Anterior Palpation Procedure • Place theE6296/Speicher/Fig. patient in a relaxed supine hip-flexed 06.02/532077/JG/R2 position. • Locate the inferior pole of the patella and slide the fingers just inferior to and onto the patellar tendon. • Strum across the tendon downward to its insertion at the tibial tuberosity. • Be certain to palpate the medial and lateral borders of the patellar tendon as well as its anterior fibers. • Note the location of any tender points or fasciculatory response of the tendon and its origin and insertion. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. 96 Patellar tendon palpation procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. KNEE AND THIGH: ANTERIOR STRUCTURES PRT Clinician Procedure • Place the patient supine. • Place a bolster or rolled towel under the femur just above knee joint. • Apply a posterior translational force with your far hand at the distal femur above the patella, being careful not to compress the patella. • Gently translate the patella inferiorly with your far hand. • With the far hand, rotate the patella and femur to fine-tune. • Corollary tissues treated: Quadriceps tendon, patellar retinaculum, joint capsule See video 6.1 for the patellar tendon PRT procedure. Patient Self-Treatment Procedure • Sit with the knee extended. • Place a bolster or rolled towel under the femur above the knee joint. • Apply a posterior translational force at the distal femur above the patella, being careful not to compress the patella. • Gently translate the patella inferiorly. • Rotate the patella and femur to fine-tune. • Maintain the treatment position until the fasciculatory response abates or for three to five minutes. Patellar tendon PRT clinician procedure. Patellar tendon patient self-treatment procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 97 KNEE AND THIGH: ANTERIOR STRUCTURES Quadriceps Tendon Quadricep tendon Fibrous expansion of quadriceps femoris tendon Tibial collateral ligament Patellar ligament Palpation Procedure • Place patient in a short-sit position with the E6296/Speicher/Fig. 06.03/532081/JG/R1 knee fully extended. • With two fingers, strum across its fibers, noting its distinct borders and medial and lateral depressions. • Note the location of any tender points or fasciculatory response of the tendon and its origin and insertion. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. 98 The quadriceps tendon is a convergence of the inferior fibers of the rectus femoris, vastus medialis, vastus intermedius, and vastus lateralis. Most of the tendon’s fibers are formed by the rectus femoris and vastus lateralis. The quadriceps tendon is not as often injured as its cousin the patellar tendon, but it can be a site of irritation due to muscular imbalance between the vastus medialis and vastus lateralis. Origin: Musculotendinous junction of the quadriceps Insertion: Superior pole of the patella Action: Patellar stabilization and transmission of force production to produce and slow knee movement Quadriceps tendon palpation procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. KNEE AND THIGH: ANTERIOR STRUCTURES PRT Clinician Procedure • Place the patient supine with the knee extended and the hip flexed to 60°. Place the lower leg on your knee or a bolster. • With your far hand, apply downward pressure on the tibia below the patella to encourage knee hyperextension. • Also use your far hand to translate the soft tissue superiorly. • Rotate the tibia and patella with the far hand to fine-tune. • Corollary tissues treated: Patella, patellar tendon, quadriceps group Patient Self-Treatment Procedure • Place the lower leg and foot on a stool or couch arm. • Lean forward and place two fingers over the tendon to monitor the fasciculatory response and tissue relaxation. • Place the palm of the other hand over the tibia below the kneecap and press downward; then translate the tissue up toward the tendon. • Rotate the tibia and patella to fine-tune. • Maintain the treatment position until the fasciculatory response abates or for three to five minutes. Quadriceps tendon PRT clinician procedure. Quadriceps tendon patient self-treatment procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 99 KNEE AND THIGH: ANTERIOR STRUCTURES Rectus Femoris Gracilis Rectus femoris Adductor magnus Vastus medialis The rectus femoris is the only quadriceps muscle that attaches at two joints: the hip and knee. Its superficial fibers are bipennate and its deep fibers are parallel and vertically oriented down the center of the thigh. Origin: Anterior inferior iliac spine, acetabulum, hip capsule Insertion: Quadriceps tendon coursing into the patellar tendon to affix to the tibial tuberosity Action: Knee extension, hip flexion Innervation: L2-L4 (femoral nerve) Patellar tendon Palpation Procedure • Place the patient supine with the knee bolE6296/Speicher/Fig. 6.4/532085/JG/R1 stered. • Follow the tendon’s insertion point at the anterior inferior iliac spine to the superior pole of the patella. • Strum across the fibers. The muscle is approximately two to three fingers in width. • Resistive hip and knee flexion will make this muscle more pronounced for palpation. • Note the location of any tender points or fasciculatory response of the muscle and its tendon and respective attachment sites. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. 100 Rectus femoris palpation procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. KNEE AND THIGH: ANTERIOR STRUCTURES PRT Clinician Procedure • The patient is supine with the hip flexed and the ankle on your shoulder. • Using your far hand, apply a posterior pressure at the femur just above the patella to encourage knee hyperextension while moving the quadriceps toward the hip. • With the far hand, apply rotation to the tissues or femur, or both. • Compress the femur up toward the hip joint with your body for fine-tuning. • Corollary tissues treated: Quadriceps tendon, adductors, vasti See video 6.2 for the rectus femoris PRT procedure. Patient Self-Treatment Procedure • Place the lower leg and foot on a stool or couch arm. • Lean forward and place one or both hands over the femur just above the patella and simultaneously push the femur down and pull the quadriceps toward the hip. • If possible, monitor the fasciculatory response and tissue relaxation at the site of pain. • Rotate the femur to fine-tune. • Maintain the treatment position until the fasciculatory response abates or for three to five minutes. Rectus femoris PRT clinician procedure. Rectus femoris patient self-treatment procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 101 KNEE AND THIGH: ANTERIOR STRUCTURES Patella Fibrous expansion of quadriceps femoris tendon Patella Tibial collateral ligament The patella, the largest sesamoid bone in the body, is located within the quadriceps femoris tendon. Its anterior location at the knee allows it to protect the tibiofemoral joint and serve as a fulcrum for the production of joint force and movement. The patella also serves as an attachment site for multiple tissues. Its posterior surface and margins are often sites of irritation when its tracking in the trochlear groove of the knee is abnormal as a result of muscle imbalance, pain, or tissue tightness. Patellar ligament Palpation Procedure • Place the patient supine in a short-sit position with theE6296/Speicher/Fig. knee fully extended. 06.01/532074/JG/R1 • Palpate the surface and edges of the patella with light pressure so as not to compress the patella downward. • Shift and tilt the patella upward in all directions to expose the under margin. Apply light pressure to its undersurfaces. • Note the location of any tender points or fasciculatory response at or around the structure. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. Patella PRT clinician procedure. PRT Clinician Procedure • The patient is supine in a short-sit position. • Move the patella toward the tender point with your far hand. • With the far hand, tilt or rotate the patella to fine-tune. Patient Self-Treatment Procedure • Sit against a wall with the knee fully extended. • Shift, tilt, and rotate the patella toward the area of tenderness to achieve maximal relaxation of the tissue coupled with a rise in the fasciculatory response while keeping the fingers on the area with submaximal pressure. 102 Patella patient self-treatment procedure. • Maintain the treatment position until the fasciculatory response abates or for three to five minutes. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. KNEE AND THIGH: MEDIAL STRUCTURES Medial Collateral Ligament Articular capsule Oblique popliteal ligament Medial head of gastrocnemius muscle Lateral head of gastrocnemius muscle Medial collateral ligament Fibular (lateral) collateral ligament Arcuate ligament Tendon of semimembranosus muscle The medial collateral ligament (MCL) is composed of superficial and deep fibers to provide the knee with medial and rotatory stability. Its deep fibers may be torn with meniscal tears because of their direct attachment. Origin: Posterior aspect of the medial femoral condyle Insertion: Medial tibial flare 5 cm (2 in.) below the joint line and underneath the pes anserine Action: Limits valgus and rotatory knee stress Interosseous membrane Palpation Procedure • Place the patient in a knee-flexed seated posiE6296/Speicher/Fig. 06.06/532092/JG/R2 tion to move the iliotibial band posteriorly. • Move medially off the patellar tendon and toward the medial joint line. • Strum over the joint line, and then palpate lightly up and down onto the femoral and tibial condyles. • Note the location of any tender points or fasciculatory response of the ligament and its origin and insertions. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. MCL palpation procedure. PRT Clinician Procedure • The patient is supine. • Place the patient’s knee over your thigh to position it at approximately 30° of flexion. • Apply a varus force at the knee using your far hand at the ankle. • Apply marked ankle inversion with your far hand. • Internally rotate and compress the tibia upward to fine-tune with your far hand. • Corollary tissues treated: Knee capsule, patellar tendon See video 6.3 for the MCL PRT procedure. MCL PRT clinician procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 103 KNEE AND THIGH: MEDIAL STRUCTURES Pes Anserine Semitendinosus Gracilis Sartorius The pes anserine is composed of three conjoined tendons (sartorius, gracilis, and semitendinosus) at the medial knee that assist in rotatory control of the knee during gait. Overuse of eccentric hip rotation or lack of eccentric hip rotatory control is often attributed to the development of pes anserine bursitis and tendinopathy. A mnemonic for the orientation of the tendons from anterior to posterior is say (sartorius) grace (gracilis) before tea (semitendinosus). Origin: Respective musculotendinous junction of the associated musculature Insertion: Medial to the tibial tuberosity Action: Provides rotatory control and stability of the knee during gait; assists with hip external rotation and flexion Palpation Procedure • The patient is supine. 6.5/532089/JG/R1 E6296/Speicher/Fig. • Slide the fingers approximately 1 inch (2.5 cm) medially from the tibial tuberosity onto the bony insertion site. On the well-developed patient, the mass of the tendons can be grasped as a group at the medial knee. • With the pads of the fingers, lightly pin the tendons against the bone while strumming the tendons up and over the bone medial to lateral. • Be sure to palpate the conjoined tendon from its bony insertion to the individual musculotendinous junction of the respective tendons just above the medial femoral condyle. • Note the location of any tender points or fasciculatory response of the tendons and their attachment sites. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. 104 Pes anserine palpation procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. KNEE AND THIGH: MEDIAL STRUCTURES PRT Clinician Procedure • The patient is supine. • With the knee over the treatment table or your thigh, place the patient into slight hip extension. • Using your far hand, move the knee into approximately 40 to 60° of flexion. • With the far hand, move the lower leg into adduction, closing the medial joint line. • Internally rotate the tibia at the ankle with the far hand. • Using the far hand, apply marked calcaneal and forefoot inversion. • Apply tibial traction or upward compression with the far hand for fine-tuning. • Corollary tissues treated: Medial collateral ligament, posterior tibialis See video 6.4 for the pes anserine PRT procedure. Pes anserine PRT clinician procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 105 KNEE AND THIGH: MEDIAL STRUCTURES Vastus Medialis Oblique The vastus medialis oblique (VMO) is a small teardrop-looking muscle on the inside of the knee in well-developed people. Its obliquely oriented fibers (50-55°) help to stabilize the patella against the pull of the lateralis. Imbalance between these two muscles has been attributed to patellar maltracking, leading to pain and atrophy. Rectus femoris Vastus medialis Vastus lateralis Vastus medialis oblique E6296/Speicher/Fig. Palpation Procedure 06.07/532095/JG/R1 • Place the patient in a supine short-sit position. • Place your fingers just superior and medial to the patella over the knee. • Instruct the patient to extend the knee to feel the contraction of the VMO fibers and also to observe the tracking of the patella. • Note the location of any tender points or fasciculatory response of the muscle and its attachment site. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. Origin: Femur, adductor magnus tendon, medial intermuscular septum Insertion: Patella, medial quadriceps tendon, patellar tendon Action: Assist with terminal knee extension; stabilizes the patella Innervation: L2-L4 (femoral nerve) VMO palpation procedure. PRT Clinician Procedure • The patient is supine. • Place the patient’s lower leg on your thigh. • Grasp above the VMO muscle belly with your near thumb and translate the tissues diagonally toward the inferior lateral knee while using one of the fingers of your near hand to monitor the lesion. • Apply a posterior force at the superior tibia below the patella with your far hand to encourage hyperextension. 106 T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. KNEE AND THIGH: MEDIAL STRUCTURES • Rotate the tibia with your far hand to fine-tune. • Corollary tissues treated: Knee capsule, quadriceps tendon, rectus femoris Patient Self-Treatment Procedure • Place the lower leg and foot on a stool or couch arm. • Lean forward and place one hand below the patella at the tibia and the other just superior of the VMO muscle belly. • Apply downward pressure below the patella while translating the muscle belly diagonally toward the lateral knee. • Rotate the tibia to fine-tune. • Monitor the VMO for a fasciculatory response and tissue relaxation at the site of pain. • Maintain the treatment position until the fasciculatory response abates or for three to five minutes. VMO PRT clinician procedure. VMO patient self-treatment procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 107 KNEE AND THIGH: MEDIAL STRUCTURES Adductor Group The adductor group is composed of the adductor magnus, longus, and brevis; the pectineus; and the gracilis. The adductors as a group stabilize the pelvic complex and the lower articulations during locomotion; however, they also produce adduction and assist with hip flexion during open-chain movements. Pubic bone Pectineus Obturator externus Adductor brevis Adductor magnus Adductor longus Gracilis Origin: Adductor magnus: Inferior ramus of the pubis, ischial tuberosity Adductor longus: Pubic tubercle E6296/Speicher/Fig. 6.8/532099/JG/R1 Adductor brevis: Inferior ramus of the pubis Pectineus: Superior ramus of the pubis Gracilis: Inferior ramus of the pubis Insertion: Adductor magnus: Linea aspera of the femur, adductor tubercle Adductor longus: Middle third of the linea aspera medial lip Adductor brevis: Proximal third of the linea aspera medial lip Pectineus: Pectineal line of the femur Gracilis: Medial tibial surface below the tibial condyle, pes anserine Action: Adductor magnus: Hip adduction, extension (inferior fibers), and flexion (superior fibers); assists with hip rotation Adductor longus: Hip adduction; assists with hip flexion and rotation Adductor brevis: Hip adduction and flexion Pectineus: Hip adduction; assists with hip flexion Gracilis: Hip adduction, knee flexion; assists with medial knee rotation Innervation: Adductor magnus: Superior and middle fibers, L2-L4 (obturator nerve); inferior fibers, L2-L4 (sciatic nerve) Adductor longus: L2-L4 (obturator nerve) Adductor brevis: L2-L4 (obturator nerve) Pectineus: L2-L3 (femoral nerve and accessory obturator nerve when present) Gracilis: L2-L3 (obturator nerve) 108 T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. KNEE AND THIGH: MEDIAL STRUCTURES Palpation Procedure • Locate the common adductor tendon at the adductor tubercle of the inferior ramus of the pubis. The tendon is formed by the adductor longus and gracilis and is the largest and most prominent tendon in the medial groin area. • The pectineus is located lateral and anterior to the common adductor tendon. • Place the patient in a supine position. The thigh will naturally rotate outward in this position exposing the adductors for palpation. • Instruct the patient to adduct against resistance to differentiate the adductors’ fibers from the vastus medialis musculature. • Work either from the distal or proximal medial thigh and strum the adductors upward against the femur as a group. • Note the location of any tender points or fasciculatory response of the muscles and their tendons, origin, and insertions. • Determine the most dominant tender point or fasciculation (or both) and maintain light pressure with the pad(s) of the finger(s) throughout the treatment until reassessment has occurred. PRT Clinician Procedure • The patient is supine. • Move the limb into straight-leg hip flexion with your far hand to assess where the adductors feel the most relaxed or a fasciculation manifests, and place the limb on either a bolster or your thigh when found. Typically, the more proximal the lesion is, the more hip flexion will be needed. • Move the limb into adduction with the far hand. • Apply marked calcaneal and foot inversion with the far hand. • Apply marked internal rotation of the limb with the far hand. • Medially translate the quadriceps and fascia toward the lesion with your near hand while using one of the fingers of that hand to monitor the lesion. • Compress the limb upward with the far hand for fine-tuning. • Corollary tissues treated: Vastus medialis, sartorius Adductor group palpation procedure. Adductor group PRT clinician procedure. Patient Self-Treatment Procedure • Lie supine. • While palpating the tender area with one hand to assess tissue relaxation and the presence of a fasciculation, cross the involved leg over the other, and rest it on it or within the range of adduction where the greatest position of comfort and tissue fasciculation occurs. • Internally rotate the leg. Adductor group patient self-treatment procedure. See video 6.5 for the adductor group PRT procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 109 KNEE AND THIGH: MEDIAL STRUCTURES Pectineus Pectineus Adductor longus Gracilis Adductor magnus Vastus medialis The pectineus is highlighted in the adductor group because anterior hip pain is often the result of a pectineus lesion rather than from an issue originating from the rectus femoris. A pectineus lesion can present within the muscle belly, but it is often found at its origin on the ramus. However, both are treated with the same PRT procedure. Origin: Superior ramus of the pubis Insertion: Pectineal line of the femur Action: Hip adduction; assists with hip flexion Innervation: L2-L3 (femoral nerve and accessory obturator nerve when present) Anterior E6296/Speicher/Fig. 06.09/532103/JG/R2 Palpation Procedure • Place the patient supine with the hip partially flexed and the knee bolstered. • Locate the common adductor tendon of the longus and gracilis and move laterally into the soft tissues, where the belly of the pectineus is located. • With downward pressure, strum the muscle belly of the pectineus; then trace it upward to its tendinous origin on the superior ramus. • Palpate the superior ramus with light pressure. • Instruct the patient to adduct the hip during palpation of the pectineus to accentuate its location and tendinous origin. • Determine the most dominant tender point or fasciculation (or both) and maintain light pressure with the pad(s) of the finger(s) throughout the treatment until reassessment has occurred. PRT Clinician Procedure • The patient is supine with the clinician standing at the side of the table of the involved limb. • Place the patient’s noninvolved leg over the involved one, and place both on your thigh. This procedure can also be done with just the involved limb. • Move the hips into approximately 90° of flexion and, using the far hand, apply adduction while internally rotating the hip. • Compress the femur downward with your far hand or torso. 110 Pectineus palpation procedure. Pectineus PRT clinician procedure. • Corollary tissues treated: Adductor magnus, psoas, rectus femoris Patient Self-Treatment Procedure Use the adductor group patient self-treatment procedure previously described. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. KNEE AND THIGH: POSTERIOR STRUCTURES Popliteus The popliteus is considered a weak flexor of the knee, but also an integral muscle during the screw home mechanism, helping the knee to unlock from an extended position. Typically, the muscle is not palpable because of its depth at the popliteal fossa. However, when a popliteal lesion is present, it may be possible to palpate its superior fibers as they course diagonally from the lateral femoral condyle, where the tendon can also be palpated. Plantaris Popliteus Achilles tendon Origin: Lateral condyle of the femur, arcuate popliteal ligament, lateral meniscus of the knee Insertion: Proximal posterior surface of the tibia Flexor digitorum longus Flexor retinaculum Intermediate posterior Palpation Procedure E6296/Speicher/Fig. 06.10/532106/JG/R1 • Place the patient in a prone knee-flexed position. • Locate the inferior lateral femoral condyle and the fibular head. • Strum the tendon over the posterior aspect of the fibular head as it courses diagonally toward the tibia. • Trace its line diagonally toward the tibia, orienting the tips of your fingers toward the popliteal fossa. • With deep pressure, strum your fingers over the hypercontracted popliteus’ superior fibers as they pass below the inferior aspect of the posterior tibial condyle. • Determine the most dominant tender point or fasciculation (or both) and maintain light pressure with the pad(s) of the finger(s) throughout the treatment until reassessment has occurred. PRT Clinician Procedure • The patient is prone with the knee flexed. • Move the knee through flexion and extension; the treatment position is typically at approximately 70 to 90° of knee flexion. • While grasping the calcaneus with your far hand, apply significant downward compression of the lower limb with either the far hand or your torso. • Apply internal and external rotation to the tibia with the far hand (internal for medial lesions and external for lateral lesions). Action: Knee flexion, knee internal rotation (proximal attachment fixed), hip external rotation (tibia fixed) Innervation: L4-S1 (tibial nerve) Popliteus palpation procedure. Popliteus PRT clinician procedure. • Corollary tissues treated: Gastrocnemius, soleus, hamstrings See video 6.6 for the popliteus PRT procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 111 KNEE AND THIGH: POSTERIOR STRUCTURES Hamstrings The hamstrings as a group (biceps femoris, semitendinosus, semimembranosus) are typically associated with producing knee flexion and hip extension. However, during the gait cycle, they assist with knee rotation control; therefore, weak hip abductors and rotators may lead to hamstring pathology. If hamstring pathology is implicated, the adductor magnus and sacrotuberous ligament should also be explored because of their communication with the hamstrings’ common origin at the ischial tuberosity. Biceps femoris (short head) Biceps femoris (long head) cut and removed Semitendinosus Semimembranosus Origin: Long head of the biceps femoris: Ischial tuberosity, sacrotuberous ligament Short head of the biceps femoris: Linea aspera lateral lip E6296/Speicher/Fig. 6.11/532109/JG/R1 Semitendinosus: Ischial tuberosity Semimembranosus: Ischial tuberosity Insertion: Biceps femoris: Fibular head, lateral tibial condyle via the lamina of the lateral hamstring tendon Semitendinosus: Proximal medial tibial shaft, pes anserine Semimenbranosus: Posterior medial tibial condyle Action: Long head of the biceps femoris: Knee flexion and external rotation, hip extension and external rotation Short head of the biceps femoris: Knee flexion and external rotation Semitendinosus: Knee flexion and internal rotation, hip extension; assists with hip internal rotation Semimembranosus: Knee flexion and internal rotation, hip extension; assists with hip internal rotation Innervation: L5-S2 (sciatic nerve); all of the hamstrings except the short head of biceps femoris (peroneal branch) share the tibial branch of the sciatic nerve. Palpation Procedure • Place the patient prone in a relaxed and supported knee-flexed position. • Starting at the popliteal fossa, locate the biceps femoris tendon and trace the tendon to the muscle tissue by strumming across its fibers. • Deeper pressure will be needed as the muscular tissue is gained. The muscular fibers of 112 the biceps femoris can be isolated by applying pressure with the fingers or thumb of the other hand to the midposterior thigh. • Continue to apply a deep strumming pressure while moving upward to the ischial tuberosity. • Apply the technique and approach used for the biceps femoris to isolate the semitendinosus on the medial side of the posterior thigh. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. KNEE AND THIGH: POSTERIOR STRUCTURES • The tendon of the semimembranosus is difficult to isolate, but the inferior fibers of the muscle lie just lateral to the semitendinosus tendon above the popliteal fossa before they dip deep under the semitendinosus. • Applying resistive knee flexion can accentuate the hamstrings for palpation. • Note the location of any tender points or fasciculatory response at the muscle and tendon and their respective origins and insertions. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. PRT Clinician Procedure • The patient is prone. • Place the involved limb into hip extension on your thigh or a bolster. • Typically, the higher the tissue lesion is, the more hip extension will be required. • Using your far hand, apply hip abduction and internal rotation for the biceps femoris and hip adduction and external rotation for the semitendinosus. • Once an optimal hip position is found, move the knee through flexion with your far hand. The knee flexion treatment position is typically 60 to 70°. • Grasp the calcaneus with your far hand to externally rotate the tibia with light downward compression to isolate the biceps femoris and internally rotate the tibia to isolate the semitendinosus. • Apply a downward translational force to the posterior femur below the gluteal fold with the near hand. At the same time, perform a distal translational movement of the fascia with your near hand toward the knee to accentuate relaxation and the fasciculatory response of the tissue. Use one of the fingers of your near hand to monitor the lesion, if possible. • Using your far hand, apply marked ankle plantar flexion and big-toe flexion to reduce the strain on the sciatic nerve. • Corollary tissues treated: Posterior hip capsule, gluteal muscles, sacrotuberous ligament, thoracolumbar fascia See video 6.7 for the hamstrings PRT procedure. Hamstrings palpation procedure. Hamstrings PRT clinician procedure. Patient Self-Treatment Procedure • Lie prone with the hip extended and knee flexed. • Lying on a couch with pillows propped under the femur to accentuate hip flexion and positioning the ankle on the arm of the couch closely replicates the general release position. • Maintain this position for three to five minutes or apply heat or ice in this position for 20 to 30 minutes to facilitate greater relaxation and pain control. Hamstrings patient self-treatment procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 113 KNEE AND THIGH: LATERAL STRUCTURES Iliotibial Band Iliotibial band Biceps femoris Patella Iliotibial band Gerdy’s tubercle Tibia Fibula Palpation Procedure • Stand on the side of the supine patient that is E6296/Speicher/Fig. 6.12/532113/JG/R1 opposite the band to be palpated. • With your hands flat, align them over the lateral thigh just below the greater trochanter of the femur. • Pull the band upward and away from the hamstrings. • When translating the band upward and across the vastus lateralis, note its movement or lack thereof as well as any pain. • Continue to palpate in the same manner when approaching the knee; firmer strumming will be needed when assessing the denser cordlike fibers. • Determine the most dominant tender point or fasciculation (or both) and maintain light pressure with the pad(s) of the finger(s) throughout the treatment until reassessment has occurred. PRT Clinician Procedure • The patient is supine. • Grasp the medial ankle with your far hand to move the hip into approximately 20° of flexion. • Move the hip through the range of hip abduction with your far hand, noting any tissue resistance from the adductors. If tissue resistance overcomes normal range of motion, release the adductors first. • Using your far hand, externally rotate the limb. • Apply marked calcaneal eversion with the far hand. 114 The iliotibial band, or tract, arises from the gluteal fascia and tensor fasciae latae muscle at the lateral hip. Its vertical fibers become dense as they approach the knee and become cordlike as they cross over the lateral epicondyle of the femur. The lateral epicondyle is often a site of iliotibial band irritation, which has been attributed to increased tension or compression (or both) of the iliotibial band during its movement over this structure when running or squatting. Origin: Gluteal fascia, tensor fasciae latae Insertion: Gerdy’s tubercle with fascial slip connections to the fibular head and lateral patellar retinaculum Action: Stabilizes the knee against varus and rotational stress; assists with the screw home mechanism Iliotibial band palpation procedure. Iliotibial band PRT clinician procedure. • Place your hip against and below the joint line of the knee as a fulcrum while applying a valgus force to the knee. • Apply cephalad compression of the limb with the far hand or your body to fine-tune. • Corollary tissues treated: Gluteus medius, tensor fasciae latae See video 6.8 for the iliotibial band PRT procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. KNEE AND THIGH: LATERAL STRUCTURES Lateral Collateral Ligament Lateral collateral ligament The lateral collateral ligament (LCL), also known as the fibular collateral ligament, is the primary restraint against lateral, or varus, stress at the knee. Unlike its cousin the medial collateral ligament, the LCL does not communicate with the knee capsule or lateral meniscus. Therefore, LCL injury is not often associated with lateral meniscal injury; rather, it is associated with hyperextension because the LCL is a secondary restraint to this motion. Origin: Lateral femoral epicondyle Insertion: Fibular head Action: Restraint against varus and internal rotation force at the knee Palpation Procedure • If possible, have the patient place the ankle of the involved side on the opposite thigh. • The LCL will be very prominent as it crosses the E6296/Speicher/Fig. 6.13/532116/JG/R2-alw lateral joint line of the knee. • If pain or lack of range of motion inhibits the preceding maneuver, strum across the lateral joint line with the pads of the fingers with the patient in a supine or seated knee-flexed position. • Note the location of any tender points or fasciculatory response at the ligament and its origin and insertion. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. LCL palpation procedure. PRT Clinician Procedure • The patient is supine. • Place the knee over your thigh to position the knee at approximately 30° of flexion. • Using your far hand at the ankle, apply a valgus force at the knee. • Apply marked calcaneal eversion with your far hand. • Rotate the tibia and compress it upward for fine-tuning with the far hand. • Corollary tissues treated: Iliotibial band, peroneals LCL PRT clinician procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 115 KNEE AND THIGH: LATERAL STRUCTURES Vastus Lateralis The vastus lateralis, the largest of the quadriceps group, is partially covered by the iliotibial band. Imbalance in the timing and strength of contraction between the lateralis and vastus medialis has often been attributed to the development of patellar maltracking. However, weak hip abductors may also play a primary role. Iliotibial band Vastus intermedius (beneath the rectus femoris) Rectus femoris Vastus lateralis Origin: Lateral lip of the femoral linea aspera Insertion: Tibial tuberosity via the quadriceps tendon, ligamentum patellae Action: Knee extension Innervation: L2-L4 (femoral nerve) Vastus medialis Palpation Procedure • The vastus lateralis can be palpated in a supine E6296/Speicher/Fig. or side-lying position. 6.14/532119/JG/R1 • Locate the iliotibial band and slide your fingers off the band noting the transition into the softer vastus lateralis, both posterior and anterior to the band. • The patient can actively extend the knee to accentuate the fibers for palpation. • Note the location of any tender points or fasciculatory response of the muscle and its attachment sites. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. PRT Clinician Procedure • The patient is supine. • Place the lower leg on your thigh at approximately 30°. • Apply a posterior force at the superior tibia below the patella using your far hand to encourage knee hyperextension. • With your near hand, laterally translate the vastus lateralis muscle belly while monitoring its lesion with the one of the fingers of your near hand. • With the far hand, apply external limb rotation and a lateral patellar glide for fine-tuning. • Corollary tissue treated: Iliotibial band 116 Vastus lateralis palpation procedure. Vastus lateralis PRT clinician procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. KNEE AND THIGH: LATERAL STRUCTURES Patient Self-Treatment Procedure • Place the lower leg and foot on a stool or couch arm. • Lean forward and place one hand below the patella at the tibia and the other just above the patella on the vastus lateralis. • Apply a downward pressure below the patella while translating the muscle belly diagonally away from the patella. • Externally rotate the limb and glide the patella laterally to fine-tune. • Monitor the vastus lateralis for a fasciculatory response and tissue relaxation at the site of pain. • Maintain the treatment position until the fasciculatory response abates or for three to five minutes. Vastus lateralis patient self-treatment procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 117