Lower extremity osteopathy

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

Knee

Bones

• See “the knee joint” in the article on the thigh, knee, and popliteal fossa.

Osteopathic landmarks

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

Motion

• Flexion: 130–150°
• Extension: - 5°
• Internal rotation: 10°
• External rotation: 10°
• Abduction: 1–2°
• Adduction: 1–2°

Ankle

Bones

• See “bones and joints” in the article on the leg, ankle, and foot.

Osteopathic landmarks

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

Motion

• Dorsiflexion: 20°
• Plantarflexion: 50°
• Subtalar inversion: 5°
• Forefoot adduction: 20°
• Forefoot abduction: 10°

Knee

Patella testing

Ballottement test (of the patella)

• See “Clinical features” in “Meniscus tear.”

Bulge sign

• Function: effusion in the suprapatellar bursa
• Position: supine with knee extended
• Procedure
  1. Stroke the knee from the medial aspect of the knee joint (“milking”) to reduce fluid.
  2. Apply pressure on the lateral side and observe for ripples or a “bulge” on medial side.
  3. Repeat from the other side.
• Positive test: observation of a fluid wave

Patellar grind test

• See “patellar grind test” in the article on osteoarthritis of the hip and knee.

Ligament Testing

Anterior drawer test (of the knee)

• See “anterior drawer test” in the article on knee ligament injuries.

Lachman test (anterior cruciate ligament)

• See “Lachman test” in the article on knee ligament injuries.

Posterior drawer test (of the knee)

• See “posterior drawer test” in the article on knee ligament injuries.

Valgus stress test (medial collateral ligament)

• See “valgus stress test” in the article on knee ligament injuries.

Varus stress test (lateral collateral ligament)

• See “varus stress test” in the article on knee ligament injuries.

Meniscus Testing

McMurray test

• See “McMurray test” in the article on meniscus tear.

Apley grind test

• See “Apley grind test” in the article on meniscus tear.

Steinman test

• See “Steinman test” in the article on meniscus tear.

Ankle/Foot

Anterior drawer test (of the ankle)

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

Thompson test (Achilles tendon)

• See “Thompson test” in the article on Achilles tendon rupture.

Kleiger test (external rotation test)

• Function: assesses for injury to the distal tibiofibular ligament
• Position: seated
• Procedure: dorsiflex and externally rotate the ankle.
• Positive test: pain

Talar tilt test

• Function
  • Inversion (lateral) stress: calcaneofibular or anterior talofibular ligament
  • Eversion (medial) stress: deltoid ligament
• Position: seated
• Procedure
  • Inversion stress: Stabilize ankle and translate into adduction (inversion).
  • Eversion stress: Stabilize ankle and translate into abduction (eversion).
• Positive test
  • Pain on inversion
  • Pain on eversion

Squeeze test (fibular compression test)

• Function: assesses for high ankle sprain
• Position: seated
• Procedure: apply a circumferential force above the ankle joint.
• Positive test: pain (at the ankle joint)

Tinel sign (of the ankle)

• Function: entrapment of the posterior tibial nerve
• Position: seated
• Procedure: gently tap over the medial aspect of the tarsal tunnel (just posterior to the medial malleolus).
• Positive test: pain, tingling, and/or paresthesia

Knee flexion dysfunction

Diagnosis

• There is knee extension restriction.

Treatment

Muscle energy

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

Knee extension dysfunction

Diagnosis

• There is knee flexion restriction.

Treatment

Muscle energy

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

Anterior fibular head dysfunction (pronation dysfunction)

Diagnosis

• The proximal fibular head resists posterior glide.

Treatment

Muscle energy

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

High-velocity low-amplitude

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

Posterior fibular head dysfunction (supination dysfunction)

Diagnosis

• The proximal fibular head resists anterior glide.

Treatment

Muscle energy

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

High-velocity low-amplitude

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

Dorsiflexion dysfunction

Diagnosis

• There is ankle plantarflexion restriction.

Treatment

Muscle energy

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

Plantarflexion dysfunction

Diagnosis

• There is ankle dorsiflexion restriction.

Treatment

Muscle energy

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

Calcaneal eversion dysfunction

Diagnosis

• There is calcaneal inversion restriction.

Treatment

Muscle energy

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

Calcaneal inversion dysfunction

Diagnosis

• There is calcaneal eversion restriction.

Treatment

Muscle energy

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

1. Destefano L. Greenman's Principles of Manual Medicine. Wolters Kluwer Law & Business ; 2015
2. Nicholas A. Atlas of Osteopathic Techniques. LWW ; 2015