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Soft Tissue Therapy

for the Lower Limb
Hands-On Guides for Therapists

Jane Johnson, PhD

 Library of Congress Cataloging-in-Publication Data

Names: Johnson, Jane, 1965- author.

Title: Soft tissue therapy for the lower limb / Jane Johnson.
Other titles: Hands-on guides for therapists.
Description: Champaign, IL : Human Kinetics, [2025] | Series: Hands-on
guides for therapists | Includes bibliographical references.
Identifiers: LCCN 2023059549 (print) | LCCN 2023059550 (ebook) | ISBN
9781718215597 (paperback) | ISBN 9781718215603 (epub) | ISBN
9781718215610 (pdf)
Subjects: MESH: Therapy, Soft Tissue--methods | Lower Extremity--physiology
| BISAC: MEDICAL / Allied Health Services / Massage Therapy | MEDICAL /
Alternative & Complementary Medicine
Classification: LCC R697.A4 (print) | LCC R697.A4 (ebook) | NLM WB 535 |
DDC 610.73/7--dc23/eng/20240214
LC record available at https://lccn.loc.gov/2023059549
LC ebook record available at https://lccn.loc.gov/2023059550
ISBN: 978-1-7182-1559-7 (print)
Copyright © 2025 by Jane Johnson
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E8778
 Contents

Series Preface vii ■ Preface viii ■ Acknowledgements x

PART I Assessment Techniques

and Treatment Outcomes
1 Postural Assessment of the Lower Limb 3
Anterior View 5
Stance 5 ■ Lateral Tilt of the Pelvis 6 ■ Pelvic Rotation 8 ■ Muscle
Bulk and Tone 10 ■ Genu Varum (Bow-Leggedness) 11 ■ Genu Valgum
(Knock Knees) 14 ■ Patellar Position 16 ■ Rotation of the Lower
Limb 18 ■ Tibial Torsion 19 ■ Q Angle 23 ■ Ankles 24 ■ Foot
Position 25 ■ Other Observations 26
Posterior View 27
Pelvic Rim 27 ■ Posterior Superior Iliac Spines 29 ■ Buttock Crease 30
Pelvic Rotation 32 ■ Internal Rotation of the Hip 34 ■ Muscle Bulk
and Tone 37 ■ Posterior Knee 38 ■ Calf Midline 39 ■ Achilles
Tendon 41 ■ Pes Valgus (Pronated Foot) 42 ■ Pes Varus (Supinated
Foot) 45 ■ Foot Position 47 ■ Other Observations 48
Lateral View 49
Overall Lower Limb Posture 49 ■ Anterior Pelvic Tilt 50 ■ Posterior
Pelvic Tilt 53 ■ Genu Recurvatum (Knee Hyperextension) 55 ■ Genu
Flexum (Flexed Knee) 58 ■ Ankle Position 60 ■ Pes Cavus (High
Arches) 61 ■ Pes Planus (Flatfoot) 63 ■ Other Observations 66
Quick Questions 66

2 Measuring the Effectiveness of Your Treatment 67

Deciding on an Overall Treatment Aim 68
Creating Specific Treatment Goals 68
Determining the Most Appropriate Measure of Effectiveness 71
Measuring Pain 71 ■ Measuring Muscle Length 71 ■ Measuring Joint Range
of Motion 72 ■ Measuring Function 72
Quick Questions 74

PART II Hands-On Techniques

for Common Muscular Problems
3 Gluteal, Groin and Hip Flexor Muscles 77
Trigger Points in the Gluteal Muscles 78
Trigger Point Release 78 ■ Stretching 80 ■ Soft Tissue Release 81

iii
iv Contents

Piriformis Syndrome 84
Massage 84 ■ Trigger Point Release 84 ■ Soft Tissue Release 84
Stretching 84 ■ Strengthening 85 ■ Sitting Habits 85
Groin Strain 86
Acute Stage 86 ■ Sub-Acute Stage 86 ■ Massage 86
Stretching 87 ■ Strengthening 87
Tight Hip Adductors 88
Massage 88 ■ Stretching 88 ■ Strengthening 90
Tight Hip Flexors 91
Trigger Point Release 91 ■ Stretching 93 ■ Strengthening 95
Quick Questions 96

4 Hamstrings and Quadriceps 97

Hamstring Strain 98
Acute Stage 98 ■ Sub-Acute Stage 98 ■ Massage 98
Active Stretches 99 ■ Passive Stretches 100 ■ Strengthening 100
Tight Hamstrings 101
Massage 101 ■ Trigger Point Release 101 ■ Stretching 103
Soft Tissue Release 104
Hamstring Cramping 110
Stretching 110 ■ Massage 111
Tight Quadriceps 112
Massage 112 ■ Trigger Point Release 112 ■ Stretching 114
Soft Tissue Release 115
Quick Questions 118

5 Knee, Calf and Shin 119

Calf Muscle Strain 120
Massage 120 ■ Stretching 120 ■ Strengthening 120
Tight Calf Muscles 121
Massage 121 ■ Trigger Point Release 124 ■ Stretching 125
Soft Tissue Release 127 ■ Strengthening 132
Calf Cramping 133
Stretching 133 ■ Massage 134 ■ Strengthening 134
Shin Splints 135
Massage 135 ■ Soft Tissue Release 135 ■ Stretching 136
Strengthening 137 ■ Running Footwear and Gait 137
Tight Tibialis Anterior 138
Massage 138 ■ Trigger Point Release 138 ■ Soft Tissue Release 139
Strengthening 140
Tight Peroneal (Fibular) Muscles 141
Soft Tissue Release 141 ■ Strengthening 142 ■ Podiatry 142
Osteoarthritis in the Knee 143
Trigger Point Release 143 ■ Massage 143 ■ Stretching 143
Strengthening 145 ■ Bracing and Walking Aids 145
After Knee Surgery 146
Massage 146 ■ Stretching 146 ■ Soft Tissue Release 147
Strengthening 147
Iliotibial Band Friction Syndrome (Runner’s Knee) 148
Massage 148 ■ Trigger Point Release 149 ■ Stretching 150
Soft Tissue Release 151 ■ Strengthening 152 ■ Kinesio Taping 152
Contents v

Genu Recurvatum (Knee Hyperextension) 153

Education 153 ■ Taping 153 ■ Massage 154 ■ Stretching 154
Strengthening 155 ■ Referral to a Specialist 155
Genu Flexum (Flexed Knee) 157
Myofascial Release 157 ■ Massage 157 ■ Soft Tissue Release 158
Stretching 159
Genu Varum (Bow-Leggedness) 162
Taping 162 ■ Massage 163 ■ Trigger Point Release 163
Stretching 164 ■ Strengthening 166 ■ Podiatry 166
Genu Valgum (Knock Knees) 167
Education 167 ■ Taping 167 ■ Massage 168 ■ Trigger Point
Release 168 ■ Myofascial Release and Soft Tissue Release 169
Stretching 171 ■ Podiatry 171
Quick Questions 172

6 Foot and Ankle 173

Ankle Sprains 174
Education 174 ■ Active Ankle Movement 174 ■ Massage 176
Strengthening 176 ■ Braces 176
Ankle Fracture 177
Active Ankle Movement 177 ■ Stretching 177 ■ Strengthening 177
Active Controlled Motion 177
Achilles Tendinopathy 178
Education 178 ■ Massage 178 ■ Trigger Point Release 178
Stretching 178 ■ Soft Tissue Release 179 ■ Strengthening 179
Referral to a Specialist 179
Stiff Ankle 180
Massage 180 ■ Stretching 180
Plantar Fasciitis and Stiff Feet 183
Massage 183 ■ Trigger Point Release 183 ■ Stretching 183
Specialist Referrals 184
Pes Planus (Flatfoot) 185
Massage 185 ■ Stretching 185 ■ Strengthening 185
Manual Therapist 185
Pes Cavus (High Arches) 186
Massage 186 ■ Stretching 186 ■ Strengthening 186 ■ Podiatry 186
Pes Valgus (Pronated Foot) 187
Massage 187 ■ Soft Tissue Release 187 ■ Stretching 187
Taping 188 ■ Strengthening 188 ■ Myofascial Release and Podiatry 188
Pes Varus (Supinated Foot) 189
Massage 189 ■ Stretching 189 ■ Strengthening 190 ■ Podiatry 190
Quick Questions 190

PART III Lower Limb Strengthening Exercises

Testing Lower Limb Strength 191
Strengthening Exercise Types 192
Regaining Function After an Injury 192
Non-Functional Exercises Versus Functional Exercises 192
Balance Exercises 193
Exercise Positions and Repetitions 193
Exercise Progression 194
Improving Exercise Plan Adherence 194
vi Contents

7 Hips 197
Testing the Strength of the Hip Muscles 197
Hip Extensors 198
Identifying Weakness in the Hip Extensors 198 ■ Hip Extensor
Strengthening 199 ■ Making Hip Extension More Functional 200
Hip Abductors 202
Identifying Weakness in the Hip Abductors 202 ■ Hip Abductor
Strengthening 202 ■ Making Hip Abduction More Functional 204
Hip Adductors 206
Identifying Weakness in the Hip Adductors 206 ■ Hip Adductor
Strengthening 206 ■ Making Hip Adduction More Functional 207
Hip Flexors 208
Identifying Weakness in the Hip Flexors 208 ■ Hip Flexor Strengthening 208
Making Hip Flexion More Functional 208
Quick Questions 210

8 Knees 211
Testing Knee Strength 212
Knee Flexors 213
Identifying Weakness in the Knee Flexors 213 ■ Knee Flexor
Strengthening 214
Knee Extensors 216
Identifying Weakness in the Knee Extensors 216 ■ Knee Extensor
Strengthening 217
Functional Knee Exercises 219
Quick Questions 224

9 Feet and Ankles 225

Testing Ankle Strength 226
Plantar Flexors 227
Plantar Flexor Muscle Strengthening 227
Dorsiflexors 230
Dorsiflexor Muscle Strengthening 230
Evertors 232
Evertor Muscle Strengthening 232
Invertors 233
Invertor Muscle Strengthening 233
Balance Exercises 234
Functional Exercises to Strengthen the Ankle and Improve Balance 236
Exercises to Strengthen the Feet and Toes 238
Quick Questions 239

Appendix 240 Answers to Quick Questions 250

■ References 254
■

About the Author 261 Earn Continuing Education Credits/Units 262

■
 Series Preface

M
assage may be one of the oldest therapies still used today. At present, more
therapists than ever before are practising an ever-expanding range of massage
techniques. Many of these techniques are taught through massage schools and
within degree courses. Our need now is to provide the best clinical and educational
resources that will enable massage therapists to learn the required techniques for deliv-
ering massage therapy to clients. Human Kinetics has developed the Hands-On Guides
for Therapists series with this in mind.
The Hands-On Guides for Therapists series provides specific tools of assessment
and treatment that fall within the realm of massage therapists but may also be useful
for other bodyworkers, such as physical therapists, osteopaths, chiropractors, sports
therapists and fitness instructors. Each book in the series is a step-by-step guide to
delivering the techniques to clients. Each book features a full-colour interior packed
with photos illustrating every technique. Tips provide handy advice to help you adjust
your technique, and throughout each book are questions that enable you to test your
knowledge and skill, which will be particularly helpful if you are attempting to pass a
qualification exam. We’ve even provided the answers!
You might be using a book from the Hands-On Guides for Therapists series to obtain
the required skills to help you pass a course or to brush up on skills you learned in the
past. You might be a course tutor looking for new ways to make postural assessment
or soft tissue techniques come alive with your students. This series provides easy-to-
follow steps that will make the transition from theory to practice seem effortless. The
Hands-On Guides for Therapists series is an essential resource for all those who are
serious about massage therapy.

vii
Preface

S
oft Tissue Therapy for the Lower Limb is intended for use by professionals who use
hands-on skills as part of their treatment. This book will help you to apply mas-
sage, stretching, soft tissue release (STR) and trigger point release techniques when
working with clients with common lower limb conditions. It also includes a chapter
on postural assessment of the lower limb (chapter 1) and three chapters on strengthen-
ing exercises (chapters 7-9 in part III). In this book, you will find specific information
about which soft tissue techniques and strengthening exercises are appropriate for 31
different musculoskeletal conditions affecting the hips, buttocks, thighs, knees, legs,
ankles and feet.
Part I focuses on assessment techniques and treatment outcomes. In chapter 1, you
will learn how to assess lower limb posture from the anterior, posterior and lateral views,
learning to identify, for example, lateral tilt of the pelvis, pelvic rotation, genu varum
(bow-leggedness), genu valgum (knock knees), genu recurvatum (hyperextension of
the knees), genu flexum (flexed knees), tibial torsion, pes valgus (ankle pronation), pes
varus (ankle supination), pes planus (flatfootedness) and pes cavus (high arches), and
the consequences of these postures on soft tissues. An appendix provides a handy lower
limb postural assessment chart you can use to document your findings or to simply use
as an aide-mémoire. Chapter 2 explains how to decide on an overall treatment plan by
working with your client to set specific treatment goals and provides examples of how
to do this. It is important that we can demonstrate the effectiveness of our treatments,
and in this chapter, you will find tips on measuring pain, muscle length, joint range
and everyday function.
Part II is divided into four chapters, each discussing common musculoskeletal con-
ditions affecting a different part of the lower limb. This part of the book begins with
chapter 3, discussing the gluteal, groin and hip flexor muscles. Chapter 4 covers the
hamstrings and quadriceps and chapter 5, the knee, calf and shin, whilst conditions
affecting the foot and ankle can be found in chapter 6. The pattern of information
in these chapters is the same: for each condition, you will discover when it may be
appropriate to use massage, trigger point release, STR and stretching. For conditions
for which strengthening exercises are useful, you are directed to the relevant chapter
later in the book. As part of recovery from a musculoskeletal condition, it is important
that a person is as engaged as possible with their rehabilitation. For this reason, active
STR, active stretches and active trigger point release techniques are included where
relevant. Research into the effectiveness of hands-on techniques is limited. However,
where a useful reference has been identified for a particular technique, this has been
included along with a description of that source. The full list of references cited in the
text can be found at the end of the book, organised by chapter.
In part III, the focus is on strengthening exercises – specifically, exercises that a person
can perform safely with minimal equipment and without supervision. The chapters in
this part of the book further reinforce the importance of a person’s active engagement

viii
in their recovery. In this section, you will find exercises to help in the treatment of
conditions affecting the hips (chapter 7), knees (chapter 8) and feet and ankles (chapter
9). To gauge the effectiveness of a strengthening programme, it is important to know
which muscles are weak. Each of these chapters is organised the same way, begin-
ning with how to test the strength of specific groups of muscles followed by suitable
exercises to use if those muscles are found to be weak. Wherever possible, multiple
testing positions are illustrated – standing, seated, supine, prone or side-lying – so that
whatever the capacity of your client, you are certain to find a position that they find
comfortable. Similarly, multiple different exercise positions are also shown. Wherever
possible, exercises have been presented from those likely to be easiest to those likely
to be more difficult, with explanations as to how to progress an exercise and for whom
an exercise may be suitable. The aim of the information in this part of the book is to
help people to regain their everyday function, and to that end, examples of functional
exercises are also provided.
As with other titles in the Hands-On Guides for Therapists series, in Soft Tissue Therapy
for the Lower Limb, you will find tips based on the author’s many years of experience as
a physiotherapist and soft tissue therapist, along with multiple photographs illustrating
the techniques. Special thanks to Tim Allardyce from RehabMyPatient.com for kindly
permitting use of his exercise images in chapters 7, 8 and 9.

ix
 Acknowledg
gements

T
his book has been made possible with the support of the team at Human Kinetics.
Thank you to Jolynn Gower, the original acquisitions editor who accepted my idea
for this title; to Diana Vincer, the acquisitions editor who took over the project;
and to Amy Stahl, the developmental editor who joined Diana in providing support
throughout the process. I would also like to thank the copyeditor, Jenny MacKay, for
asking important clarifying questions. Thank you to the designer, Denise Lowry, for her
essential role in bringing the book to life. I would like to do a shout-out to Barry John-
son, Human Kinetics’ international sales director, and his team, including Lisa Lehnert,
whose efforts have resulted in other titles in the Hands-On series being translated into
multiple languages. It is wonderful that the information in this series is now available
to therapists worldwide, and I have every confidence that Barry and his team will have
equal success with this book too. Thank you also to the marketing implementation man-
ager, Jenny Lokshin, and the marketing manager, Madeline Koenig-Schappe, for their
roles in raising awareness of this title. I don’t think I have ever seen a royalty accoun-
tant acknowledged, and I would like to rectify that. Tina Kinder has been my royalty
accountant and, over the years, has diligently processed my royalties and answered my
questions about them. I love sharing information, I love writing books and, of course,
it’s rather nice to get paid for it.
A very big thank you must go to Tim Allardyce, who generously let me use images
from his online exercise prescription platform Rehab My Patient (www.rehabmypatient
.com) and was extremely patient in the process of getting these implemented. You can
find these wonderfully clear photos in chapters 7, 8 and 9.

x
 PART I

Assessment Techniques
and Treatment
Outcomes
T
he first part of this book is all about assessment: how to assess a client’s posture
and how to perform tests that will later help you determine whether your treatment
has been effective. Chapter 1 provides a step-by-step guide to postural assessment
of the lower limb and teaches you what to look for when conducting an assessment
from the anterior, posterior and lateral views. Chapter 2 explains how to use common
muscle length and joint range of motion tests, pain and symptoms scores and functional
assessment scales. These tests, scores and scales are valuable when used before and
after treatment because they help determine whether your client has benefitted from,
for example, an increase in muscle length, a reduction in pain or an improvement in
function.

1
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 1
Postural Assessment
of the Lower Limb
Learning Outcomes
After reading this chapter, you should be able to do the following:
■ Assess a client for lateral tilt of the pelvis and pelvic rotation.
■ Determine whether a client has genu varum or genu valgum knees.
■ Describe at least one consequence of each of the lateral pelvic tilt, pelvic
rotation, genu varum and genu valgum postures.
■ Identify internal rotation of the femur and the consequences of this posture.
■ Judge whether a client has a neutral, anteriorly tilted or posteriorly tilted pelvis
and what might be the consequences of these postures.
■ State what a person’s stance and the shape and tone of their muscles might
indicate.
■ Identify the position of the knee and whether there is rotation of the lower
limb, rotation of the tibia or both.
■ Describe the consequences of rotation on the lower limb, knee or tibia.
■ Explain how to measure the Q angle.
■ Determine whether a person has a neutral, genu recurvatum or genu flexum
knee posture.
■ Recognise pes valgus and pes varus ankle postures.
■ Identify pes planus and pes cavus foot postures.

T
his chapter contains three sections that provide detailed information about the kinds
of things you might observe when conducting a postural assessment of the lower
limb. It does not matter in which order you carry out the assessment – whether you
start with an anterior (front), posterior (back) or lateral (side) view – but it is helpful to
be systematic in your approach so as not to miss anything. You may find the lower limb

3
4 Soft Tissue Therapy for the Lower Limb

postural assessment chart in the appendix useful. Try not to jump to conclusions about
what your observations mean. To form an opinion as to what might be the problem
and what kind of treatment might be most helpful, document your findings and use
these together with the subjective history you take from your client and any other tests
you perform. This is important because the postural assessment alone provides only
some of the information required to help you formulate a treatment plan. For example,
it will not tell you about the range of movement in a joint, the strength of muscles or
how a lower limb problem is affecting a person’s function. A postural assessment does,
however, provide clues that can be invaluable for eliciting further information from
the client. The anatomical consequences of many of the postures are detailed in the
sections that follow.
Once you have gained an overview of the client’s stance, turn your attention to more
specific items, such as whether any muscles appear to be atrophied (thinner and wasted)
or hypertrophied (larger and bulkier). Next, consider each part of the lower limbs: the
pelvis, knees, ankles and feet. Examine these in more detail, observing their position
and shape and whether there is evidence of injury (bruising), surgery (scars) or an
underlying condition (swelling, skin discolouration, varicose veins). Finally, remember
to always record whether a person walks with an aid or uses a supportive device, such
as a knee brace or foot orthotic.
Throughout this chapter, you will find tables detailing whether a muscle is likely to
be shortened or lengthened in each specific posture. This is useful because one of your
treatment goals might be to lengthen a shortened muscle or to shorten a lengthened one.
 STANCE

Anterior View
Stance
Take an overview of how your client stands. Do they naturally stand with their legs
together, or are they more comfortable with a wide stance? Consider the foot position
and weight distribution (see figure 1.1). Do they look comfortable as they stand? Are they
happy to place their weight equally through both legs, or do they appear to favour one leg
more than the other? If so, why might that be? Are they recovering from a recent injury or
operation, or could this be a habit they have developed due to a previous problem? Do
they need the support of an aid, such as a stick, crutch, knee brace or ankle brace? Do
the lower limbs appear to be shaped the same, or is there evidence of genu varum (bow-
leggedness) or genu valgum (knock knees)? (You can read more about how to identify
genu varum and valgum and the consequences of these postures later in this section.)

a b c

Figure 1.1 Examples of (a) wide, (b) narrow and (c) supported stances.
Courtesy of Emma Kelly Photography.

TIP
If you notice your client is standing in a wide stance, ask them to stand with their feet
together (so the medial malleoli of the ankles are as close as possible), if you believe it is
safe to do so. Ask how they feel. Clients with weak adductor muscles of the hip may dislike
this position and feel particularly unbalanced. You can get a sense of this yourself by stand-
ing with your feet together. Notice your adductors contracting to keep you in this position.

Consequences
Clients who stand in a wide stance create a wide base of support for themselves. Why
might they do this? Is it because they feel unbalanced? Could it be that in some cases
they have weak hip adductor muscles relative to their abductor muscles?

5
LATERAL TILT OF THE PELVIS

Anterior View
Lateral Tilt of the Pelvis
The pelvis is laterally tilted when one side is higher than the other. This posture is
sometimes called ‘hip hitch’ because the pelvis has been hitched up on one side. The
illustration shown in figure 1.2 has been deliberately exaggerated to show a pelvis
that is tilted upwards on the right. In reality, it is more common to see a subtle shift,
as in figure 1.3. The amount of pelvic tilt shown in the photograph may not at first be
apparent, but if you observe this man’s left knee and left hand, you will see that these
are both lower than the right knee and right hand.

Figure 1.2 Exaggerated to show the pelvis Figure 1.3 Pelvis laterally tilted on
E8778/Johnson/F 01.02/717036/pulled/R1
tilted upwards on the right. the client’s right side.
Courtesy of Emma Kelly Photography.

TIP
When you are first using anterior postural assessment, it is easy to confuse a person’s left
and right. Remember that the right side of the photograph in figure 1.3 is the man’s left
side; the left side of the photograph is the man’s right side.

6
 LATERAL TILT OF THE PELVIS

TIP
To experience what a laterally tilted pelvis feels like, stand in front of a mirror, with both
feet on the floor. Imagine that you have your leg in a cast and cannot flex at the knee.
Place your hands on your hips and slowly lift the heel of your right foot off the floor, but
keep the toes of your right foot on the floor as you do this. You can see and feel the right
side of your pelvis as it rises and as you laterally flex to the right at your lumbar spine to
accommodate this position.

Consequences
Table 1.1 lists the muscle lengths associated with a laterally tilted pelvis. For example,
to compensate for a pelvis that is raised on the right, a client may have increased lateral
flexion of the lumbar spine (to the right), which may correspond with the appearance
of more or deeper skin creases on the right. In this case, the right quadratus lumborum
muscle may be shorter, as may some of the right lumbar erector spinae muscles. The
hip joints are affected also. The right hip is adducted, whereas the left hip is abducted.
Therefore, a client may have a pelvis raised on the right with shortened hip abductors
on the left and shortened adductor muscles on the right.

Table 1.1 Muscle Lengths Associated With a Laterally Tilted Pelvis

Pelvis raised on the right Pelvis raised on the left
Lumbar spine Flexed to the right; concave on Flexed to the left; concave on
the right the left
Lumbar muscles Shortened right quadratus lum- Shortened left quadratus lum-
borum and right lumbar erec- borum and left lumbar erector
tor spinae spinae
Effects on the hip joint Right hip is adducted; left hip Left hip is adducted; right hip is
is abducted abducted
Effects on the muscles Shortening of right hip adduc- Shortening of left hip adduc-
of the hip tors and left hip abductors; tors and right hip abductors;
imbalance between the left imbalance between the left
and right hamstrings and right hamstrings

7
PELVIC ROTATION

Anterior View
Pelvic Rotation
Imagine the pelvis can rotate with respect to the spine in the way that a bead can rotate
with respect to a string. A good way to determine whether your client has a rotated
pelvis is to examine the position of the anterior superior iliac spines (ASIS). When the
pelvis is rotated clockwise, the client’s left ASIS will be closer to you and the right ASIS
will move away from you. When the pelvis is rotated anticlockwise, the client’s right
ASIS will be closer to you and the left ASIS farther away. The illustrations in figure 1.4
exaggerate rotator movements; in reality, they are far more subtle.

Posterior rotation Posterior rotation

of the right ilium of the left ilium

Clockwise Anticlockwise
rotation rotation

Forward rotation Forward rotation

a of the left ilium b c of the right ilium

Figure 1.4 Pelvic rotation with (a) clockwise rotation, (b) no rotation and (c) anticlock-
wise rotation.

TIP E8778/Johnson/F01.04/717531/pulled/R1

To determine pelvic rotation, it helps to imagine that the client is standing between two
Saved
sheets of glass, one in frontasand
717531
one -behind.
ID# 717532
Doesand 717533
the areone
ASIS on not needed
side of the pelvis appear
to be closer to the glass behind the client than that on the other side?

Consequences
If the pelvis is rotated away from you on the left (clockwise), the right internal oblique
and left external oblique may be shortened. If the client has a pelvis rotated forwards to
the right (anticlockwise), the opposite may be true. Pelvic rotation has a corkscrewing
effect on the entire body. The result is that muscles and joints throughout the body are
affected, including the feet (see figure 1.5).

8
 PELVIC ROTATION

a b c
Figure 1.5 (a) Neutral pelvis with both anterior superior iliac spines aligned. Knees
E8778/Johnson/Fig01.05c/717039/pulled/R1
E8778/Johnson/Fig 01.05b/717038/pulled/R1
E8778/Johnson/Fig 01.05a/717037/pulled/R1
face forwards. There is equal pressure beneath the medial and lateral sides of the foot.
(b) The whole pelvis is rotated to the right. Knees no longer face forwards. There is
increased pressure on the lateral side of the right foot. (c) The whole pelvis is rotated to
the left. Knees no longer face forwards. There is increased pressure on the lateral side of
the left foot.

TIP
Table 1.2 sets out the effect of pelvic rotation on the feet. You can easily test the effect
pelvic rotation has on the feet by rotating to the left and right and feeling what happens
to the contact points of the soles of your feet with the floor.

Table 1.2 Pelvic Rotation and Its Effect on the Feet

ROTATION OF THE PELVIS TO THE LEFT
Left foot Right foot
• Increased supination • Increased pronation
• There is increased pressure on the lateral • The pressure is roughly equal on the lat-
side of the foot and decreased pressure eral and medial sides of the foot
on the medial side of the foot as a result
of increased inversion of the forefoot
ROTATION OF THE PELVIS TO THE RIGHT
Left foot Right foot
• Increased pronation • Increased supination
• The pressure is roughly equal on the lat- • There is increased pressure on the lateral
eral and medial sides of the foot side of the foot and decreased pressure
on the medial side of the foot as a result
of increased inversion of the forefoot

9
MUSCLE BULK AND TONE

Anterior View
Muscle Bulk and Tone
Compare muscle bulk (figure 1.6a) and the tone of the left and right thighs. Does the
girth of each thigh appear equal? Would you agree that the region of the vastus medialis
on this client appears hypertrophied on his right thigh compared to his left (figure 1.6b)?

a b

Figure 1.6 Assessing

E8778/Johnson/Fig the girth of the thigh muscles (a) to determine if they are the same
01.06a/717040/pulled/R1
or (b) whether there is any hypertrophy.
Photo b courtesy of Emma Kelly Photography.

TIP
Shadows falling on the limbs can make it difficult to determine whether there is any asym-
metry in muscle bulk. If in doubt, either change the light source or move your client slightly
to help determine whether what you are observing is indeed atrophy or hypertrophy or
simply shadow.

Consequences
An increase in bulk suggests increased use or weight bearing on that side of the body,
whereas atrophy of muscles (in a healthy person) suggests disuse. Atrophy in muscles of
the lower limb is common after immobilisation of the limb or a prolonged period of bed
rest. Atrophy in a muscle will result in decreased strength in that muscle. If this occurs
in one thigh only, there will be imbalance, and this can lead to additional stressors on
the muscles and joints of the opposite leg.

10
 GENU VARUM

Anterior View
Genu Varum (Bow-Leggedness)
Next, let’s look at the knees. Genu varum, popularly termed bow legs because the
lower limbs take on the shape of an archer’s bow, is misalignment of the knee joint.
Ask your client to stand with the feet together, the medial malleoli as close together
as possible. Observe the distance of the medial femoral condyles and their distance
from an imaginary plumb line. If one knee appears to be farther from the midline and
the overall limb has taken on a bowlike appearance, this is evidence of genu varum
(figure 1.7a). Genu varum affects both the knee joint itself and the muscles supporting
it. Osteoarthritic changes or degradation of menisci may be more likely to occur on the
side of the knee subject to greater compressive forces. Overstretching of soft tissues is
likely on the opposite side of the knee. In this posture, there is gapping of the lateral
aspect of the knee and increased tension on the lateral collateral ligament as well as
compression of the medial meniscus (figure 1.7b).

Lateral
collateral Medial
ligament meniscus

Tensile Compressive
knee stress knee stress

Compressive Tensile
ankle stress ankle stress
a b

Figure 1.7 Assessing for (a) genu varum and (b) the gapping and compressive forces
in this posture.
E8778/Johnson/Fig01.07a/717557/pulled/R1
TIP
If you are the sort of person who likes to quantify posture, you may be interested to know
that the typical angle formed between the anatomical axis of the femur
E8778/Johnson/Fig and the anatomical
01.07b/717556/pulled/R1
axis of the tibia on the medial side of the knee is approximately 195 degrees (Levangie
and Norkin 2001). In the genu varum knee posture, the medial tibiofemoral angle is less
than 180 degrees.

11
GENU VARUM

Consequences
In the genu varum posture (figure 1.7a), there is increased tensile stress on the lateral
side of the knee and medial side of the ankle and increased compressive force on the
medial side of the knee and lateral side of the ankle (figure 1.7b). A way to appreciate
the consequence of these strains is to imagine the gapping motion that has occurred
in the lateral aspect of the knee joint. Gapping means that the lateral collateral knee
ligament is tensed and possibly weakened, providing less stability and increasing the
likelihood of lateral collateral ligament injury. The medial meniscus is compressed,
possibly causing damage there too.
The mechanical axis of the knee is vertical, meaning that during typical bilateral
weight bearing, forces are transmitted through the centre of the knee joint and distributed
equally through the medial and lateral compartments. Malalignment of the joint shifts the
transition of force to the medial aspect of the knee, which affects balance and gait and
may predispose a client to knee pathology. For example, some studies have found that
knee malalignment is associated with higher rates of knee osteoarthritis (McWilliams et
al. 2010). Whether a joint’s pathology progresses to severe osteoarthritis depends on its
existing state of vulnerability: A joint with mild osteoarthritis, for example, may be less
vulnerable to the biomechanical effects of malalignment than a more damaged joint
(Cerejo et al. 2002). If you imagine the mechanical axis in figure 1.7b as a bowstring,
you can see how the genu varum posture gets its nickname and how it has a tendency to
worsen. People with osteoarthritis who demonstrate this posture often report knee pain.
As you can see from table 1.3, in the genu varum posture, certain muscles are
lengthened and others are shortened; you can see that the iliotibial band is tensed and
lengthened compared to a neutral posture, as is the biceps femoris, whereas the gracilis
and semitendinosus are shortened. This may have little impact on day-to-day activities
but could compromise a client’s participation in sport, for example.
Additionally, not only does the genu varum posture shorten the quadriceps, it also
affects the direction of pull by the quadriceps on the patella. There may be a tendency
for the patella to be pulled medially. The direction of pull of the patella is important
for overall knee stability; altering the direction could disrupt this bone’s normal gliding
mechanism and lead to instability of the knee. In extreme cases, the genu varum posture
could contribute to degenerative changes in the patellofemoral joint.
Postural bow legs occur as a result of medial rotation of the femur and pronation of
the foot (Kendall, McCreary, and Provance 1993). The atypical joint position is also likely
to affect the normal glide and roll of the femur on the tibia that occurs during flexion
and extension movements of the knee. During weight bearing, there may be medial
rotation of the leg, and in turn, the medial side of the foot can be elevated from the
floor unless compensatory subtalar pronation occurs. Other compensatory movement
may include eversion of the talus and pronation of the intertarsal joints as a means of
regaining contact with the ground surface. This posture adversely affects balance and is
significant especially in the older population, in which genu varum is more common,
as are falls. Genu varum deformity has been shown to increase neutral postural sway
in the mediolateral direction and increase risk of falls (Samaei et al. 2012).

12
 GENU VARUM

Table 1.3 Muscle Lengths Associated With Genu Varum Knee Posture
Area Shortened muscles Lengthened muscles
Thigh Quadriceps Lateral rotators of the hip
Internal hip rotators Biceps femoris relative to semitendi-
Gracilis nosus and semimembranosus
Semitendinosus and semimembrano-
sus relative to biceps femoris
Leg Fibular (peroneal) muscles Popliteus
Tibialis posterior
Long toe flexors

13
GENU VALGUM

Anterior View
Genu Valgum (Knock Knees)
This posture is assessed by asking your client to stand with their medial femoral condyles
touching. Observe the distance of the medial malleoli from the midline (figure 1.8). If
one ankle appears to be farther from the midline, this is evidence of genu valgum. As
with genu varum, this knee posture affects both the knee joint itself and the muscles
supporting it. Osteoarthritic changes or degradation of the meniscus may be more likely
to occur on the side of the knee subject to greater compressive forces; overstretching
of soft tissues is likely on the opposite side of the knee (figure 1.8b).
An increase in the valgus angle of the knee often coincides with leg-length discrep-
ancy. It occurs on the side where the leg is longer, and there is also posterior pelvic
torsion of the ilium on that side (Cooperstein and Lew 2009).

Medial
Lateral collateral
meniscus ligament

Compressive Tensile
knee stress knee stress

Compressive Tensile
ankle stress ankle stress
a b
Figure 1.8 Assessing for (a) genu valgum and (b) the gapping and compressive forces
in this posture.

T IE8778/Johnson/Fig
P 01.08a/717564/pulled/R1

As you learned in the section about the genu varum posture, the typical angle formed
between the anatomical axis of the femur and the anatomical axis
E8775/Johnson/F of the tibia on the medial
01.08b/717563/pulled/R1
side of the knee is approximately 195 degrees (Levangie and Norkin 2001). In the genu
valgum knee posture, the medial tibiofemoral angle is greater than 195 degrees.

14
 GENU VALGUM

Consequences
In the genu valgum posture, there is increased tensile stress on the medial side of the
knee and ankle and increased compressive force on the lateral side of the knee and
ankle. People with this posture commonly report pain, though it cannot be assumed
that this is due to the posture itself.
In this posture, there is gapping of the medial aspect of the knee, with increased
tension in the medial collateral ligament, which could become weakened, providing
less stability for the knee and increasing the likelihood of medial collateral ligament
injury. The lateral meniscus is compressed, possibly causing damage there too.
During typical bilateral weight bearing, forces are transmitted through the centre of
the knee joint and distributed equally through the medial and lateral compartments.
In the genu valgum posture, force is shifted to the lateral aspect of the knee and could
affect balance and gait. Altered joint mechanics may predispose a patient to knee
pathology. Malalignment is associated with higher rates of knee osteoarthritis (McWil-
liams et al. 2010).
The gracilis, semitendinosus and sartorius are all lengthened and tensed. The tensor
fasciae latae and the iliotibial band are compressed, as are tissues of the lateral leg
compartment (see table 1.4).
The atypical joint position is also likely to affect the normal glide and roll of the
femur on the tibia that occur during flexion and extension movements of the knee.
There may also be a tendency for the patella to be pulled laterally, which could dis-
rupt this bone’s usual gliding mechanism. Together, these altered joint mechanics are
likely to compromise knee function. In extreme cases, the genu valgum posture could
contribute to degenerative changes in the patellofemoral joint. Proprioception is likely
to be altered, which could affect balance.
Genu valgum is associated with postural change in other joints. This includes lumbar
spine rotation on the contralateral side and excessive adduction and medial rotation
of the hip, lateral tibial torsion, inversion of the talus, supination of the subtalar joints
or intertarsal joints and pes planus (Riegger-Krugh and Keysor 1996).

Table 1.4 Muscle Lengths Associated With Genu Valgum Knee Posture
Area Shortened muscles Lengthened muscles
Thigh Biceps femoris relative to semimem- Gracilis
branosus and semitendinosus Semimembranosus and semitendino-
Tensor fasciae latae sus relative to biceps femoris
Hip adductors Sartorius
Leg Fibular (peroneal) muscles

15
PATELLAR POSITION

Anterior View
Patellar Position
The patella should be positioned in line with the tibial tuberosity. Observing the position
of the patella does not reveal how it moves; therefore, this part of the anterior assessment
is a good example of why it is important to also assess a person’s function (see chapter
2) in addition to carrying out an assessment of their posture. It is nevertheless important
to observe the position of the patella, because this can provide a clue as to whether
maltracking of this bone is likely. Does it sit over the centre of the knee joint, or is it
resting laterally (figure 1.9a) or medially (figure 1.9b)? Another question you might ask
yourself is whether the patellae seem to sit neutrally or whether they appear compressed
and tilting against the knee joints. People who stand with their knees hyperextended
cause the patellae to be compressed, and although hyperextension is best examined from
a lateral view, it is still possible to get a sense of whether the patellae rest comfortably
against the tibiofemoral joints or whether they appear squashed against the joints due
to hyperextension.

a b
Figure 1.9 A right knee with (a) lateral maltracking and (b) medial maltracking.
E8778/Johnson/F 01.09a-b/717080/pulled/R1
TIP This was saved as one figure and save as 717080. ID 717081 is not needed.
One way to assess whether the patellae are compressed when performing an anterior view
assessment is to imagine each knee is the headlight of a car. Imagine where the beam of
that light might fall on the ground in front of the client. Do both beams hit at the same
distance from the client? Where a patella is compressed, as in hyperextension of the knee,
the beam will hit the floor closer on that side than the beam of the opposite knee (unless
there is hyperextension of both joints). An illustration of how this might appear when view-
ing the knees posteriorly can be found in the section on posterior assessment.

16
 PATELLAR POSITION

Consequences
Because the patella is housed within the quadriceps tendon, and this in turn is housed
in fascia connected to other structures, could an increase in tension in the muscles or
the fascia of the medial or lateral sides of the knee (or both) contribute to maltracking
(see table 1.5)? For example, could lateral maltracking be due to increased tension in
the lateral retinaculum of the knee and the iliotibial band? Could medial maltracking
be due to increased tension in the vastus medialis? Maltracking of the patella could
potentially lead to pain and subluxation of that bone, disrupting typical function of the
knee. Anterior knee pain can sometimes be explained by patellae tilting such that their
inferior poles stick into the fat pad beneath the knee, a condition perhaps aggravated
by forced or prolonged knee extension.

Table 1.5 Possible Consequences of Soft Tissue Tension in the Lateral

and Medial Aspects of the Knee on Patella Tracking
Area of soft tissue tension Lateral retinaculum of the knee Vastus medialis
Iliotibial band
Possible consequence Lateral maltracking of the Medial maltracking of the
patella patella

17
ROTATION OF THE LOWER LIMB

Anterior View
Rotation of the Lower Limb
Assessing for rotation of the lower limb is the first step in helping to identify whether
there is tibial torsion or rotation of the hip or femur. In a neutral position, the patella
should point straight ahead with respect to the tibiofemoral joint. This means that if
a client stands with the feet turned out slightly, as might be expected, the patella will
also face outwards slightly but should still be aligned over the joint. Therefore, begin
by observing the knee to get a general feel for whether it is in a neutral position or
whether it is internally or externally rotated (figure 1.10).

b
a External (lateral) rotation b Internal (medial) rotation

Figure 1.10 Circles approximate the position of the kneecap and represent (a) external
and (b) internal rotation of the knee.
E8778/Johnson/F 01.10a/717082/pulled/R1
E8778/Johnson/F 01.10b/717083/pulled/R3
TIP
Standing in front of a full-length mirror, turn both of your feet outwards, rotating the entire
lower limb externally, and notice the position of your patellae. In this position, the femurs,
knees and tibiae are externally rotated as a group. Next, reverse the position and stand
pigeon-toed, rotating both lower limbs internally so that your feet are pointing inwards.
Again, notice what happens to your patellae in this exaggerated posture. In this stance,
the femurs, knees and tibiae are all internally rotated as a group.

Consequences
Because the femur and tibia attach at the knee joint, and this joint permits a small
amount of rotation, it is possible for each bone to rotate in a different direction with
respect to one another, and this can cause tibial torsion. You can read about tibial
torsion in the next section, and you can read about an internally rotated femur as part
of the posterior postural assessment.

18
 TIBIAL TORSION

Anterior View
Tibial Torsion
After assessing the position of the knee, it is helpful to consider whether there is any
tibial torsion. In a clinical setting, tibial torsion tends to refer to torsion of the leg (i.e.,
rotation between the tibia and femur at the knee joint and movement between the tibia
and talus at the ankle joint). Whether torsion is pure (within the bone itself, irrespective
of joints) or clinical (longitudinal rotation about the leg due to lower limb joint positions),
it is difficult to identify purely from postural assessment. A good starting point is to
observe your client from the front and to note where the tibial tuberosities lie. Are they
facing forwards and symmetrical, or does one face inwards (internal tibial torsion) or
outwards (external tibial torsion)? Observe the position of the feet. Internal tibial torsion
is associated with a toe-in posture and external torsion with a toe-out posture.
However, a patient can appear to have neutral tibiae when in fact they have torsion.
An example is in figure 1.11. At first glance, the patient’s legs appear neutral because
her left and right tibial tuberosities are facing forwards, but observe her right knee,
which does not face forwards. This indicates internal rotation of the femur. With internal
rotation of the femur, you would expect to also have in-toeing, yet the client’s feet are
facing forwards. For the feet to face forwards, the tibia must have torsion externally.

TIP
A way of testing whether there is external rotation is to ask your client to stand so that the
knees are facing forwards, if able. When a patient with external tibial torsion stands with
the knees facing forwards, the external tibial torsion will be much more marked because
the feet will have been placed in a marked toe-out position.

Although not all studies agree, some have found that torsion varies between the left
and right legs within the same individual, with greater outward rotation of the right
leg compared to the left (Clementz 1988; Mullaji et al. 2008). The reasons for this are
not clear.

Internally rotated
right femur

Internally
positioned
patella Tibial
tuberosity
Tibial
tuberosity

Externally
rotated tibia

Figure 1.11 Patient with external tibial torsion of the right leg, which at first glance
appears neutral.
Photo courtesy of Emma Kelly Photography.

19
TIBIAL TORSION

Consequences
During walking, the pelvis rotates about the weight-bearing hip joint, with the pelvis
on the side of the swinging leg moving forward. Various segments of the leg rotate in
the same direction as the pelvis and in phase with pelvic rotation. The amplitude of
rotation increases proximally to distally, with the tibia rotating about its long axis three
times as much as the pelvis rotates (Inman 1966). Rotation of this kind is a typical part
of gait; excessive internal or external rotation will adversely affect these biomechanics
and therefore is likely to increase the energy expenditure of walking.
Some muscles can affect joints they do not cross. The mechanisms for this are unclear
but are likely to include the interconnectedness of muscles synchronised via the fascial
system. The gluteal muscles and soleus can each affect both the hip and the knee joints.
Excessive tibial torsion has been found to reduce the capacity of these muscles and, as
a result, diminish hip and knee extension during gait (Hicks et al. 2007).
Certain sports might aggravate this posture. For example, golfers develop postures
throughout their bodies that are associated with rotation, including in the joints of the
lower limbs and in the soft tissues associated with these joints. The pivoting movement
inherent to golf increases the likelihood of tibial torsion on the leg that remains static.
For example, moving the club to the right at the start of a swing and rotating the upper
body clockwise to the right produce internal rotation of the left hip and internal torsion
on the right leg, which is fixed to the ground.
Torsion of the tibia alters the position of the meniscus with respect to the femur and
the direction of pull of the patella. Ultimately, this affects how forces are transmitted
through the knee joint. These could be reasons why tibial torsion is associated with
early-onset arthritis, patellofemoral arthritis, genu valgum and genu varum. Malalign-
ment of the knee joint could increase the risk of knee injury.
Clinical tibial torsion also affects the feet and ankles (see table 1.6). Lateral tibial tor-
sion is associated with a toe-out foot position and increased supination, heel inversion
and accentuation of the medial longitudinal arch. Medial tibial torsion is associated with
a toe-in foot position, which can lead to tripping or feeling clumsy when walking. There
is increased subtalar pronation, the heel is everted and the medial longitudinal arch is
decreased. These changes may cause pain, reduce balance and affect gait. Atypical joint
positions in the foot and ankle are likely to impair sporting performance, and in some
cases, they could contribute to early joint degeneration, especially in sports or occu-
pations involving repeated high impact. In a study of 836 patients, Turner and Smillie
(1981) found that external torsion of the tibia was correlated with lesions of the extensor
apparatus, notably in patients with unstable patellofemoral joints and Osgood-Schlatter
disease. It was not known whether these conditions led to the development of increased
external tibial torsion or whether pre-existing increased tibial torsion predisposed the
patients to subsequent development of patellofemoral instability and Osgood-Schlatter
disease. By contrast, patients with inverted feet (associated with internal tibial torsion)
have an advantage when running distances of 15 to 20 metres (16-22 yd), because this
posture promotes short, rapid steps, theoretically because tibial torsion shortens the
hamstrings, limiting a wider step. Thus, there is greater ground contact whilst moving,
and this may improve dynamic balance (Bloomfield, Ackland, and Elliott 1994).
Because tibial torsion can affect and be affected by movements in the pelvis, hip, foot
and ankle, there may be imbalance in muscles throughout the entire lower limb, and these

20
 TIBIAL TORSION

will be highly individualised. Muscles shown in table 1.7 provide a guide only. Because
of the small degree of rotational movement involved in tibial torsion, there are few sig-
nificant changes to the length of muscles in this posture. Joint position and the effect on
ligaments and articular structures may be of greater significance than muscle lengths. It
is likely that many structures contribute to the checking of knee rotation, including the
cruciate ligaments, collateral ligaments, posteromedial capsule, posterolateral capsule,
popliteus tendon and menisci distorted in the direction of the corresponding femoral
condyle (Levangie and Norkin 2001). These structures will be affected when there is an
increase in torsion involving joints (rather than pure torsion within the tibia). The degree
of change in the muscles listed in table 1.7 may be minor and is included only to show
that some change is likely to occur, as when, for example, the distal attachments of the
hamstrings are reorientated as the tibia rotates either internally or externally.

Table 1.6 Tibial Torsion and Corresponding Changes in the Foot

Lateral tibial torsion Medial tibial torsion
Foot position Toe-out Toe-in
Foot changes Increased subtalar supination Increased subtalar pronation
Inversion of heel Eversion of heel
Accentuation of medial longitudi- Decrease in medial longitudinal
nal arch arch

Table 1.7 Muscle Lengths Associated With Increased Tibial Torsion

Direction of torsion Shortened muscles Lengthened muscles
External tibial torsion Biceps femoris relative to semi- Semitendinosus and semimem-
tendinosus and semimembra- branosus relative to biceps
nosus femoris
Iliotibial band Popliteus
Sartorius Muscles and ligaments associ-
Muscles and ligaments associ- ated with pronation of the
ated with pronation of the foot
foot
Internal tibial torsion Semitendinosus and semi- Biceps femoris relative to semi-
membranosus relative to the tendinosus and semimembra-
biceps femoris nosus
Popliteus Iliotibial band
Muscles and ligaments associ- Sartorius
ated with supination of the Muscles and ligaments associ-
foot ated with supination of the
foot

Measuring Tibial Torsion

True tibial torsion is the twisting of the tibia within the bone itself around its longitudinal
axis. With respect to the proximal end, the distal end of the tibia is twisted laterally
(continued)

21
 TIBIAL TORSION

Measuring Tibial Torsion (continued)

and contributes to the toe-out posture observed in typical standing. There is no agreed
norm for the degree of twist, because studies have used different proximal and distal
end points on the tibia when making measurements. One method of measurement
is to take either magnetic resonance imaging or computed tomography scans of the
proximal (figure 1.12a) and distal (figure 1.12b) ends of the tibia, just below and above
the articulating surfaces, respectively, then draw lines bisecting each scan image. The
tibial torsion angle is the angle formed by the bisecting lines (figure 1.12c).

a. Proximal tibia scan

c. Tibial torsion
angle

b. Distal tibia scan

Figure 1.12 One method for calculating true tibial torsion, using the left leg as an
example. (a) Proximal tibia scan, just below the articulating surface (note the absence of
the fibula at this point of the cross-section). (b) Distal tibia scan, just above the articulat-
ing surface (the fibula is present at this level of the cross-section and can be seen as the
E8778/Johnson/F 01.12/717567/pulled/R1
smaller bone). (c) Tibial torsion angle.

In their review of nine studies carried out between 1909 and 1975, Turner and
Smillie (1981) reported tibial torsion measurements ranging from 14 to 23 degrees
but noted that different measuring devices were used, making comparison difficult. In
a more recent study, Strecker and colleagues (1997) recorded torsion in 504 typical
tibiae as 34.9 ± 15.9 degrees. Levangie and Norkin (2001) suggested using the figure
of 20 to 30 degrees for tibial torsion in the general population.
Assessing tibial torsion before treatment is a challenge. Not only are there differences
in the degree of tibial torsion between different studies, but different degrees of torsion
have been found between the left and right tibiae of the same patient (Gandhi et al.
2014; Strecker et al. 1997) and amongst ethnic groups. For example, Mullaji and col-
leagues (2008) recorded tibial torsion of only 21.6 ± 7.6 degrees in 100 limbs in a study
of non-arthritic Indian adults and suggested that the variation between groups could be
due to culture-specific sitting postures. For example, Japanese people traditionally sit on
the floor in knee flexion, with the feet turned inwards and the buttocks resting on the
feet, exerting an internal force on the tibia, whereas sitting cross-legged, as is common
in some Indian populations (the lotus position in yoga), increases external tibial rotation.

22
 Q ANGLE

Anterior View
Q Angle Anterior superior
iliac spine
The Q angle describes the relationships between the
pelvis, leg and foot. It measures the angle between
the rectus femoris quadriceps muscle – hence, the
name Q angle – and the patellar tendon (see figure
1.13). It is useful because, theoretically, it may
help predict the likelihood of some types of knee
problems, and as such, it may indicate the need for Q angle
prophylactic treatment. To determine the Q angle of
a client, follow these steps with the client standing:
1. Find the midpoint of the patella.
2. From this point, draw a line running longitu-
dinally up the femur to the anterior superior
iliac spine (ASIS).
3. Find the tibial tuberosity.
4. Draw a line from the midpoint of the pa- Midpoint of the
tella to the tibial tuberosity. Extend this line patella
superior to the patella, thus creating an angle
Tibial tuberosity
with your first line.
The angle between these two lines is the Q angle
and is usually around 15 to 20 degrees, but it varies
between males and females and amongst individuals. The Q angle.
Figure 1.13 01.13/717084/pulled/R2
E8778/Johnson/F

TIP
It is more accurate to measure the Q angle of a client when they are standing than supine,
because when a client is standing, the patella is under the usual weight-bearing stresses.

Consequences
As a result of a wider pelvis, women have a greater Q angle than men do. It has been
postulated that when the Q angle is greater than typical, the client might experience
greater stress through the patella when performing repetitive exercises that rely on the
use of the knee. This could lead to maltracking of the patella so that it does not glide
smoothly on the femoral grooves, which in turn could lead to microtrauma. Over time,
this microtrauma could develop into more serious pathology, such as degradation of
the patellofemoral cartilage.
Clients with increased pronation of the foot may have an atypical Q angle, perhaps
as a result of internal rotation of the tibia. If this rotation is prolonged, the alteration
in usual biomechanics could result in increased stress on the knee joint. This in turn
could lead to more serious knee problems. It is important to remember, however, that an
atypical Q angle does not mean that a client will definitely experience knee problems.

23
ANKLES

Anterior View
Ankles
When observing the ankles, the medial malleoli should be level with each other, and
the lateral malleoli should be level with each other. Look also to see whether any
swelling or discolouration is evident. Do you observe any eversion or inversion? In
other words, does the client appear to be rolling in onto the medial side of the foot,
or rolling out with greater pressure on the outside of the foot and an increased space
between the medial side of the foot and the floor? Figure 1.14 demonstrates how postural
assessment can help provide important information about injuries to the lower limb,
in this example, to the ankle.

Figure 1.14 The ankles of the person shown here demonstrate how childhood musculo-
skeletal injuries can have lifelong effects. This 74-year-old woman fractured her left ankle
very badly as a young girl. Can you see, from the anterior view, that the ankle appears
to have rolled inwards on the medial side, with loss of the arch?
Courtesy of Emma Kelly Photography.

TIP
The ankle inversion posture is not common. Therefore, if you can see a gap between the
underside of your client’s foot in the region of the medial arch, this could simply mean
that they have a high arch and not that their foot is inverted.

Consequences
Please refer to the sections on pes valgus and pes varus of the posterior postural
assessment for a full description of what changes in the position of the malleoli might
mean.

24
 FOOT POSITION

Anterior View
Foot Position
In typical standing, the feet turn outwards slightly by about 6 to 8 degrees (figure 1.15).
How has your client positioned their feet? The feet should be turned out to the same
angle, equidistant from an imaginary plumb line.

Figure 1.15 Common foot position.

TIP
If you observe asymmetry in theE8778/Johnson/F
foot positions or01.15/717086/pulled/R1
the feet are not positioned as in figure 1.15,
ask your client to take a few steps forwards and backwards and then reassess them. If they
return to the same foot position, then this is likely to be the typical foot position for them.

Consequences
Feet turned out in a ballet-type stance could result from external rotation at the hip joint,
lateral tibial torsion or both. External hip rotation could indicate shortening of the gluteus
maximus and the posterior fibres of the gluteus medius, along with the iliotibial band. A
client who stands with their feet turned inwards (pigeon-toed) may have shortened internal
rotators of the hip, a medially rotated tibia or both. Table 1.8 summarises this information.

Table 1.8 Changes Associated With Toe-Out and Toe-In Foot Positions
Toe-out position Toe-in position
Possible position of the hip joint Externally rotated Internally rotated
Possible position of the tibia Lateral tibial torsion Medial tibial torsion
Muscles that might be shortened External rotators of the Internal rotators of the femur
femur; iliotibial band

25
OTHER OBSERVATIONS

Anterior View
Other Observations
Finally, note anything else that you have not yet documented. Pay particular attention
to swelling around the joints, skin discolouration and scars. In the photograph in figure
1.16a, can you see the increase in tension in the tendon of the person’s right tibialis
anterior muscle? It could have been that they were correcting postural sway just as
this photograph was taken, or they could have a significant difference between the
tendons of this muscle on their left and right legs. Noting your observations regarding
the client’s toes can also be helpful. The ankles and feet of the client in figure 1.16b
appear swollen, and the second toe of the right foot is squashed, potentially causing
pain or affecting gait.

a b

Figure 1.16 (a) Tension in the right tibialis anterior muscle; (b) an example of ankle
and foot swelling and a squashed toe.
Courtesy of Emma Kelly Photography.

26
 PELVIC RIM

Posterior View
Pelvic Rim
Lateral tilt of the pelvis was discussed in the anterior view section of this chapter and
can also be assessed posteriorly. A good way to check whether the pelvis is level when
you are new to postural assessment is to sit or crouch down behind your client and
gently place your hands on their waist. Press first into the fleshy part of the waist and
then down onto the bony iliac crests, or the pelvic rim (figure 1.17). Gauge whether
the left and right sides of the pelvis feel level.

a b

1.17 (a) A neutral pelvis and (b) a pelvis laterally

FigureE8778/Johnson/F01.17a/717046/pulled/R1 tilted upwards
E8778/Johnson/F to the right.
01.17b/717047/pulled/R1

TIP
To help you visualise the effect a laterally tilted pelvis has on the hips, picture the pelvis
as a tabletop with two table legs beneath it (Levangie and Norkin 2001) (figure 1.18).
The legs are free to swing left and right (i.e., to abduct or adduct). Now imagine tilting
the tabletop down to the left (up to the right). What happens to the table legs? They will
continue to hang down perpendicularly, but notice what has happened to the angles they
now form with the tabletop (representing the attachment of the femur at the hip). The
right leg is adducted (the internal angle has decreased), and the left leg is abducted (the
external angle has increased).
(continued)

27
PELVIC RIM

TIP (continued)

90°

45°

a b
Figure 1.18 Illustration exaggerating a pelvis that is higher on one side than the other
E8778/Johnson/F 01.18b/717049/pulled/R1
and the effect of this on the right
E8778/Johnson/F hip.
01.18a/717048/pulled/R1

Next, consider the ischium. In the illustration in figure 1.19, can you see that it is
elevated on the right? What consequences might this have for the length of the hamstring
muscles? If the knee joints were level, could the left hamstrings be shorter than those on
the right? These findings are summarised in table 1.1.

a b
Figure 1.19 Position
E8778/Johnson/F of the ischia in (a) a neutral pelvis and (b) a pelvis tilted upwards
01.19a/717050/pulled/R1 E8778/Johnson/F 01.19b/717051/pulled/R1
on the right.

Consequences
The consequences of a lateral pelvic tilt can be seen in table 1.1.

28
 POSTERIOR SUPERIOR ILIAC SPINES

Posterior View
Posterior Superior Iliac Spines
The posterior superior iliac spines (PSIS) are located directly beneath the dimples some
clients have in this region (figure 1.20a). In the photos in figures 1.20b and 1.20c, the
position of the dimples suggests that the right PSIS is higher than the left PSIS in each
example. Do you think the spine in each photo is straight or slightly flexed laterally
to the right?

x x

a b c
Figure 1.20 (a) Location of the PSIS. (b, c) Examples of clients whose right PSIS is
E8778/Johnson/F 01.20a/717052/pulled/R1
higher than their left PSIS.
Photos b and c courtesy of Emma Kelly Photography.

TIP
Placing your thumbs over the PSIS dimples and observing your thumbs with respect to
one another can help you gauge whether the PSIS points are level and therefore whether
there may be any lateral pelvic tilt.

Consequences
If you determine that the left and right PSIS should be positioned on the same horizontal
plane, yet you observe one to be higher, this suggests that the pelvis is laterally tilted.
The consequences of a lateral pelvic tilt are shown in table 1.1.

29
BUTTOCK CREASE

Posterior View
Buttock Crease
It is not always possible or appropriate to observe the crease of the buttock where it
meets the proximal thigh (see figure 1.21). If the client is wearing long shorts or cycling
shorts, you will not be able to see these creases.

Figure 1.21 Location of the buttock crease.

E8778/Johnson/F 01.21/717054/pulled/r1
TIP
The buttock crease is formed by the fat overlying the buttock muscles and does not indicate
the location of the inferior fibres of the gluteus maximus muscle.

The person in figure 1.22 is a good example of someone

with uneven buttock creases. Observe the position of their
underwear too. Does it look like the right side of the pelvis
is higher than the left? Could either the right tibia or femur,
or both, be longer than the left, causing the pelvis to be
raised on the right?

Figure 1.22 Example of uneven

buttock creases.
Courtesy of Emma Kelly Photography.

30
 BUTTOCK CREASE

Consequences
Clients who bear weight more on one side of the body than the other may have a deeper
buttock crease on that side. This is also often true of clients with a laterally tilted pelvis.
Thus, a client with a pelvis tilted upwards on the right (figure 1.22) might appear to
have a deeper left buttock crease. Could differences in the depth of the buttock creases
also correspond with leg-length discrepancies? Figure 1.23 illustrates the appearance
of varying bone lengths in the lower limb with respect to the buttocks.

a Neutral b Right femur longer c Right tibia longer

Figure 1.23 Examples of variations in leg length and how these might appear and
affect the position of the E8778/Johnson/F
buttock crease.01.23a-c/717056/pulled/r1
save as 1 figure. ID# 717057 and 717058 are not needed

31
PELVIC ROTATION

Posterior View
Pelvic Rotation
You learned that rotation of the pelvis can be assessed by comparing the position of
the ASIS of your client in the anterior view. You can also assess for pelvic rotation in
the posterior view, by observing the position of the PSIS. As with the anterior view, it
helps to imagine your client is standing between two sheets of glass and to ask yourself
which side of the pelvis would touch the glass if there were pelvic rotation. Which side
of the pelvis would be closer to you? Figure 1.24 shows a neutral pelvis in the centre
(1.24b) and provides exaggerated examples of rotation (1.24a and 1.24c).

Left ilium Right ilium

a (and left PSIS) b c (and right PSIS)

Figure 1.24 (a) The left posterior superior iliac spine (PSIS) is closer to the examiner. (b)
Neutral pelvis. (c) The right PSIS is closer to the examiner.

TIP E8778/Johnson/F01.24a-c/718266/pulled/R1
Your findings in the posterior view should correspond with your findings in the anterior
view. That is, if your Saved
client’s
asleft PSIS-isID#
717531 closer to you
718267 in the posterior
and 718268 view, it must be farther
are not needed
away from you in the anterior view (figure 1.25).

32
 PELVIC ROTATION

Pelvis rotated Neutral pelvis Pelvis rotated

anticlockwise clockwise

Left ilium Right ilium

(and left PSIS) (and right PSIS)

Pelvis rotated anticlockwise Pelvis rotated clockwise

Viewing the client Viewing the client
posteriorly, left PSIS is posteriorly, right PSIS is
closest to the observer. closest to the observer.

Pelvis rotated anticlockwise Pelvis rotated clockwise

Viewing the client Viewing the client
anteriorly, right ASIS is anteriorly, left ASIS is
closest to the observer. closest to the observer.

Right ilium Left ilium

(and right ASIS) (and left ASIS)

Figure 1.25 Comparing the posterior and anterior views of the same posture.

Consequences E8778/Johnson/F 01.25/718269/kh/R3t

The consequences of pelvic rotation are described in the corresponding section of the
anterior postural assessment.

33
INTERNAL ROTATION OF THE HIP

Posterior View
Internal Rotation of the Hip
As part of the anterior postural assessment, you looked to see whether there was any
internal rotation of the lower limbs and learned that there may be internal or external
rotation of an entire limb, or part of that limb. Internal rotation of the hip is internal
rotation around the long axis of the femur. A patient with this posture may have a
characteristic toe-in foot position, where the tibia is also internally rotated, or the foot
position may be neutral. Unlike some of the other postures with signs that are visibly
apparent, the degree of inward rotation of the femur is more difficult to identify from
postural assessment alone, and for this reason, muscle length tests are important for
determining whether a patient has a reduction in external hip rotation, which is a
corresponding finding with this posture.
It is important to note that internal rotation of the hip is not the same as internal tor-
sion of the femur. Femoral torsion is rotation within a bone itself, a twisting of the bone,
whereas internal rotation of the hip occurs between bones, at the coxofemoral joint.
Each results in a change in the orientation of the femoral condyles in the transverse
plane. Thus, observing the client’s knees anteriorly and posteriorly can be helpful in
identifying internal rotation of the hip. With both internal rotation of the hip and internal
femoral torsion, the lateral femoral condyle is orientated more anteriorly than typical,
and the medial femoral condyle is orientated more posteriorly. In the patient shown
in figure 1.26a, the lateral femoral condyle of the left femur is anteriorly orientated
and disappears in a posterior view, whereas the medial femoral condyle is posteriorly
orientated and appears more prominent. This indicates internal rotation of the left hip
or internal femoral torsion on that side.

TIP
To help you identify internal rotation when viewing a client posteriorly, imagine the
popliteal spaces as if they were the headlights on a car (see figure 1.26b), just as you did
when observing the knees anteriorly. Kneeling squarely behind your client but about 2
metres (2.2 yd) from them, ask yourself where the headlight beams would fall. Would a
beam be directed towards you (indicating neutral tibiofemoral alignment) or to one side
(indicating hip rotation or femoral torsion)? Observe that the popliteal spaces on this
patient’s right and left knees are not orientated in the same direction; a beam from the
left-knee headlight would fall to your left, whereas a beam from the right-knee headlight
would fall closer to you.

34
 INTERNAL ROTATION OF THE HIP

Lateral femoral Medial femoral

condyle has condyle has
moved anteriorly moved posteriorly

a b

Figure 1.26 (a) A patient with internal rotation of the left hip (internal femoral torsion).
(b) Imagining the popliteal spaces as vehicle headlights.
Photos courtesy of Emma Kelly Photography.

It is tempting to conclude that a person standing with forward-facing feet does not
have any internal rotation at the hip joint. Remember that in typical standing, the feet
turn outwards slightly by about 6 to 8 degrees, so a patient with feet facing forwards
could have an internally rotated hip, internal tibial torsion, internal femoral torsion or
a combination. (A section on tibial torsion appeared earlier in this chapter.)
The subject of internal hip rotation can be confusing because both internal rotation
of the femur and internal femoral torsion contribute to torsion of the entire lower limb.
Inward rotation of the entire lower limb may be the result of a combination of factors
at the coxofemoral and knee joints and within the femur and tibia. As with many of the
postures described in this book, it is important to clarify the degree of internal rotation
you suspect using muscle length tests rather than relying on postural assessment alone.
Consequences
With increased internal hip rotation, there is corresponding decreased external rotation
in the coxofemoral joint. Internal rotators are shortened, and external rotators are
lengthened (table 1.9). Both muscle groups may be weakened because they are not
functioning at their optimal length or within their optimal range. Weakness in external
rotators of the hip is associated with musculoskeletal disorders of the knee, such as
patellofemoral joint pain syndrome and non-contact injury to the anterior cruciate
ligament in adolescent girls (Neumann 2010). Imbalance in muscles around the hip
joint could affect the function of the joint and ultimately could affect not only gait but
also functional and sporting activities.
Femoral torsion can be a contributing factor to internal rotation of the hip. The degree
of femoral torsion is described as an angle that is formed by a line drawn longitudinally
through the neck of the femur, superimposed over a line drawn between the femoral
condyles. This angle is usually 10 to 15 degrees but varies widely. An increase in torsion
angle is called anteversion, which can cause compensatory change in the hip joint and

35
INTERNAL ROTATION OF THE HIP

affect weight bearing, muscle biomechanics and hip joint stability. It may also create
dysfunction at the knee and foot (Levangie and Norkin 2001).
Internal rotation of the hip changes the neutral orientation of the femoral head within
the acetabulum. Prolonged alteration in the distribution of forces through the articular
surfaces of the hip joint could predispose the joint to degenerative changes in the bone,
articular cartilage and connective tissue. Internal rotation of the hip threatens to pinch
anterior hip structures, causing pain.
With internal rotation of the femur, there is atypical orientation of the knee joint. This
is exacerbated where there is a neutral foot position, because this requires external rota-
tion of the tibia in cases where internal rotation of the femur is present. Altered hip and
knee biomechanics alter both walking and running ability and could therefore adversely
affect participation in recreational and sporting activities. Where internal rotation is due
to torsional deformity of the femur, this could contribute to arthritis in the knee joint:
Internal femoral torsion increases pressure on the lateral facet, producing anterior knee
pain and patellofemoral arthritis. There may be lateral patellar subluxation.
Internal rotation of the hip is often accompanied by subtalar pronation of the foot,
and this also causes problems (more information is provided later in this chapter).

Table 1.9 Muscle Lengths Associated With Internal Rotation of the Hip
Area Shortened muscles Lengthened muscles
Hip Tensor fasciae latae Gluteus maximus
Gluteus minimus Gluteus medius (posterior fibres)
Gluteus medius (anterior fibres) Piriformis
Adductor longus Quadratus femoris
Adductor brevis Obturator
Adductor magnus Gemelli muscles
Pectineus Psoas
Gracilis Sartorius

TIP
Note that the piriformis, posterior fibres of the gluteus minimus and anterior fibres of the
gluteus maximus change from being external to internal rotators as the hip is progressively
flexed.

36
 MUSCLE BULK AND TONE

Posterior View
Muscle Bulk and Tone
As with the anterior assessment, compare the shape and size of the thighs and calves,
asking yourself whether there is any hypertrophy or atrophy (figure 1.27).

a b

Checking the 01.27a/717059/pulled/R1

Figure 1.27 E8778/Johnson/F girth of the (a) thighE8778/Johnson/F
and (b) calf. 01.27b/717061/pulled/R1

Consequences
Greater thigh or calf bulk on one side suggests an increased use of the thigh or calf
muscles of that leg with respect to the other. An alternative explanation might be poor
lymphatic drainage, as is seen in patients with lymphoedema; in this case, the limb
will appear swollen rather than there being an increase in muscle bulk. Limb atrophy
may be observed in clients after illness or immobility and is due to muscle atrophy.

TIP
Clients who have injured a leg, foot or ankle are often observed to have less bulk in the
lower limb on that side, simply because they are using that limb less. This may be accom-
panied by a compensatory increase in the muscle bulk of the other side. For example, a
client recovering from a ruptured right Achilles tendon, a fractured ankle or toe surgery
could have reduced bulk on the right lower limb and increased bulk on the left lower limb.
Injuries that occurred when your client was a child or teenager may manifest in asym-
metry between the lower limbs, because reduced weight bearing during childhood may
have affected muscle and bone development. Although it is subtle, you may observe some
clients shifting their weight laterally, with a subconscious disinclination to bear weight on
the side of a former injury.

37
POSTERIOR KNEE

Posterior View
Posterior Knee
Take a look at the posterior aspect of the knee and note anything unusual about it.
Does your client stand with neutral, flexed or hyperextended knees? Although this is
best assessed when you carry out the lateral postural assessment, you can sometimes
get a feel for knee position by observing how prominent the popliteal area appears
to be. Is there any oedema, or are there signs of bursitis? You learned in the anterior
assessment to look for genu varum and valgum. Check for this also when carrying out
your posterior assessment. Figure 1.28 is an example of someone with a slight genu
valgum posture of the right knee.

Figure 1.28 Slight genu valgum of the right knee.

Courtesy of Emma Kelly Photography.

Consequences
The consequences will depend on whether the client has a flexed or hyperextended
knee. These postures are best determined in the lateral view, combined with range-of-
motion tests.

TIP
If the posterior knee seems more deeply creased than typical, this could indicate that the
client is standing with a flexed knee. If the posterior knee is prominent, with the popliteus
muscle seeming to protrude slightly, this could indicate that the client is hyperextending
at this joint. Bursitis presents with an obvious protrusion.

38
 CALF MIDLINE

Posterior View
Calf Midline
Imagine a line running vertically down the centre of the client’s calf from the knee
crease through the Achilles tendon (figure 1.29). If necessary, draw this line using a body
crayon. Compare the left and right calves and their relationship to the midline of the
body. Look also at the shape of the legs and whether there is evidence of tibial bowing.

Figure 1.29 Use an imagined or drawn line

E8778/Johnson/F along the midline of the calf.
01.29/717062/pulled/R1

TIP
One way to understand how hip rotation can affect the position of the calf is to draw the
vertical calf lines on your client and then stand back and observe these lines when you
instruct the client to alter their hip position. Ask them first to stand with one foot pigeon-
toed. Compare the calf line on this leg with that of the other leg, and you will see that
the line has moved outwards, away from the midline of the body, because the client has
rotated the hip internally to stand pigeon-toed. Then ask the client to turn their foot out on
that side whilst keeping the other foot facing forwards or in a neutral position. This time,
the opposite happens: The calf line moves inwards, towards the midline of the body, as
the client contracts the external hip rotators.

39
CALF MIDLINE

Consequences
The experiment described in the preceding tip box demonstrates that a line that appears
to be lateral (rather than central) on the calf could result from an internally rotated hip
on that side or a tibia that is medially rotated against the femur on that side. In either
case, the foot position may also change when the person stands pigeon-toed. A line
that appears to be medial (rather than central) on the calf indicates the opposite: an
externally rotated hip on that side or a tibia that is laterally rotated against the femur
on that side. In this case, the client may stand with the feet turned out. Table 1.10
summarises this information and provides a reminder of the muscles acting on the hip
to bring about either internal or external rotation.
If a client comes to you with a hip problem, a postural assessment is a good place
to start, because it may reveal shortness in one group of muscles and the need to test
for tightness in these muscles later. Remember that it is ultimately important to discern
whether the position of the calf is due to imbalances in hip muscles or torsion in the
tibia, because your treatment protocol will be different for each.
Bowing of the tibia could indicate osteomalacia or increased compressive forces on
the concave side of the bone.

Table 1.10 Calf Line and Corresponding Effects on the Feet

and the Leg Muscles
Calf line appears lateral Calf line appears medial
Position of the hip, Indicates internal rotation of Indicates external rotation of
tibia or both the hip, the tibia or both the hip, the tibia or both
Foot position Sometimes, the client stands Sometimes, the client stands
pigeon-toed with the feet turned out
Muscles that may be Internal rotators of the hip: External rotators of the hip:
shortened Gluteus minimus Gluteus maximus
Gluteus medius (anterior fibres) Gluteus medius (posterior
Adductors fibres)
Pectineus Piriformis
Gracilis Quadratus femoris
Obturator
Gemelli muscles
Psoas*
Sartorius
*The psoas is not a definitive rotator, yet it may be more involved in stability of the spine, including rotation, than
originally thought.

40
 ACHILLES TENDON

Posterior View
Achilles Tendon
Observation of the ankles can provide clues relating to pain and dysfunction not only in
the ankle itself but also in the feet and knees. Start by looking at the Achilles tendon and
the position of the calcaneus. Figure 1.30 shows six ankles belonging to three clients.
Observe the variety of shapes of the Achilles tendon, the position of the calcaneus
and the position of the ankle joint itself, plus the foot position chosen by clients when
undergoing postural assessment.

a b c

Figure 1.30 Observe the Achilles tendon.

Courtesy of Emma Kelly Photography.

It can be helpful to use a body crayon to draw a line vertically down the Achilles
tendon, over the calcaneus and to the floor (figure 1.31), then to stand back and observe
the line you have drawn. Is the tendon straight, concave or convex? Do the feet appear
to roll out or to roll in? You can read more detailed information about ankle postures
in the sections on pes valgus and pes varus.

a Calcaneovalgus b Neutral c Calcaneovarus

Figure 1.31 (a) Calcaneovalgus, (b) neutral and (c) calcaneovarus postures.

Consequences
The observation ofE8778/Johnson/F
the Achilles tendon can help provide information about excessive
01.31/717063/pulled/R1
ankle eversion or inversion. Clients with excessive eversion, sometimes popularly
One figure; ID# 717064 and 717065 are not needed
referred to as overpronation, may have shortened peroneal (fibular) muscles on that leg.

41
PES VALGUS

Posterior View
Pes Valgus (Pronated Foot)
The positions of the malleoli provide clues as to whether your client has a neutral ankle
position (figure 1.32a) or whether there is evidence of pes valgus (figure 1.32b) or pes
varus. Pes is a term restricted to any foot deformity of acquired origin, and valgus refers
to bones distal to the joint moving in a single plane away from the midline (Ritchie and
Keim 1964). In the pes valgus foot posture (pronated foot), the calcaneus is the bone
that moves away from the midline and is often described as being abducted (figure
1.32b). Another way to describe the pes valgus posture is that there is eversion (or
valgus) of the heel. There is pronation of the foot, and the medial longitudinal arch is
reduced in height.

Medial
malleolus Medial
malleolus
Lateral
malleolus Lateral
malleolus

Calcaneus Calcaneus

Medial Lateral
a b aspect of heel aspect of heel

Figure 1.32 (a) Neutral

E8778/Johnson/F foot posture and (b) pes valgus foot posture.
01.32a/717580/pulled/R1

The posture is easy to identify because in neutralE8778/Johnson/F

foot posture, 01.32b/717581/pulled/R1
the lateral malleolus is
positioned slightly inferior to the medial malleolus, whereas in the pes valgus posture,
the lateral malleolus lies even lower. Your client may appear to be bearing weight more
on the medial side of the heel (often evidenced by increased wear on the sole of the
shoe), with less pressure on the lateral side of the heel. When assessing a client, it can
sometimes be helpful to imagine a line through the tibia, talus and calcaneus; in the
neutral foot posture, it is vertical, but it deviates in the pes valgus posture, forming an
obtuse angle on the lateral side of the ankle.
The person in figure 1.33 has prominent medial malleoli. Could it be that her tibiae
are twisted so that each knee turns inwards as the whole of the tibia, including the distal
end, rotates medially? Could that explain why we can see more of the medial malleoli
on both the left and right ankles?

42
 PES VALGUS

Figure 1.33 Observe the malleoli to help determine ankle posture.

Courtesy of Emma Kelly Photography.

Consequences
In the pes valgus posture, there are increased tensile stresses on the medial side of the
ankle and increased compressive stresses on the lateral side of the ankle (figure 1.32b).
Anatomic foot type does not appear to be a risk factor for ankle sprains (Beynnon,
Murphy, and Alosa 2002), although many studies have tested participants standing
barefoot and not dynamically. Nevertheless, theoretically, increased tensile stress on
the medial side of the ankle could lengthen and weaken the medial collateral (deltoid)
ligament, predisposing a patient to medial collateral ankle sprain.
Ligaments between the tibia and fibula contribute to the function of both superior
and inferior tibiofibular joints (Levangie and Norkin 2001). Compressive stress on the
lateral side of the ankle could therefore affect the proper functioning not only of the
distal tibiofibular joint but also of the proximal tibiofibular joint.
A pronated foot increases the likelihood of having hallux valgus and overlapping
toes (Hagedorn et al. 2013) as well as metatarsalgia, interdigital neuritis and plantar
fasciitis (Fowler 2004).
Table 1.11 illustrates muscle length changes associated with the pes valgus posture.
Such changes may explain why a pronated foot requires more muscle work for main-
taining stance stability than does a supinated foot (Magee 2002) and why there may be
myositis or tendinitis of the tibialis anterior and tibialis posterior (Fowler 2004). People
with pronated feet are more likely to have Achilles tendinitis or tendinosis due to greater
demands placed on the tendon when walking (American College of Foot and Ankle
Surgeons 2023a). Spindles in ankle muscles are significant for the control of posture
and balance whilst walking (Sorensen, Holland, and Patla 2002). Muscles listed in table
1.11 all cross the ankle joint, and changes to their length or health are therefore likely
to affect balance too. This could be particularly significant for older adults.
Fowler (2004) suggests that excessive foot pronation is associated with calcaneal
bursitis and may contribute to medial knee injury, patellofemoral syndrome, iliotibial
band syndrome, shin splints, trochanteric bursitis, anterior shift of the pelvis and lumbar
facet syndrome along with sacrococcygeal dysfunction in the spine.

43
PES VALGUS

Patients with osteoarthritis in the medial compartment of the knee have been found
to have a more pronated foot compared to control individuals (Levinger et al. 2010)
and to walk with greater rearfoot eversion (Levinger et al. 2012), as in the pes valgus
posture. It is not clear whether pes valgus develops in response to medial-compartment
knee osteoarthritis or whether the foot posture itself contributes to the development
of this knee pathology. There may be pain in both the medial and lateral sides of the
talocrural joint (Gross 1995).
Proper joint movement in the foot and ankle is essential for neutral gait, and atypi-
cal pronation results in the inability of the foot to absorb the forces of weight bearing
effectively (Donatelli 1987). In the pes valgus posture, the heel abducts (everts). In
the closed chain (weight bearing), this forces the talus to adduct and leads to plantar
flexion. The tibia follows the motion of the talus and thus is forced into slight internal
rotation. Additionally, there may be internal rotation of the femur and rotation of the
pelvis (Riegger-Krugh and Keysor 1996). Pes valgus may be associated with the genu
valgum (knock-kneed) posture. Raising the lateral side of the foot (as in the pes valgus
foot posture) results in significant changes in pelvic tilt and torsion (Betsch et al. 2011).
Given the changes in other joints of the lower limb associated with the pes valgus
posture, it is easy to see why it is popularly believed that pes valgus may be associated
with an increased risk of injury. However, measurements of static lower limb biome-
chanical alignment have not been found to be related to injury in recreational athletes
(Lun et al. 2004).

Table 1.11 Muscle Lengths Associated With Pes Valgus

Area Shortened muscles Lengthened muscles
Ankle and leg Fibular (peroneal) muscles Tibialis posterior
Gastrocnemius Adductor hallucis
Soleus Flexor hallucis longus
Flexor digitorum longus
Thigh Where there are associated Where there are associated
changes at the hip and knee: changes at the hip and knee:
biceps femoris, hip adductors, gluteus maximus, gluteus medius
tensor fasciae latae

TIP
In addition to shortening of muscles on the lateral side of the leg, there may be tightness
in the iliotibial band.

44
 PES VARUS

Posterior View
Pes Varus (Supinated Foot)
Just as with the pes valgus posture, you can use the position of the malleoli to determine
whether your client has a neutral (figure 1.34a) or pes varus (figure 1.34b) ankle posture.
The term varus means that bones distal to the joint move in a single plane towards the
midline (Ritchie and Keim 1964). In the pes varus foot posture (supinated foot), the
calcaneus is the bone that moves towards the midline, and it is often described as being
adducted. Another way to describe the pes varus posture is to say that there is inversion
(or varus) of the heel. There is supination of the foot, and the medial longitudinal arch
may be accentuated.
In neutral foot posture, the lateral malleolus is positioned slightly inferior to the medial
malleolus (figure 1.34a), whereas in the pes varus posture, the lateral malleolus lies
higher, more parallel with the medial malleolus (figure 1.34b). Your client may appear
to be bearing weight more on the lateral side of the heel, often evidenced by increased
wear on the sole of the shoe, with less pressure on the medial side of the heel. When
assessing a client, it can sometimes be helpful to imagine a line through the tibia, talus
and calcaneus, which in the neutral foot posture is vertical but deviates in the pes varus
posture, forming an obtuse angle on the medial side of the ankle.

Medial
malleolus

Lateral Medial Lateral

malleolus malleolus malleolus

Calcaneus
Calcaneus

Medial Lateral
a b aspect of heel aspect of heel
E8778/Johnson/F 01.34a/717584/pulled/R1
Figure 1.34 (a) Neutral foot posture and (b) pes varus foot posture.

E8778/Johnson/F 01.34b/717585/pulled/R1

45
PES VARUS

Consequences
There are increased compressive stresses on the medial side of the ankle and increased
tensile stresses on the lateral side of the ankle. It is commonly believed that the pes varus
posture predisposes a patient to ankle sprains, and this could be due to weakening of
the lateral collateral ankle ligaments as a result of increased tensile stress. However, as
previously indicated, Beynnon, Murphy and Alosa (2002) reported that anatomic foot
type does not appear to be a risk factor for ankle sprains.
Increased tensile stress on the lateral side of the ankle could affect the proper func-
tioning of the distal tibiofibular joint. Because both the distal and superior tibiofibular
joints are linked, ligaments between the tibia and fibula contribute to the function of
both joints (Levangie and Norkin 2001).
Table 1.12 illustrates muscle length changes associated with the pes varus posture.
Spindles in ankle muscles are significant for the control of posture and balance whilst
walking (Sorensen, Holland, and Patla 2002). Muscles listed in table 1.12 all cross the
ankle joint; changes to their length or health are therefore likely to affect balance. This
could be particularly significant for older adults. Furthermore, in the pes varus posture,
the toes are lifted from the ground, and often, there is flexion of the big toe as it attempts
to regain contact with the ground. It is essential that the toes function properly, not just
for balance but so that body weight can be distributed more evenly when standing and
walking (Hughes, Clark, and Klenerman 1990).
In the pes varus posture, the heel adducts (inverts). In the closed chain (weight bear-
ing), this forces the talus to abduct and dorsiflex. Because the tibia follows the motion
of the talus, the tibia is thus forced to externally rotate. This posture is also associated
with external rotation of the femur and rotation of the pelvis (Riegger-Krugh and Keysor
1996). The consequences of this can be found in the section on tibial torsion.
Patients with excessive supination may develop plantar fasciitis, heel spurs, Achilles
tendinitis, metatarsalgia and calcaneal bursitis (Donatelli 1987).
As with pes valgus, changes in joints of the lower limb associated with pes varus
contribute to the popular belief that this posture may be associated with an increased
risk of injury. Measurements of static lower limb biomechanical alignment have not been
found to be related to injury in recreational athletes (Lun et al. 2004). However, review-
ing the research into predictive factors for lateral ankle sprains, Beynnon, Murphy and
Alosa (2002) reported that increased hindfoot inversion (as is the case with an inverted
heel) is a risk factor predisposing military trainees to lower extremity overuse injury.

Table 1.12 Muscle Lengths Associated With Pes Varus

Area Shortened muscles Lengthened muscles
Foot Flexor hallucis longus Fibular (peroneal) muscles
Flexor digitorum longus Extensor digitorum longus
Tibialis anterior Extensor hallucis longus

TIP
The plantar fascia on the sole of the foot is shortened.

46
 FOOT POSITION

Posterior View
Foot Position
You began the anterior postural assessment by observing
the stance adopted by your client. Another useful factor
to consider is the specific position of the feet. Each foot
usually turns out equidistant from the midline of the body, Figure 1.35 Example of
but sometimes, a person favours a toe-in or toe-out position external rotation of the
of one or both feet. Can you see how the client in figure right lower limb.
1.35 is standing with their right foot turned out slightly Courtesy of Emma Kelly
compared to their left? Photography.

TIP
One way to assess foot position in the posterior view is to ask yourself how much of the
lateral side of the foot you can see (i.e., how many toes). The more of the lateral aspect
of the foot you can see (i.e., the more toes), the greater the degree of the toe-out position
on that side.

Consequences
As you learned in the section on anterior assessment, the position of the foot (and leg)
ties in with the position of the hip and tibia. Table 1.13 shows changes associated with
toe-out and toe-in foot positions.

Table 1.13 Changes Associated With Toe-Out and Toe-In Foot Positions
Toe-out position Toe-in position
Possible position of the hip Externally rotated Internally rotated
joint
Possible position of the tibia Lateral tibial torsion Medial tibial torsion
Muscles that might be short- External rotators of the Internal rotators of the femur
ened femur; iliotibial band

TIP
If, based on the position of the feet, you suspect that your client has shortened hip rotators,
a crude but effective test is simply to ask them to stand in the foot position that would
stretch those rotators. For example, if the client stands pigeon-toed, ask them to stand with
the feet turned out like a ballet dancer. If the internal rotators really are tight, the client
will find this toe-out position slightly uncomfortable.

47
OTHER OBSERVATIONS

Posterior View
Other Observations
Finally, as you did for the lower body anterior postural assessment, make note of any
scars, blemishes or unusual marks on the client’s skin. Has any strapping or taping been
applied, perhaps in the treatment of an injury?

48
 OVERALL LOWER LIMB POSTURE

Lateral View
Overall Lower Limb Posture
Stand back and take an overall view of your client. Use of a plumb line can be helpful
in assessing where ground forces may be affecting the lower limbs. The plumb line is
positioned just anterior to the lateral malleolus (as shown in figure 1.36), and in a neutral
posture, it bisects the leg, knee and pelvis. What do you notice about the lower limb
postures of the clients in figure 1.37? Comparing each photograph to figure 1.36 reveals
that none of these people have a neutral lower limb posture, because the plumb line
does not bisect the legs, knees and pelvis equally. In addition, as might be expected,
each of their postures differ. You will learn more about what the lateral assessment can
reveal about the position of the pelvis, knees and ankles in later sections.

a b c d

Figure 1.36 A Figure 1.37 Superimposing a plumb line over postural photo-
plumb line drawn graphs.
over a neutral Photos courtesy of Emma Kelly Photography.
posture.01.36/717074/pulled/R1
E8778/Johnson/F

TIP
With practice, you will learn to visualise a plumb line. If you are new to postural assess-
ment, you may find it helpful to manually draw a plumb line over a photograph of your
client or superimpose the line on a digital photograph.

49
 ANTERIOR PELVIC TILT

Lateral View
Anterior Pelvic Tilt
When we walk, the pelvis naturally moves anteriorly and posteriorly (figure 1.38).
Anterior pelvic tilt describes the position of the pelvis with the ASIS positioned anterior
to the pubis in the sagittal plane.

ASIS

Pubic bone

c
a b
Figure 1.38
E8778/Johnson/F (a) A neutral pelvis. (b) An anteriorly tilted pelvis. (c) A
01.38a/717523/pulled/R1 client with an ante-
E8778/Johnson/F 01.38b/717524/pulled/R1
riorly tilted pelvis and the characteristic sloped appearance of the underwear.
Photo c courtesy of Emma Kelly Photography.

TIP
To better understand anterior and posterior pelvic tilting, try this: Standing, push your
abdomen forwards and your buttocks out, extending your lumbar region. This produces
an anterior pelvic tilt. Return to your neutral, resting position. Now contract your buttocks,
pushing your groin forwards and flattening your lumbar spine. This produces a posterior
pelvic tilt.

TIP
There is a trick to help you determine whether your client is standing with a particularly
lordotic lumbar region or whether this region is flattened. Ask your client to perform the
tilting manoeuvres you tried for yourself in the preceding tip. Once the client understands
what to do, observe what occurs as they perform an anterior tilt and then a posterior tilt.
If the client has difficulty tilting the pelvis anteriorly, increasing the lumbar curve, this
could be because they are already in an anteriorly tilted position. If they have difficulty
posteriorly tilting the pelvis, flattening the lumbar curve, this could be because they are
already in a posteriorly tilted position.

50
 ANTERIOR PELVIC TILT

Consequences
The position of the sacrum is associated with various degrees of spinal curvature, as is
the shape of the auricular facet of the sacroiliac joint (SIJ) (Kapandji 2008). Compared
with the position of the sacrum associated with a more neutral spine shape, in which
there is increased curvature (and associated anterior pelvic tilt), the position of the
sacrum becomes more horizontally orientated. This in itself may be of little consequence.
However, the shape of the auricular facet has been found to vary amongst sacra
associated with different spinal shapes, and it seems reasonable to assume that the
shape of this facet suits the particular spinal shape with which it is associated. Could
changing the orientation of the pelvis (and sacrum) from a neutral position to an anterior
pelvic tilt have a detrimental effect on SIJ function by reducing the ability of this joint
to withstand forces?
Nutation and counternutation are movements of the sacrum about an axis with
respect to the ilia. (There is debate about where the axis of rotation lies.) With anterior
pelvic tilt (red arrows in figure 1.39a), the sacrum moves in the opposite direction (blue
arrows in figure 1.39a), a movement that has been termed counternutation. Looking
at figure 1.39, consider the position in which the spine would move if there were no
counternutation of the sacrum: Fixed at its base to the first sacral bone, the lumbar
spine (and all of the vertebrae above it) would be forced forward, away from the verti-
cal position. Counternutation is important because it marginally decreases the degree
to which the spine must right itself back to vertical.

a b
Figure 1.39 (a) Counternutation and (b) nutation of the sacrum, as seen in the anterior
and posterior pelvic01.39a/717526/pulled/R1
E8778/Johnson/F tilt conditions, respectively.
E8778/Johnson/F 01.39b/717527/pulled/R1

51
ANTERIOR PELVIC TILT

Where anterior pelvic tilt is pronounced or prolonged, could the sacrum be forced
into counternutation for the spine to remain in a vertical position? What consequence
might this have for the SIJ? Although the degree of SIJ movement is considered small
(1-3 mm [0.0-0.1 in.]) (Houglum and Bertoti 2012), many therapists attribute back
pain to dysfunction in this joint. Also, the sacral ligaments are strong and counter both
nutation and counternutation. However, could prolonged anterior rotation of the pelvis
stress the ligaments responsible for checking such movement, perhaps even affecting
muscles associated with these ligaments (e.g., the superior tendon of the biceps femoris
and the sacrotuberous ligament)?
Anterior movement of the acetabulum over the head of the femur changes the point
of contact between these bony surfaces, the consequences of which are not known.
Additionally, increased hip flexion corresponds with increased torque of the medial
rotators of the hip and decreased torque of the lateral rotators. This could also affect
the position of the femoral head in the acetabulum and the area of the head of the
femur and acetabulum through which weight bearing and ground reaction forces are
transmitted. Theoretically, this could lead to degenerative changes and adversely affect
hip function in the long term.
An anteriorly tilted posture corresponds with an imbalance in flexor and extensor
muscles (see the following list of factors corresponding to anterior pelvic tilt), which
could adversely affect hip function. In addition, this posture corresponds with an
increase in the lumbar curve and shares the consequences of that posture: As the pelvis
tilts anteriorly, soft tissues of the posterior lumbar spine are compressed and greater
pressure is placed on the posterior aspect of intervertebral discs than on the anterior
lumbar spine, affecting nutrient exchange (Adams and Hutton 1985); facet joints are
subject to increased stress, and there is a possibility of capsular strain (Scannell and
McGill 2003). Imbalance between longitudinal ligaments of the lumbar spine could
alter their stabilising capabilities; an anteriorly tilted pelvis could predispose a patient
to osteoarthritis in lumbar facet joints, degenerative changes in parts of the lumbar discs
and low back pain, and it could also give rise to symptoms affecting the lower limbs.
Factors Corresponding to Anterior Pelvic Tilt
Position of the ASIS: held anterior to the pubis
Corresponding position of the lumbar spine: increased lordosis
Shortened muscles: extensors of the lumbar spine, psoas major, rectus femoris,
iliacus, tensor fasciae latae, sartorius
Lengthened muscles: rectus abdominis, hip extensors

52
 POSTERIOR PELVIC TILT

Lateral View
Posterior Pelvic Tilt
Compared with a neutral pelvic posture (figure 1.40a), in the posterior pelvic tilt posture,
the position of the ASIS is posterior to the pubis in the sagittal plane (figure 1.40b). With
the lower limb fixed, posterior tilt of the pelvis produces hip extension and corresponds
with a decrease in the lumbar curve. There is sometimes tension in the abdominal
muscles, which may be observed by an increased transverse abdominal crease (figure
1.40c). As with anterior pelvic tilt, there is asymmetry in muscles of the anterior and
posterior body (see the section on factors corresponding to posterior pelvic tilt).

ASIS

Pubic bone

a b c

Figure 1.40 (a) A neutral pelvis. (b) A posteriorly tilted pelvis. (c) A client with a poste-
riorly tilted pelvis and an increased transverse abdominal crease.
E8778/Johnson/F 01.40a/717528/pulled/R1
Photo c courtesy E8778/Johnson/F 01.40b/717529/pulled/R1
of Emma Kelly Photography.

TIP
If there is tension in the abdominal muscles, they can pull on the anterior fascia, depress-
ing the rib cage and hampering thoracic extension.

53
POSTERIOR PELVIC TILT

Consequences
Compared to a neutral pelvis, as the pelvis tilts posteriorly, the sacrum becomes more
vertical and the coccygeal bones fall closer to vertical. Unless there is a significant
change in pelvic tilt when seated, a patient with a posteriorly tilted pelvis could have
coccygeal pain when sitting for prolonged periods.
With posterior tilt of the pelvis, the sacrum is forced into nutation (see figure 1.39b)
for the spine to remain in a vertical position. As with the opposite posture (anterior
pelvic tilt), changing the position of the SIJ, as well as the way it transmits forces from
the ground and lower limbs to the spine and from the torso and upper limbs to the legs,
could be detrimental to the functioning of this joint.
Factors corresponding to posterior pelvic tilt are listed here. As with hypolordosis
of the lumbar spine, there is increased compressive stress on the anterior annuli of the
discs and increased hydrostatic pressure in the nucleus at low load levels (Adams and
Hutton 1985).
Factors Corresponding to Posterior Pelvic Tilt
Position of the ASIS: held posterior to the pubis
Corresponding position of the lumbar spine: decreased lordosis
Shortened muscles: lower abdominals, gluteus maximus
Lengthened muscles: lumbar erector spinae, psoas, iliacus, rectus femoris

54
 GENU RECURVATUM

Lateral View
Genu Recurvatum (Knee Hyperextension)
The lateral assessment is an excellent opportunity to observe what is happening at
your client’s knee joint. Commonly termed knee hyperextension, this posture describes
extension at the knee (tibiofemoral) joint greater than neutral or zero degrees when
weight bearing. Remember that when using a plumb line, you position your line just
anterior to the lateral malleolus. This line bisects the tibia longitudinally in neutral
knee posture (figure 1.41a). In the genu recurvatum posture, a larger portion of the
calf falls posterior to the plumb line, which no longer bisects the leg (figure 1.41b).
In this posture, the calf appears prominent in the lateral view, and the popliteal space
appears prominent when you view your client posteriorly. The patella also appears
to point downwards and to be compressed when you view your client anteriorly. The
client shown in figure 1.41c is a good example of someone who stands with increased
extension at the knee joint. Observe the front of this woman’s knee. Can you see how it
appears to be compressed, with the patella pushed into the front of the joint? Can you
see how if you were to draw a plumb line onto this image, the leg would fall posterior
to the plumb line? This posture is associated with excessive femoral internal rotation,
genu varum or genu valgum, tibial varum and excessive subtalar joint pronation, all
more apparent when you view your client anteriorly.

a b c

Figure 1.41 (a) Neutral knee alignment. (b) Genu recurvatum. (c) Mild genu recurva-
tum. E8778/Johnson/F 01.41b/717546/pulled/R1
E8778/Johnson/F 01.41a/717545/pulled/R1
Photo c courtesy of Emma Kelly Photography.

55
GENU RECURVATUM

TIP
If you can see more of the popliteal area (and perhaps also the calf) of the right leg when
viewing the left side of the client, this indicates that the right knee is hyperextended. Being
able to see more of the left leg when viewing the client’s right side suggests that there may
be increased extension in the left knee joint.

Consequences
In this posture, there is tension in posterior knee structures (such as the popliteus) and
compression of anterior structures (such as the patellofemoral joint). As a consequence,
adults who stand in knee hyperextension may have pain in the popliteal space (Kendall,
McCreary, and Provance 1993) and patellofemoral pain. People with hypermobility have
laxity in knee ligaments and stand in the genu recurvatum posture. The knee is the most
painful joint in people with knee hypermobility, and patellofemoral pain syndrome is
a common problem (Tinkle 2008).
Additionally, the typical kinematics of the knee are affected by alteration of tib-
iofemoral mechanics. In usual weight bearing, the femur rolls anteriorly and glides
posteriorly on the fixed tibia, but in knee hyperextension, the femur tilts forwards,
resulting in anterior compression of the femur and tibia. In weight bearing, capsular
and ligamentous structures of the posterior knee are at risk of injury, and this in turn
may lead to functional gait deficits. Patients with genu recurvatum posture walk more
slowly than is typical, and many have higher knee extensor torque values than people
with neutral knee posture (Kerrigan, Deming, and Holden 1996).
Other joints are also affected. There is increased hip extension and decreased ankle
dorsiflexion, both of which are likely to affect gait and impair sporting performance
that relies on lower limb agility. At the hip, there can be excessive anterior tilt. The
genu recurvatum posture results in gait deviation and requires greater effort to maintain
forward momentum (Fish and Kosta 1998).
The quadriceps and soleus muscles are shortened, and the knee extensor muscles
are lengthened. Imbalance between knee flexors and extensors compromises the func-
tion and stability of both the knee and hip joints. Stretching of the popliteus reduces
its ability to rotate the leg medially on the thigh and flex the knee and therefore affects
optimal knee function. There may be a proprioceptive deficit near the end of the range
of extension (Loudon, Goist, and Loudon 1998), and patients may feel the sensation
of knee instability.
A positive correlation between genu recurvatum and anterior cruciate ligament
injury in female athletes has been found (Loudon, Goist, and Loudon 1998). Genu
recurvatum posture may predispose female athletes to overuse injuries of the knee
(Devan et al. 2004). Knee hyperextension may be prevalent in some swimmers, and it
has been postulated that this is the result of overstretching of the cruciate ligaments due
to repetitive kicking. This posture gives a greater range of anterior-to-posterior motion
at the knee, but it is not clear whether genu recurvatum is advantageous to swimmers
(Bloomfield, Ackland, and Elliott 1994).

56
 GENU RECURVATUM

Factors corresponding to the genu recurvatum posture are listed here.

Factors Corresponding to Genu Recurvatum
Shortened muscles: quadriceps, soleus
Lengthened muscles: gastrocnemius
Hip position: increased hip extension
Ankle position: decreased dorsiflexion
Other: stretching of the posterior joint capsule of the knee; increased likelihood of
degenerative changes to the patellofemoral joint

57
 GENU FLEXUM

Lateral View
Genu Flexum (Flexed Knee)
As the name indicates, in the genu flexum (flexed knee) posture, a person bears weight
through a knee that is flexed to a greater degree than is typical when standing. Less
common than genu recurvatum, this posture is observed in older patients or in patients
who have been sedentary and whose knees have been allowed to rest in a flexed position
for prolonged periods. Viewed laterally, an imaginary line drawn vertically from just
anterior to the lateral malleolus bisects the tibia longitudinally in neutral knee posture
(figure 1.42a). In the genu flexum posture, the knee itself falls anterior to this line, which
no longer bisects the leg (figure 1.42b). This posture is best identified by viewing your
client in the sagittal plane, as with the patient in figure 1.42c. Note the increased ankle
dorsiflexion commonly associated with this posture.

a b c

Figure 1.42 (a) Neutral knee alignment. (b) Genu flexum. (c) A client with genu flexum
of the right
E8778/Johnson/F leg.
01.42a/717552/pulled/R1
E8778/Johnson/F
Photo c courtesy of Emma Kelly Photography. 01.42b/717553/pulled/R1

58
 GENU FLEXUM

Consequences
When the knee is extended, the collateral ligaments are relatively taut, helping to stabilise
the joint. They slacken when the knee flexes and permit some axial rotation. Repeated
weight bearing through a flexed knee could increase the likelihood of rotational injury
to the knee.
Constant muscular effort is required for standing in knee flexion, which can be
fatiguing. Constant contraction of the quadriceps has another disadvantage. This muscle
exerts a pull on the tibia at the insertion of the tibial tuberosity, and this could lead to
tenderness or the development of unwanted teno-osseous pathology. There is increased
pressure on the anterior aspect of the ankle due to increased dorsiflexion.
Prolonged unilateral knee flexion is associated with pronation of the foot and medial
rotation of the contralateral thigh along with ipsilateral hip drop (contralateral hip
hitch), convex curving of the spine towards the affected side and contralateral drop
of the shoulder (Kendall, McCreary, and Provance 1993). For example, a patient with
right knee flexion is more likely to have pronation of the left foot, internal rotation of
the left thigh, a dropped hip on the right side (but a raised hip on the left side) and a
dropped left shoulder.
Factors corresponding to the genu flexum posture are listed here.
Factors Corresponding to Genu Flexum
Shortened muscles: hamstrings, popliteus
Lengthened muscles: quadriceps, soleus
Hip position: increased hip flexion
Ankle position: increased dorsiflexion
Other: increased pressure on structures of the anterior ankle joint

TIP
Swelling of the knee can make it difficult to determine if someone has a genu flexum
knee posture. This is a good example of why additional tests should always be used when
assessing a joint. In this example, the additional tests would include active and passive
knee flexion and extension.

59
ANKLE POSITION

Lateral View
Ankle Position
Examine your client’s ankles. Are they neutral, or do you notice any increased or
decreased dorsiflexion? Decreased dorsiflexion is associated with the genu recurvatum
posture, whereas increased dorsiflexion is associated with genu flexum. The three
people in figure 1.43 are good examples of individuals with decreased dorsiflexion at
the ankle, as is common with knee hyperextension.

a b c

Figure 1.43 Examples of decreased ankle dorsiflexion.

Courtesy of Emma Kelly Photography.

Consequences
Increased dorsiflexion in standing is observed in clients who stand with flexed knees.
In these clients, ground forces are no longer distributed evenly up through the tibiae
during walking. Possible consequences might be pain and early degenerative joint
changes. There may be a shortened tibialis anterior muscle and increased pressure to
the anterior aspect of the ankle retinaculum. Decreased dorsiflexion is associated with
shortened quadriceps and increased pressure to the anterior of the knee joint.

TIP
As when observing genu recurvatum, ankle position can be masked by swelling. Here
again, it is advisable to perform range-of-motion tests in addition to your postural assess-
ment to determine whether there are any restrictions in the joint, or conversely, whether
there is increased laxity.

60
 PES CAVUS

Lateral View
Pes Cavus (High Arches)
You have probably heard people speak about having ‘flat feet’ or ‘high arches’. These
are lay terms for positions of the foot bones. Observing whether your client has an
exaggerated foot posture is helpful in determining the kinds of forces that might be
passing through their lower limbs. In the pes cavus posture (high arches), the calcaneus
is supinated, and the plantar arch is higher (figure 1.44c) compared to a neutral foot
(figure 1.44a). There is a greater-than-usual space between the floor and the medial side
of the foot. Typically, there is a varus (inverted) hindfoot, a plantar flexed first metatarsal,
an adducted forefoot and claw toes (Burns et al. 2007). Footprints of a patient with
pes cavus reveal reduced contact points with the ground (figure 1.44d) compared
to footprints of a patient with a neutral foot posture (figure 1.44b). In observing this
posture, look for claw toes, splaying of the forefoot and a raised arch. Posteriorly, you
may observe that the calcaneus is supinated (pes varus).

Navicular bone
Feiss
line

a Talus bone Calcaneus b

E8778/Johnson/F 01.44a/717574/pulled/R1
E8778/Johnson/F 01.44b/717575/pulled/R1

c d

Figure 1.44 (a, b) Neutral foot and (c, d) pes cavus foot, with their associated foot-
prints. E8778/Johnson/F 01.44c/717576/pulled/R1

E8778/Johnson/F 01.44d/717577/pulled/R1

61
PES CAVUS

TIP
Many providers of sport footwear now have pressure plates on-site to assess how potential
buyers distribute their weight both when standing and running. A crude way to determine
weight bearing when standing is simply to take footprints. This is not something that is
usually done as part of a postural assessment, but it is a fun activity to carry out at home
to clarify your observations of family and friends.

Consequences
In the pes cavus posture, there is increased pressure on the ball of the foot. It is suggested
that patients with pes cavus may have hammertoes or claw toes; calluses on the ball,
side or heel of the foot; pain when standing or walking; and an increased likelihood
of ankle sprains due to the heel tilting inwards (supinating) (American College of Foot
and Ankle Surgeons 2023b).
Individuals with pes cavus sometimes have difficulty finding footwear that fits and
have reduced tolerance for walking (Burns et al. 2007). Runners with high arches
report a greater incidence of ankle injuries, bony injuries and lateral injuries (Williams,
McClay, and Hamill 2001). There may be painful calluses beneath the metatarsal heads,
caused by loss of the metatarsal arch, and there also may be osteoarthritic changes in
the tarsal region (Magee 2002).
If the subtalar and transverse tarsal joints are locked into supination, this will prevent
shock absorption, and the hindfoot supination may cause rotational stress on the leg
(Levangie and Norkin 2001). As with pes planus, an alteration in foot function affects
the entire kinetic chain of the lower limb.
Anatomical and functional changes associated with the pes cavus posture are listed
here.
Changes Associated With Pes Cavus
Change in plantar arch: higher than typical
Change in the position of the foot bones: the calcaneus supinates; the remainder
of the foot pronates
Change in soft tissues: shortening of the intrinsic foot muscles and the plantar fas-
cia; where there are claw toes, the associated toe extensor tendons are short
Relationship to trunk rotation: trunk rotation to the left increases supination of the
left foot and pressure through the lateral side of the left foot; trunk rotation to the
right increases supination of the right foot and pressure through the lateral side of
the right foot

TIP
With the longitudinal arch raised, the opposite ends of the arch are brought closer together,
and there is shortening of the plantar fascia.

62
 PES PLANUS

Lateral View
Pes Planus (Flatfoot)
Commonly termed flatfoot, pes planus differs from the neutral foot posture (figure
1.45a), and the footprint of a person with pes planus differs from the footprint a neutral
foot produces (figure 1.45b). In the pes planus foot posture, there is loss of the typical
longitudinal plantar arch, giving the foot a flattened appearance (figure 1.45c). When pes
planus is present in both weight-bearing and non–weight-bearing positions, it is known
as rigid flatfoot. When the arch is absent in standing but present in non–weight-bearing
positions, it is termed flexible flatfoot. In this posture, there is excessive pronation as
the talus glides medially over the calcaneus and comes into contact with the ground.
The medial side of the foot may be touching the floor completely, leaving no gap at
all. This is reflected by the shape of the footprint (figure 1.45d), which shows greater
surface area than usual because a greater portion of the sole is in contact with the
ground. The flattened appearance of the foot makes this an easy posture to identify in
a patient (figure 1.45e).

Navicular bone
Feiss
line

a Talus bone Calcaneus b

E8778/Johnson/F 01.45a/717569/pulled/R1
E8778/Johnson/F 01.45b/717570/pulled/R1

Navicular bone
Feiss
line

e
c Talus bone Calcaneus d

Figure 1.45 (a, b) Neutral foot; (c, d, e) pes planus foot.

Photo e courtesy of Emma Kelly Photography.
E8778/Johnson/F 01.45d/717572/pulled/R1
E8778/Johnson/F 01.45c/717571/pulled/R1
63
PES PLANUS

Pes planus occurs when the navicular bone (figure 1.45c) lies beneath the Feiss line,
a line running from the top of the medial malleolus to the base of the first metatarsal
in the neutral foot (figure 1.45a).
In addition to flattening of the foot, when you observe the client from behind, you
may notice that the toes drift outwards and the ankle appears to fall inwards as the
calcaneus pronates (the pes valgus ankle posture). Pes planus is considered mild if
hindfoot valgus is 4 to 6 degrees, moderate if it is 6 to 10 degrees, and severe if it is
10 to 15 degrees (Magee 2002). For more information on calcaneal pronation, see the
section on the pes valgus posture.
Consequences
The arch of the foot provides a spring mechanism essential for helping to absorb and
dissipate forces during gait. Loss of the arch means reduced shock absorption, which
could contribute to the development of stress injuries to the feet, the ankles and the
bones of the legs. In some cases, the pes planus posture could impair balance and
stability. However, studies carried out using military personnel did not support the
notion of increased incidence of injury in patients with flat feet (Giladi et al. 1987;
Jones et al. 1993).
During the midstance of gait, the foot pronates slightly via the talus and goes into
slight supination during push-off. The tibia responds to these movements by rotating
internally and then externally. Therefore, a talus that is incorrectly placed or does not
function optimally hinders tibial function and affects the entire kinetic chain of the
lower limb. The gait of a patient with pes planus has been described as slouchy and
jarring, with exaggerated flexion of the knee and weight bearing on the heel, such that
the demands of muscular activity are increased (Whitman 2010). An increase in tension
in the muscles of the feet whilst walking has been found in patients with pes planus,
which could explain why people with flat feet experience pain when they walk for
long periods (Fan et al. 2011).
People with flexible flatfoot are more likely to have hammertoes and overlapping
toes (Hagedorn et al. 2013). These can cause discomfort and difficulty wearing certain
types of footwear.
Individuals with severe pes planus have pain. In addition to pain in the heel, arch
and ankle and along the outside of the foot, there may be pain in the shinbone and
even low back, hip or knee (American College of Foot and Ankle Surgeons 2023b).
There may be pain and swelling of the tibialis posterior tendon and pain not only during
activities such as running but also when walking or standing (American Academy of
Orthopedic Surgeons 2023).
The pes planus foot posture stretches and weakens the plantar aponeurosis and the
intrinsic muscles of the foot and ligaments. Patients with hypermobility syndromes who
already have increased laxity in the ligaments of the foot may have pain and weakness
in the foot, ankle and leg (Tinkle 2008).
Specimens of the tibialis posterior tendon taken from patients with adult-acquired
flatfoot reveal the presence of enzymes that break down and weaken the tendon (Corps
et al. 2012).
Dysfunction of the posterior tibial tendon results in relative internal rotation of
the tibia and talus and a flattening of the medial arch. Over time, this contributes to

64
 PES PLANUS

deformity of the ankle, eventually leading the calcaneus to impinge against the fibula,
causing pain (Myerson 1996).
Anatomical and functional changes associated with the pes planus posture are listed
here.
Changes Associated With Pes Planus
Change in plantar arch: loss of the plantar arch
Change in the position of the foot bones: the talus glides medially over the calca-
neus
Change in soft tissues: weakness in the intrinsic plantar muscles; overstretching of
the long muscles of the sole of the foot; lengthening of the tendon of the tibialis
posterior; overstretching of the ligaments and plantar fascia; shortening of the
fibular muscles due to excessive pronation
Relationship to trunk rotation: trunk rotation to the left increases pronation of the
right foot; trunk rotation to the right increases pronation of the left foot

TIP
In addition to lengthening of muscles, there is overstretching of ligaments and of the
plantar fascia.

65
OTHER OBSERVATIONS

Lateral View
Other Observations
In this step, make any observations not yet recorded in the earlier steps for the lateral
view of the lower half of the body, such as scars and bruising. For example, the person
in figure 1.46 has edematous feet. Observe also the second toe of the right foot.

Figure 1.46 Example of edematous feet.

Courtesy of Emma Kelly Photography.

Quick Questions
1. When using the anterior view, which bony landmark is it useful to use when
assessing someone for pelvic rotation?
2. Why is it more accurate to measure the Q angle with your client standing
rather than supine?
3. When someone has a pelvis that is laterally tilted upwards on the right, which
hip is adducted and which hip is abducted?
4. In the posterior view, what is the purpose of imagining or drawing a line down
the midline of the calf?
5. What key observations might indicate to you that someone has genu recurvatum
posture (knee hyperextension)?

66
 2
Measuring
the Effectiveness
of Your Treatment
Learning Outcomes
After reading this chapter, you should be able to do the following:
■ Recall examples of overall treatment aims.
■ Develop specific treatment goals.
■ Determine the most appropriate way to measure the effectiveness of your
treatments.

W
henever you provide treatment to a client with a lower limb issue – whether
this is the use of a hands-on technique, the prescription of exercises or the
giving of advice, for example – you want to know whether it has been helpful.
You need to ask yourself whether or not what you have provided to the client has been
effective, because this will help to plan further treatment or to know when someone no
longer needs treatment. With any form of therapy, it is vital to identify not only when
something has worked but also when something has failed. It is important to acknowledge
failure as well as success, because by doing this, you can identify barriers to recovery.
To determine whether something has been effective, you need to answer three ques-
tions:
1. What was the overall treatment aim?
2. What treatment was provided?
3. How are you going to measure effectiveness?
This chapter provides ideas for how to determine an overall treatment aim, set more
specific treatment goals, and measure their outcomes.

67
68 Soft Tissue Therapy for the Lower Limb

Deciding on an Overall Treatment Aim

Before you can create a specific treatment goal, it is necessary to decide on an overall
treatment aim. You may be thinking that the treatment aim is obvious: recovery from
a hamstring strain, for example. However, it is helpful to break this down into more
specific components, because by doing so, you create the foundation on which to base
the goal of your treatment and measure its effectiveness. Examples of overall treatment
aims are listed below.
Examples of Overall Treatment Aims
■ Reduce pain
■ Reduce swelling
■ Improve balance
■ Overcome the sensation of muscle stiffness
■ Overcome or prevent muscle cramping
■ Regain normal movement in a joint
■ Improve weight bearing through the lower limb
■ Improve lower limb strength
■ Regain everyday lower limb function
■ Educate the client
■ Help correct postural imbalance
The overall aim is likely to be different for each client you are treating. For example,
you could be treating someone recovering from a recent injury who has pain and swell-
ing and is unable to walk, or you may be treating someone who has not been injured
but suffers from persistent calf cramps. You may be treating someone who is managing
a long-term condition such as osteoarthritis in the knee whose main aim is to maintain
normal daily function, or perhaps you have been approached by someone waiting
for surgery who has been advised to strengthen their legs in preparation. Use the list
of suggested overall treatment aims to help you identify your main aim or treatment.
If you are treating someone over several weeks or months, it is important to return to
this list periodically and ask whether the overall aim has changed, because this is likely
to be the case. Your specific treatment goals will then need to be revised. Think of your
treatment aim as a target, with the goals as specific steps you need to take to reach it.

Creating Specific Treatment Goals

Once you have identified the main aim of your treatment, the next step is to determine
a more specific treatment goal. This is important because it helps you to measure the
effectiveness of your treatment. Table 2.1 provides two examples for how each of the
overall treatment aims listed previously might be developed into more specific goals.
Please note that these are just a few examples and that there are many possible treat-
ment goals relating to each general treatment aim.
Measuring the Effectiveness of Your Treatment 69

Table 2.1 Developing Specific Lower Limb Treatment Goals

Examples
of general
treatment aims Examples of specific treatment goals
Reduce pain Over the next 2 weeks, reduce the severity and incidence of pain in the
left knee from a daily 8 out of 10 on a numerical pain rating scale.
Over the next 4 weeks, reduce the severity and incidence of pain in
the right hip from 5 out of 10 on a visual analogue scale.
Reduce swelling Over the next 24 hours, reduce swelling in the right ankle from an
ankle girth circumference of 35.5 cm (14 in.).
Over the next 2 days, reduce swelling in the left knee from a circumfer-
ence of 43 cm (17 in.), measured at approximately the tibial tuberos-
ity.
Improve balance Over the next 3 weeks, be able to sway confidently from side to side
from the left to right foot, maintaining contact with the floor.
Within the next 10 days, progress from static right-leg standing to
right-leg standing whilst brushing teeth, combing hair etc.
Overcome the Over the next 14 days, reduce the frequency and sensation of daily
sensation of stiffness in the left hamstrings from 9 out of 10.
muscle stiffness Within the next 4 weeks, reduce the frequency and sensation of stiff-
ness in both calves from a daily 5 out of 10.
Overcome or Over the next 7 days, reduce the frequency of cramping in the right
prevent muscle calf and toes at night.
cramping Over the next 14 days, reduce the frequency of postexercise cramping
in the left hamstrings.
Regain normal Within the next 3 months, regain full extension in the left knee.
movement in a Over the next 6 weeks, regain full active range of motion in the right
joint ankle in all ranges.
Improve weight Over the next 2 weeks, be able to sit in a chair with both feet on the
bearing through ground.
the lower limb Over the next 10 days, be able to bear weight fully through the right
leg when standing.
Improve lower Over the next 12 weeks, improve the strength of the left hip extensor
limb strength muscles.
Within the next 12 weeks, improve the strength of the right calf muscle.
Regain everyday Over the next 4 weeks, be able to walk 9 m (10 yd) without pain.
lower limb Over the next 2 weeks, be able to alternate between sit-to-stand and
function stand-to-sit positions.
Educate the client At the next treatment session, provide education regarding the condi-
tion of plantar fasciitis by using an anatomical model of a foot.
At the next appointment, provide education regarding typical healing
times after a lateral ankle sprain and the importance of a balance
training programme.
Help correct pos- Perform a posterior pelvic tilt in the standing position using 1 set of 5
tural imbalance repetitions performed 3 times during the day.
Daily, practise walking conscientiously for 3 minutes with a more neu-
tral foot posture, avoiding the toe-in position.
70 Soft Tissue Therapy for the Lower Limb

Observe how each of the more specific goals begins with a time frame. Clients some-
times have a specific date in mind that marks the start of a holiday, a return to work, a
birthday or an anniversary, so a specific date could be used, such as ‘by the 28th of April’.
Quite often, the time frame is determined according to the next appointment the person
may have with you. For some people, having this kind of accountability can be helpful.
Usually, a treatment goal is developed in discussion with the client. Once they have
agreed on a treatment goal, you can then determine how best this might be achieved.
It is extremely important to create a recovery or maintenance programme that is cus-
tomized to each client. For example, table 2.2 provides examples of three clients who
have all sustained a confirmed moderate sprain to the lateral ligament of the ankle and
contrasts their lifestyle and health behaviours. Assuming you had no other informa-
tion than that provided in table 2.2, what are your immediate thoughts when you read
these descriptions? Would you agree that these clients are likely to respond differently
to treatment? What barriers do you perceive there to be? For example, is there anything
that suggests the likelihood of compliance with an exercise programme?

Table 2.2 Contrasting Three Clients With a Moderate Lateral Ankle Sprain
Client Health Lifestyle and psychosocial factors
Aged 86: Considers self to be in good For the past 5 years, has enjoyed partici-
Sustained health. Non-smoker. pating in a daily yoga class that involves
sprain when Reports osteoarthritis in strength and mobility. Walks 40 min-
knocked into both knees but says that utes daily. Lives alone, independently.
by someone this does not significantly Describes being generally of a happy
on a skate- impair function other than disposition. Reports growing up in ‘war
board in the in the winter months, when years’ and states, ‘It’s just a sprain’. Is
park pain is slightly increased keen to recover in order to return to
and it takes longer to get yoga. Wants to know which exercises
dressed in the mornings. are best for recovery. Has asked whether
No previous ankle injuries. it would be OK to start tai chi classes.
Aged 51: Non-smoker. Hypertension. Sedentary worker. Never been physically
Sustained Prediabetic. Four ankle active due to having a large family and
sprain after sprains to the same ankle lacking time. Has been thinking about
slipping on over the past 4 years; says, losing weight. Was intending to start
liquid in the ‘It’s my bad ankle’. recreational cycling with family. Is con-
supermarket sidering starting swimming classes but
when shop- is concerned about body size. Expects
ping to sprain the ankle again, given the past
history of this.
Aged 45: Smoker. Hypertension. High Manual worker. Believes work is to
Tripped at cholesterol. Chronic low blame for the injury. Intends to seek
work back pain. Pain in knees compensation. Lives alone. Reports
and both ankles, which having been advised to exercise for the
doctor attributes to signifi- management of back and lower limb
cant weight gain but which pain in the past but found this ‘a waste
client disputes. of time’ because ‘I need a scan to know
what’s wrong’. Believes an orthotic
boot should have been provided to
wear after this ankle injury.
Measuring the Effectiveness of Your Treatment 71

Determining the Most Appropriate Measure

of Effectiveness
There are many different ways to measure the effectiveness of your treatment. Which
measure you select depends on what your specific goal is. For example, if your goal
is to reduce pain, then you would use a pain measurement scale, and if your goal is
to improve a client’s ability to perform an everyday function, then you would use a
functional assessment scale. Examples of the different ways you could measure a treat-
ment’s effectiveness are described in this section. At the end of this chapter, you will
find examples of pretreatment and posttreatment measurements used to determine the
effectiveness of a treatment for trigger points in the gluteal muscles.

Measuring Pain
Pain is measured using self-report tools, the two most common being the Visual Analogue
Scale (VAS) and the Numerical Pain Rating Scale (NPRS). Both of these scales have been
adopted as recommended outcome measures by the Faculty of Pain Medicine and the
British Pain Society (2019). The VAS is simply an unmarked horizontal line, with the left
end signifying being pain free and the right end signifying the worst pain imaginable.
The client marks the line according to how close to one end of the scale they rate their
pain. The value of this scale is that it could be modified to record other sensations, such
as stiffness, aching or discomfort. This scale can easily be quantified if the length of the
line used matches a predetermined length. For example, if a line measuring 10 cm (4
in.) is drawn and the client marks the centre of the line, this equates to ‘5’; if they mark
close to the right-hand side of the line, this might equate to ‘9’; if they mark close to
the left-hand side, this might equate to ‘2’.
The NPRS is also a horizontal line, but it is different than the VAS in that it has the
numbers 0 to 10 assigned to it at regular intervals: 0 on the left end of the line and 10
on the right end. The client marks the number that they believe represents their pain.
For example, 6 would be recorded as 6 out of 10.
One thing to note about the use of pain scales is that they are often embedded within
functional assessment scales. If you are using a functional assessment scale that includes
a pain score, you would not need to also use the VAS or the NPRS.

Measuring Muscle Length

One of the best sources for information on testing the length of muscles is the book
Muscles: Testing and Function (Kendall, McCreary, and Provance, 1993), which provides
illustrations of how to test specific muscles. Common tests for the lower limb are the
prone knee bend test (for the length of the quadriceps), the straight-leg raise test (for
the length of the hamstrings), the Thomas test (for the length of the hip flexors) and the
Ober test (for the length of the iliotibial band). A useful test for the length of the calf
muscles is to have the client stand facing a wall and step one foot backwards, as if to do
a calf stretch. Notice how far from the wall the heel reaches on that leg; repeat with the
other leg and compare. The farther the heel is from the wall, the longer the calf muscles.
72 Soft Tissue Therapy for the Lower Limb

TIP
It is important to remember that it is impossible to isolate individual muscles because they
are wrapped in fascia, and fascia is connected to other structures, including in the lower
limb. Therefore, the measurement derived depends on multiple structures, and restrictions
in length may be due to connecting structures as well as a muscle itself.

In very simple terms, on the posterior aspect of the body, the fascia of the sole of
the foot, the calf and the hamstrings is connected, and this fascia in turn is connected
to the gluteal muscles and lower back. On the anterior aspect, the fascia of the hip
flexors is also connected to the abdomen above and to the shin below. This means that
any technique used to lengthen a muscle is likely to have an effect on the soft tissues
above and below it. For example, lengthening the tissues of the lower back and calf
results in an improvement in the straight-leg raise test, even if no techniques are applied
to the hamstrings.

Measuring Joint Range of Motion

For detailed information on using a goniometre and the ranges of motion considered
typical in human joints, refer to The Clinical Measurement of Joint Motion (Greene
and Heckman 1994). When assessing a joint, remember that many factors can limit
the range of motion, including a restriction in the joint itself (such as the shape of the
joint) and laxity or tightness in the soft tissues surrounding the joint. It is important to
test the range of motion both passively and actively. A passive test might reveal that a
person has a good range of motion that would otherwise be difficult to determine when
assessed actively, because active movements could be limited by pain or lack of strength.

Measuring Function
There are many different functional assessment scales, and some of these have been
developed specifically for the assessment of lower limb conditions. For example, Binkley
and colleagues (1999) developed the Lower Extremity Functional Scale. This simple scale
asks users to score the level of difficulty they have, or would have, if attempting certain
activities, irrespective of what lower limb condition they have. The kinds of activities listed
include putting on shoes, sitting for an hour, walking between rooms and getting out of
a bath. In a systematic review, Mehta and colleagues (2016) found this scale to be valid
and reliable for assessing a wide range of patients with lower extremity musculoskeletal
conditions. Other functional assessment scales have been developed specific to the
hamstrings, knee, ankle and foot. Some of these are described in the following section.

Functional Assessment Tools

Hamstrings
The Hamstring Outcome Score is a 5-domain questionnaire that assesses an athlete’s
soreness, symptoms, pain, activities (sports) and quality of life. Questions are scored
from 0 to 4, from no complaints to maximum complaints. A score of 100% suggests no
Measuring the Effectiveness of Your Treatment 73

complaints in all domains. A score of 80% or more indicates a low risk for hamstring
strain injury, whereas a score below 80% indicates a high risk for hamstring strain
injury. This tool can also be used as a predictor of future hamstring injuries (van de
Hoef et al. 2021).
Another useful scale is the Functional Assessment Scale for Acute Hamstring Inju-
ries. This is a reliable and validated 10-item questionnaire used to assess function after
an acute hamstring injury (Malliaropoulos et al. 2014). Additionally, clinical practice
guidelines that summarise the best evidence for the assessment of and outcome mea-
sures for hamstring strain are provided by Martin and colleagues (2022).

Knee
A useful tool for measuring knee function is the Knee Injury and Osteoarthritis Out-
come Score. This tool encompasses 5 different subscales: pain, symptoms, activities of
daily living, sport and recreational function and quality of life. The composite of these
scores is measured on a scale of 100, with 0 being extreme knee dysfunction and 100
being no knee dysfunction. Roos and Lohmander (2003) provide a helpful review of
this measurement tool.
A useful tool for assessing people with knee problems is the International Knee
Documentation Committee Subjective Knee Form (Irrgang et al. 2001). This can be
used to evaluate people with problems of the meniscus or knee ligaments, patello-
femoral dysfunction and osteoarthritis. The form is used to assess a person’s subjective
responses to questions such as the highest level of activity they can perform without
significant knee pain and other questions related to swelling and locking of the knee.
The Knee Society Knee Scoring System is another assessment tool that is specifically
designed for use before and after knee replacement surgery. This measurement tool
includes both subjective and objective (knee alignment, instability and joint motion)
measurements. It includes a patient’s perception of everyday activities such as stand-
ing, walking and using stairs as well as a range of physical recreational and sporting
activities that may be important to them. Scuderi and colleagues (2012) provide a
detailed description of this system.

Foot and Ankle

If you were treating someone with plantar fasciitis, it would be appropriate to use a
questionnaire such as the Plantar Fasciitis Pain and Disability Scale questionnaire. Willis
and colleagues (2009) found this to be a useful way to differentiate between pain due
to plantar fasciitis and heel pain from other causes.
The Ankle Osteoarthritis Scale (Domsic and Saltzman 1998) uses a simple scor-
ing method to measure pain when performing everyday activities and the perceived
difficulty in performing everyday activities in people with osteoarthritis in the ankle.
Many of the functional assessment tools for the ankle involve hopping and jumping,
because these test strength, balance and coordination. For example, Madsen, Hall and
Docherty (2018) provided a useful example of a test for assessing outcomes in people
with chronic ankle instability. Their study used a simple hopping test and measured the
time it took to perform the test, the distance hopped and the participant’s perceived

(continued)
 74 Soft Tissue Therapy for the Lower Limb

Functional Assessment Tools (continued)

amount of ankle instability. You may, however, be treating someone who is unable to
hop, and there is nothing wrong with assessing less strenuous everyday activities such
as walking, climbing stairs or standing from a sitting position. You might even decide
that simply asking a person to rate their perceived effort in transferring weight from
one limb to the other is sufficient in the early stages of rehabilitation.

Examples of Pretreatment and Posttreatment Measurements

Huguenin and colleagues (2005) examined the effect of dry needling trigger points in
the gluteal muscles during the straight-leg raise test and internal rotation of the hip.
They randomly assigned 59 male runners to a group that received dry needling to trig-
ger points in the gluteal muscles or a group that received placebo needling to trigger
points. Triggers were reported in most participants to be in the upper outer buttock
quadrant and were pierced by the dry needle in one group, but in the placebo group,
the needle only touched the skin without piercing it. The straight-leg raise test and inter-
nal rotation of the hip were measured at baseline, immediately after the intervention
and at 24 and 72 hours after the intervention by taking digital photographs of the test
positions. Visual analogue scale scores were also recorded. There was no significant
change in VAS scores or gluteal pain after running, but both groups showed significant
improvement in reported hamstring tightness, hamstring pain and gluteal tightness after
running. The authors commented that the results could indicate one of three things: (1)
The postulated restriction in range of motion measured by the straight-leg raise test and
internal rotation test may not be associated with symptoms, (2) dry needling had no
effect on muscle length in these muscles or (3) the outcome measures used were not
appropriate to measure change resulting from dry needling of trigger points.

Quick Questions
1. What is the difference between a treatment aim and a treatment goal?
2. List five of the treatment aims mentioned in this chapter.
3. Name the two pain measurement tools described in this chapter.
4. Using the information in this chapter, list four common tests used to assess the
length of lower limb muscles.
5. What is the Lower Extremity Functional Scale, and how is it scored?
 PART II

Hands-On Techniques
for Common Muscular
Problems
T
his part of the book concentrates on hands-on techniques, such as massage, trig-
ger point release, soft tissue release (STR) and taping, which can be used to help
address common musculoskeletal conditions affecting the lower limb. Passive and
active stretches are included too.
There are four chapters within this part of the book. Chapter 3 covers conditions
affecting the gluteal, groin and hip flexor muscles. Chapter 4 describes conditions
affecting the thigh – specifically, the hamstrings and quadriceps. In chapter 5, you will
learn how to use hands-on techniques to help clients with knee, calf and shin prob-
lems, and for clients with problems in their ankles and feet, you will find information
in chapter 6. With almost all conditions, it is important to maintain or regain strength
and balance in the affected body part and in the lower limb in general, and part III is
devoted to this specialised topic. Within chapters 3 through 6, you will be directed to
the chapters with relevant material related to strengthening.
In a few cases, the order of the techniques provided is arbitrary. In many cases, how-
ever, the techniques most likely to be most effective are described first. For example, in
a case of acute injury, active techniques are preferable to passive ones simply because
there is reduced likelihood of reinjury, and when treating chronic conditions, passive
techniques are valuable in jump-starting the rehabilitation process. However, in all
cases, it is important to reduce the client’s reliance on you and increase their active
participation in recovery. If a client has become used to long-term hands-on treatment,
this can be a challenge.
As with other titles in the Hands-On Guides for Therapists series, in Soft Tissue Therapy
for the Lower Limb, material has been organised by compartmentalising the body. This
is for ease of description. You are most likely reading this book as someone who has
hands-on therapy skills or whose training involves these skills. You will therefore know
that when treating someone, we need to view them holistically and that a condition in
one part of the body almost always affects another part of the body.

75
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 3
Gluteal, Groin and
Hip Flexor Muscles
Learning Outcomes
After reading this chapter, you should be able to do the following:
■ Apply trigger point release to the gluteal muscles and hip flexors.
■ Use the forearms, fists or elbows as appropriate when applying massage to
treat piriformis syndrome, groin strain and tight hip adductors.
■ Apply soft tissue release strategies to the gluteal muscles and hip flexors.
■ Use passive stretches to stretch the gluteal muscles, hip adductors and hip
flexors.
■ Explain which active stretches might be most appropriate for the gluteal
muscles, hip adductors and hip flexors.

I
n this chapter, you will learn how to help clients with trigger points in the gluteal
muscles, piriformis syndrome, groin strain, tight hip adductors and tight hip flexors
using massage, trigger point release, soft tissue release (STR) and both active and
passive stretching. In almost all cases, strengthening is valuable for assisting recovery,
whether this is to regain strength in the muscle itself or to strengthen an opposing
muscle group for reciprocal inhibition. People with an acute injury often compensate
by overusing the opposite limb; people with a condition affecting their right hip, for
example, commonly have pain in their left knee. Reducing the pain of a hip condition
is therefore important because it can help a person to regain a proper gait pattern before
compensation has a detrimental effect on the hip and knee joints. Chapter 7 contains
examples of helpful exercises to strengthen the hip. Because hip conditions also affect
the rest of the lower limb, you may discover that your client has issues in their knee or
even their ankle, and chapters 4, 5 and 6 may also be helpful.

77
TRIGGER POINTS IN THE GLUTEAL MUSCLES

Trigger Points in the Gluteal Muscles

Trigger Point Release
Trigger points are found throughout all three gluteal muscles – in the gluteus maximus
close to the lateral border of the sacrum, in the gluteus medius running inferior to the
iliac crest and in the gluteus minimus. Trigger points in the gluteal muscles are aggravated
by prolonged immobility, either when sitting or standing, and they are associated with
trigger points in the quadratus lumborum muscle. Some of the gluteal trigger points are
illustrated in figure 3.1 with white circles.

Gluteus
medius (cut)

Gluteus
Gluteus
maximus (cut)
medius

Gluteus
minimus

Gluteus
maximus

Figure 3.1 Trigger points in the gluteal muscles.

The gluteus maximus trigger point causes pain along the sacroiliac joint and into
the base of the buttock on that side, and it is easy to identify when your client is in a
E8778/Johnson/F
side-lying position. The gluteus maximus03.01/718247/pulled/R1
is also associated with trigger points in the
hamstrings and lumbar erector spinae; pain is perpetuated by prolonged sitting and
activities that require hip and spine extension, such as repeated lifting of a heavy object.
The trigger points in the gluteus medius cause pain in the sacrum, sacroiliac joint
and ipsilateral (same-side) buttock. Palpate for these triggers when your client is in
either the side-lying or the prone position, sliding your fingers inferiorly off the iliac
crest. Trigger points in the gluteus medius, perhaps more than in the other two gluteal
muscles, are perpetuated by gait abnormalities, as might be caused by leg-length dis-
crepancy or Morton foot (in which the second toe is longer than the big toe). They are
also aggravated by prolonged sitting and prolonged hip flexion.
Trigger points are found throughout the upper portion of the gluteus minimus and
cause pain in the buttock and lateral thigh and leg on that side. To palpate these trigger
points, position your client supine, locate the tensor fasciae latae, and work your fingers
posteriorly into the gluteus minimus. Because it is a deep muscle, you are unlikely
to be able to identify specific triggers easily, but you may be able to reproduce mild
tenderness when applying pressure here.
Onik and colleagues (2020) conducted an interesting study of myofascial trigger
points in the gluteal region that they had identified using both palpation and thermal
imaging. Their study involved 30 participants who were asked to rank pretreatment and
posttreatment trigger point pain that was reproducible on palpation, using a numerical
rating scale. Treatment consisted of simple progressive compression of a trigger point for

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 TRIGGER POINTS IN THE GLUTEAL MUSCLES

1 minute. All participants reported a significant reduction in posttreatment pain and had
an initial increase in skin surface temperature, followed by a decrease. The research-
ers postulated that after compression of the trigger point, there was local occlusion of
blood to the area, followed by vasodilation once the pressure was released. They were
reluctant to speculate as to the reasons for this; however, their study provides a useful
contribution to the understanding of trigger points.

TIP
Using Gentle Pressure to Release Trigger Points
A great way to alleviate tension in the gluteal area is simply to compress the tissues, focus-
ing on areas of tightness. You can do this using your forearm or elbow. Start by working
over the area consistently with your forearm, avoiding the use of your elbows. Figure 3.2
illustrates the procedure (the client shown in the figure is more side-lying than three-quarter
lying; however, three-quarter lying will give you better access to the gluteal muscles). You
can continue to treat the area in this way, or you can apply a little oil, place a towel over
the area, and work through the towel. The oil will grip the towel, and you can use a twist-
ing movement to stretch and compress the tissues. This is a nice alternative to treating the
gluteal muscles in the prone position and can be combined with treatment to the lateral
thigh of the limb and the tensor fasciae latae muscle on the same side.

Figure 3.2 Gentle pressure using the forearm to release trigger points.

TIP
A mistake some therapists make when treating gluteal muscles is to use too much pressure
too soon in too precise an area. In the three-quarter lying position, the client will sense
the pressure far more than when prone.

With the client positioned as for figure 3.2, use your elbows as a way to focus pres-
sure to more defined areas. Start by leaning onto the client, using your forearm to gauge
their sensitivity to pressure. Should the client require deeper pressure, slowly flex your
elbow (figure 3.3). Remember that you need to flex your elbow only a few degrees for
the client to experience a disproportionate rise in pressure. This technique is a great
way to focus pressure to localised areas. However, this area is highly sensitive to pres-
sure in many people, so apply this technique cautiously.

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TRIGGER POINTS IN THE GLUTEAL MUSCLES

Figure 3.3 Gentle pressure using the elbow to release trigger points.

TIP
In whichever treatment position you are using (prone, side-lying or three-quarter lying),
be aware of deep pressure to the piriformis muscle, because this can be painful. Note
that discomfort does not necessarily indicate piriformis syndrome, as is believed by some
therapists.

You can teach clients how to release trigger points themselves. To do this, have them
stand with their back to a wall and place a ball between the buttock on one side and
the wall (figure 3.4).

Figure 3.4 Positioning a ball to self-release trigger points in the gluteal muscles.

Stretching
Figure 3.5 (a, b) provides examples of active stretches that are useful after trigger point
release. The passive stretch shown in figure 3.5c is useful but difficult to apply with a

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 TRIGGER POINTS IN THE GLUTEAL MUSCLES

client on a treatment couch because of the force needed to stretch the strong muscles
of the buttock region. To perform the passive stretch, start with the client’s hip and
knee at a 90-degree angle, as shown, and move the lower limb towards the client in an
attempt to stretch the gluteal region. Solicit feedback from the client to help determine
the best position to hold the stretch. Some clients find this position uncomfortable when
it compresses the rectus femoris tendon on the anterior of the hip.

Figure 3.5 (a, b) Active and (c) passive stretches for gluteal muscles after deactivation
of trigger points.

Soft Tissue Release

Soft tissue release can be used successfully to release trigger points in the gluteal muscles
too. It can be done with your client in the side-lying position or prone. Two methods
are described here.
With experimentation, it is possible to locate the fibres of the gluteus minimus with
your client in the side-lying position. Trigger points in this muscle can be more dif-
ficult to access when using STR in the prone position. You may find that you need to
lower your treatment couch to make working with the side-lying client easier, because
their body will be higher than when they rest prone or supine. When you begin, it is

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TRIGGER POINTS IN THE GLUTEAL MUSCLES

challenging to keep a client balanced in the side-lying position whilst you focus your
lock in the correct spot on the muscles. With practice, you will be able to identify trig-
gers in the gluteus maximus and use STR in this position to deactivate them. With your
client in the side-lying position and the hip in neutral, use your forearm (close to the
elbow) to lock the gluteal muscles, directing your pressure towards the sacrum (figure
3.6a). Whilst maintaining your lock, ask your client to flex the hip, perhaps by asking
them to take the knee to the chest (figure 3.6b). Repeat this action for a few minutes,
varying the position of your lock and working on the area that feels most beneficial
for the client.

Figure 3.6 (a) Locking the gluteal muscles close to the sacrum with the hip in a neutral
position followed by (b) active hip flexion.

TIP
It is quite challenging to apply active assisted STR to the gluteal muscles, and it takes prac-
tice to focus your lock in the correct spot on the muscles. With experience, however, you
will discover a small area that, when locked, provides for the greatest degree of stretch.

Another way to apply STR to the gluteal muscles is with your client in the prone
position. Grasp the ankle of the leg closest to you and flex the knee. Gently lock the
tissues using your elbow, fist or thumb. In figure 3.7a, the therapist has chosen to use
the elbow to lock fibres of the gluteus medius. Maintaining your lock, rotate the femur
by passively moving the ankle towards you or away from you, experimenting to deter-
mine where your client feels the stretch most (figure 3.7b).

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 TRIGGER POINTS IN THE GLUTEAL MUSCLES

a b

Figure 3.7 (a) Gently locking the gluteal muscles with an elbow, then (b) passively
rotating the femur whilst locking the tissues of the buttock to bring about a stretch.

One way for your client to perform STR on the gluteal muscles is to use a tennis ball
(figure 3.8a), just as they did for simple trigger point release, but then to flex their hip
(figure 3.8b). Because this technique requires standing on one leg as the hip is flexed,
it can be difficult for people with poor balance.

a b

Figure 3.8 (a) Static pressure to the gluteal muscles using a tennis ball followed by (b)
active hip flexion brings about a stretch in the gluteal muscles.

TIP
To stretch the gluteus medius and minimus, the client could change their position so that
their back is turned away from the wall or they are standing almost with the side of their
body to the wall as they not only flex but adduct the hip. Try this for yourself. Notice how
medial rotation of the hip can bring about a stretch in some parts of the gluteal muscles
once you have locked them using a ball.

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PIRIFORMIS SYNDROME

Piriformis Syndrome
Piriformis syndrome is the name given to pain in the buttocks and lower limb resulting
from compression of the sciatic nerve in the region of the piriformis muscle, perhaps
caused by the muscle itself. As the sciatic nerve runs from the sacrum and down the
lower limb, it passes above, below or through the piriformis muscle. When piriformis
syndrome results from compression of the nerve by the piriformis muscle, you have
the opportunity to reduce symptoms. Some therapists erroneously believe that if they
position the client into a side-lying pose and press the midregion of the buttock, the
resulting pain indicates piriformis syndrome or trigger points. It is certainly possible
to access the region of the piriformis muscle with the client in the side-lying position,
but unsurprisingly, localised pressure here will be painful, as this is precisely how to
access the sciatic nerve.
Clients with piriformis syndrome are likely to have a positive hip flexion, adduction
and internal rotation sign, and this test can be helpful in determining treatment. Impor-
tantly, pain in this region can result from other conditions, such as spinal stenosis, and
people with a poor response to treatment should be referred to a doctor.

Massage
It can be helpful to address trigger points in the surrounding muscles instead of
attempting to massage the piriformis itself. As mentioned, the sciatic nerve is sensitive
in many clients because of its proximity to the piriformis muscle, and if your pressure
is too deep when massaging, clients will simply contract their muscles, defeating your
efforts. The trick with massage to the region is to work the area within the client’s pain
threshold without causing spasm in the muscles.

Trigger Point Release

Trigger point release to the gluteal muscles using the techniques previously described
is helpful at reducing tension in surrounding soft tissues.

Soft Tissue Release

Soft tissue release to the gluteal muscles as previously described is useful in reducing
tension in the gluteal region.

Stretching
Both passive and active stretches are helpful to reduce pain from compression of the
sciatic nerve in the piriformis region. The rationale for the use of stretching is twofold:
to increase the resting length of the piriformis muscle and to reduce pressure on the
sciatic nerve. The stretches shown in figure 3.5 are all appropriate. Unfortunately,
whether performed actively or passively, the stretch initially tenses the muscle, and
this in turn can compress the nerve, appearing to aggravate symptoms. Therefore, it is
necessary to gradually build up the client’s tolerance to stretching; otherwise, you risk
turning them off to the use of this treatment.
Gulledge and colleagues (2014) conducted a study of the effectiveness of piriformis
stretching among seven women diagnosed with piriformis syndrome. Three computed

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 PIRIFORMIS SYNDROME

tomography scans were taken of participants who stretched their piriformis muscle
before the second and third scans using stretches lasting 20 to 30 seconds repeated
over a 5-minute period, for a total of 7 to 14 stretches. Gentle overpressure was used
to a point at which the stretch was still tolerable. Gulledge and colleagues identified a
15% increase in the length of the piriformis after stretching. They reported that the most
effective position for stretching this muscle was by placing the hip joint either in 115
degrees of hip flexion, 40 degrees of external rotation and 25 degrees of adduction or in
120 degrees of hip flexion, 50 degrees of external rotation and 30 degrees of adduction.

Strengthening
In piriformis syndrome, there is often atrophy of the gluteal muscles. It is therefore very
important to engage your client in a programme of gluteal strengthening. Please see
chapter 7 for more information.

Sitting Habits
Prolonged sitting is likely to be an aggravating factor in people with piriformis syndrome.
Therefore, it will be important to work with your client to introduce short, frequent
breaks if sitting is part of their occupation or to change their behaviour if prolonged
sitting is habitual.

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GROIN STRAIN

Groin Strain
Groin strains are particularly common in sports where muscles such as the adductor
longus or the gracilis may be damaged by impact, sudden contraction or overstretching.
There is pain on palpation of the insertion of the adductors at the pubis and pain on
both resisted adduction and on stretching these muscles.

Acute Stage
All forms of deep massage and stretching should be avoided during the early stages of
tissue repair.

Sub-Acute Stage
In the sub-acute stage, massage to the adductors could be applied with the client in
the supine position. With a low treatment couch, position your client so that the thigh
is gently abducted and supported on your thigh, as shown in figure 3.9a. Use a folded
towel under the client’s leg (figure 3.9b) for support, if necessary. To treat the left
adductors, use your left arm. Starting just above the knee, glide your forearm slowly
across the adductors towards the groin.

a b

Figure 3.9 (a) Using your forearm to gently massage the adductors; (b) using a towel
for support.

Massage
Working with your client in the three-quarter
lying position, you can access the adductors
of the limb when it is against the plinth. For
example, to treat the right adductor muscles,
have your client lie on their right side, with the
adductors clearly exposed. One way to achieve
this is for the client to flex their left hip, bringing
the knee of that hip to rest on the plinth. Taking
care not to press into the popliteal space at the
back of the knee, gently rest your forearm on the
client and slowly but firmly glide towards the
Figure 3.10 Massage the adduc-
ischium (figure 3.10). Take care to protect your
tors using the forearm.
posture when leaning forwards to apply pressure.

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 GROIN STRAIN

Stretching
Stretching should be conservative to prevent reinjuring muscles not yet fully healed.
Groin strains can take a long time to heal; therefore, implementation of an early active
stretching programme is recommended, providing this does not cause pain. Passive
stretches are not recommended for groin strains, but many varieties of active stretches
may be used.
Lying on a bed or the floor, a client could begin by gently abducting the legs (with the
knees extended). If this is tolerable, they could progress to sitting cross-legged (figure
3.11a), placing pillows beneath each knee for support if there is discomfort. Once this
position is tolerable, they could progress to the position in figure 3.11b, with the soles
of the feet touching. To increase the stretch in either position, the client can simply
place gentle downward pressure on the knees.

a b

Figure 3.11 Progressing an active groin stretch from (a) the cross-legged position to (b)
the sole-touching position, perhaps with overpressure on the knees.

An alternative adductor stretch is shown

in figure 3.12. To increase this stretch, the
client simply leans forwards; to decrease it,
they lean backwards. Note that this stretch
also requires flexibility in the hamstrings.

Strengthening
Strengthening of the adductor muscles is
extremely important for preventing further
groin strains. Chapter 7 provides detailed
information about this.

Figure 3.12 A groin stretch that also

requires hamstring flexibility.

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TIGHT HIP ADDUCTORS

Tight Hip Adductors

People who engage in sporting activities such as running, football and swimming often
find it is beneficial to stretch their adductor muscles as part of their cooldown programme
of stretches or simply to decrease sensations of stiffness after exercise. Adductors
contract as we walk, so people who walk a lot as part of their general lifestyle or fitness
activities may also benefit from stretching these muscles. Adductors may become tight
after periods of immobility, leading to muscle imbalance in the pelvis and lower limbs.

Massage
Warming the tissues using the forearm in either the supine (figure 3.13a) or side-lying
(figure 3.13b) position is appropriate. To apply deeper pressure, you could use your fists
(figure 3.13c), and for more specific work, you could use your elbow (figure 3.13d) to
target specific tissues.

a b

c d

Figure 3.13 Massage to the adductors using (a, b) the forearm, (c) the fists, or (d) an
elbow.

Stretching
Useful passive adductor stretches are shown in figure 3.14. Notice how in figure 3.14a,
the therapist prevents the pelvis from moving by gently placing pressure on the anterior
superior iliac spine. This can be uncomfortable for some clients, so you might want to
place a sponge or small towel between your hand and the client’s hip. In figure 3.14b,
the therapist is abducting the leg whilst being sure to support the knee. Notice that in
this position, extension of the lumbar spine may be exaggerated, and this is a position
that may aggravate back pain in some clients.

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 TIGHT HIP ADDUCTORS

a b

Figure 3.14 (a) Passive stretch to adductors of the left hip by stabilising the pelvis and
applying gentle pressure to the right anterior superior iliac spine and (b) passive stretch
to adductors of the right hip with the knee supported in extension.

TIP
Notice how in figure 3.14b, the leg that is not being stretched has been hooked over one
side of the treatment couch. This prevents the client from being pulled to one side of the
couch. First check that this position is comfortable, and perhaps insert a sponge between
the client’s knee and the side of the couch.

Each of the stretches in the groin

strain section are helpful for combat-
ting tight adductors. Other stretches
include those shown in figures 3.15
and 3.16. Obviously, the stretch shown
in figure 3.15 is not suitable for cli-
ents with balance problems, and the
stretch shown in figure 3.16 places
pressure on the knee of the leg not
being stretched, so it is not suitable for
all clients. Both of these stretches are
safe, but bear in mind that they place
more pressure on the medial collateral
ligaments of the knee than the stretches
shown in figure 3.11.

Figure 3.15 A standing adductor

stretch.

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TIGHT HIP ADDUCTORS

Figure 3.16 A kneeling adductor stretch.

Strengthening
Strengthening of the opposing muscle group – in this case, the hip abductor muscles
– is beneficial. Chapter 7 describes specific gluteal strengthening exercises that may
be helpful.

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 TIGHT HIP FLEXORS

Tight Hip Flexors

The hip flexors include the psoas, iliacus, rectus femoris and tensor fasciae latae, all of
which may feel tight after prolonged hip flexion or sporting activity. Because the rectus
femoris is one of the quadriceps muscles, you would also benefit from reading about
how to treat tight quadriceps in chapter 4.
A common belief among therapists is that people with shortened hip flexors will
have reduced strength in the gluteal muscles, which could impair sporting performance,
for example. However, Calvillo, Escalante and Kolber (2021) did not find this to be
the case. Using techniques such as stretching to increase length in the hip flexors may
therefore have little impact on gluteal strength, should that be your goal. Nonetheless,
the material in this section will be useful for other reasons, such as for treating clients
who report discomfort due to tension in their hip flexors or in whom you believe that
hip flexor tension may be contributing to anterior pelvic tilt and potentially to low back
pain. Reducing tension in the hip flexors may also be helpful in preventing injury: Tight
hip flexors have been identified as a significant risk factor for hamstring injury in older
adults who play Australian football (Gabbe, Bennell, and Finch 2006).

Trigger Point Release

A trigger point in the iliacus is located high in the
muscle, just inferior to the iliac crest on the anterior
of the ilium (figure 3.17). It sends pain down the upper Iliopsoas:
part of the anterior thigh. Palpate for it with your Psoas major
client in the side-lying position, hooking your fingers Psoas minor
gently over the crest and pressing them towards you Iliacus
(figure 3.18a). Prolonged hip flexion aggravates this
trigger, which is associated with triggers in the psoas
and quadratus lumborum muscles. Ferguson (2014)
provides three case studies of clients with idiopathic
scoliosis, describing how trigger points in muscles,
including the iliacus, affect and are affected by spine
shape.
Oh and colleagues (2016) describe how an inflat-
able ball was used to deactivate triggers in a range
of muscles, including the iliacus, in a group of older
patients with chronic low back pain. All participants Figure 3.17 Trigger point in
had trigger points in the gluteus maximus, gluteus the E8778/Johnson/F
iliacus.
03.17/718257/pulled/R1
medius, iliopsoas and quadratus lumborum on at least
one side that had persisted for more than 2 months. The iliopsoas was treated actively
with the patients in the prone position; the hip on the affected side was abducted to
approximately 45 degrees, and the knee was flexed to 90 degrees. Significant improve-
ments were found in pain scores on the Visual Analogue Scale, pressure pain sensitivity
and lumbar flexion.
Some clients may find this technique invasive; therefore, show your client where you
intend to place your hands, and be sure to obtain the client’s approval before performing

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TIGHT HIP FLEXORS

this stretch. With your client in the side-lying position with the hip flexed, lock into the
iliacus on the anterior surface of the ilium (figure 3.18a). The abdomen falls away in the
side-lying position, so having the client in this position rather than supine is relatively
safer. Whilst maintaining your lock, ask your client to straighten the leg, which extends
the hip (figure 3.18b). The area to be worked is small, so the lock may be repeated in
the same place or a centimetre to one side. Usually, performing the stretch three times
this way will provide some relief from tension in the hip area.
If the client requires a greater degree of stretch, have them extend their hip at the
end of the movement rather than pressing more firmly with your fingers. One way to
explain this action is to ask the client to press into your fingers when you get to the
end of the movement.

a b

Figure 3.18 (a) Locking the iliacus with a client in the side-lying position, followed by
(b) active hip extension as the lock is maintained by the therapist.

TIP
This area can be ticklish. An alternative approach is to ask the client to place their own
hand on the area, and then you press over it. You can also dissipate your pressure by work-
ing through a facecloth folded into fourths.

It is always useful to explore whether there are trigger points in the tensor fasciae latae
(figure 3.19). Locate this muscle by asking your client to raise their leg off the treatment
couch, rotating it internally. Once you find the muscle, position a massage tool gently
against it (figure 3.20). Press firmly into the muscle, searching for trigger spots. When
you locate one, apply gentle pressure for 60 seconds, allowing the ‘grateful pain’ to
dissipate. This is a great technique to save therapists’ thumbs when deep pressure needs
to be applied to this small muscle. Using a massage tool safely and effectively takes
some practice; take care to avoid pressure to the greater trochanter.

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 TIGHT HIP FLEXORS

Tensor fasciae
latae

Sartorius

Rectus femoris

Vastus lateralis

Vastus medialis

Figure 3.19 The tensor fasciae latae and its relationship to the quadriceps.

E8778/Johnson/F 03.19/718236/pulled/R1

Figure 3.20 Treating trigger points in the tensor fasciae latae using a massage tool.

TIP
To identify the tensor fasciae latae, position the client supine and palpate the iliac crest.
The muscle originates from the posterior aspect of the crest and will contract if you have
the client lift their leg off the treatment couch and rotate the hip internally. (You can try this
yourself whilst standing: Flex your hip and internally rotate it, keeping your knee straight.)

Stretching
Passive stretches for the hip flexors could be performed in the prone (figure 3.21) or
supine (figure 3.22) position. To perform the stretch with the client prone, insert a
small towel beneath the knee to take the hip into slight extension. In some clients,
this increases lordosis in the lumbar spine and may be uncomfortable. Stretching the
rectus femoris muscle in the prone position could be harmful if a client has a history of
trauma to the low back, because the lumbar spine extends in this position. One way to

93
TIGHT HIP FLEXORS

reduce lumbar extension is for clients to perform a posterior pelvic tilt whilst you retain
the position of the leg; thus, they perform the stretch themselves without your needing
to flex the knee farther. This is also a good starting position for using Muscle Energy
Technique (MET). An alternative is to place your hand on the pelvis before flexing the
knee, preventing movement in the pelvis and spine.
Notice that in figure 3.22, the client needs to be positioned so that they are able to
extend the hip (thereby stretching the hip flexors) and not have the thigh supported, as
shown in the photograph.

Figure 3.21 Using a towel increases exten- Figure 3.22 Hip flexor stretching in the
sion of the hip and therefore facilitates hip supine position.
flexor stretching in the prone position.

It is important to have a variety of stretches you can demonstrate for clients who have
tight hip flexors. For example, figure 3.23 illustrates how to stretch the hip flexors by
hanging the affected leg off one side of a bed. Kneeling (figure 3.24) is an alternative
for clients who are comfortable on their knees. In both positions, flattening the low
back so the pelvis is posteriorly tilted increases the stretch on the hip flexors. An easy
way to explain this is to suggest that the client contract the buttock muscles. The stretch
shown in figure 3.24 can be further enhanced if the client raises their arm above their
head and turns towards the flexed knee of the opposite leg (figure 3.25). In this way,
all the fasciae connecting the anterior hip and thigh and the lateral side of the body
are tensioned.

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 TIGHT HIP FLEXORS

Figure 3.23 A supine hip flexor stretch.

Figure 3.24 A kneeling hip flexor stretch. Figure 3.25 Enhancing a kneeling
hip flexor stretch.
Strengthening
Due to reciprocal inhibition, strengthening of the opposing muscle group – in this
case, the hip extensor muscles – is likely to be beneficial in reducing tension in the
hip flexors. Chapter 7 has more information.

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96 Soft Tissue Therapy for the Lower Limb

Quick Questions
1. Which nerve is affected in piriformis syndrome?
2. What are three ways the adductor muscles may be damaged in a groin strain?
3. If you wanted to apply a gentle passive stretch in the supine position to some-
one with tight left hip adductors, where would you position your right hand
to stabilise the pelvis?
4. When treating someone with tight hip flexors, you decide to apply soft tissue
release to the iliacus. In which treatment position do you apply this technique:
prone, supine or side-lying?
5. How do you identify the tensor fasciae latae with a client in the supine position?
 4
Hamstrings
and Quadriceps
Learning Outcomes
After reading this chapter, you should be able to do the following:
■ Explain why active rather than passive techniques are the most appropriate
intervention in the treatment of an acute hamstring strain.
■ Demonstrate passive stretches for the hamstrings and quadriceps.
■ Use the forearms, fists or elbows, as appropriate, when applying trigger point
release to the hamstrings and quadriceps.
■ Teach active stretches for the hamstrings and quadriceps.
■ Apply soft tissue release to the hamstrings and quadriceps.

T
his chapter focuses on four common conditions affecting the hamstring and quadri-
ceps muscles. You will learn which hands-on techniques might be most appropriate
for hamstring strains and cramps and how to best help clients who report tension in
these muscles. You will also learn how to deactivate trigger points in the hamstrings and
quadriceps and which active and passive stretches are helpful. Strengthening exercises
are important after a hamstring strain; chapter 7 explains how to do these.

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HAMSTRING STRAIN

Hamstring Strain
Tears to hamstring muscles are common and frequently involve the proximal
musculotendinous junction of the biceps femoris. Strains are classified as mild, moderate
.

or severe. In mild strains, few muscle fibres are torn. Moderate strains cause damage to
more fibres and a distinct loss of function. When the strain is severe, complete rupture
of the muscle occurs. In addition to being very painful, moderate to severe strains are
extremely disabling. In all cases, there is pain on palpation, pain on stretching of the
muscle and pain on resisted knee flexion or resisted hip extension. In severe cases,
there is bruising and loss of strength in knee flexion or hip extension. A systematic
review by Green and colleagues (2020) provides useful information about risk factors
for hamstring strain injury. However, there is inconclusive evidence regarding the most
effective interventions for a hamstring strain. A systematic review by Prior, Guerin and
Grimmer (2009) provides a clear discussion of this topic.

Acute Stage
Deep tissue massage and all forms of stretching are avoided during the early stages
of tissue repair after a hamstring strain, when protection of the damaged tissues is the
goal of treatment.

Sub-Acute Stage
With a strain to any muscle, it is important to remember that pain subsides long before
the healing process is complete. It is therefore wise to treat the client conservatively
during the sub-acute phase of a hamstring strain, when there may be decreased pain
and swelling. During this phase of recovery, the treatment aims are to minimise loss of
hamstring strength and loss of range of motion in the hip and knee joints.

Massage
In the sub-acute stage of a hamstring strain, light effleurage superior to the site of the
tear could be helpful in aiding lymphatic drainage, but deep tissue massage should
be avoided. Begin with exploratory massage, using your fingertips to identify areas
of adhesion. Using your forearms (figure 4.1) is an easy way to deliver broad strokes,
which, along with stretching, can help collagen fibres realign in a more optimal way
than they otherwise might. Whilst supporting yourself in flexion at the waist, position
your forearm just above the knee. Use your left forearm if treating the client’s right
hamstrings. Lean onto the client and glide gently up to the ischium. End your stroke at
the point on the thigh that is appropriate for your client. In sport massage, it is common
to take the stroke all the way to the origin of the hamstrings at the ischium. For you to
fully access these muscles, either your client will need to wear short shorts or you will
need to provide towel draping.

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 HAMSTRING STRAIN

Figure 4.1 Gentle effleurage to the hamstrings using the forearm.

Another technique is to apply massage with your client supine. In this position, the
hamstrings are shortened, and this can be helpful. This technique is ideal for clients
who cannot lay prone because of injury; however, the technique is not appropriate for
all clients, some of whom might not wish to place their leg in this position.
Ensure the client is correctly draped in a towel, if necessary. Apply gentle strokes
with your forearm (figure 4.2a) or fist (figure 4.2b), gliding from just below the knee
to the ischium.

a b

Figure 4.2 Massage to the hamstrings in the supine position using (a) the forearm or
(b) the fist.

TIP
Instead of the client holding their leg, practise resting their leg on your shoulder.

Active Stretches
Active stretches are particularly useful, provided that the client remains within a pain-
free range. This may mean that the client avoids lengthening the muscle at the end-of-
joint range. Begin with gentle stretches, such as those shown in figures 4.3a and 4.3b,
which tense the tissues not only of the calf but also of the hamstrings. Alternatively,
refer to figure 5.39 in chapter 5.

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HAMSTRING STRAIN

a b

Figure 4.3 Stretching of all the tissues of the posterior lower limb, including the ham-
strings, in the early stage of recovery using (a) active dorsiflexion or (b) a towel to
increase tension.

Passive Stretches
Passive stretching is not recommended for hamstring strains but can be very useful when
the muscle is healed, especially if adhesions have resulted in a sensation of tightness
or have reduced muscle length.

Strengthening
Strengthening is an important part of hamstring strain rehabilitation. Chapter 8 provides
details.

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 TIGHT HAMSTRINGS

Tight Hamstrings
There are many reasons why tightness may develop in the posterior thigh. Tightness
is commonly reported by runners and people regularly engaged in sports involving
the lower limbs, such as tennis or rowing. Shortening of soft tissues of the posterior
compartment of the thigh and knee is also likely to occur in people who remain seated
for long periods of time, such as drivers, office workers or people with a sedentary
lifestyle. Trigger point release, active and passive stretches and soft tissue release (STR)
are all helpful in combatting tight hamstrings.

Massage
Massage feels soothing to receive and is likely to have a relaxing effect on muscles.
However, it is unlikely that massage alone will be effective in alleviating tight hamstrings,
and therefore, you may wish to use the additional techniques described here.

Trigger Point Release

Trigger points are found in the middle to lower portions of all three hamstring muscles
– the semimembranosus, semitendinosus and biceps femoris (see figure 4.4). These
triggers refer pain primarily to the back of the knee and proximal part of the posterior
thigh and are perpetuated by activities such as sitting for prolonged periods with the
knees flexed, as when driving or working at a desk or when immobilised in bed or a
wheelchair after an injury or illness. Prolonged pressure to the back of the thigh is another
perpetuating factor. You can palpate trigger points in this muscle group with your client
in the prone, side-lying and even supine positions, in each case with the knee flexed.

Semimembranosus
Semitendinosus
Biceps femoris
(long head)

Figure 4.4 Trigger points in the hamstrings.

Studying a group ofE8778/Johnson/F

30 physically 04.04/718202/pulled/R1
active males with tight hamstrings and at least
one trigger point, Trampas and colleagues (2010) compared the effects of trigger point
release combined with stretching and of stretching alone with a control group that
received no intervention. They measured knee range of motion, stretch perception, the

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pressure pain threshold and subjective pain (using the Visual Analogue Scale) before
and after intervention. Non-painful cross-fibre friction massage was used over the trigger
points in the group receiving trigger point release plus stretching. Both this group and
the group receiving stretching alone showed improvements in posttreatment measures
compared with the control group, and the group that received trigger point release as
well as stretching showed a significant improvement in outcomes compared to the
group that received stretching alone.

TIP
Pain radiating down the back of the thigh is not necessarily sciatica and can be an indica-
tion of trigger points in the hamstrings.

Use your thumb to identify trigger points (figure 4.5). You could deactivate the triggers
using your thumb or apply the pressure using your elbow, with the client in a prone
(figure 4.6a) or supine (figure 4.6b) position.

Figure 4.5 Palpating the hamstrings for trigger points using the thumb.

a b

Figure 4.6 Treating trigger points using the elbow in the (a) prone and (b) supine posi-
tions.

Your client could deactivate trigger points using a tennis ball, either by sitting with
the ball against a trigger point (figure 4.7a) or holding the ball against their thigh (figure
4.7b). Sitting on the ball requires less effort than holding the ball against the thigh, but

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care is needed because the lower limb is heavy; thus, when a client is using a ball in
a seated position, they should move it approximately every 30 seconds.

a b

Figure 4.7 Using a tennis ball to deactivate trigger points in the hamstrings in the (a)
sitting and (b) supine positions.

Stretching
There is a wide variety of stretches that are useful after deactivation of trigger points in
the hamstrings, and these can all be used as standalone stretches too. Vachhani and
Sharma (2021) conducted an interesting study in which they compared the effectiveness
of a suboccipital muscle inhibition technique with a muscle energy technique. The
position used for the Muscle Energy Technique stretch is shown in figure 4.8. You can
see from the photograph that the hip is passively flexed, lengthening the hamstrings.
The study participants were asked to use their leg to apply pressure to the therapist’s
shoulder for 7 to 10 seconds, followed by a rest of 2 to 3 seconds. The therapist then
passively flexed the hip farther and held it in this new position of stretch for 30 seconds.
This was repeated two more
times. The rationale for use of
the second technique, muscle
inhibition, is that by decreasing
myofascial tension in the
suboccipital region, there is a
decrease in tone in the knee
flexors. When applying the
muscle inhibition technique,
the participants were supine,
with the therapist cupping
the base of the participant’s
skull such that the tips of
the therapist’s fingers were
pressed into the participant’s
suboccipital muscles. This
position was maintained for 2 Figure 4.8 A traditional hamstring stretch.

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TIGHT HAMSTRINGS

minutes on each of 5 consecutive days. Vachhani and Sharma reported both methods
to be effective in improving hamstring flexibility.
In addition to the simple stretches shown in figure 4.3, the client could use a towel,
as in figure 4.9. Bear in mind that dorsiflexing the foot in this way also stretches the calf,
and for some clients, this may feel uncomfortable. Clients who do not wish to do their
stretches on the floor could try simply placing one leg on a stool and leaning forward
to stretch the hamstrings of that limb. Obviously, this is not appropriate for clients with
impaired balance. Remember that the hamstrings are hip extensors, so taking the hip
into flexion, as in figure 4.10, will also help stretch these muscles. In the photograph
in figure 4.10, the hamstrings of the right leg are being stretched because this is the hip
that has been taken into flexion. Clients with knee problems should avoid this stretch,
which places pressure on the knee opposite the thigh being stretched.

Figure 4.9 An active hamstring stretch using a towel.

Figure 4.10 Stretching the hamstrings of the right leg.

Soft Tissue Release

There are many techniques for applying STR to the hamstrings, and these all work well
for stretching this muscle group when it is perceived to be tight.

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 TIGHT HAMSTRINGS

Passive Soft Tissue Release for Hamstrings: Prone

With your client in the prone position, passively shorten the hamstrings by flexing the
client’s knee. Lock the muscle close to its origin at the ischium (figure 4.11a) using your
thumb or a soft fist. Each time you lock the fibres in this stretch, direct your pressure
towards the ischium rather than perpendicularly. If using your thumb to lock the tissues,
take care to press only lightly, as overuse may be damaging to your thumbs. Whilst
maintaining your lock, gently stretch the muscle by extending the knee (figure 4.11b).
Many clients do not feel much stretch at this point.

a b

Figure 4.11 (a) Lock the hamstrings as close to the ischium as possible, then (b) stretch
the tissues whilst maintaining the lock.

TIP
It is a good idea to explain to the client where the lock is going to be before beginning the
treatment. Some clients may consider locking under the buttock in this way to be invasive.
In figure 4.11, the therapist has chosen to place the first lock distal to the ischium, on the
upper part of the thigh.

Again, with the knee passively flexed, choose a new, slightly more distal lock, per-
haps in the midline of the thigh (figure 4.12a). Whilst maintaining your lock, stretch
the tissues by passively extending the knee (figure 4.12b).

a b

Figure 4.12 (a) Create a more distal lock on the hamstrings, then (b) stretch the tissues
whilst maintaining the lock.

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TIGHT HAMSTRINGS

Work down the length of the hamstrings from proximal to distal insertions, repeat-
ing this procedure. Avoid pressing into the popliteal space behind the knee. If you are
performing the technique correctly, your client will experience an increasing sensation
of stretch as you work towards the hamstring tendons. If your client does not feel the
stretch, you will need to do active assisted STR.

TIP
You can use STR to help assess the pliability of the hamstring muscles. Notice the resistance
you feel as you work proximally to distally on these muscles. Can you sense which muscles
are tightest – the biceps femoris (laterally) or the semimembranosus and semitendinosus
(medially)?

If you wish to use STR to help deactivate trigger points, use your thumb to apply gentle
pressure to a trigger, repeating the procedure over the trigger rather than to other parts
of the muscle. Only when the trigger has dissipated should you move to another area.
After STR for trigger point release, instruct your client to perform hamstring stretches
to maintain length in the muscle fibres.
The hamstrings are strong, powerful muscles that require a firm lock to fix the tissues.
Using a fist to lock the tissues is one method, but it is not as powerful as using a forearm
(as in active assisted STR). Elbows may be used to lock the tissues, but due to the length
of the lever in this case, using the elbow makes passive flexion and extension of the
knee difficult and may compromise your posture as you lean forward to lock the tissues.
Active Assisted Soft Tissue Release for Hamstrings: Prone
Whilst your client is in a prone position, ask them to flex the knee. Using the side of your
forearm or your elbow, lock the hamstrings close to the ischium. Direct your pressure
towards the buttock to take up some of the slack in the soft tissues before the stretch
(figure 4.13a). Leaning over to lock tissues could hurt your back, so take care to guard
your posture. Take a wide stance and ensure that your upper body weight is supported
by the client or treatment couch. With practice, this is easy. Whilst maintaining your
lock, ask your client to lower the leg back to the couch (figure 4.13b). Release your lock.

a b

Figure 4.13 (a) Lock the hamstrings close to the ischium using an elbow, then (b) stretch
the tissues as the client lowers the leg to the couch.

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 TIGHT HAMSTRINGS

Choose a new lock, more distal to the first. Repeat the lock-and-stretch motion,
working in lines down the posterior thigh from the ischium to the hamstring tendons.
Avoid pressing into the popliteal space behind the knee.

TIP
The knee does not need to be fully flexed at the start of the technique or fully extended
afterwards. Indeed, when working with a client with severe tightness on the posterior of
the knee, full extension may not be desirable or possible initially.

Working on the leg closest to you (figure 4.14) is often easier than stretching across
the body to the opposite leg. Using the right arm when treating the left leg (or left arm
when treating the right leg) can also make application easier.
Using the point of your elbow creates a more specific lock and can be a useful alter-
native to thumbs when using STR to deactivate trigger points that you have first identi-
fied with finger palpation (figure 4.15). However, it is more difficult to use the elbow
in this way as you reach the distal end of the muscles, where a thumb lock is better.

Figure 4.14 Applying soft tissue release Figure 4.15 Using the point of the
to the leg closest to the therapist. elbow to create a lock.

Active Assisted Soft Tissue Release for Hamstrings: Supine

An alternative position for applying STR to the hamstrings is to work with your client
supine, their hip and knee flexed to at least 90 degrees. In this position, you can use
your elbow to press into the hamstrings (figure 4.16). Maintaining pressure, ask your
client to slowly extend the knee until it is straight.

Figure 4.16 Using the elbow to apply soft tissue release to the hamstrings in the supine
position.
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TIGHT HAMSTRINGS

Active Soft Tissue Release for Hamstrings

Soft tissue release can be used by your client in the seated or supine positions.
If supine, instruct your client to shorten the muscle by flexing the knee, and place
a tennis ball beneath part of the hamstring muscles (figure 4.17a). Whilst holding the
tennis ball, gently extend the knee (figure 4.17b).

a b

Figure 4.17 (a) Apply a ball to the hamstrings; then, maintaining the lock, (b) slowly
extend the knee.

Practise this for yourself. Place your first lock (using the ball) near the ischium and
gradually work down towards your knee with subsequent locks. Because the hamstrings
are a large muscle group, you will need to work all over them to fully benefit from the
stretches. Sometimes it is best to work systematically, perhaps starting with the biceps
femoris on the lateral side of the thigh and moving from proximal to distal (ischium to
knee). When you feel you have worked this section enough, move your locks to a more
medial position so that you are over the semimembranosus and the semitendinosus;
continue to work this area in the same way. To use the technique to deactivate trigger
points in the hamstrings, palpate the muscle until you locate a trigger, place the ball
over it and repeat the STR on that same spot several times until the trigger dissipates.

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TIP
Observe the position of the foot and ankle of the two clients shown in figure 4.18. Most
people, when they attempt active STR in the supine position, will have their foot in
semi–plantar flexion (figure 4.18a). However, for even more of a stretch, the ankle may
be dorsiflexed, as the client has done in figure 4.18b.

a b

Figure 4.18 Active soft tissue release with the ankle in (a) a neutral and (b) a dorsi-
flexed position.

When STR is used in a seated position, start with the knee flexed and a ball between
the thigh and the chair (figure 4.19a), then extend the knee (figure 4.19b). Sitting STR
is useful for treating hamstrings during the day if your client has a desk job.

a b

Figure 4.19 (a) Starting position for active soft tissue release for the hamstrings. (b)
Extension of the knee to bring about a stretch in the tissues.

Applying STR in a seated position takes less effort than when lying down, because
it does not require the ball to be held in place with the hands.

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HAMSTRING CRAMPING

Hamstring Cramping
Involuntary contraction in the hamstrings is painful, albeit temporary. Hamstring cramping
is more likely to occur after vigorous physical exertion or in patients who remain positioned
for long periods of time in knee flexion. In such cases, without treatment, the cramp will
eventually dissipate. However, there are other causes of cramping, and an interesting and
detailed overview is provided by Swash, Czesnik and de Carvalho (2019).

Stretching
Although both active and passive stretches are helpful for hamstring cramps, active
stretches may be the most beneficial, because contraction of the quadriceps or hip flexors
inhibits the hamstrings, which therefore cannot contract involuntarily (i.e., cramp).
All active stretches, such as those shown in figures 4.9 and 4.10, are helpful in com-
batting hamstring cramps. Additionally, it is useful to teach your client how to perform
an isometric contraction of their quadriceps to overcome hamstring cramping. One
way to demonstrate this is to place your hand over the ankle of the leg that is cramping
and ask the client to try to straighten the leg, pushing against you (figure 4.20), until the
knee is extended. As with the previous stretch, contraction of the quadriceps in this way
inhibits contraction of the hamstrings. Once your client understands this principle, they
can use it to overcome a hamstring cramp – for example, by placing their foot under
an immovable object such as a heavy bed.

Figure 4.20 Teaching a client about isometric contraction of the quadriceps to over-
come hamstring cramping.

Nocturnal leg cramps are also common in pregnancy. In a study by Anandhi, Ansari
and Sivakumar (2019), 43 women reporting nocturnal lower limb cramps were divided
into two groups. Group A performed non-stretching exercises (simple ankle dorsiflexion

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 HAMSTRING CRAMPING

and plantar flexion) plus stretching exercises, and group B performed only the non-
stretching exercises. The stretching exercises performed by group A were for the ham-
strings and soleus muscles. Both groups completed their exercises three times a day for
4 weeks and were assessed before and after the intervention using the Visual Analogue
Scale and a muscle and joint measurement questionnaire. The researchers found that
there was a statistically significant reduction in the reported intensity of muscle cramps
in the group that performed stretching exercises, leading the authors to conclude not
only that stretching should be used to reduce nocturnal muscle cramps in antenatal
women but that these stretches should be taught in antenatal classes as a preventative
measure. If you are working with antenatal clients, it is important to remember that
due to the hormone relaxin, ligaments are more lax throughout the body, so stretches
should be performed slowly and carefully, avoiding straining at the end-of-joint range.
Passive stretches are also useful. The hamstrings sometimes cramp when clients are
lying prone and actively flex their knees or, more commonly, when they are receiving
massage in this position after a sporting event. In either case, it is useful to have some
stretches to help overcome cramping.
If the cramp occurs when the client is prone, ask them to flex their knee and push
their ankle into your hand (figure 4.21), contracting their quadriceps to extend their
knee. Contraction of the quadriceps in this way inhibits the hamstrings and helps reduce
the cramp. Ask the client to push their leg back down onto the therapy couch (or floor,
if you are working on the floor) as you apply gentle resistance.

Figure 4.21 Overcoming a hamstring cramp using isometric contraction of the quadri-
ceps.

Massage
Massage may feel soothing for the client who has experienced a hamstring cramp, but
it is unlikely to be as effective as isometric contraction of the quadriceps and active or
passive stretching of the hamstrings. When using massage, it is important to focus on
the use of slow, deep strokes rather than techniques such as tapotement, because the
goal of massage when treating a cramp is to reduce excitability in the nervous system
and thereby reduce muscle tension. Tapotement is a stimulatory technique and is best
avoided in the treatment of cramps.

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TIGHT QUADRICEPS

Tight Quadriceps
The quadriceps may feel tight as a result of a sporting activity or after injury.

Massage
Once you have warmed the area using effleurage and petrissage, applying deep massage to
the quadriceps is helpful to reduce feelings of tightness in this muscle group. For example,
you could glide from just superior to the patella to the proximal end of the thigh using
your forearm (figure 4.22a), or you could grip and squeeze the muscle (figure 4.22b).

a b

Figure 4.22 Applying deep tissue massage to the quadriceps by (a) gliding with the
forearm or (b) gripping.

Trigger Point Release

Deactivation of trigger points in the thigh can also help reduce feelings of tightness. Four
common trigger points are found in the quadriceps. The trigger point at the proximal
attachment of the rectus femoris is close to the anterior superior iliac spine (figure 4.23)
and refers pain into the knee. To identify the rectus femoris, palpate the area as you
have your client perform isometric knee extension in a manner that does not engage the
hip. The rectus femoris will contract, and you will be able to palpate it for this trigger.
Two trigger points in the vastus medialis (figure 4.23) refer pain to the medial thigh
and knee. To palpate for these trigger points, either stand facing the side of the couch
with the client in the supine position and gently glide your fingers from the adductors
through to the vastus medialis or begin at the knee and palpate from the knee to the hip.
Trigger points exist in the proximal, distal and middle portions of the vastus lateralis,
one of which is shown in figure 4.23. The section on iliotibial band friction syndrome
in chapter 5 gives more information on how to treat the lateral thigh area.
There are trigger points in the vastus intermedialis (not shown in figure 4.23), and
they refer pain over the anterolateral portion of the thigh.
The trigger points in the quadriceps are aggravated by trigger points in the hamstrings,
and they may not resolve unless the hamstrings are first addressed. Tight hamstrings
can prevent full knee extension, meaning that the hamstrings are unnecessarily strained
during weight bearing. Trigger points in the hamstring muscles are perpetuated by
immobilisation of the thigh, as is common after injury.

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 TIGHT QUADRICEPS

Tensor fasciae
latae

Sartorius

Rectus femoris

Vastus lateralis

Vastus medialis

Figure 4.23 Trigger points in the quadriceps.

Espí-López and colleagues (2017)

E8778/Johnson/F recruited 60 people with patellofemoral pain to
04.23/718281/pulled/R1
compare the effectiveness of adding dry needling into trigger points to manual therapy
and exercise. For 3 weeks, half the group received manual therapy and exercise and half
the group received the same manual therapy and exercise plus dry needling into trigger
points into the vastus medialis and vastus lateralis muscles. Outcome measures used
were the Knee Injury and Osteoarthritis Outcome Score, the Knee Society Knee Scoring
System, the International Knee Documentation Committee Subjective Knee Form, and
the Numerical Pain Rating Scale. Measures were taken at baseline, 15 days posttreat-
ment, and 3 months later. Both groups showed moderate to large improvements in all
scores; no significant differences existed between
the two groups, leading the authors to conclude
that combining dry needling to trigger points with
a manual therapy and exercise intervention did
not result in improved outcomes for patients with
knee pain and disability.
One way to apply pressure is using your elbow.
Position your hand and elbow as shown in figure
4.24, with the client’s knee supported with a bolster
if necessary. Using oil, apply pressure with your
elbow, and use your hand to guide your elbow
Figure 4.24 Using the elbow slowly up towards the hip. Take care that your guide
with care on the quadriceps. hand does not encroach on the client’s inner thigh.

TIP
The quadriceps can be bulky muscles, so do not be tempted to apply this technique without
a guide hand, because it can be difficult to stay in place.

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TIGHT QUADRICEPS

Alternatively, you could teach your client how to deactivate the trigger points by
resting on a ball (figure 4.25). Remember to advise caution against keeping the ball in
the same place for too long.

Figure 4.25 Deactivation of a trigger point in the quadriceps using a ball.

Stretching
Both active and passive stretches are helpful to alleviate the sensation of tight quadriceps
and should be used after the deactivation of trigger points.
Passive Stretches
Figures 4.26a and 4.26b show common ways to passively stretch the quadriceps. If
your client does not feel the stretch in this position, use of a small towel beneath the
knee (figure 4.26b) can be helpful to extend the hip and create a deeper stretch of the
rectus femoris.

a b

Figure 4.26 (a) Passively stretching the quadriceps and (b) enhancing the stretch with
use of a towel.

Active Stretches
The quadriceps can be actively stretched in the lying (figure 4.27) or standing (figure
4.28) position. In each, the client needs to be able to reach behind their body to hold
their ankle, and this requires good flexibility in the muscles of the chest and anterior

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 TIGHT QUADRICEPS

shoulder joint. The standing stretch is not appropriate for clients with poor balance or
who cannot bear weight through their hip, knee or ankle. To make this stretch safer, ask
the client to perform it against a wall for support or to place one hand on a table for
balance. The stretch in figure 4.28 could also be performed in the side-lying position.

Figure 4.27 An active quadriceps stretch in the prone position.

Figure 4.28 An active quadriceps stretch in the standing position.

Soft Tissue Release

Active assisted STR works well to stretch the quadriceps. One advantage of this technique
is that you will be able to achieve a strong, broad lock on these powerful muscles. This
method is useful if you find that a general stretching programme for the quadriceps is
not targeting specific tissues. For example, by positioning a lock to the lateral side of
the thigh, you are more likely to access the vastus lateralis.
With your client sitting, lock the proximal portion of the quadriceps with the client’s
knee in active extension, directing your pressure towards the hip (figure 4.29a). Once the

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TIGHT QUADRICEPS

knee is flexed (figure 4.29b), release your lock and repeat, placing a new lock slightly
more distal to the first. Work your way down the quadriceps from hip to knee. Work
slowly and carefully as you approach the distal end of the quadriceps; this increases
the stretch and thus places greater pressure on the patella.

a b

Figure 4.29 (a) Lock the quadriceps using the soft side of the elbow and (b) maintain
the lock as your client flexes the knee to bring about a stretch in the quadriceps.

Note that the knee does not need to be fully flexed for the client to feel a stretch in the
tissues. Practise locking the vastus lateralis and rectus femoris to locate areas of tension.

TIP
Although you can also perform this stretch using your left arm to lock the client’s right
quadriceps, both you and the client may find this position slightly invasive.

Active Soft Tissue Release for the Quadriceps With a Tennis Ball
Another approach is to teach your client how to apply STR to their quadriceps. This
technique may be uncomfortable for some people, because the leg’s entire weight is
on the tennis ball. As with deactivation of trigger points, instruct your client to lie face
down on a mat and position a tennis ball beneath the thigh, with the knee in extension
(figure 4.30a). Then, simply have them flex the knee (figure 4.30b).

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 TIGHT QUADRICEPS

Figure 4.30 (a) Positioning of a ball at the start of active soft tissue release for the
quadriceps followed by (b) active knee flexion, which brings about the stretch.

Encourage your client to practise positioning the ball against various parts of the
thigh, and notice where they most feel the stretch. Position the ball near the hip at first;
with subsequent locks, work towards the knee.

TIP
Pressing the pelvis forward (flattening the lumbar spine in a posterior pelvic tilt) increases
the stretch in both positions.

Konrad and colleagues (2022) conducted a systematic review of the use of foam
rolling to increase joint range of motion. Their review included an assessment of stud-
ies in which foam rolling was used on the quadriceps. They concluded that responses
appeared to be muscle or joint specific. That is, foam rolling the quadriceps was likely
to increase the range of motion in the hip and knee joints but not necessarily in other
joints. Konrad and colleagues also concluded that interventions longer than 4 weeks
were needed to induce gains in range of motion. Therefore, if you believe tightness in
your client’s quadriceps is not simply a sensation of, for example, muscle stiffness but
may correspond with a shortened muscle and that lengthening this muscle to improve
joint range of motion would be a valuable treatment goal, then teaching your client
how to use a foam roller is likely to be helpful.

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118 Soft Tissue Therapy for the Lower Limb

Quick Questions
1. List four ways to identify a hamstring strain.
2. When a client is using soft tissue release to their hamstrings in the supine posi-
tion, what effect does changing the position of the ankle have?
3. After what duration of time should a client move a ball when using it to deac-
tivate trigger points in the sitting position?
4. What is the effect of placing a towel beneath the knee when stretching the
quadriceps in the prone position?
5. For a client who experiences tight quadriceps, what simple tool might you
suggest would be helpful to use?
 5
Knee, Calf and Shin
Learning Outcomes
After reading this chapter, you should be able to do the following:
■ Explain why active stretches are more appropriate than passive stretches for
acute calf muscle strain.
■ Demonstrate passive stretches for calf cramps, tight calf muscles and shin
splints.
■ Teach active stretches for use with calf cramps, tight calf muscles and shin
splints.
■ Apply trigger point release to the calf and tibialis anterior and explain how to
use this for the treatment of iliotibial band friction syndrome.
■ Explain and give the rationale for which techniques are most appropriate
when treating someone with osteoarthritis in the knee or after knee surgery.
■ Demonstrate taping for genu recurvatum, genu varum and genu valgum.
■ Describe the conditions presented in this chapter for which massage may be
an appropriate hands-on technique and give your rationale for this.

I
n anatomical terms, leg refers to the part of the lower limb beneath the knee. This
chapter discusses conditions affecting leg muscles (strain of the calf, tight calf muscles,
cramp in the calf, shin splints, tight tibialis anterior and tight peroneal muscles),
conditions relating specifically to the knee joint (osteoarthritis in the knee and knee
surgery) and four postures relating to the knee (genu recurvatum, genu flexum, genu
varum and genu valgum). Iliotibial band friction syndrome does not fit nicely into these
categories because it is a condition postulated to be due to biomechanical factors plus
factors affecting the fascia of the thigh, which, combined, cause knee pain.

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CALF MUSCLE STRAIN

Calf Muscle Strain

Calf muscle strains are tears in muscle fibres of the calf and may involve the
gastrocnemius, soleus or both. Strains vary in severity from a few fibres being torn to
complete rupture. Localised pain and swelling increase with the severity of the tear.
The ability to actively plantar flex is reduced, and there is pain on stretching the calf.
Scar tissue is laid down as part of the healing process, the quantity of which depends
on the severity of the injury and the quality of rehabilitation the client receives. Large
amounts of scar tissue may impair function. Meek and colleagues (2022) provide a nice
overview of calf strain in athletes.

Massage
Massage is contraindicated in the acute stage of a calf strain. In sub-acute stages, light
effleurage may help with recovery, but caution is needed to avoid damage to tissues
whilst they repair. Gentle massage superior to the site of the tear could be helpful in
aiding lymphatic drainage, but deep tissue massage should be avoided.

Stretching
Even where a strain is believed to be mild, all forms of stretching should be avoided
in the acute stages of injury, during which time it is important to allow tissues to begin
their repair process.
In the sub-acute stage, pain, swelling and inflammation have subsided. It is wise to
be cautious in recommending stretches during this stage, because tissues are not yet
healed and overzealous stretching could result in reinjury to the muscle, delaying the
healing process.
Active Stretches
With care, active stretches may be used, provided that the client remains within a pain-
free range. Dorsiflexion of the ankle in a non–weight-bearing position, either seated
on a chair or with the legs extended as in figure 5.1, is a good starting stretch. Towards
the end of the healing process, progression to standing calf stretches such as those
shown in the section on tight calf muscles
is recommended if the client believes the
calf is particularly tight. Remember that
with calf strains, pain subsides before
healing is complete, and clients should be
encouraged to stop if any of the stretches
cause pain.
Passive Stretches
Passive stretching is not recommended for
calf muscle strains, but it can be helpful in
later stages when the calf may feel tight.

Strengthening
Figure 5.1 A non–weight-bearing calf
Please see chapter 9 for suitable calf stretch used in early recovery from a calf
strengthening exercises. strain.

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Tight Calf Muscles

Many people suffer from tight calf muscles. The muscles in the posterior compartment
of the leg bring about not only plantar flexion of the foot and ankle but also flexion of
the knee (gastrocnemius), inversion of the foot and ankle (tibialis anterior and posterior)
and flexion of the toes (long toe flexors). It is not surprising that clients who engage in
sporting activities that use the leg muscles may be prone to tension in these areas, as
might people who wear high heels (which force the ankle into plantar flexion). Clients
who remain seated for long periods of time may also experience shortening of tissues
in this compartment, because the gastrocnemius and the fascia associated with this
part of the lower limb are held in a shortened position.
Massage, trigger point release, both active and passive stretching and soft tissue
release (STR) are all helpful for treating tight calves.

Massage
Although many therapists treat the calves with a client in the prone position, two useful
techniques with the client supine and two with the client in a side-lying position are
described here. These techniques are a nice way to treat the calf muscle in clients who
cannot lay prone.
One method is to flex your client’s knee and gently sit on their foot to support the
limb (otherwise, they might try to keep the knee flexed rather than relaxing). Using oil,
cup the distal end of the calf and squeeze it gently, allowing your palms to slide off the
muscle, pulling it gently away from the bone (figure 5.2). To assist venous and lymphatic
drainage, work from the ankle to the belly of the muscle just below the knee, rather
than from the knee to the ankle. With the knee flexed and the ankle plantar flexed, the
muscles of the posterior calf are in a passively shortened position; the gentle traction
of these muscles away from the tibia feels pleasurable for most clients. However, this
is a much more powerful technique than it might initially appear to be, so start gently
and gradually build up the strength of your grip.

Figure 5.2 Squeezing the calf muscles away from the tibia.

Another method of treating a tight calf muscle in the supine position is to use your
forearm. Flex your client’s knee and gently sit on their foot to support the limb (oth-
erwise, they might keep the knee flexed rather than relaxing). Use your forearm to

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effleurage from the ankle to below the knee (figure 5.3). Practise pulling your forearm
up and across the calf, sliding it from your elbow to your wrist as you do so. Support
the client’s knee with your other hand. Change forearms and repeat the procedure.

Figure 5.3 Using the forearm to ‘roll’ the calf muscle with the client supine.

Various deep tissue massage techniques can be used with your client in the prone
position, four of which are described here. If you position your client with their feet off
the end of the treatment couch so they can dorsiflex at the ankle, this will be helpful
should you later wish to use STR.
The first technique is to use your forearm (figure 5.4a). Using oil, lean onto the client
starting just above the Achilles tendon and glide slowly and firmly up the calf, stopping
before you reach the popliteal space at the back of the knee. Notice that you can angle
your forearm to redirect your pressure to the medial side of the calf using this arm, but
to massage the lateral calf more firmly, you need to switch to your other arm, keeping
your wrist and hand high so they do not intrude on the client’s opposite leg.
As an alternative to using your forearm, try using reinforced fists. Starting where the
gastrocnemius and soleus muscles insert into the Achilles tendon, press into the calf,
gliding up the tissue and stopping before you reach the popliteal space at the back
of the knee (figure 5.4b). Keep your elbows and wrists straight as far as possible. The
therapist in figure 5.4b is using two hands. Practise what it feels like to press through
a single fist, perhaps supporting your wrist with the other hand.
For even greater pressure, you could use your elbow (figure 5.4c). Locate the Achilles
tendon and place your elbow against the calf, supported by the web of your thumb. Start
where the gastrocnemius and soleus muscles insert into the Achilles tendon. Using oil,
glide firmly and slowly up the calf, using your hand to keep your elbow from slipping
off the bulk of the muscle. This technique can be used to apply compression alone to
a specific spot, should this be required – for example, when deactivating trigger points
in the calf.
Finally, squeezing the calf is another method of applying deep tissue massage. Start
by flexing your client’s knee and resting it against your shoulder, passively shortening
the calf muscles. This position has the added benefit of aiding venous and lymphatic
drainage from the ankle. Starting close to the Achilles tendon, squeeze the muscles
away from the bone, working from the ankle towards the knee (figure 5.4d).

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a b

c d

Figure 5.4 Massage tissue techniques for the calf include use of the (a) forearm, (b) fist
and (c) elbow and (d) squeezing the calf.

Working with your client in a side-lying position is useful for stubbornly tight calves
and when needing to treat specific areas of tightness. However, because this technique
is so powerful, be cautious not to massage too deeply too soon.
Start where the calf muscles insert into the Achilles tendon. Using a reinforced fist or
fists, glide firmly from this point to the medial side of the knee, compressing the tissues
as you go (figure 5.5a). Once the tissues are warmed, you could work more deeply
using your elbow. Touch the calf with your elbow, then glide slowly but firmly up the
medial side of the calf in a continuous line (figure 5.5b).

a b

Figure 5.5 Applying massage to the medial side of the right calf using (a) reinforced
fists or (b) an elbow.

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Trigger Point Release

Figure 5.6 shows trigger points in the medial and lateral
portions of the gastrocnemius muscle. The medial triggers refer
pain primarily to the instep and medial aspect of the posterior
Gastrocnemius
knee, radiating on the medial aspect of the calf, whilst the
lateral triggers refer pain locally and to the lateral inferior knee
region. These triggers are aggravated by forceful plantar flexion
of the ankle, as might occur when going en pointe in ballet Soleus
or when walking up a steep hill. They are also perpetuated by
compression of the calf, as when wearing tight socks or sitting
with the legs outstretched and the calves resting on a footstool. Achilles tendon
Prolonged passive plantar flexion is also likely to aggravate
triggers, as occurs when sleeping or wearing high heels.
Grieve, Barnett and colleagues (2013) examined myofascial
trigger point therapy for the triceps surae in 10 participants with
calf pain. Baseline measurements were taken before and after
Figure 5.6 Trigger
each treatment: the pressure pain threshold, the presence of E8778/Johnson/F
points in the05.06/718215/pulled/R1
calf.
trigger points, ankle dorsiflexion range of movement, the Lower
Extremity Functional Scale and a verbal numerical rating scale. A therapist found trigger
points in the gastrocnemius and soleus muscles using a thumb, then passively stretched
the calf. Participants were also advised to self-treat their trigger points using a tennis ball
or foam roller at least once a day, followed by active stretching of the calf. Thirteen active
triggers had been identified at baseline across the 10 participants, which reduced to zero
after the intervention. However, the 31 latent trigger points that had been identified across
the participants were only reduced to 30. Ankle dorsiflexion for both the gastrocnemius
and soleus improved after treatment, as did the pressure pain scores for all participants.
Grieve, Cranston and colleagues (2013) also explored deactivation of latent triggers
in the triceps surae of 22 recreational runners. Participants ran at least twice a week
and had at least one latent trigger point in either the gastrocnemius or soleus. All had
restricted ankle dorsiflexion. Trigger point release was performed with thumb pressure
for 10 minutes, followed by stretching the gastrocnemius and soleus muscles for 10 sec-
onds each. The control group received no intervention, but both groups had pretest and
posttest ankle dorsiflexion measurements taken using a goniometre. Ankle dorsiflexion
increased in both groups but was greater in the intervention group. In the intervention
group, the increase was statistically significant compared to baseline measurements
for both the soleus and gastrocnemius, leading the authors to conclude that myofascial
trigger point release provided an immediate improvement in ankle dorsiflexion.
More recently, in a study involving 50 participants, Wilke, Vogt and Banzer (2018)
compared the effectiveness of self–myofascial release of trigger points in the calf. They
found that static pressure applied to the trigger with a foam roller was more effective at
reducing the trigger than using the foam roller to slowly compress the length of the calf.

TIP
If a client complains of waking at night with a cramp in the calf, in the absence of any
serious pathology, consider the presence of trigger points in the gastrocnemius.

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Trigger points in the calf can be deactivated using simple elbow pressure (figure 5.7).
Note that the client in the figure has been deliberately positioned with their feet off the
edge of the couch because this is the position needed for STR. If you use this position
to deactivate trigger points and you intend to also use STR, it will prevent your client
from having to shuffle down the couch between use of these two techniques during a
treatment. You could also teach your client how to deactivate triggers by resting their
leg on a tennis ball (figure 5.8).

Figure 5.7 Deactivating trigger Figure 5.8 Active trigger point release.
points using the elbow to apply pres-
sure.

Stretching
After trigger point release, stretch the muscle using either passive or active stretches.
Stretching is a helpful stand-alone technique for relieving feelings of tightness in the
calf, and a variety of options are described here.
Passive Stretches
Useful passive stretches are shown in figures 5.9a and 5.9b. In the prone position, flexing
the knee focuses the stretch more to the soleus, whereas with the knee in neutral, both
the gastrocnemius and soleus are stretched, as well as other ankle plantar flexors. Notice
that in figure 5.9a, the therapist is using the thigh to increase dorsiflexion at the ankle,
an action that requires considerable force when using your hand. The stretch shown in
figure 5.9b increases the stretch to the soleus muscle but may not be appropriate for
clients who are unable to lie prone or for those who have knee problems on the side
being stretched (as you can see, this particular stretch puts quite a lot of pressure on
the knee). Another stretch that may be helpful is to passively dorsiflex the ankle in the
supine position (figure 5.9c). However, these stretches can be less effective for strong,
physically active people, because the force required to promote the stretch is more
difficult to apply with the client in the prone position.

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a b c

Figure 5.9 Passive stretches for the calf (a) using the thigh to increase dorsiflexion, (b)
targeting the soleus muscle and (c) in the supine position.

Active Stretches
It could be argued that active stretches are more effective at combatting tightness than
passive stretches because the client is able to use their body weight to facilitate the
stretch. Simple and effective calf stretches that use the client’s body weight include the
standing calf stretches shown in figures 5.10a and 5.10b. Figure 5.10a is a traditional
calf stretch (in this example, for the left leg). If your client requires a more powerful
stretch, they can raise the toes, because this increases dorsiflexion. One way to do this
is to place a small block beneath the toes (figure 5.10b).

a b

Figure 5.10 Active stretches in a standing position include (a) a traditional calf stretch,
shown here for the left leg, and (b) the use of a small block to increase dorsiflexion and
therefore increase the stretch.

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TIP
In the first stretch (figure 5.10a), it is important that the client’s feet are facing forwards.
Try this for yourself and notice that turning the foot out slightly decreases the sensation
of the stretch.

Soft Tissue Release

Soft tissue release is an excellent method to help reduce the sensation of tightness in the
calf muscles, and there are many different ways to apply the lock, including gripping
the calf or using the thumbs, fists, forearm or elbow.
Active Assisted Soft Tissue Release for the Calf Using Grip Lock
Perhaps one of the simplest ways to apply
STR to the calf is with your client in the
prone position. Passive flexion of the knee
facilitates slackening of the calf muscle,
which permits a deeper lock and a different
stretch sensation for the client. This provides
a general stretch that is not localised to a
specific part of the calf.
Passively flex the client’s knee and grasp
the calf (figure 5.11). Whilst in this position,
ask your client to plantar flex and dorsiflex
the foot and ankle as you maintain the lock.
Take care not to grip the muscle too hard. Figure 5.11 Using a grip lock on the
When using STR in the prone position, it calf.
is first important to position your client cor-
rectly and check that you can dorsiflex their foot passively. Usually, it is best to shorten
a muscle slightly before performing STR. The calf is an exception to this rule, because
the foot and ankle naturally fall into plantar flexion, in which the muscles are already
neutral (neither stretched nor contracted). Position your client prone with the feet off
the end of the treatment couch (figure 5.12a). Check for clips on the edge of the treat-
ment couch that may press into the client’s foot. Make sure the client can dorsiflex at
the ankle. One way to do so is to gently push the ankle into dorsiflexion (figure 5.12b).

a b

Figure 5.12 (a) Positioning your client on the couch and (b) passively dorsiflexing the
ankle.

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TIP
Practise positioning your thigh on various aspects of your client’s foot, either medially
or laterally. Find the position that provides the client with the greatest stretch. When you
apply this technique, you will need to provide passive dorsiflexion of the ankle to at least
90 degrees. Notice that to do so, you need to angle the client’s foot so as to stretch the calf
muscle, not simply press on the foot, thereby pushing the client up the treatment table.

Passive Soft Tissue Release for the Calf Using Thumbs: Prone
Using reinforced thumbs to apply STR is useful because it is a good way to use STR to
treat trigger points in the upper part of the gastrocnemius. However, it is essential for
all therapists to protect their own limbs, and overuse of the thumbs should be avoided.
Because they are plantar flexors, calf muscles are exceptionally strong, and it may
be necessary to use a particularly firm lock when treating them. Although it may be
tempting to press harder with your thumbs, you should avoid doing it.
When applying STR to the calf, it does not matter whether you start STR in the centre
of the calf or to the lateral or medial side. Usually, STR applied approximately three
times to one group of muscle fibres is adequate to help stretch these fibres and increase
the range of motion at a joint.
Whilst standing at the end of the couch, lock the calf using reinforced thumbs, just
distal to the knee joint, perhaps in the centre of the calf. Each time you lock the fibres
in this stretch, direct your pressure towards the knee rather than perpendicularly (figure
5.13a). Whilst maintaining your lock, use your thigh to dorsiflex the client’s ankle
(figure 5.13b).

a b

Figure 5.13 (a) Locking the calf using the thumbs, then (b) stretching the calf passively
by dorsiflexing the ankle using the thigh.

Once you have dorsiflexed the ankle, release your lock, remove your thigh and move
to a new locking position distal to your first lock (figure 5.14a). Dorsiflex the ankle
once again (figure 5.14b).

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a b

Figure 5.14 (a) Lock tissues in the midline of the calf, then (b) passively dorsiflex the
ankle to bring about a stretch whilst maintaining a lock.

Once you have dorsiflexed the ankle, release the lock and your thigh. Then, place a new,
more distal lock (figure 5.15a). Once again, passively dorsiflex the ankle (figure 5.15b).

a b

Figure 5.15 (a) Create a final, distal lock on the calf, then (b) passively stretch the calf
whilst maintaining a distal lock.

Work down the length of the muscle proximally to the junction of the muscle with
the Achilles tendon. Repeat this action along the same line of the calf up to three times.

TIP
The gastrocnemius, the most superficial calf muscle, is a bipennate muscle: It has two
bellies. Once you have performed STR down the centre of the muscle, move to the lateral
or medial aspect of the calf, following the same steps. Working on the lateral and medial
sides of the calf will help you to identify trigger points here. Notice that many clients have
a palpable band of tension running down their lateral calf. Could this band be thickened
fascia between the lateral and posterior compartments of the leg?

Passive Soft Tissue Release for the Calf Using Fists: Prone
The only difference between applying passive STR to the calf using the fists instead of
the thumbs is in the method of locking. With your client in the prone position, instead of
using your thumbs, make a gentle fist to create the lock (figure 5.16a). Whilst maintaining
your lock, gently dorsiflex the ankle (figure 5.16b).

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a b

Figure 5.16 (a) Lock the calf using your fists, then (b) use your thigh to passively dorsi-
flex the ankle to bring about the stretch.

Passive Soft Tissue Release for the Calf Using Fists to Glide:
Prone With Knee Extension
This can be a soothing form of STR for clients with large, bulky muscles for whom you
find it difficult to maintain a lock or for clients with tender calves for whom a specific
lock is uncomfortable.
Apply a small amount of massage medium, such as oil or wax. As you dorsiflex the
ankle, use your fist to apply pressure as you glide from the ankle to the top of the calf,
reducing pressure when you reach the knee (figure 5.17).

Glide

Figure 5.17 Applying gliding soft tissue release on the calf using the fists.

Passive Soft Tissue Release for the Calf Using Forearms to Glide:
Prone With Knee Flexion
This method can feel soothing and also aid blood and lymph flow towards the knee.
However, it can take practice to become proficient in passive dorsiflexion of the ankle
with simultaneous gliding.
Rest your client’s ankle on your thigh as they lie in the prone position, and place
your hand on their toes (figure 5.18a). Using your forearm, glide from the ankle to the
knee as you passively dorsiflex the ankle (figure 5.18b).

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 TIGHT CALF MUSCLES

a b

Figure 5.18 (a) Place your hands on the client’s toes in preparation to glide up the calf,
then (b) passively dorsiflex the ankle whilst gliding up the calf with the forearm.

Active Assisted Soft Tissue Release for the Calf Using the Elbow: Prone
Active assisted STR is helpful because the client is likely to dorsiflex to a greater extent
than through passive STR to the calf and may therefore experience a greater stretch.
Using the elbow is also an effective method of using STR to deactivate trigger points in
addition to being a useful method of stretching the calf.
Lock the calf muscle using your elbow. Place your first lock just inferior to the knee
joint, taking care not to press into the popliteal space at the back of the knee (figure
5.19a). Notice that the muscle naturally falls into a neutral position with the client
prone and therefore does not need to be actively shortened. Whilst maintaining your
lock, ask your client to pull up the toes, thus dorsiflexing the foot and ankle (figure
5.19b). Once the client has done so, remove your lock and move to a new position.
Repeat the action. Work down the calf towards the ankle, stopping when you reach
the Achilles tendon. Repeat in lines from the proximal to the distal ends of the muscle.
Because constant dorsiflexion fatigues the tibialis anterior muscle, limit the time you
spend on active assisted STR to the calf.

a b

Figure 5.19 (a) Gentle locking of the calf using the elbow followed by (b) active con-
traction of the tibialis anterior, which brings about the stretch.

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TIP
For an alternative to using your elbow, use your thumbs (figure 5.20a). For a broader lock,
use your forearm (figure 5.20b).

a b

Figure 5.20 Alternative locks used for the application of active assisted soft tissue
release to the calf include (a) reinforced thumbs and (b) the forearm.

Active Soft Tissue Release for the Calf: Supine

If you wish to teach your clients how to use STR to stretch their calves, show them
how to place the calf on a ball (figure 5.21a). To shorten the calf, you would normally
plantar flex. However, you will find that the ankle falls naturally into plantar flexion in
this position. Gently dorsiflex the ankle (figure 5.21b).

a b

Figure 5.21 Active soft tissue release applied to the calf involves (a) positioning a ball
and then (b) dorsiflexing the ankle.

TIP
For a broader, less specific lock, an alternative is to place the leg on a cylinder, such as a
can, and apply the stretch.

Strengthening
Strengthening of the tibialis anterior muscle can be a useful way to reduce tightness in
the calf, because the tibialis is the antagonist muscle to the gastrocnemius and soleus.
Please see chapter 9 for examples of exercises.

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Calf Cramping
A cramp is an involuntary contraction and is commonly felt in muscles of the calf; the
exact cause is unknown. It is painful, aggravated by active or passive shortening of a
muscle and often experienced at night when the ankle naturally falls into a position
of plantar flexion. Of short duration, cramping subsides naturally but is nevertheless
painful and limits function. Swash, Czesnik and de Carvalho (2019) provide a useful
review of the pathophysiology of cramping and current treatment interventions.

Stretching
Both active and passive stretching of the calf can be helpful in reducing cramping.
Remember the long toe flexors originate in the posterior calf, so stretching the toes
into extension can also be helpful. See the section on stiff feet and ankles in chapter
6 for more details.
Active Stretches
Many people who experience calf cramps know that by standing up and walking about,
the cramp eventually subsides. During walking, the foot is dorsiflexed, thus stretching the
calf muscles. A useful way to combat a cramp is to contract the opposing muscle group,
actively dorsiflexing the foot and ankle as in figure 5.22 to inhibit contraction in the
muscles of the calf. The client should sustain this dorsiflexion until the cramp subsides.
However, it can be challenging to dorsiflex the
ankle through its entire range of motion, so using
a stretch such as in figure 5.23 may be necessary.
Calf cramping, especially at night, is common
during pregnancy. The study by Anandhi, Ansari
and Sivakumar (2019) described in chapter 4 con-
cluded that stretching should be used to reduce
nocturnal muscle cramps in antenatal women. An
active, standing calf stretch was used in that study
(figure 5.23).

Figure 5.22 Active contraction of the ankle Figure 5.23 A stand-

dorsiflexor muscles to overcome a cramp in ing stretch to overcome a
the calf. cramp in the calf.

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Passive Stretches
Passive stretches are useful if a cramp occurs during a massage treatment or if you
happen to be treating a client before or after a sporting event. If the client is in the prone
position, you could use the stretches shown in figures 5.24a and 5.24b. If the client is
in the supine position, use the stretch shown in figure 5.24c.

a b c

Figure 5.24 Examples of passive stretches to overcome a cramp in the calf can be
applied in the (a, b) prone and (c) supine positions.

Massage
Massage alone is unlikely to reduce cramping in the calf. When using massage, it is
important to focus on slow, deep strokes (a stimulatory technique) rather than techniques
such as tapotement, because the goal of massage is to reduce muscle tension by reducing
excitability in the nervous system.

Strengthening
Contraction of the antagonist muscle to the muscle that is cramping can be an effective
way to overcome the cramp. If the cramp is in the posterior compartment of the calf
(gastrocnemius and soleus), then it is important to contract the tibialis anterior, but if
the cramp is in the lateral compartment (fibular muscles), then it is important to contract
the invertors. Chapter 9 explains how to do this.

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 SHIN SPLINTS

Shin Splints
Shin splints is a generic lay term used to describe pain on the anterior leg, commonly
the result of overuse activities such as running. The therapeutic name is medial tibial
stress syndrome. There is pain on the medial tibial border, and often, there is pes planus
foot posture. The client may have a tight Achilles tendon, and dorsiflexion is usually
restricted. Many factors may contribute to the development of this condition. Massage
and stretching can be soothing.

Massage
Passively flex your client’s knee. Starting at the ankle, use your fist to massage from the
ankle to the knee (figure 5.25).

Figure 5.25 Gentle massage to the shin using a fist.

Soft Tissue Release

Soft tissue release is helpful in addressing tension in the tissues of the anterior leg and
may be performed with the client in the prone or supine position.
Active Assisted Gliding Soft Tissue Release for the Tibialis Anterior: Prone
With your client in the prone position, apply a small amount of a massage medium,
such as oil or wax, to the front of the leg. Starting at the ankle, gently glide your fist
along the length of the tibialis anterior muscle as your client actively dorsiflexes and
plantar flexes the ankle (figure 5.26).

Client dorsiflexes
and plantar flexes

Glide

Figure 5.26 Using gliding soft tissue release on the tibialis anterior.

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SHIN SPLINTS

Active Assisted Soft Tissue Release for the Tibialis Anterior: Supine
To apply STR in the supine position, start by shortening the muscle. Next, apply gentle
pressure to the muscle (figure 5.27a), close to its origin. Maintaining this pressure,
lengthen the muscle in question by either passively or actively plantar flexing the ankle
(figure 5.27b). When you have done this, select a different spot on the muscle, perhaps
distal to where you first applied pressure, and repeat the process of first shortening the
muscle, then applying pressure and maintaining this pressure whilst plantar flexing
the ankle.

a b

Figure 5.27 Applying active assisted soft tissue release to the tibialis anterior involves
(a) first applying a lock with the ankle in dorsiflexion and then (b) asking your client to
plantar flex the foot and ankle.

Note that in this example, a therapist experienced in the use of STR is using the
elbow to gently compress the tibialis anterior. If you are unfamiliar with this technique,
it is better to start by gently fixing or locking the muscle using your thumbs to avoid
potentially bruising the tissues covering the shin.

TIP
It is obviously important to ensure that pain on the anterior shin is not the result of stress
fractures, in which case, this technique would be contraindicated.

Stretching
Stretching is important following soft tissue release to the tibialis anterior. When treating
someone for shin splints, stretching the calf muscles is also needed because of the likely
restriction in this muscle group. Please see the previous sections on tight calf muscles
and calf cramping.
Passive Stretches
Passive stretching of the tibialis anterior is not particularly effective, because
this compresses the posterior ankle, squashing the Achilles tendon, and can be
uncomfortable. However, adding slight traction as you perform the stretch can help
reduce this compression and make the stretch feel more comfortable (figure 5.28).

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Figure 5.28 Passively stretching the tibialis anterior by plantar flexing the ankle.

Active Stretches
A simple active stretch is to point the toes, thus plantar flexing the foot and stretching
the tibialis anterior (as in figure 5.29).

Figure 5.29 Actively stretching the tibialis anterior.

Strengthening
Strengthening of both the tibialis anterior and posterior calf muscles is crucial to recovery
from shin splints, especially if your client is engaged in sporting activity or recreational
fitness. Please see chapter 9 for more details.

Running Footwear and Gait

A review of the footwear the person uses when engaged in impact sports such as running
is likely to be helpful, because adequate shock absorption could reduce the likelihood
of reinjury. In some cases, orthotics may be useful. Use of compression stockings has
also been reported to ease symptoms. If your client is a runner, referral to a specialist for
analysis of their running gait could help identify whether running retraining is needed.

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Tight Tibialis Anterior

When a client reports having a tight tibialis anterior, deeper techniques may be used
than those for shin splints. Not only is massage helpful, but so is the deactivation of
trigger points, followed by stretching, such as STR.

Massage
Once you have warmed the muscle, perhaps using techniques such as the one shown
in figure 5.25, you are ready to work more deeply and perhaps more specifically on the
muscle. This might be with your elbow or knuckle. Help your client get comfortable in
a side-lying position. Locate the tibialis anterior by asking your client to dorsiflex the
foot and ankle. Then, using your elbow (figure 5.30) or a knuckle, press gently into the
muscle just above the ankle and glide slowly towards the origin. The shin is a sensitive
area for most clients, so little pressure is needed when using the elbow.

Figure 5.30 Applying deep tissue massage using the elbow.

TIP
By placing the client’s foot over the end of the treatment couch, it is possible to passively
turn the foot gently into inversion whilst applying this massage technique; this serves to
stretch the fascia of the lateral and anterolateral leg. (Gently plantar flexing the client’s
ankle helps stretch the tibialis anterior.)

Trigger Point Release

A trigger point is found in the upper third of the tibialis anterior (figure 5.31) and refers
pain to the dorsal aspect of the big toe and the front of the ankle. The point is easy to
identify, just lateral to the ridge of the tibia. Trigger points in the tibialis anterior are likely
activated by trauma to the ankle or foot. Trigger points can be deactivated by applying
static pressure using the elbow (figure 5.32a), a knuckle (figure 5.32b) or a thumb.

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 TIGHT TIBIALIS ANTERIOR

Tibialis
anterior

Figure 5.31 Trigger point in the tibialis anterior.

E8778/Johnson/F 05.31/718241/pulled/R1

a b

Figure 5.32 Applying static pressure using (a) the elbow or (b) a knuckle to deactivate
trigger points in the tibialis anterior.

Soft Tissue Release

Although active soft tissue release to the tibialis anterior is possible using a therapy
ball, it is somewhat difficult. Active assisted STR can be included as part of a massage
routine where the gliding STR technique described here can be particularly helpful.
Active Assisted Soft Tissue Release for the Tibialis Anterior
There are several positions in which you could apply this technique. One of the easiest
is with your client in the prone position. Ask them to dorsiflex and plantar flex their
foot as you slowly glide your fist from the ankle to the knee (figure 5.33).

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TIGHT TIBIALIS ANTERIOR

Client dorsiflexes
and plantar flexes

Glide

Figure 5.33 Using gliding soft tissue release on the tibialis anterior.

For deeper pressure, position your client either side-lying or supine. Locate the
tibialis anterior by asking your client to pull up the toes. Whilst the client’s ankle is in
dorsiflexion, lock the muscle. The tibialis anterior is a straplike muscle, and locking it
gently using the elbow works well, directing your pressure towards the knee. Whilst
maintaining your lock, ask your client to point the toes. Once the toes are pointed,
release your lock and choose a new position, slightly more distal, for your second lock.
With the ankle in dorsiflexion, lock in and repeat, working proximally to distally as
long as the client feels the stretch and it is comfortable.

TIP
The tibialis anterior becomes tendinous fairly quickly, so it is not necessary to work all the
way down the length of the muscle to the ankle; to do so may be uncomfortable for the
client because this muscle lies over the tibia.

Strengthening
Strengthening the muscles of the posterior calf can help reduce feelings of tightness in
the tibialis anterior. Please see chapter 9 for more information.

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 TIGHT PERONEAL (FIBULAR) MUSCLES

Tight Peroneal (Fibular) Muscles

The peroneal (fibular) muscles of the lateral leg are primarily evertors of the foot and
ankle. They can become shortened in people who are flatfooted, and these muscles are
prone to cramping in some people. Unfortunately, they are difficult to stretch actively
or passively, because this requires inversion of the ankle, and a client can still report
feelings of tightness even with full inversion. Massage can be soothing but is unlikely
to have a lasting effect on sensations of tightness. One of the best methods to treat
these muscles is STR, because it can be localised to trigger points to release them and
reduce sensations of tightness.
Trigger points in the peroneal (fibular) muscles refer pain to the lateral malleolus, to
the anterolateral aspect of the ankle and sometimes to the heel (figure 5.34). You can
easily locate them by palpating the lateral side of the leg with your client in a side-lying
position. Take care when palpating the proximal end of
the muscle, because the common peroneal nerve courses
around the head of the fibula here, and pressure to the
nerve causes a tingling sensation.
Immobilisation of the ankle for any reason may per-
petuate triggers, and clients with triggers may report Peroneus
frequent ankle sprains or a feeling that the ankle is longus
unstable. Other perpetuating factors include leg-length Peroneus
discrepancy, flatfootedness, wearing high heels and brevis
prolonged plantar flexion.
In a randomised controlled trial, Rossi and colleagues
(2017) examined whether spinal and peripheral dry
needling were any better than peripheral dry needling
for people with a history of lateral ankle sprain. Twenty Peroneus
participants with a history of ankle sprain were randomly tertius
assigned to one of two groups. One group received dry
needling into trigger points in the multifidus and fibular
muscles; the other group received dry needling to fibular
muscles alone. Measurements were taken at baseline,
Figure 5.34 Trigger points
immediately after the intervention and 6 or 7 days later.
in the peroneal (fibular)
Measurements included the Foot and Ankle Disability E8778/Johnson/F 05.34/718244/pulled/R1
muscles.
Index, the Cumberland Ankle Instability Tool, unilateral
strength, performance on a balance and hop test and pain measured on the Visual
Analogue Scale. There was no significant difference between the groups at the end of
the study, leading the authors to conclude that dry needling of the multifidus in addi-
tion to dry needling of trigger points in the fibular muscles did not result in short-term
improvements over and above dry needling trigger points in the fibular muscles alone.

Soft Tissue Release

With your client in the side-lying position, ask them to evert the foot; demonstrate
what you mean. Lock the muscle, which is now in a shortened position, directing your
pressure towards the knee (figure 5.35a). For demonstration purposes, the therapist in
the photo has chosen to use reinforced thumbs to lock the muscle and has positioned

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TIGHT PERONEAL (FIBULAR) MUSCLES

the client’s leg on a bolster to facilitate movement of the ankle. Alternatively, you can
use your elbow, using caution to prevent bruising the tissue against the fibula. Whilst
maintaining your lock, ask the client to invert the foot. You may want to show the client
how to do this motion first, and rather than using the term inversion, ask them to turn
the sole of the foot inwards (figure 5.35b). Work in a single line down the muscle,
from proximal to distal, as long as the client feels the stretch and remains comfortable.

a b

Figure 5.35 Maintaining a lock on the peroneal (fibular) muscles using (a) reinforced
thumbs followed by (b) active inversion of the ankle produces a stretch in these muscles.

Strengthening
Tension in the fibular muscles can be reduced by strengthening the invertors of the
ankle. Chapter 9 provides details.

Podiatry
If your client overpronates their foot, referral to a podiatrist could be useful in identifying
whether the use of orthotics would help the incidence of fibular tightness or cramping.

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 OSTEOARTHRITIS IN THE KNEE

Osteoarthritis in the Knee

Osteoarthritis is a natural part of the aging process and is caused by degeneration of
the hyaline cartilage of synovial joints. It commonly occurs in older adults in weight-
bearing joints such as the hips, knees and lumbar spine. As the condition worsens,
there is increasing pain, swelling and inflammation of the joint as more and more
of the hyaline cartilage wears away. Degeneration of the hyaline cartilage covering
the articulating bones of the knee joint is painful when the patient stands and during
weight-bearing activities such as climbing or descending stairs, when the articulating
surfaces of the knee joint grind together. In advanced stages of the condition, the knee
becomes less stable.
When describing this condition to your client, it is extremely important to explain
that osteoarthritis is a natural part of the aging process and that someone can have
osteoarthritis and be symptom free. Hearing terms such as wear and tear, degenerating
or chronic can make a person fearful, and this can be a barrier to management of the
condition. Therefore, the words you use when treating clients with this condition need
to be chosen carefully.
Guidelines from the National Institute for Health and Care Excellence (NICE) (2022)
recommend providing only soft tissue techniques alongside therapeutic exercise,
because there is not enough evidence to support the use of manual therapy alone.

Trigger Point Release

Researchers Lin and colleagues (2022) examined nine randomised controlled trials
relating to the treatment of knee pain to evaluate the effectiveness of acupuncture
inactivation of myofascial trigger points in people with knee osteoarthritis. The studies
they examined included a total of 724 patients. Lin and colleagues concluded that
acupuncture inactivation of the triggers was a safe, effective and rapid intervention for
the treatment of knee osteoarthritis.

Massage
Massaging is useful for pain management in clients with osteoarthritis but is unlikely to
affect the underlying condition. As the condition progresses and weight bearing through
the knee becomes increasingly painful, it is common for someone with osteoarthritis to
start bearing more weight through their opposite leg, and they may begin to experience
pain and dysfunction in that leg too. Massaging the quadriceps and hamstrings is useful
for soothing postexercise tension.

Stretching
Gentle stretching of the hamstrings and quadriceps is helpful for alleviating tension,
although it is necessary to avoid pressure through the knee. Often, the joint is swollen
and painful to move. Whilst stretching is not a treatment per se for osteoarthritis in the
knee, the movement required to perform some of the stretches helps increase synovial
fluid in the joint and helps combat the muscular tension that may develop in patients
enrolled in a lower limb strengthening programme before knee surgery for this particular
condition.

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OSTEOARTHRITIS IN THE KNEE

Active Stretches
Ask your client to gently bend and straighten the leg whilst in the supine position, flexing
and extending the knee as shown in figure 5.36. Flexion helps stretch the quadriceps, whilst
extension tenses the popliteus, the hamstrings, the heads of the gastrocnemius and the fascia
associated with these muscles. This is the most simple stretch for knee osteoarthritis and is
helpful for clients who are limited in their mobility and ability to perform other stretches.

Figure 5.36 Simple flexion and extension of the knee in the supine position for clients
who have severe mobility limitations.

Passive Stretches
You could start by assisting your client in knee flexion and extension in the supine
position as shown in figure 5.36. You can gently add pressure in the position of flexion,
provided that this does not elicit pain. Alternatively, gentle traction to the lower limb
helps stretch all lower limb tissues, including those of the knee joint, and may provide
temporary relief. To do this, gently cup the client’s ankle and apply slow, steady traction,
one limb at a time, as shown in figure 5.37. Obviously, this also tractions the ankle and
hip joints and cannot be performed if there are any acute conditions affecting either of
these. Experiment to discover the handhold that works best for you.
If your client is able to lie in the prone position, you could gently stretch the quad-
riceps as in figure 5.38.

Figure 5.37 Handhold used to Figure 5.38 Gentle passive knee flex-
apply gentle passive traction to the ion in the prone position.
lower limb, including the knee joint.

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 OSTEOARTHRITIS IN THE KNEE

Strengthening
The Osteoarthritis Research Society International (Bannuru et al. 2019) report that core
treatments deemed safe for most individuals with osteoarthritis in the knee are structured,
land-based programmes and mind–body programmes such as tai chi and yoga. They state
that aquatic exercise demonstrates robust evidence for pain management and objective
measurements for function. People with osteoarthritis in the knee are usually advised
to take part in exercises designed to strengthen the quadriceps and hamstrings, with
the goal of providing additional muscular support to the joint. Please refer to chapter
8 for information about specific exercises that might be of benefit.

Bracing and Walking Aids

In their literature review of conservative treatment for knee osteoarthritis, Lim and
Al-Dadah (2022) reported that clinical studies do not support the use of braces: They are
ineffective at improving overall pain or function, and there is often non-compliance due
to skin chafing. The Osteoarthritis Research Society International (Bannuru et al. 2019)
specifically recommend against the use of knee bracing. According to the evidence-
based guidelines provided by NICE (2022), bracing should not be routinely provided for
people with knee osteoarthritis except where there is atypical biomechanical loading
and joint instability, and therapeutic exercise is ineffective without the addition of an
aid or device; however, the addition of an aid or device is likely to improve function.
The NICE do, however, recommend considering the use of walking aids for people
with lower limb osteoarthritis.

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AFTER KNEE SURGERY

After Knee Surgery

Patients who have undergone surgery to the knee for conditions such as total or partial
knee replacement, repair of cruciate ligaments or removal of a meniscus usually
experience considerable swelling in the joint, which may have been immobilised after
the operation. It is therefore not uncommon for such patients to experience stiffness in
the knee and a decreased range of motion post-operatively. Massage and active and
passive stretches are useful but should be carried out only once medical approval has
been given.

Massage
Gentle massage such as effleurage or manual lymphatic drainage can be helpful to
stimulate lymphatic drainage and reduce post-operative swelling when applied superior
to the knee itself.

Stretching
Active flexion and extension movements within the patient’s pain-free range will not
only facilitate the lengthening of soft tissue structures to restore typical range of motion
at the knee but will also help reduce swelling.
Active Stretches
The stretch shown in figure 5.36 is a good starting point. This could then be progressed
to flexion and extension in a seated position. Alternatively, the patient could sit with the
knee in extension, resting the calf and foot on a chair or stool to stretch the posterior
capsule of the knee (figure 5.39). This is particularly helpful for patients who have been
unable to achieve full knee extension; in this position, gravity helps gently stretch the
posterior of the joint.

Figure 5.39 Stretching the soft tissues of the posterior knee.

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 AFTER KNEE SURGERY

Passive Stretches
A simple passive stretch is performed by facilitating gentle flexion and extension of
the knee whilst supporting the lower limb beneath the knee and ankle, as shown in
figure 5.40.

Figure 5.40 Gentle passive flexion of the knee in the supine position.

Passive knee flexion can also be encouraged in the prone position. However, some
patients may feel uncomfortable in this position, particularly if they have an anterior
scar that they feel anxious about resting on.

Soft Tissue Release

Active assisted STR to the hamstrings is particularly useful as part of the rehabilitation
process after surgery to the knee or immobilisation of the knee joint, because it increases
knee range of motion and hamstring strength. The hamstrings contract concentrically
each time the client actively flexes their knee; they contract eccentrically as the client
lowers their knee, thus helping to maintain strength in these muscles.
When the STR technique is used after knee replacement surgery, it may help increase
both knee flexion and extension, because the client works within their pain-free range
and is likely to increase range at the knee in a way that is safer than post-operative
passive stretching.

Strengthening
When someone has been unable to bear weight due to pain prior to surgery, there
is likely to be muscle wasting. There is also likely to be atrophy in muscles in cases
where surgery required a period of immobilisation or rest. In such cases, strength will
be reduced in the entire lower limb, and it will be important to regain this strength.
Please see chapter 8 for further information.

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ILIOTIBIAL BAND FRICTION SYNDROME

Iliotibial Band Friction Syndrome (Runner’s Knee)

Iliotibial band friction syndrome is often referred to simply as ITBS or by the lay term
runner’s knee. It is not entirely clear what causes the lateral knee pain experienced by
some runners, but some believe the pain is due to the iliotibial band (ITB) of the lateral
thigh rubbing against the epicondyle of the femur. Hutchinson and colleagues (2022)
provide a clear description of the anatomy and function of the ITB. Kondrup, Gaudreault
and Venne (2022) reviewed deep fascia and its role in chronic pain and pathological
conditions. They say that ITBS resembles other fascial pathologies and that more research
is needed relating to innervation of fascia, inflammation and tissue contracture.
It has been postulated that deep tissue massage, trigger point release and stretching
will alleviate the pain of ITBS, and this section provides some ideas for working the
lateral side of the thigh. Evidence is limited for stretching of the ITB itself. Because the
gluteal muscles insert into the ITB, treatment is likely to be more effective if you treat
those muscles also. For more information, please refer to the section on trigger points
in the gluteal muscles.

Massage
It is unknown whether massage to the lateral thigh will alleviate runner’s knee, especially
if the cause is due to biomechanical imbalance. However, it can prove temporarily
soothing. Two ways to apply massage to this area involve using your forearm with your
client in the three-quarter lying position.
For the first method, begin by standing so you are facing the front of the client. Posi-
tion your forearm just above the knee; using your other hand for reinforcement, glide
slowly and deeply up the lateral thigh, compressing the ITB and vastus lateralis muscle
(figure 5.41a). An alternative method is to stand behind the client and pull your forearm
across the tissues, again from the knee to the thigh (figure 5.41b).

a b

Figure 5.41 Use the forearm to massage the lateral thigh either (a) facing your client or
(b) standing behind them.

TIP
Some clients feel more comfortable with a small, folded towel or cushion beneath their
knee on the side you are treating.

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 ILIOTIBIAL BAND FRICTION SYNDROME

Instead of using your forearms on the ITB, a stronger technique is to use reinforced
fists. This is a useful technique for working the distal end of the ITB and vastus latera-
lis. Begin with the client in the three-quarter lying position, and place your fists gently
near the knee, avoiding bony structures. Keeping your wrists and elbows as straight as
possible, glide firmly towards the hip (figure 5.42).

Figure 5.42 Massaging the lateral thigh using the fists.

Trigger Point Release

The ITB is a thickening of the fascia covering the lateral side
of the thigh and overlying the vastus lateralis (figure 5.43).
Tender spots here are likely to be triggers in this muscle, and
they refer pain throughout the side of the thigh from the hip
to the knee. Palpate for these triggers with your client in the
supine position, turned slightly away from you so that the
lateral part of the thigh closest to you is raised off the couch
a little. These trigger points are difficult to identify due to the
thick fascial covering.
Pavkovich (2015) noted improvements in the Lower Extrem-
ity Functional Scale and Quadruple Visual Analogue Scale
for four trigger points in the vastus lateralis as well as trigger
points in the gluteus maximus, gluteus medius, piriformis and
greater trochanter area in a recreational walker with chronic
lateral hip and thigh pain. Trigger points were treated with
dry needling twice a week for 8 weeks. The patient reported
a significant improvement in quality of life in terms of being Figure 5.43 Trigger
pain points in
able to sleep on the affected side, walk farther without E8778/Johnson/F the vastus
05.43/718254/pulled/R1
and stand for extended periods. The author notes that strength lateralis.
in the lower limb improved and postulated that the improve-
ment was a result of the participant having less pain and an
improved gait posture.

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ILIOTIBIAL BAND FRICTION SYNDROME

Simple, static pressure to the trigger points can be applied using your fingers, thumbs
or an elbow. Some people advocate using a foam roller to deactivate trigger points in
the lateral thigh, in which case you would need to instruct your client to rest on a roller
(figure 5.44), positioning over sensitive spots on the lateral thigh. However, this can be
a difficult position for many people to attain.
As always, it is important to stretch the muscle after trigger point release.

Figure 5.44 Active trigger point release of the lateral thigh using a foam roller.

Stretching
Although a standing stretch performed actively has been popularly advocated by others
as a stretch of the ITB and for the treatment of runner’s knee, in the author’s experience,
this is not particularly effective. Clients who wish to help alleviate this condition with
the use of stretching are recommended to instead stretch the gluteus maximus and
tensor fasciae latae muscles. These muscles insert into the ITB and, when stretched,
theoretically reduce tension in the lateral side of the thigh and might therefore reduce
the symptoms of runner’s knee. Useful passive stretches are included in this section.
Passive Stretches
Myofascial release of the region could be helpful, using the position shown in figure
5.45 with the client in the side-lying position. Be careful when using this stretch,
because it requires the client to be positioned close to the edge of the treatment couch.
Passively stretch the gluteal muscles
also. If using the supine gluteal stretch
shown in figure 5.46, aim to take the
knee towards the opposite shoulder,
thus stretching the gluteal muscles
and lateral thigh simultaneously. In
this example, the client’s left knee
would be moved towards their right
shoulder.

Figure 5.45 Passively tensing the lateral thigh.

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 ILIOTIBIAL BAND FRICTION SYNDROME

Figure 5.46 Passively stretching the gluteal muscles and lateral thigh.

Soft Tissue Release

Soft tissue release can be a useful way to tense the lateral thigh. With your client in
the side-lying position, check that they can flex the knee comfortably; if not, place a
small towel or sponge between the client’s knee and the edge of the couch. With the
knee extended, direct your pressure towards the hip as you gently lock the tissues with
soft fists (figure 5.47a). Maintain your lock as your client slowly flexes the knee (figure
5.47b). Select a different lock position that is more proximal than your first and repeat
the procedure.

a b

Figure 5.47 (a) Gently lock the iliotibial band with soft fists followed by (b) active knee
flexion.

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ILIOTIBIAL BAND FRICTION SYNDROME

TIP
You can modify the active assisted gliding STR used for the calf and tibialis anterior to
gliding STR for the lateral thigh. Begin by simply applying a little massage medium, then
place your lock just above the knee, gliding from the knee to the hip as your client actively
flexes and extends the knee.

Strengthening
Iliotibial band friction syndrome is associated with hip abductor weakness. In a study
of 62 people with ITBS, Abdelmowla, Abdelmowla and Fahem (2022) examined the
effect of home exercise and function. Half of the participants completed a set of stretches
and strengthening exercises once per day, 7 days a week for 8 weeks, performing
three sets of 10 repetitions. The objective measurements the researchers used were the
Numerical Pain Rating Scale and the Lower Extremity Functional Scale. At 4 weeks
and 8 weeks, they found a significant reduction in pain in the exercise group and a
significant improvement in function. Please refer to chapter 7 for more information
about hip abductor strengthening.

Kinesio Taping
Watcharakhueankhan and colleagues (2022) examined the immediate effects of Kinesio
Taping on running biomechanics, muscle activity, and perceived changes in comfort,
stability and running performance in healthy runners. Their study found that running
mechanics could be altered with the use of Kinesio Taping by reducing activation in
the tensor fasciae latae and increasing external rotation of the femur, leading them to
conclude that this could be a useful treatment for ITBS.
Placement of a foam roller beneath the lateral thigh and actively rolling along this
area has anecdotally been found to be helpful in symptom management.

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 GENU RECURVATUM

Genu Recurvatum (Knee Hyperextension)

In the genu recurvatum posture, the degree of knee extension is greater than in the neutral
posture. People with this posture sometimes experience patellofemoral pain as the patella
is compressed against the underlying tibiofemoral joint, and weight bearing through a
hyperextended knee strains the tissues of the posterior knee, leading to an imbalance
between the anterior and posterior of the joint and increasing the likelihood of injury.

Education
One of the most helpful things you can do is to educate your client about this posture.
Instruct your client about maintaining good postural alignment, helping them to identify
those times when they stand with the knees locked out in the hyperextended posture.
A person with hyperextended knees needs to be conscious of knee postures during
everyday activities. They need to practise good knee alignment in static postures, taking
particular care with standing postures by avoiding locking out the knee. They also need
to avoid placing the ankles on a footstool when seated, because this allows the knees
to sag into extension, stretching posterior tissues. They should also practise good knee
alignment during dynamic functions such as standing up from a sitting position and
when stair climbing.
When working with a client who engages in regular stretching, advise them to avoid
exercises and stretches that force the knee into extension. For example, they should
take care with standing hamstring and calf stretches.

Taping
Rather than preventing hyperextension, the purpose of taping is to provide sensory
feedback to help your client identify when they have a tendency to hyperextend. This may
be particularly useful when treating dancers with hypermobility syndrome (Knight 2011).
Ultimately, self-correction of the posture is preferable to reliance on tape, which should
be used only in the short term whilst your client is learning to avoid hyperextension. Tape
can be applied in a variety of ways, such as a single wide strip (figure 5.48a), two narrower
strips (figure 5.48b) or a cross (figure 5.48c). Whichever method you choose, apply the
tape with the knee in a neutral position. Rather than attempting this with your client
standing, ask them to lie face down, where the knee usually rests in a neutral position.

a b c

Figure 5.48 Taping for genu recurvatum using (a) one or (b) two pieces of tape or (c)
applying tape in a cross shape.

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GENU RECURVATUM

Massage
In the genu recurvatum posture, the quadriceps are shortened with respect to the
hamstrings, pressing the patella against the underlying bony tibiofemoral joint. Massage
can be used to help relax and lengthen the quadriceps – for example, by using a gliding
stroke from just superior to the patella to the proximal end of the thigh using your
forearm (figure 5.49a) or gripping and squeezing the muscle (figure 5.49b).

a b

Figure 5.49 Apply deep tissue massage to the quadriceps by (a) gliding with the fore-
arm or (b) gripping.

Stretching
In this posture, the quadriceps are shortened relative to the hamstrings. Therefore,
stretching of this muscle group can help reduce the imbalance between the anterior
and posterior muscles.
Passive Stretches
Examples of passive stretches are shown in figures 5.50a and 5.50b.

a b

Figure 5.50 (a) Passively stretching the quadriceps and (b) enhancing the stretch with
use of a towel.

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 GENU RECURVATUM

Active Stretches
Figures 5.51a and 5.51b are examples of useful active
stretches. When your client is in the standing position,
remember to instruct them to avoid locking and
hyperextending the leg they are standing on. One way
to avoid hyperextension of the supporting leg is to stand
with that knee slightly flexed.

a b

Figure 5.51 An active quadriceps stretch in the (a) prone and (b) standing positions.

Strengthening
If you think it falls within your professional remit,
provide exercises to strengthen the knee flexors. These
could include regular hamstring and calf strengthening
or asking your client to perform slight knee flexion
against the gentle resistance of your hands placed just
beneath the knee (figure 5.52) within a small range of
motion. Take care of your own posture when facilitating
this exercise, perhaps by asking your client to stand
on a raised platform so that you do not have to stoop
too much.
Chapter 8 provides additional exercises on knee
strengthening, and chapter 9 provides exercises on
balance, all of which can be useful for clients needing
to manage knee hyperextension.
Figure 5.52 Handhold for
Referral to a Specialist facilitating knee strengthening
Consider referring your client to a podiatrist, who may in a specific range of motion.
have suggestions for treatment to limit the extent of
hyperextension during daily activities. For example, using a slightly elevated heel creates
knee flexion during walking, which slows the gait but can be helpful in preventing
hyperextension. Use of orthotics under the medial border of the foot can help limit
subtalar pronation, a posture associated with genu recurvatum. Ankle Foot Orthoses

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GENU RECURVATUM

(AFO), rigid ankle and foot boots, are sometimes prescribed to help correct genu
recurvatum whilst walking; however, although these reduce the energy requirement of
walking, they do not always reduce extensor movement at the knee (Kerrigan, Deming,
and Holden 1996).
Finally, if your client is engaged in sporting activity, you could also consider referral
to a sports therapist for sport-specific drills. These kinds of drills can help your client
master a flexed knee position during fast, dynamic movements and therefore reduce the
likelihood of injury. Your client should consider protecting the knees against hyperex-
tension during sporting activities, especially those involving impact, such as jumping.
Discuss which forms of sporting activity may be most suitable to someone with genu
recurvatum posture. Prevention of knee hyperextension requires focused control of the
joint and could be aggravated by sports involving fast movements. This posture may
be disadvantageous to participation in field sports such as rugby, football, hockey and
lacrosse (Bloomfield, Ackland, and Elliott 1994). It is likely to be disadvantageous for
participation in jumping sports and sports that involve excessive loading of the lower
limb. Clients with hyperextended knees would be better suited to activities such as tai
chi, where movements are slow and controlled, rather than high-impact sports involv-
ing frequent changes of direction, such as racquet sports. Simple balancing exercises
are beneficial to these clients because they adopt a neutral knee position and attempt
to maintain it.

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 GENU FLEXUM

Genu Flexum (Flexed Knee)

A person may have a genu flexum knee posture for a variety of reasons. It may occur
simply through the retention of a flexed knee position for long periods of time, as in
people who are sedentary. It may also occur after surgery when posterior knee structures
tighten, combined with prolonged bed rest and lack of movement of the knee. As with
hyperextension of the knee, you can help by educating your client with regards to how
to treat this posture. For example, advise them to avoid sitting for prolonged periods
with the knees flexed. If they have a seated job, advise them to take short breaks and
stand every hour to stretch the back of the legs. In some cases, it might be useful for a
client to temporarily avoid sports that might perpetuate a flexed knee posture, such as
rowing and cycling.
Caution is needed when attempting to address genu flexum after knee surgery and
when working with clients who use wheelchairs or spend much of their time in a chair,
such as someone who might be frail or recovering from illness or injury.
For each of the techniques suggested, consider whether deep pressure (as might be
used when applying STR or addressing trigger points) is contraindicated for your client.
Recognise that intervention may be limited for clients in whom genu flexum results
from abnormal high tone (e.g., spasticity associated with cerebral palsy).

Myofascial Release
Passively release posterior knee tissues using the myofascial release technique. This is
an ideal technique to use for this posture, in which tissues on the back of the knee are
tensed and pressure into the back of the knee must be avoided because of the presence
of the popliteal artery and lymph nodes. A simple cross-hand technique could work
well here, with one hand placed superior to the knee and one inferior to it.

Massage
Massage can be used to encourage relaxation and lengthening of the hamstrings (figure
5.53) and gastrocnemius (figure 5.54), the two muscles that cross the posterior knee
joint along with the popliteus. Remember to avoid direct pressure to the knee joint itself.
Treat any trigger points that you find in posterior tissues using localised static pressure
and taking care not to press directly into the popliteal space.

a b

Figure 5.53 (a) Massage to the hamstrings using the forearm, with (b) use of the elbow
to deactivate trigger points.

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GENU FLEXUM

a b

Figure 5.54 (a) Massage to the gastrocnemius using the forearm, with (b) use of the
elbow to deactivate trigger points.

Soft Tissue Release

Soft tissue release is useful for a client with flexed knees because it permits you or
your client to work within a range of knee flexion postures, stretching localised tissues
only as far as is comfortable. Active STR to the hamstrings (figures 5.55a and 5.55b)
is preferable, because once the client has pressed the tennis ball against their thigh,
contraction of the opposing muscle group (in this case, the quadriceps) helps reduce tone
in the hamstrings. For clients who find it difficult to rest supine, STR can be performed
seated (figure 5.56). However, this requires the knee to be extended against gravity,
and this is more difficult than knee extension in the supine position.

a b

Figure 5.55 Active soft tissue release (a) begins with pressing a ball into the hamstrings
and (b) helps reduce tone in the hamstrings, and therefore knee flexion, through contrac-
tion of the quadriceps.

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 GENU FLEXUM

a b

Figure 5.56 Active soft tissue release in the seated position begins with (a) compres-
sion of the hamstrings using a ball, followed by (b) knee extension.

Stretching
The hamstrings and soleus are shortened in the genu flexum posture. Stretching these
(and also strengthening the quadriceps) may help reduce the effects of this posture on
the joint.
Passive Stretches
There are many ways to do this, including simple stretches held at the end of the existing
range (figure 5.57). One advantage of a simple supine hamstring stretch is that it can be
performed with the knee flexed. Instead of passively flexing the hip at the end of the range,
ask your client to extend the knee. Contraction of the quadriceps will facilitate relaxation
of the hamstrings, increasing knee extension without the need for further hip flexion.

Figure 5.57 A traditional passive hamstring stretch.

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GENU FLEXUM

Your client can help by resting in positions likely to stretch the posterior knee tis-
sues. For example, when using a footrest, the posterior knee is stretched through gravity
(figure 5.58). Notice the tension in the tissues of the person’s right thigh in the figure.

Figure 5.58 Letting gravity stretch the posterior tissues in a sitting position.

Active Stretches
Active stretching of the hamstrings (figure 5.59) and gastrocnemius (figure 5.60) is useful.
Using a towel (figure 5.61) helps stretch both the hamstrings and gastrocnemius together.

Figure 5.59 An active hamstring stretch.

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 GENU FLEXUM

a b

Figure 5.60 Active stretches of the gastrocnemius of the left leg.

Figure 5.61 Using a towel to facilitate a stretch of the hamstrings and gastrocnemius at
the same time.

Another technique is for the client to rest in the prone position, with their feet off the
couch; a light weight can be added to the ankle. This too will stretch posterior tissues
of the knee, but take care when using the prone position so as not to injure the front
of the knee against the side of the couch or bed. The prone position is not suitable for
clients with patellofemoral conditions in which compression of the patella could be
aggravating.

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GENU VARUM

Genu Varum (Bow-Leggedness)

It is important to recognise that where a change to bone tissue has occurred, such as
bowing of the femur or tibia or both, non-surgical intervention is limited. Where bow-
leggedness appears to be postural only, with little or no anatomical change, it is helpful
to encourage your client to identify and avoid movements that may aggravate this posture
(e.g., shifting weight to the affected leg and permitting the knee to bow outwards). If
possible, the client should avoid sports that involve high impact or excessive loading,
because these increase stress through the knee joint, further compressing and tensing
structures. They might consider wearing a knee brace when taking part in sporting
activities. This may alleviate pain during weight bearing and may lessen the chances
of injury.

Taping
Although controversial, anecdotal evidence suggests that taping may be helpful in
training gluteal muscles. The method shown in figure 5.62 is based on that recommended
by Langendoen and Sertel (2011). One at a time, apply two strips of tape from the
proximal anterior thigh, running them posteriorly to mimic the direction of gluteal fibres.
Taping the lateral side of the knee joint (figure 5.63) is a temporary measure usually
used to address knee pain. It can be useful in providing sensory feedback to clients
but will have little if any impact on anatomical (rather than postural) genu varum. One
approach is to tape as if for a lateral collateral ligament sprain, where your aim is to
prevent further gapping of the lateral side of the knee. In this case, you would attach a
horizontal fixing strip above and below the knee
and then make a cross shape between them, using
two further pieces of tape, aiming for the centre of
the cross to fall over the lateral collateral ligament.
Some therapists tape with the client standing, but
it can be helpful for the client to be in a side-lying
position with the affected knee uppermost. In
this way, gravity helps reduce the gapping on the
lateral side of the knee before taping.

Figure 5.62 Taping the Figure 5.63 Taping the lateral aspect
gluteal muscles to facili- of the knee.
tate external rotation of
the hip.

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 GENU VARUM

Massage
Massaging muscles that are relatively short could be beneficial, but similar to stretching, it
may have a limited effect with regards to the genu varum posture. Note that massaging the
adductors with your client in the supine position can cause discomfort, which sometimes
tenses the lateral side of the knee, so a side-lying position can be preferable (figure 5.64).

Figure 5.64 Massage to the adductors with the client in a side-lying position.

Trigger Point Release

It can be helpful to release trigger points in the tensor fasciae latae (figure 5.65a) and
the anterior fibres of the gluteus medius (figure 5.65b). You will need to experiment
with the best position to access these muscles. For example, the gluteus medius might
also be accessed posteriorly (figure 5.65c).

a b

Figure 5.65 Releasing trigger points in (a) the tensor fasciae latae and gluteus medius
in the (b) prone and (c) side-lying positions.

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GENU VARUM

Stretching
Although it may have a limited effect, stretching muscles that are relatively short in the
genu varum posture (the internal rotators of the hip, the quadriceps and the gracilis)
could be beneficial.
Passive Stretches
Figure 5.66 shows three ways to stretch the internal rotators of the hip passively. One of
the challenges in doing this is that the supine stretches (figure 5.66a and 5.66b) usually
advocated for these muscles promote gapping of the lateral side of the knee, so they
need to be performed with care.

a b c

Figure 5.66 Passively stretching the internal rotators of the hip in the (a, b) supine and
(c) prone positions.

When passively stretching the gracilis, take care not to strain the outside of the knee,
because this has a tendency to become compressed as the hip is abducted. Experiment
with different positions (figure 5.67)

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 GENU VARUM

a b

Figure 5.67 Positions for passively stretching the gracilis: (a) with the knee flexed and
the opposite side of the pelvis fixed and (b) with the knee extended and one leg hooked
over the table to add stability.

Active Stretches
Figure 5.68 shows two ways to stretch the internal rotators of the hip actively.

a b

Figure 5.68 Active stretching of the internal rotators of the hip in the (a) supine and (b)
seated positions.

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GENU VARUM

Strengthening
To correct postural bow legs, Kendall, McCreary and Provance (1993) advocate standing
with the feet about 5 centimetres (2 in.) apart and the knees comfortably relaxed, then
tightening the buttock muscles to experience a lifting of the arches of the feet. Transfer a
slight amount of weight onto the lateral sides of the feet, then tighten the buttocks further
in an attempt to rotate the legs slightly outward and have the patellae facing forwards.
Strengthening of the external hip rotators using exercises such as prone hip extension
and bridging is helpful, as might be strengthening of the tibialis posterior and the long
toe flexor muscles. Please see chapter 7 for more information on hip strengthening and
chapter 9 for toe flexor strengthening. Shams Abrigh and Moghaddami (2020) reported
success with use of a strengthening programme when used with teenage footballers with
genu varum knee posture. To determine the effectiveness of the programme, the authors
measured the distance between the condyles of the participants’ knees. They used small
sets of high-repetition exercises for 8 weeks. In the exercise group, they reported a
significant difference in pretest and posttest genu varum measurements. However, the
effect of strengthening on knee posture is likely to be minimal in the adult population
when joint posture is more fixed, and the high numbers of repetitions required for the
exercises is likely to affect adherence to such a programme.

Podiatry
Consider referring your client to a podiatrist, who may be able to offer specialist advice.
For example, angled insoles can be used to transfer the load from the medial to the
lateral compartment of the knee and perhaps alter the tibiofemoral angle. Lateral forefoot
and rearfoot wedge insoles have been used to facilitate foot pronation (Gross 1995).

166
 GENU VALGUM

Genu Valgum (Knock Knees)

You learned in chapter 1 that in the genu valgum posture, the tensor fasciae latae and
the ITB are compressed along with tissues of the lateral leg compartment. Because there
is often structural change in the knee joint, it is important to educate your client as to
the limitations of soft tissue techniques with regards to changing this posture. There
are, however, useful tips you can provide to help reduce pain.

Education
As with the genu varum knee posture, it is important to educate your client with regards
to how they might avoid stressing the structures of their knee. For example, they need
to identify and avoid lazy standing postures that aggravate the genu valgum stance. This
sometimes occurs when tired or in the habit of shifting weight onto one leg. They should
avoid resting the feet around chair legs when sitting (figure 5.69), because this strains
the medial side of the knee and ankle. If possible, they should avoid sports that involve
high impact, because these increase stress through the knee joint, further compressing
and tensing the structures. A knee brace is an option. Note that this may alleviate pain
during weight bearing but will not redress bony structures.

Figure 5.69 Avoid hooking the feet around chair legs when sitting.

Taping
You can tape the medial side of the knee joint,
but note that this is a temporary measure usually
used for overcoming pain and will not provide
long-term correction of a genu valgum knee.
One way to apply tape is as if you were taping a
medial collateral sprain, attempting to orientate
the centre of a cross over the medial collateral
ligament (figure 5.70).

Figure 5.70 Taping the medial side

of the knee.

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GENU VALGUM

TIP
A tip here is to position your client in a side-lying position, resting on the affected limb.
In this position, the medial collateral ligament will be uppermost, but the knee will be
supported by the couch. You can apply gentle pressure as you apply the tape, taking the
knee into a more neutral position if this is comfortable for the client.

Massage
Massage the gracilis if this is found to
be shortened. If you choose to treat your
client in the side-lying position with the
client resting on the affected limb, the
adductors will be accessible, yet the knee
will be supported by the couch (figure
5.71), and you can massage the gracilis
without the risk of gapping the knee joint
further.

Figure 5.71 Massage to the adductors in

the side-lying position.

Trigger Point Release

Static pressure to the tensor fasciae latae
(figure 5.72) can be used to address
any trigger points found in this muscle Tensor fasciae
latae
(figure 5.73) and to encourage
relaxation and lengthening of the
tissue. Using a tennis ball to trigger
and stretch the tensor fasciae latae
can be useful, but in practice,
it can be a difficult position
for many clients to achieve
without compromising the
knee joint in the process
(figure 5.74). One solution
is to tape the knee joint
before the client attempts
to use the ball or for the
client to wear a knee brace Figure 5.72 Tensor fasciae latae trigger point.
whilst using the ball.
E8778/Johnson/F 05.72/718324 /pulled/R1

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 GENU VALGUM

Figure 5.73 Using a tool to apply Figure 5.74 The position needed to self-trigger
static pressure to the tensor fasciae the tensor fasciae latae using a tennis ball can
latae. be challenging.

Myofascial Release and Soft Tissue Release

In the genu varum posture, the ITB is shortened relative to a neutral posture, and the
vastus lateralis can develop trigger points (figure 5.75). Figure 5.76 shows a useful
position to apply myofascial release to the ITB, and STR is also useful in releasing
tension in this tissue.

Figure 5.75 Trigger points in Figure 5.76 A useful position to apply myofas-
the vastus lateralis.
E8778/Johnson/F 05.75/718326/pulled/R1 cial release to the lateral thigh.

To apply STR, work with your client in the side-lying position. Gently lock the tis-
sues with the client’s knee in extension (figure 5.77a), and then ask the client to flex
their knee (figure 5.77b).

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GENU VALGUM

a b

Figure 5.77 Applying soft tissue release to the lateral thigh begins (a) with the knee in
extension followed by (b) active knee flexion.

In the genu valgum posture, the knees fall inwards and the ankle everts. A con-
sequence of this is that the peroneal (fibular) muscles are in a shortened rather than
neutral position and can develop trigger points (figure 5.78). Because the degree of
ankle inversion and eversion is less than that of plantar flexion and extension, STR
can be used to release trigger points in the peroneal muscles (figure 5.79). With your
client in the side-lying position and the ankle everted, lock the tissues at the proximal
end of the muscle (figure 5.79a). Maintaining your lock, ask your client to invert their
ankle (figure 5.79b).

Peroneus
longus
Peroneus
brevis

Peroneus
tertius

Figure 5.78 Trigger points in the peroneal (fibular) muscles.

E8778/Johnson/F 05.78/718329/pulled/R1

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 GENU VALGUM

a b

Figure 5.79 Soft tissue release to the peroneal muscles begins with (a) a lock applied
to the proximal end of the tissues whilst the client has their ankle in eversion, followed
by (b) active inversion of the ankle as the therapist maintains the lock.

Stretching
Stretching of the lateral thigh is challenging. Because the gluteal muscles insert into the
ITB, it may be more effective to stretch them, either passively (figure 5.80a) or actively
(figure 5.80b).

a b

Figure 5.80 (a) Passive and (b) active stretching of the gluteal muscles to reduce ten-
sion in the iliotibial band.

Podiatry
Consider referring your client to a podiatrist, who may be able to offer specialist
advice. For example, angled insoles can be used to transfer the load from the lateral to
the medial compartment of the knee and perhaps alter the tibiofemoral angle. Use of
medial wedge insoles has been found to reduce pain and improve function in patients
with valgus knee osteoarthritis (Rodrigues et al. 2008).

171
172 Soft Tissue Therapy for the Lower Limb

Quick Questions
1. Which muscle can someone actively contract to help reduce the sensation of
cramping in the calf?
2. What is a more accurate term for shin splints?
3. When preparing to work on trigger points to the peroneal (fibular) muscles,
of which nerve should you be careful in the region of the head of the fibula?
4. When working with someone with osteoarthritis in the knee, why should soft
tissue techniques only be used in conjunction with therapeutic exercise?
5. In which knee posture is tape applied for the treatment of genu recurvatum –
knee flexion, knee extension or a neutral knee posture?
 6
Foot and Ankle
Learning Outcomes
After reading this chapter, you should be able to do the following:
■ Teach a client simple range-of-motion exercises after an ankle sprain and as
part of ankle fracture rehabilitation.
■ Describe which techniques are appropriate for the treatment of Achilles ten-
dinopathy.
■ Explain why the use of active dorsiflexion may be more effective than passive
dorsiflexion.
■ Describe which stretches are appropriate for the treatment of plantar fasciitis.
■ Demonstrate soft tissue release to the fibular muscles.
■ List the foot and ankle conditions for which strengthening exercises are useful.

I
n this chapter, you will learn which hands-on techniques are appropriate for two acute
injuries: a lateral ankle sprain (the most common injury affecting the ankle) and an
ankle fracture. By contrast, you will also discover how to treat Achilles tendinopathy.
Unlike a sprain or a fracture, an Achilles tendinopathy is not usually an immediate injury
but a condition that develops over time. After a sprain or a fracture, the ankle and foot
can become stiff, depending on what treatment has been undertaken; therefore, this
chapter has a section on how to treat a stiff ankle, and stiffness in the feet is covered in
a section on plantar fasciitis, another common condition that is problematic for many
people. This chapter also discusses four common foot postures: pes planus, pes cavus,
pes valgus and pes varus. Although hands-on techniques cannot significantly alter the
posture of the foot, they can be used to alleviate resulting muscle pain, so the chapter
has sections on all four postures. For all conditions, strengthening is important; please
refer to chapter 9 for ankle and foot strengthening exercises.

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ANKLE SPRAINS

Ankle Sprains
An ankle sprain is the wrenching and tearing of ligaments on either the lateral or medial
side of the ankle joint, sometimes with damage to the anterior of the joint capsule. The
most common form of sprain is an inversion sprain, in which the lateral ligaments are
damaged. Less common is an eversion sprain, in which the strong deltoid ligament on
the medial side of the ankle is torn. There is pain, swelling and in some cases, bruising,
usually resulting in the person having to limp due to an inability to bear weight through
the ankle joint. In serious inversion sprains, there may be an avulsion fracture to the
fifth metatarsal as the fibularis brevis muscle is wrenched from its insertion. With severe
eversion sprains, damage to the distal end of the fibula sometimes occurs when sharp
eversion of the foot crushes or snaps that end of the bone.
A Dutch consensus statement (Vuurberg et al. 2018) developed by a multidisciplinary
research panel recommends that rest, ice, compression and elevation (RICE), along with
immobilisation, should not be used in the treatment of ankle sprains, that supervised
exercise programmes are preferable to passive modalities and that exercise should begin
as soon as possible. However, the National Institute for Health and Clinical Excellence
(2020) continues to recommend the RICE protocol, with the addition of ‘P’ – protect
from further injury (PRICE) – as a self-management approach within the first 24 to 48
hours after injury. Therefore, it is important that you use hands-on techniques only as
an adjunct to exercises and not as a stand-alone treatment.
With regards to hands-on techniques, massage and passive stretching are best
avoided in the acute and sub-acute stages of the sprain, because it is important to gain
a balance between keeping the ankle mobile and avoiding retearing soft tissues that
are repairing. However, movement of the ankle is important, because this helps the
collagen that is being laid down to realign in a more optimal pattern than if the ankle
is completely immobilised.

Education
Wikstrom and colleagues (2021) conducted a systematic review of lateral ankle sprains
and risk of reinjury. Their review included 19 studies with a total of 6,567 patients and
concluded that there is strong evidence that having had a previous lateral ankle sprain
is a risk factor for subsequent re-sprain. Interestingly, they reported that there are barriers
to rehabilitation, one of which is the erroneous public perception that ankle sprains
are inconsequential injuries that do not require rehabilitation. Part of your approach
when dealing with clients with an ankle sprain is to provide education in this regard.

Active Ankle Movement

With caution, it is important to begin a gentle ankle movement programme sooner
rather than later, because this may help realign collagen fibres in such a way that
fibrous adhesions are less likely to occur. Weight bearing should be avoided initially,
and movement should be well within a client’s pain-free range. Figure 6.1 shows the
position most beneficial for the rehabilitation of ankle sprains and in which active
movements should be performed.

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 ANKLE SPRAINS

Figure 6.1 Resting position in which to perform active movements of the ankle.

The aim of your initial treatment might be to help the client maintain (and later
improve) range of motion in the ankle. It is important that all ranges of movement are
restored. Figure 6.2 shows two of these movements: dorsiflexion (a) and plantar flexion
(c), compared to a neutral position (b). Figure 6.3 shows the other two ankle move-
ments, inversion and eversion. Instruct your client in performing gentle dorsiflexion
and plantar flexion with the foot elevated as shown in figure 6.1, stressing that this
should be done within a pain-free range. Later, introduce the movements of eversion
and inversion. Dorsiflexion and plantar flexion are used first, because the ankle natu-
rally falls into plantar flexion at rest; if the foot is allowed to remain in this position,
it will lead to stiffening of the posterior ankle joint and shortening of muscles in the
posterior compartment of the leg. Dorsiflexion and plantar flexion are also the easiest
ankle movements. Movements of eversion and inversion are harder for most clients to
perform, yet they are important to include at some stage of the rehabilitative process,
because they will help restore range of motion in the joint.

a b c

Figure 6.2 The ankle joint (a) dorsiflexed, (b) neutral and (c) plantar flexed.

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ANKLE SPRAINS

a b

Figure 6.3 Ankle (a) inversion and (b) eversion.

TIP
Lying supine is an excellent position in which to perform the ankle range-of-motion exer-
cises, because it facilitates lymphatic drainage and thus helps reduce swelling.

Massage
Only extremely light massage in the form of effleurage is advised in the early stages of an
ankle sprain. Your client may be hypersensitive to touch in the early stages of repair, but
once they can tolerate gentle active movement of the ankle, you could apply extremely
light effleurage in the prone position with the knee flexed. In this position, gravity and
effleurage from ankle to knee will help reduce swelling of the ankle.
If the ankle has been immobilised after a sprain, with no active range-of-motion
exercises, the client may experience a stiffening of the joint as soft tissues shorten and
adhere to one another. In this case, you could follow the rehabilitation process described
in the section on stiff ankles.

Strengthening
Please see chapter 9 for details of appropriate balance and ankle strengthening exercises.

Braces
In a systematic review of evidence-based treatment choices for acute lateral ankle
sprains, Altomare and colleagues (2022) found some evidence to support the use of
braces, with a preference for flexible ankle braces because these allowed an earlier
return to daily activities.

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 ANKLE FRACTURE

Ankle Fracture
An ankle fracture is an acute injury accompanied by immediate pain and swelling.
Fractures can occur spontaneously in people with osteoporosis. The distal ends of the
tibia and fibula or the talus bone of the ankle may be broken. There is usually damage
to ligaments of the joint, resulting in swelling of the foot and ankle and sometimes the
leg also. Massage and stretching are contraindicated in the acute stage of an ankle
fracture. In the sub-acute stage, pain and swelling are reduced, but the ankle is far from
being healed, so caution is required.

Active Ankle Movement

Gentle, active movements to maintain and improve range of motion may be helpful,
provided there are no complications and you have medical approval. It is not always
possible to perform active range of motion treatments if the ankle is immobilised (e.g.,
in a cast or brace). However, if movements are possible, treat the ankle as you would for
a sub-acute ankle sprain. Advise the client to perform active range-of-motion stretches
(see figures 6.2 and 6.3) and to avoid weight-bearing stretches.

TIP
Even when patients have been given medical approval to carry out gentle movements of
the ankle, they are often fearful of doing so, perhaps believing it will result in reinjury. You
can reassure your client that discomfort is likely as a normal part of the healing process
but that extreme pain is not. Progress is usually made when you encourage your clients
to begin with slow and gentle movements.

Stretching
Remember that immobilisation of the ankle will result in decreased mobility in joints
of the foot and toes. Thus, once the fracture is healed, it is important to mobilise and
stretch these joints, using stretches suggested in the section on plantar fasciitis and stiff
feet later in this chapter.

Strengthening
Loss of lower limb strength is common after an ankle fracture. Therefore, exercises
to regain strength and balance are essential. Please see chapter 9 for details on these
exercises.

Active Controlled Motion

The term active controlled motion (ACM) is somewhat misleading, because it refers to
use of a device to perform continuous passive movement. In a randomised controlled
trial, Jansen and colleagues (2018) investigated the use of ACM in early rehabilitation and
found that it improved outcomes after ankle fractures. Their study involved 50 patients
with unstable ankle fractures and the need for only partial weight bearing for 6 weeks.
They compared physiotherapy alone with physiotherapy combined with ACM and found
that the group receiving ACM had better outcomes across all the questionnaires that
were used, better balance and an earlier return to work than the group that received
only physiotherapy.

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ACHILLES TENDINOPATHY

Achilles Tendinopathy
The Achilles tendon is the largest tendon in the body, and the strongest. Blood supply
to the tendon is poor. Achilles tendinopathy is usually due to overuse of and excessive
stress on the tendon and involves changes in the tendon. Overloading can lead to
inflammation and tendon degeneration. This condition is not restricted to people engaged
in sporting activity; overload can occur for other reasons, such as one’s occupation.
Overpronation of the foot has been suggested as a contributing factor. There is usually
pain in the tendon on weight bearing after awakening, and in some cases, there may
be swelling. The injury is often aggravated by repetitive movement and may therefore
limit your client from exercising.
A stiff Achilles tendon that lacks pliability may increase a person’s risk of tendinopathy.
Therefore, any techniques aimed at reducing tension in the tendon and increasing pli-
ability are beneficial: massage, trigger point release, soft tissue release and both active
and passive stretching. Additionally, the fascia of the tendon and calf is concurrent with
that of the posterior thigh and foot. Therefore, massage, stretching and trigger point
release to the hamstrings and foot are also very helpful. Please see the sections on tight
hamstrings (in chapter 4) and plantar fasciitis (later in this chapter) for these techniques.

Education
Before you begin any hands-on treatment, it is important to help your client to identify
and reduce activities that are causing overload to the tendon. You will likely need to
educate your client with regards to how they might modify their physical activity.

Massage
Massage to the calf is helpful prior to stretching, because this helps reduce tension and
improve pliability in the soft tissues into which the Achilles tendon inserts. Apply any of
the techniques described in the section on the treatment of tight calf muscles in chapter
5. Also helpful is massage to the hamstrings (chapter 4) and the plantar aspect of the
foot (as described in the section on plantar fasciitis in this chapter). There is limited
evidence for the use of friction, but anecdotally, this has been reported as useful when
the condition has become chronic.

Trigger Point Release

Release of tension in the calf may help with the management of Achilles tendinopathy.
The trigger point release techniques described in the section on the treatment of tight calf
muscles in chapter 5 are appropriate. Also helpful are deactivation of the trigger points
to the hamstrings (chapter 4) and those used in plantar fasciitis (later in this chapter).

Stretching
Both active and passive stretches are contraindicated in the acute stage of Achilles
tendinopathy. In the sub-acute stage, both pain and inflammation (if there is any) may
have subsided, yet the condition persists. Passive and active stretches are both helpful
in the treatment of this condition. It is important to perform passive stretches to both the
gastrocnemius and the soleus muscles. Any of the techniques described in the section

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 ACHILLES TENDINOPATHY

on the treatment of tight calf muscles in chapter 5 are appropriate. Stretches described
in the section on the treatment of tight hamstrings (chapter 4) and plantar fasciitis (later
in this chapter) are useful additions.

Soft Tissue Release

In sub-acute stages of Achilles tendinopathy, soft tissue release (STR) may be helpful.
The method of applying STR to the calf described in the section on the treatment of
tight calf muscles in chapter 5 is useful. Soft tissue release for tight hamstrings (chapter
4) is also helpful.

Strengthening
Unlike the treatment of an ankle sprain, for which weight bearing is to be avoided
initially, weight bearing may be safe for sub-acute and chronic tendinopathy and is
possibly advantageous, because the Achilles tendon can withstand remarkably high
forces. Strengthening in the form of controlled tendon loading is particularly important.
Chapter 9 also describes important exercises designed to strengthen this tendon.

Referral to a Specialist
Because overpronation of the foot has been linked to Achilles tendinopathy, please see
the section on pes valgus in this chapter for treatment ideas. Referral to a specialist (e.g.,
a physical therapist, osteopath or chiropractor) for gait analysis may be helpful. If the
condition is the result of joint dysfunction, referral to a specialist for joint mobilisation
may also be of benefit.

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STIFF ANKLE

Stiff Ankle
Many people suffer from stiff ankles. This condition may result from a sedentary lifestyle
or direct immobilisation of the lower limb due to serious injury or surgery. Clients
sometimes complain of stiffness resulting from a previous injury for which there was
little or no intervention; function has been restored, but limitations in range of motion
remain. Any modality that improves pliability of soft tissues and movement of the ankle
joint is likely to be helpful.

Massage
General massage to the whole leg and the ankle is helpful to mobilise tissues before
stretching.

Stretching
Both active and passive stretches are helpful to increase range of motion in the ankle
and reduce the sensation of stiffness. It is important to first determine whether there
is a reduction in any particular range of motion or whether the entire ankle is stiff.
Simply pointing the toes may increase plantar flexion (figure 6.4a), but if active flexion
is limited, passive stretching may be required (figure 6.4b). Remember that the ankle
naturally falls into plantar flexion at rest, and it is important not to passively overstretch
the soft tissues of the anterior aspect of this joint when using this position.

a b

Figure 6.4 (a) Active and (b) passive stretches to increase plantar flexion.

Eversion may be particularly challenging to achieve. Placing a towel beneath the

lateral side of the foot (figure 6.5a) and simply standing in this position helps increase
the movement of eversion by stretching the invertor muscles. Passive stretches are
useful if a client has not been bearing weight for a while and may have lost their sense
of balance (figure 6.5b).

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 STIFF ANKLE

a b

Figure 6.5 Use of a towel to increase eversion (a) actively and (b) passively.

TIP
Passive stretching to increase eversion is best performed with the client in a side-lying posi-
tion (figure 6.5b). Use a small towel, rolled or folded to form a pad to elevate the ankle.

The preinjury range of dorsiflexion is relatively easy to regain, because the ankle is
at a 90-degree angle to the floor when we stand. Therefore, reducing plantar flexion to
achieve a 90-degree angle at the ankle joint simply requires the client to stand. If your
client is bedbound but intends to walk in the future, passive stretching of the ankle into
dorsiflexion will be helpful. The active and passive stretches shown in the section on
treating tight calf muscles in chapter 5 are all useful.
A common mistake made when trying to regain dorsiflexion to overcome a stiff ankle
is to limit the range of motion to 90 degrees. Although this facilitates standing with
the sole of the foot flat on the floor, it limits normal walking. Increasing the range of
dorsiflexion from 90 degrees is important. When we rest, the ankle naturally falls into
plantar flexion (figure 6.6a), and even with the application of a strong passive stretch,
the ankle may only reach 90 degrees of dorsiflexion (figure 6.6b).

a b

Figure 6.6 (a) At rest, the ankle falls into plantar flexion; (b) passive stretching may
increase the range of motion to around 90 degrees.

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STIFF ANKLE

The calf muscles are extremely strong, allowing us to raise up onto our tiptoes.
Therefore, active stretches are one of the best ways to increase dorsiflexion past 90
degrees; your client can use their own body weight to increase the angle of the ankle
by placing a block beneath the toes (figure 6.7a) or standing with one leg behind the
body (figure 6.7b). Notice that in each of these stretches, the angle of the ankle is less
than 90 degrees.

a b

Figure 6.7 Active ankle stretches to improve dorsiflexion by (a) placing a block
beneath the toes or (b) putting the leg behind the body.

TIP
It is important to include stretches to the toes, especially the flexor muscles, because the
long tendons of these muscles cross the ankle joint and therefore affect the ankle’s range
of motion. Please see the discussion on plantar fasciitis and stiff feet in the next section
for how to do this.

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 PLANTAR FASCIITIS AND STIFF FEET

Plantar Fasciitis and Stiff Feet

Much more research is needed to understand the exact aetiology of plantar fasciitis.
Excessive strain may lead to microtrauma, inflammation and degeneration. It is unlikely
that this condition results purely from inflammation of the fascia, and the term fasciosis
may be more appropriate. The plantar fascia is consistent with the fascia of the calf via
the calcaneus, and massaging and stretching the tissues of one (i.e., of the foot or of
the calf) is likely to improve extensibility in tissues of the other area. This in turn could
theoretically reduce strain on the plantar fascia.

Massage
All of the massage techniques described
in the section on tight calf muscles in
chapter 5 and the hamstrings in chapter 4
are appropriate. Massaging the sole of the
foot by using your fingers to spread and
stretch the soft tissues of the metatarsal
heads is also helpful provided that it is not
painful. Stroking the foot with the fist (figure
6.8) can be soothing, but in many people,
the sole is very sore, and you may need
to restrict your massage to the calf alone.
Figure 6.8 Massaging the sole of the
Trigger Point Release foot using gentle strokes with the fist.
In a study of 100 patients with plantar
fasciopathy, Thummar, Rajaseker and Anumasa (2020) found that trigger points in
the medial gastrocnemius and quadratus plantae muscles were strongly associated
with plantar fasciitis, as were trigger points in the soleus, tibialis posterior, adductor
hallucis and adductor longus muscles. Arif and colleagues (2018) applied trigger point
release to the gastrocnemius and soleus muscles and the plantar fascia in a group of
42 patients diagnosed with plantar fasciitis. The patients were treated three times a
week for 4 weeks. A plantar fasciitis pain scale questionnaire was used before and
after intervention. This scale measured pain on awakening, when standing, walking
or running and when ascending and descending stairs. The intensity of the pain when
walking was significantly reduced after the treatment. There was also a reduction in
pain when standing and stair climbing.

Stretching
In a clinical consensus statement, the American College of Foot and Ankle Surgeons
stated that stretching is a safe and effective treatment for plantar fasciitis (Schneider et
al. 2018). Due to the connections of the fascia from the posterior thigh to the calf and
to the foot, it is always useful to include hamstring and calf stretches when treating this
condition. All the stretches shown for the treatment of tight hamstrings in chapter 4 and
a tight calf in chapter 5 could be used. The plantar fascia covers part of the sole of the
foot, and stretching the toes into extension will tense this fascia (figure 6.9).

183
PLANTAR FASCIITIS AND STIFF FEET

a b

Figure 6.9 Extension of the toes, (a) actively and (b) passively, helps to tense the plan-
tar fascia.

In figure 6.10, the client has the benefit of being able to use body weight to help
facilitate the stretch, but for some clients and in acute stages of plantar fasciitis, this may
be too uncomfortable. A third form of active stretching is for the client to slowly roll
the foot over a hard ball, such as a golf ball (figure 6.11). This stretches small sections
of the fascia, which may have an overall beneficial effect. If you decide to recommend
this stretch, make sure the client does not attempt to stand on the golf ball but instead
performs the stretch whilst sitting and gently rolls the foot over the ball.

Figure 6.10 Using body weight to Figure 6.11 Using a ball to microstretch
extend the toes and stretch the sole of the small areas of the sole of the foot.
foot.

Specialist Referrals
In the case of a stiff foot, referral to a physiotherapist, osteopath or chiropractor may be
helpful, because these professionals can use techniques to mobilise individual bones
of the foot and toes.

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 PES PLANUS

Pes Planus (Flatfoot)

People with pes planus experience pain in the foot, often in the region of the posterior
tibial tendon, and struggle to perform a single-leg heel raise. If flatfoot is due to structural
abnormality and is rigid, hands-on therapy is ineffective. The main focus of your
treatment for flexible flatfoot is on the prevention of excessive pronation when the foot is
loaded, and this is achieved by controlling valgus (eversion) of the calcaneus (Levangie
and Norkin 2001). Please refer to the pes valgus section of this chapter. Be aware that
changes made to the position of bones of the foot affect not only the lower limb but
the entire kinetic chain throughout the body. Your client may experience either relief
from or an exacerbation of symptoms elsewhere as a result of treatments to the foot.

Massage
Massage to the foot and leg, using any technique, may be helpful in alleviating pain.

Stretching
All of the gastrocnemius and soleus stretches shown in chapter 5 for the treatment of
a tight calf are useful, as are figures 6.9, 6.10 and 6.11.

Strengthening
Popularly known as foot gymnastics, foot dexterity exercises are sometimes used to help
strengthen the intrinsic muscles of the foot. However, these have not been shown to be
effective over and above general exercise (Hartmann et al. 2009). Please see chapter
9 for more information.

Manual Therapist
Referral to a manual therapist (e.g., a physical therapist, osteopath or chiropractor) who
can mobilise the bones of the foot and toes may be helpful, because this mobilisation
will assist with the overall flexibility of the foot.
The American College of Foot and Ankle Surgeons (2023a) recommend a reduc-
tion in body weight in patients who are overweight, because putting too much weight
on the foot arches may aggravate symptoms. Therefore, where appropriate, refer your
client to a dietician.
You might also refer your client to a podiatrist, who may be able to offer advice on
the use of orthotics. There is moderate evidence that orthotics may improve walking
function and reduce energy used when walking but only low-level evidence that they
improve pain, reduce rearfoot eversion, alter loading and impact forces and reduce
rearfoot inversion movements (Banwell, Mackintosh, and Thewlis 2014). If the flatfoot
is the result of dysfunction in the tibialis posterior, wearing flat, lace-up footwear that
can accommodate orthosis may help (Kohls-Gatzoulis et al. 2004).

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PES CAVUS

Pes Cavus (High Arches)

In the pes cavus foot posture, stress is placed on the ball of the foot and the heel. The
extra weight placed on the metatarsal heads of the toes can cause pain, and people with
this condition may report feeling unbalanced. If pes cavus is the result of a neurological
condition, hands-on therapy will be ineffective. Some studies have shown that there
is no evidence for the effectiveness of any treatments other than orthotics for the pes
cavus posture (Burns et al. 2007). Be aware that changes made to the position of bones
of the foot affect not only the lower limb but the entire kinetic chain throughout the
body. Your client may have either relief from or an exacerbation of symptoms elsewhere
as a result of treatments to the foot.

Massage
Although stretching of the plantar fascia with massage and passive dorsiflexion of the
toes may provide some pain relief, there is little evidence to show that it affects pes
cavus foot posture.

Stretching
Stretching of the gastrocnemius has been advocated as a useful non-surgical intervention
for pes cavus (Manoli and Graham 2005). Please refer to the gastrocnemius and soleus
stretches shown the section on tight calf muscles in chapter 5.

Strengthening
People with pes cavus foot posture are likely to benefit from balance training. This will
not change the posture of the foot but will improve balance, reducing the likelihood
of injury from, for example, sprains. For more information on balance training, please
see chapter 9.

Podiatry
Consider referring your client to a podiatrist. Orthotics, shoe modifications and bracing
may be helpful (American College of Foot and Ankle Surgeons 2023b). Custom-made
orthotics have been shown to provide significant benefit (Burns et al. 2007). The goal
of these is to realign the hindfoot and offload the lateral side of the foot.

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 PES VALGUS

Pes Valgus (Pronated Foot)

You learned in chapter 1 that in the pes valgus posture, there is eversion of the heel away
from the midline position. The consequence of this is that the foot pronates and there is loss
of the medial longitudinal arch. This causes an increase in compression of the soft tissues
of the lateral side of the ankle and tensing of the tissues on the medial side of the ankle.

Massage
Massage to shortened muscles (the fibular muscles and possibly the gastrocnemius and
soleus) may reduce tension that results from this foot posture, but it will not affect the
underlying foot structure.

Soft Tissue Release

Soft tissue release could be used to
release tension in the fibular muscles,
perhaps with your client in a side-
lying position (figure 6.12). First, ask
your client to evert their ankle; then,
apply static pressure to the lateral side
of the calf and maintain this pressure
as you ask your client to invert their
ankle. Work from proximal to distal.
You may need to experiment with
positioning the client’s leg on a bolster Figure 6.12 Soft tissue release to the fibular
to facilitate movement of the ankle muscles.
that would otherwise be restricted by the treatment couch. Take care not to compress
the peroneal nerve, which passes around the head of the fibula.

Stretching
Active stretching may reduce tension in the
fibular muscles, which are evertor muscles
(figure 6.13). Also stretch the muscles of the hip
and thigh, such as the hamstrings and adductors,
if these are found to be tight. For stretches to
these muscles, please see the sections on tight
hip adductors in chapter 3 and tight hamstrings
in chapter 4.

Figure 6.13 An active stretch of the

fibular muscles.

187
PES VALGUS

Taping
Taping is a popular intervention for the treatment of pes valgus. However, an experiment
by Luque-Suarez and colleagues (2014) to see whether the application of Kinesio Tape
helped correct excessive foot pronation found that it did not. Another study found that
taping to correct pronation during walking and jogging was effective (Vicenzino et al.
2005).

Strengthening
Useful exercises are those for the ankle invertor muscles (chapter 9) and weakened
muscles of the hip, such as the gluteal muscles (chapter 7). These are likely to help
with overall strength and balance but are unlikely to change underlying foot posture.

Myofascial Release and Podiatry

Use myofascial release for the whole lateral side of the lower limb.

TIP
Advise your client to avoid resting the feet around chair legs when sitting, because this
pushes the feet into eversion (figure 6.14).

Figure 6.14 A seated foot posture to avoid.

Courtesy of Emma Kelly Photography.

Refer your client to a podiatrist. The use of orthotics to control the amount of prona-
tion (for example, during the stance phase of gait) has profound effects on pain and
dysfunction in the lower extremity (Donatelli 1987).

188
 PES VARUS

Pes Varus (Supinated Foot)

In the supinated foot posture, the heel bone moves towards the midline, accentuating
the medial longitudinal arch. In contrast to the pes valgus foot posture, there is increased
pressure on the medial side of the ankle, and the lateral side of the ankle is tensed.

Massage
Massage and stretch shortened tissues (in this case, on the plantar surface of the foot),
focusing on the medial side and the medial aspect of the ankle and taking care not to
apply too much pressure. Positioning your client in a side-lying position can be useful
for applying massage to the medial side of the leg (figure 6.15a), and using a towel
(figure 6.15b) or your thigh (figure 6.15c) can help you access and stretch tissues on
the medial side of the ankle.

a b c

Figure 6.15 Therapist techniques for pes varus include (a) massage to the medial side
of the leg, perhaps positioning the client with the medial side of the ankle uppermost
using (b) a towel or (c) your thigh.

Stretching
Show your client how to stretch the medial side of the foot and foot invertors by placing
a small, folded towel beneath the lateral side of the foot (figure 6.16a). Active (figure
6.16b) and passive (figure 6.16c) stretching of the flexor hallucis longus is also useful.

a b c

Figure 6.16 Stretches for pes varus include (a) actively stretching the ankle invertor
muscles by standing on a towel and (b) actively and (c) passively stretching the flexor
hallucis longus.

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PES VARUS

Strengthening
Strengthen ankle evertors. Please see chapter 9 for more information.

Podiatry
Refer your client to a podiatrist. The use of orthotics to control the amount of supination
during the stance phase of gait, for example, has profound effects on pain and
dysfunction in the lower extremity (Donatelli 1987). The lateral side of the foot can be
elevated with orthotics, but it is not clear whether this has a function in altering foot
and ankle posture. Use of lateral wedge orthotics has been found to reduce symptoms
in patients with medial compartment osteoarthritis at the knee (Malvankar et al. 2012),
so it may alter lower limb posture. One of the challenges with the pes varus posture
is that orthotics designed to correct foot supination can aggravate genu valgum where
this is a corresponding posture.

Quick Questions
1. Why is it necessary to educate your client with regards to the importance of
rehabilitation after an ankle sprain?
2. When working with someone who had their ankle immobilised after a fracture,
which joints in addition to the ankle should be mobilised and stretched?
3. Why is it useful to stretch the ankle joint to more than 90 degrees of dorsiflexion
as part of treatment for a stiff ankle?
4. Which part of the ankle is compressed in the pes valgus foot posture?
5. On which side of the leg, ankle and foot should you focus when applying mas-
sage in the treatment of the pes varus foot posture?

190
 PART III

Lower Limb
Strengthening
Exercises
P
art III provides examples of strengthening exercises used in the treatment of the
lower limb conditions described in this book. Chapter 7 focuses on hip strength-
ening, chapter 8 on knee strengthening and chapter 9 on strengthening of the feet
and ankles. The rationale behind providing a separate part on strengthening exercises
is that you may be a soft tissue therapist and unfamiliar with strengthening protocols,
because these are not usually covered in massage and other soft tissue training courses.
If you have a background in fitness and rehabilitation, then you may already be familiar
with the material in these chapters. In the author’s experience, only a minority of soft
tissue therapists work alongside fitness professionals or clinicians who can provide
strengthening programmes, and they may be unaware of simple exercises that are a
useful adjunct to soft tissue treatment.
The purpose of this part of the book is not to teach you to become a fitness profes-
sional. You do not necessarily need to provide the exercises described here to your
client; simply knowing which exercises are used – and, importantly, why they are used
– can be extremely helpful in supporting your client to recover from or manage their
condition. Adherence to exercise programmes is known to be poor, and in itself, a dis-
cussion around adherence might improve compliance and therefore hasten recovery.

Testing Lower Limb Strength

Each chapter in part III describes how to identify whether a person lacks strength in a
particular muscle group. The strength tests described rely either on the client attempt-
ing a movement and informing you as to whether they perceive a strength deficit
between the left and right limbs or your providing manual resistance to a movement
and forming your own opinion as to whether there is a deficit. Ultimately, the goal of
a strength training programme is to help a person to regain everyday function, as far

191
192 Part III

as is possible. It could be argued that functional ability is more important to measure

over and above the isolated strength of a particular muscle group. Therefore, you can
also use the examples of functional strengthening exercises as measures of strength.

Strengthening Exercise Types

There are many different types of lower limb strengthening exercises, such as exercises
to develop pure strength and muscle bulk, where a person performs a single repetition
involving the maximum weight they can lift. These are typically used by powerlifters
and bodybuilders, who might perform a single knee extension using a knee extension
machine. Another type of lower limb strengthening exercise is endurance training, where
the focus is to build stamina in a group of muscles by repeating the same exercise,
perhaps in three sets of 8 or 12 repetitions, with a minute’s rest between sets. These
kinds of lower limb exercises are typically performed by people whose sporting activity
relies on lower limb endurance, such as footballers or runners. The exercises in this part
of the book have been selected to facilitate early recovery from a lower limb problem,
and they fall more into the category of the endurance required to regain function and
a return to everyday activities.

Regaining Function After an Injury

Keep in mind tasks that must be done in everyday life and that your client may be
struggling with, such as getting out of bed, standing, walking, sitting down onto a chair,
getting up out of a chair, getting washed and getting dressed. These are the activities
that we ultimately wish to facilitate through the use of strength and balance exercises,
and the exercises provided in chapters 7, 8 and 9 have this aim in mind. However,
there will be many clients who cannot yet bear weight through a joint, so standing and
walking are not possible. This is especially true after a fracture to the lower limb or a
severe sprain; weight bearing needs to be avoided, but it is still possible to perform
other, safe exercises.

Non-Functional Exercises Versus Functional Exercises

Many clinicians dislike non-functional exercises. Range-of-motion exercises – such as
actively bending and straightening the knee in isolation, circling the ankle or performing
repeated abduction of the hip in a side-lying position – are examples of non-functional
exercises. Isolated movements such as these do not replicate what we need to do with
our lower limbs in real life – bearing weight through them, walking, stepping up and
down off a pathway, using stairs, squatting down, driving and so on. However, there
is a place for non-functional exercises as well as functional exercises, such as when a
person cannot perform their usual functions but can perform some other movement.
A typical example is in the case of a severe ankle sprain. In such cases, a person
cannot bear weight through the foot or ankle because to do so in the early stages of
recovery would be injurious; they may be unable to bear weight and require crutches
Part III 193

to ambulate. It is not possible for them to replicate certain activities of daily life, such
as normal walking. Without engagement in a recovery programme, the muscles of the
lower limb will atrophy and lose strength because they are not being used. Many clients
recovering from a severe ankle sprain complain of pain in the low back or opposite
limb due to an altered gait pattern and overcompensating with use of their other leg.
In this example, a useful way to maintain strength in the lower limb is with hip, thigh
and knee strengthening.
The exercises that have been selected for inclusion in this part of the book are safe
and effective; they rely only on the use of a client’s body weight or a resistance band.
Resistance bands are available in different degrees of resistance (light, medium and
heavy) and are inexpensive, lightweight and easy to store. The value of the exercises
presented in part III is that they can be performed at home; to help a person recover
or manage a lower limb condition, it is not necessary to have access to a gymnasium
or to exercise weights. Stretches are not included in this part of the book; examples of
stretches are found in chapters 3, 4, 5 and 6, alongside the conditions for which they
may be useful.

Balance Exercises
After an injury to the lower limb, the ability to balance is almost always compromised.
The longer someone has been inactive, the poorer their balance is likely to be. Balance
exercises are therefore extremely important and are included in chapter 9. You may
have seen or heard of people standing on a ‘wobble’ board as part of their recovery
from an ankle sprain. Instructions for using wobble boards and similar devices are
not included, as these devices should be used towards the end of the rehabilitation
phase and a mistake is to use them too soon, risking reinjury. Instead, simple balance
exercises are provided and are likely to be essential for the recovery from most lower
limb conditions.
The types of balance exercises included in chapter 9 are those that involve weight
bearing through both legs whilst transferring weight from one leg to the other using
various foot positions. In addition, there are explanations of how to make simple single-
leg balancing exercises more challenging and thus safely facilitate an improvement in
balance. The value of the exercises provided in this chapter is that they can be used
early on in the rehabilitation programme.

Exercise Positions and Repetitions

Exercises are included for sitting, supine, prone and side-lying positions, to be used
where weight-bearing is not yet possible. The position in which exercises are performed
and the number of repetitions performed for each exercise depend on many different
factors: your client’s tolerance to each position, the stage of their recovery and their
general health and fitness needs, for example. Most important is the need to establish
the ultimate goal you and the client are aiming for. This is likely to change over time.
A typical endurance programme might start with two or three sets each of 5 to 7
repetitions, increasing to 12 repetitions. Although many therapists prescribe such an
194 Part III

exercise programme to be performed daily or even up to three times daily, in the author’s
experience, this can be detrimental and cause fatigue and muscle soreness. This then
reduces the client’s motivation to continue with the programme. It is better to perform
an exercise well, using perhaps a smaller number of sets or repetitions, than to perform
an exercise poorly, which tends to happen when people become fatigued or bored.

Exercise Progression
Where possible, the exercises have been presented in order from those that require
the least strength to those that require more strength. However, what one person finds
challenging, another might find easy. Once a person is used to a certain exercise, it is
beneficial to change to one requiring more strength. By contrast, if exercises are too
challenging to perform, there is a risk that the person will become demotivated or
reinjure themselves, which is why it is important for your client to set realistic goals.
The exercises provided in this part of the book are basic and focus on the early stages
of recovery. The exercises are not designed to help someone return to recreational or
competitive sport, for which more intensive and highly varied rehabilitation programmes
are needed and supervision by an exercise specialist is recommended.

Improving Exercise Plan Adherence

People quickly become bored with rehabilitation exercise, and their adherence may
lessen. This lack of adherence delays recovery. Most people want to return to their
everyday activities. Your challenge is therefore to help a client regain usual function as
soon as possible and to encourage adherence to an exercise plan as soon as it is safe
and practical. Table III.1 shows some of the reasons for non-adherence to an exercise
plan and gives suggestions for how to overcome these.
Note: Special thanks to Tim Allardyce from rehabmypatient.com for permission
to reproduce the strengthening exercises in chapters 7, 8 and 9. Rehab My Patient is
an online resource containing thousands of exercises, not just the small selection of
strengthening exercises that have been selected for inclusion in this book.
Part III 195

Table III.1 Why Exercise Plans Fail and Solutions to Overcome This
Reasons for exercise plan failure Solutions
A common misconception is that Clients need to be educated with regards to the
recovery requires ‘hands-on’ treat- value of exercise, because in most cases, the
ment or that intervention by some- reason certain exercises have been prescribed is
one else is needed to ‘fix’ a condi- that they are the most likely to facilitate recov-
tion. Therapists may often have ery.
heard someone complain that ‘they
never even touched me. They just
gave me a sheet of exercises’.
Clients may fail to understand the pur- The rationale for the exercise needs to be clearly
pose of an exercise and therefore do explained. For example, the rationale for the
not value it. stretches described in previous chapters is to
improve range of motion in a joint, aid flex-
ibility and help manage symptoms, whereas the
exercises described in chapters 7, 8 and 9 are
designed to improve muscle and joint strength
and balance. It is important to explain the ratio-
nale for an exercise that involves strengthening a
different body part to that which is affected. For
example, it is important to explain to someone
recovering from a knee or ankle issue that the
gluteal ‘bridge’ exercise helps strengthen the
buttock muscles and that this is important for
hip strength and stability, which is compromised
during periods of immobilisation, whether due
to injury or illness.
Providing too many of the same Provide safe alternatives to each exercise. The way
exercises without variety quickly to do this effectively is careful monitoring of the
becomes boring. client’s improvement and changing an exercise
to become slightly more challenging once they
are ready to progress. This could be done by
changing the exercise itself or by changing the
position in which it is performed.
The exercise is too difficult or too Programmes need to be individually tailored so
hard. A common mistake when that they are challenging enough to be slightly
providing an exercise programme effortful but not so challenging that they are
is to give every client with the same impossible.
injury the same programme.
Clients may believe that all exercise Exercises should not cause excruciating pain, but
should be pain free. some discomfort is almost always experienced
during or after exercise, as this is a normal part
of the strengthening process. Educating your cli-
ents in this regard is helpful.
(continued)
196 Part III

Table III.1 Why Exercise Plans Fail and Solutions to Overcome This (continued)
Reasons for exercise plan failure Solutions
Too many or too few exercises may It is important to tailor a programme to each
have been provided. Some cli- client. For example, someone who tires easily
ents become overwhelmed if they due to an underlying condition might benefit
are given too many exercises. If more from a smaller number of sets and rep-
it takes a long time to complete a etitions than someone who does not fatigue
series of exercises, adherence can quickly. Someone who is easily bored may need
be affected. Conversely, if too few to be provided with a greater variety of exercises
exercises are provided, some clients, or a programme where the exercises are varied
especially those used to physical on alternate days.
activity, quickly become bored and
frustrated at what they perceive to be
slow progress.
Clients may fail to improve due to All exercises should be completed with care and
poor technique. A lack of atten- concentration. The exercises provided in this
tion can lead to repetition of a poor part of the book are very simple and do not
movement pattern, which in itself require a great deal of explanation, but where
can be detrimental to overall recov- possible, clients should be observed performing
ery. their exercises and be given constructive feed-
back.

Clients fail to see improvement To regain strength, it is important to progress exer-

despite adherence. cises appropriately, eventually progressing to
functional exercises. Failure to do this risks that
a client will become very good at one or a few
specific exercises but will never progress beyond
these. Use of an exercise diary can be invalu-
able.
 7
Hips
Learning Outcomes
After reading this chapter, you should be able to do the following:
■ Demonstrate simple tests to determine the strength of the hip extensors, hip
abductors, hip adductors and hip flexors.
■ Show examples of hip strengthening exercises.
■ Teach hip strengthening exercises in prone, supine, side-lying, sitting and
standing positions.
■ Explain how to make any of the exercises in this chapter harder or easier.
■ List examples of functional hip exercises.
■ Identify which hip strengthening exercises may also be appropriate for common
conditions affecting the thigh, knee, ankle and foot.

T
his chapter focuses entirely on exercises to strengthen the hip and thigh region.
These exercises are suitable in the treatment of the conditions discussed in chapter
3 (trigger points in the gluteal muscles, piriformis syndrome, tight hip adductors,
tight hip flexors and groin strain). Many of the exercises in this chapter are also useful
in the treatment of knee, ankle or foot problems, for which strength and stability in the
hip are essential to recovery or general maintenance of everyday function.

Testing the Strength of the Hip Muscles

When treating people with any of the lower limb conditions described in this book, you
are encouraged to test the strength of the hip muscles. Hip muscle weakness is extremely
common after immobilisation, even if the injury or condition affects the knee or ankle.
This chapter describes how to test the strength of the hip extensors, flexors, abductors
and adductors. The need for isolated hip rotation, whether internal or external, is rare;
therefore, tests for the strength of those isolated movements are not included.

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HIP EXTENSORS

Hip Extensors
Identifying Weakness in the Hip Extensors
One of the simplest ways to test the strength of the hip extensors is to ask your client to
perform a ‘bridge’ exercise (figure 7.1a). If they can do this, have them repeat the test
using one leg at a time and compare both sides (figure 7.1b). Look for three things to
determine weakness. First, how easy does this appear for the client? Second, is the client
able to keep the pelvis level and parallel to the floor or plinth, indicating strength, or does
the side being lifted drop down, indicating weakness? Third, is there any shaking? Get
the client’s feedback as to whether it feels easier to lift the left or the right leg. Obviously,
this test is unsuitable for a client who cannot bear weight through their knee or ankle,
in which case, you could ask them to attempt hip extension using the prone (figure
7.1c) or side-lying positions (figure 7.1d), getting their feedback as to which hip feels
weaker. The tests for hip extensor strength can also be used as strengthening exercises.

c e

Figure 7.1 Testing and strengthening the hip extensors in (a, b) supine, (c) prone, (d)
side-lying and (e) standing positions.
Courtesy of Tim Allardyce, Rehabmypatient.com.

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 HIP EXTENSORS

Hip Extensor Strengthening

Hip extensor strengthening is part of a general gluteal strengthening programme and
is useful whenever there is weakness in the extensors, as may occur when the hip
adductor muscles are tight, after a person has sustained a groin strain or when a person
has piriformis syndrome. Strengthening is particularly helpful if a person has tightness
in the hip flexors, because strengthening of the hip extensor muscles will reduce tone
in the hip flexors.
Because the hamstrings are hip extensors in addition to being flexors of the knee,
there may be hip extensor weakness after a hamstring strain or when there is tightness
in the hamstrings. Sensations of tightness in a muscle could indicate that the hamstring
muscles are shortened, and when this occurs, this muscle group is often weak.

TIP
Note that hip extension is only one test for weakness in the hamstrings, and knee flexor
strength should also be tested. Please see chapter 8 for instructions.

Hip extension may be performed in supine, prone and standing positions. One of the
easiest ways to strengthen hip extensors is in the supine position by simply lifting the
buttocks from the floor (see figure 7.1a) without arching the back. To make this more
challenging, one leg can be extended whilst lifting the hips using the other leg (see
figure 7.1b). The aim of the one-leg position is to keep the pelvis level and to prevent
it from dropping towards the floor or plinth.

TIP
To make the exercise shown in figure 7.1b more difficult, the hips can be lifted whilst
the arms are folded across the chest. Even harder still is to use the extended leg to draw
circles in the air, thus adding the need for stabilisation of the pelvis and therefore greater
strength. Alternatively, instead of extending the leg, the foot could be rested on the knee
of the supporting leg, adding weight.

Hip extension in the prone position (see figure 7.1c) requires lifting the leg against
gravity, which necessitates more strength than performing this exercise in the side-lying
position (see figure 7.1d). The side-lying position is less stable, but it may be useful if
the client has muscle weakness.

TIP
When teaching the prone version of hip extensor strengthening, a tip is to ask your client
to try to ‘place a footprint on the ceiling’.

Hip extension can also be performed when standing (see figure 7.1e). Using a resis-
tance band increases the difficulty. This is a more functional activity than performing
the exercises lying down, but it requires strength and stability of the opposite leg, and
the client needs to keep their chest upright and avoid bending at the waist.

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HIP EXTENSORS

TIP
Active Hip Contraction
Some clients cannot perform movements of the hip because, for instance, they have knee
or ankle pain or instability. An example might be when someone has sustained an injury
to the knee or ankle that requires immobilisation in a cast or brace and ambulation is
severely restricted. In this example, contraction of the buttock muscles, whether lying or
sitting, will help minimise loss of strength in the gluteal muscles.

Making Hip Extension More Functional

Many functional activities, such as sit-to-stand movements and stair climbing, rely on
strength in the gluteal muscles, and these activities can therefore be used as part of the
rehabilitation programme. Simply standing up from a sitting position (figure 7.2a) or
stepping up as when using stairs (figure 7.2b) requires strength in the gluteal muscles.
These activities could therefore be included in a hip extensor strengthening programme.
Because they also require strength in the quadriceps muscles, these exercises are often
used as part of the rehabilitation programme for clients with knee problems too.

a b

Figure 7.2 Functional exercises to strengthen the hip extensors include (a) sit-to-stand
movements and (b) stair climbing.
Courtesy of Tim Allardyce, Rehabmypatient.com.

TIP
To make a sit-to-stand exercise easier, the client could use their hands to press up out of
the chair. To make the exercise more difficult, the client could place more weight through
their affected leg. To make it harder still, they could practise sit-to-stand exercises using
one leg only.

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 HIP EXTENSORS

Note that the exercises in figure 7.2 are different to those in figure 7.1, and not only
in that they are more functional. Compare the position of the hip in figures 7.1 and 7.2.
Notice how in figure 7.2, the hip starts in hip flexion and ends in a neutral position,
whereas in figure 7.1, the hip starts in a neutral position and ends up in extension. This
is why a variety of different exercises is almost always advocated, because different
types of exercises work the muscles of extension in different ways and therefore provide
optimal strengthening.

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HIP ABDUCTORS

Hip Abductors
Identifying Weakness in the Hip Abductors
A simple test of strength in the hip abductors is to ask your client to sit (or lie supine)
with their knees together and the hips and knees flexed and to abduct against resistance
you provide using your hands or against the resistance of an exercise band (figure 7.3a),
giving you feedback as to which side feels weaker. Another useful test is the exercise
shown in figure 7.3b. If there is weakness, the client will struggle to abduct the leg,
but note that straight-leg abduction in the supine position can also be hampered by
resistance from the surface on which the client is lying, such as a towel or bedding.
The exercises in figures 7.3c and 7.3d both require more strength as the leg (7.3c) or
pelvis (7.3d) is lifted against gravity. These are useful tests for people with considerable
pre-existing hip strength, such as those engaged in regular sporting activities. Where
there is weakness in the hip abductors, the client will struggle to maintain the position
of the abducted leg or to keep the pelvis lifted, depending on which test is used. The
strength of the hip abductors can also be tested in the standing position (figure 7.3e).

Hip Abductor Strengthening

Hip abduction occurs when taking the leg out to the side, such as when stepping
sideways when walking. Weakness occurs with disuse of the limb after immobilisation
or injury, but weakness in the gluteus medius may also be present in people who are
physically active.
One of the most stable positions in which to perform strengthening of the hip abduc-
tors is the supine position. In this exercise, the client simply abducts their hips. Usually,
what limits this movement is tightness in the muscles of the groin, not weakness in the
abductor muscles. Therefore, to make this exercise more effective, a stretchy exercise
band can be used (figure 7.3a).

TIP
If a person struggles with the exercise in figure 7.3a, they could perform it without the
exercise band. Some people prefer to perform the exercise seated, with or without a band.

The supine straight-leg abduction (figure 7.3b) and side-lying with knees flexed (figure
7.3d) positions can also be adopted to strengthen the hip abductors.

TIP
Although the supine position looks relatively easy, the lower limb is extremely heavy, and
to abduct the entire lower limb requires simultaneous hip flexion to raise the limb slightly
from the floor. This can be challenging for people with weak abdominal muscles or who
have conditions affecting the low back. Flexing the hip and knee on the side opposite to
the limb being exercised can help make this position more comfortable, because this brings
about a posterior tilt in the pelvis, reducing lumbar extension. To make the exercise easier,
the leg could be moved against a slippery surface, such as plastic sheeting.

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 HIP ABDUCTORS

Hip abduction can also be performed in the standing position (figure 7.3e), requiring
stability in the supporting leg and avoidance of leaning over to one side, away from
the hip being strengthened.

a e

b d

Figure 7.3 Exercises to strengthen the hip abductors can be performed in (a, b) supine,
(c, d) side-lying and (e) standing positions.
Courtesy of Tim Allardyce, Rehabmypatient.com.

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HIP ABDUCTORS

TIP
When performing hip abduction in the standing position, placing a resistance band above
the knees makes the exercise more difficult, and placing the band around the ankles makes
it even more challenging. Using the band around the ankles is not appropriate for people
with knee issues, because greater strain is placed on the knee to abduct the hip against
resistance in this way.

Abduction of the lower limb in a side-lying position (figure 7.3c) is one of the most
challenging exercises, because it requires lifting the entire lower limb against gravity.
This is therefore a good exercise to aim for once other positions have been tried. In
this position, it is important to keep the body straight and to avoid leaning forwards or
backwards.

TIP
To make the exercise in figure 7.3c more difficult, a resistance band can be placed around
the thighs. To increase resistance even further, the band can be placed around the ankles.
Again, care is needed when working with people who have knee issues, because a band
around the ankles adds strain to the lateral aspect of the knee. In someone with healthy
knees, using a band should cause no problems, but it is useful to be aware of the risk. An
alternative to using a band to make the exercise more difficult is to perform movements of
the abducted leg, such as small circles in the air, thus compromising stability and requiring
greater strength to balance the body.

Making Hip Abduction More Functional

Two very useful exercises can make hip abduction more functional. The first is simple
sidestepping, which exercises both the hip abductors and the hip adductors. This exercise
could involve sidestepping across the room, for example. In early stages of rehabilitation
or when working with someone with balance issues, sidestepping can be done with a
support (figure 7.4a). Another useful exercise is stepping sideways up and onto a step
(figure 7.4b). This action requires hip flexion to lift the leg, then contraction of the hip
abductors and extensors to lift the body weight to the step height. This exercise could
easily be performed on the bottom step of a staircase at home.

204
 HIP ABDUCTORS

Figure 7.4 Making hip abduction exercises more functional includes (a) sidestepping
and (b) side step-ups.
Courtesy of Tim Allardyce, Rehabmypatient.com.

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HIP ADDUCTORS

Hip Adductors
Identifying Weakness in the Hip Adductors
In the supine position, weakness in the hip adductors can be tested by asking the client
to rest with both legs abducted in a frog-type position and to then try to bring their knees
together (figure 7.5a). This has the advantage of enabling you to compare one hip with
the other. Look for any shaking, indicating weakness, and ask the client whether they
noticed that it was easier to adduct one hip compared to the other. If the client has an
issue affecting movement of the non-affected hip, the test can be performed unilaterally
(figure 7.5b). The disadvantage of this is that you cannot compare the strength of that
hip with the opposite side and therefore do not know whether the strength at the time of
testing is normal for your client. You can teach your client how to compare the strength
of their hips using a sitting position (figure 7.5c). The side-lying position (figure 7.5d) is
perhaps the most challenging for hip strength, because it requires the client to adduct
their hip against gravity. The degree of reported effort, combined with how far the leg
can be lifted or for how long the lift can be sustained, is a helpful indication of the
strength of the hip adductors.

Hip Adductor Strengthening

Strengthening of hip adductors is important after a groin strain, especially when this is
chronic. Strains of the adductor muscles can take up to 16 weeks to heal, depending on
their severity, and it is important to start a strengthening programme as soon as possible.
A simple strengthening exercise is for the client to attempt to squeeze the knees
together. This isometric exercise is good because it can be performed seated, supine or
even in a side-lying position. One of the easiest hip adduction strengthening exercises
is performed in the supine position. Many people have tight hip adductors and will
not be able to let their knees fall open to touch the ground. That is OK, because this
exercise is not about hip flexibility but strength. The client either brings their knees back
together bilaterally (figure 7.5a) or unilaterally (figure 7.5b). Clients often feel more bal-
anced performing the exercise with both legs simultaneously, but this is not essential.

TIP
An easy way to make the exercises in figures 7.5a and 7.5b more challenging is for the
client to start to bring the knees (or knee) back to the midline but to hold the leg midway
between the fullest abduction and fullest adduction. This requires the adductors to hold the
weight of the leg without moving, and the duration of the hold could be used to determine
improvements in muscle endurance.

Strengthening could also be performed in the seated position, where the client sits
with the hips abducted to begin and then tries to bring the knees together. To increase
the difficulty, the client could apply resistance by pressing their hands against their
knees (figure 7.5c). Finally, a very simple way to make hip adduction more challenging
is to lift the whole lower limb from the floor, as in figure 7.5d.

206
 HIP ADDUCTORS

a b

c d
Figure 7.5 Hip adductor strengthening can be performed in the (a, b) supine, (c)
seated or (d) side-lying positions.
Courtesy of Tim Allardyce, Rehabmypatient.com.

Making Hip Adduction More Functional

You may not realise it, but whenever you walk, your hip adductors contract to help keep
you walking in a straight line. Therefore, walking is an excellent part of hip rehabilitation.
The exercises shown in figure 7.4 are also useful because they require action in both
the hip abductors and adductors.

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HIP FLEXORS

Hip Flexors
Identifying Weakness in the Hip Flexors
With your client seated, ask them to lift one knee at a time, with resistance (figure 7.6a),
and to let you know whether it feels more difficult to lift one leg or the other. Another
way to test this is whilst you provide resistance with your hand (as in the seated position)
or with your client lying supine (figure 7.6b). Having your client attempt a hip flexion,
whether standing (figure 7.6c) or lying down (figure 7.6d), is another way to determine
the strength of the hip flexors and has the advantage of being more objective, because
you can observe the distance the leg can be lifted.

Hip Flexor Strengthening

Pressing the knee against resistance (figure 7.6a) can be used as an isometric
strengthening exercise.

TIP
To make hip strengthening easier, the client could perform this exercise in the supine
position (figure 7.6b). In this position, they are not lifting the knee against gravity, so this
is useful in the early stages of rehabilitation.

Lifting the leg against gravity can be performed standing (figure 7.6c) or lying down
(figure 7.6d). When the knee is extended, lifting the leg requires more strength, so
performing a straight-leg raise in the supine (figure 7.6d) position is more difficult than
when the knee is flexed (figure 7.6b).
Many people have shortened hip flexors that feel ‘tight’ on attempting hip flexor
stretches. Shortened muscles can lack strength in the same way as lengthened ones, and
strengthening hip flexors can be useful as part of an overall programme to strengthen
the lower limb.

Making Hip Flexion More Functional

Every time you lift your leg, the hip flexors contract. The higher the leg is lifted, the
greater the amount of strength is needed. Other than when climbing stairs, there are
few times in everyday life when significant hip flexor strength is required. Obviously,
people who play sports require greater hip flexor strength and should be referred to a
professional who is able to assist with this.

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 HIP FLEXORS

a b c

c d
Figure 7.6 Hip flexor strength can be assessed and improved in (a) sitting, (b, d) lying
and (c) standing positions.
Courtesy of Tim Allardyce, Rehabmypatient.com.

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210 Soft Tissue Therapy for the Lower Limb

Water-Based Exercise
For an all-around hip strengthening programme, consider water-based exercise. Water
provides resistance to movement, and pool-based exercises are valuable because they can
be used in the very early stages of recovery to improve hip mobility and strength. Simply
walking across the pool forwards, backwards and sideways is a great way to strengthen all
of the major muscles of the hips. Lying on one’s back to perform straight-leg abduction and
adduction movements can be useful to strengthen the abductors and adductors, respectively.

Quick Questions
1. When using the bridge exercise to test a client’s hip extensor strength, what
three things might you look for to identify if there is weakness?
2. Which two functional exercises are described in the text to strengthen hip
abductors?
3. What is the advantage of testing the strength of hip adductors bilaterally in the
frog-like supine position?
4. Whether using the standing or supine position, which requires more strength
– hip flexion with the knee flexed or hip flexion with the knee extended?
5. Why are water-based exercises helpful for someone with a hip problem?
 8
Knees
Learning Outcomes
After reading this chapter, you should be able to do the following:
■ Demonstrate simple tests to determine the strength of the knee flexor and
extensor muscles.
■ Show examples of knee strengthening exercises.
■ Teach knee strengthening exercises in prone, supine, sitting and standing
positions.
■ Explain how to make any of the exercises in this chapter harder or easier.
■ List examples of functional knee exercises.
■ Tell which exercises in this chapter are also appropriate for the treatment of
hamstring strains, tight hamstrings, hamstring cramping and tight quadriceps.
■ Identify which knee strengthening exercises may also be appropriate for
common conditions affecting the ankle.

T
his chapter focuses on exercises to strengthen the knee. These exercises are suit-
able for the treatment of conditions such as osteoarthritis in the knee and after
knee surgery. Strengthening of the opposing muscle groups can be useful in the
treatment of hamstring cramping, tight hamstrings and tight quadriceps, and although
strengthening cannot affect overall knee posture, it might be helpful in improving bal-
ance for people with genu recurvatum, genu flexum, genu varum and genu valgum knee
postures. Many of the exercises in this chapter are also useful in the treatment of ankle
or foot problems, where strength and stability in the knee are essential to recovery or
where maintaining knee function is required for everyday activities.

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212 Soft Tissue Therapy for the Lower Limb

Testing Knee Strength

The tests described in this chapter demonstrate how to test pure movements of the knee
– flexion (bending) and extension (straightening). However, as you know, we use our
knees to perform everyday tasks, and these require not just strength but flexibility and
balance – changing from a sitting to standing position (or sitting down from a stand-
ing position), using stairs, pressing the brake pedal when driving, squatting to put on
footwear or pick something up from the ground and so on. It is important to remember
this when determining a person’s knee strength. The ability to perform everyday tasks
can also be used as a determinant of recovery.
Knee strength may be tested by the client simply bending or straightening their knee, or
it may be tested against added resistance – usually provided by the therapist or a rubber
exercise band. Actively moving the knee may sound easy, but testing strength actively
is very useful in the early stages of rehabilitation or after prolonged immobilisation,
when there may be a significant loss of strength. Active knee flexion is a useful way to
test the strength of the hamstrings after a hamstring strain, and active knee extension is
a good way to test the strength of the quadriceps after a quadriceps strain, especially
in the early stages of recovery.
Testing knee strength without added resistance relies on feedback from the client –
the client tells you how difficult they feel a movement is and whether there is a deficit
between their left and right knees. You can often observe for yourself how much effort
the client appears to put into performing the movement and identify the degree of
movement through which the client is able to flex or extend their knee.
Testing the strength of the knee flexors and extensors can be performed in prone,
sitting, supine or standing positions, the same positions you might be using for range-
of-motion exercises to increase mobility in the joint. Certain test positions are slightly
more challenging than others, and these are detailed in the sections that follow. Which
test position you use will depend on the client. For example, when treating a client
with balance issues, you might avoid testing them in a standing position. Conversely, in
later stages of recovery, you may decide to use a standing position for strength training
specifically to challenge and improve the client’s balance.
 KNEE FLEXORS

Knee Flexors
Identifying Weakness in the Knee Flexors
Knee flexion occurs when the heel is pulled towards the buttock. The client can bend
each knee in the prone (figure 8.1) or supine (figure 8.2) positions and let you know
whether they perceive a strength deficit between their left and right knees when they
do this. The prone position is not suitable for clients who struggle to get into or rest in
this position. Also, do not use the prone position if there is any soft tissue trauma to the
front of the knee, because it may be uncomfortable for the client to rest with the knee
against the treatment plinth. A client could be tested when standing, but note that in the
standing position, more effort is required during knee flexion to lift the heel at the end
of the movement, whereas in the prone position, more effort is required at the start of
the movement. You may therefore get different results depending on your test position.
For a healthy individual, this test is easy, but after an injury, it may be difficult and you
may wish to begin with a client seated, for example.

Figure 8.1 Active knee flexion in the prone position.

Courtesy of Tim Allardyce, Rehabmypatient.com.

b
Figure 8.2 Active knee flexion in the supine position.
Courtesy of Tim Allardyce, Rehabmypatient.com.

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KNEE FLEXORS

TIP
If there appears to be a deficit in a client’s ability to perform knee flexion actively, it is
important to determine whether this is due to lack of strength or to restriction of the joint.

Oedema can restrict flexion, as is common after injury or surgery to the knee, but
flexion can also be restricted in healthy individuals who have extremely large muscles;
where the hamstrings and calf muscles are well developed, when brought together in
knee flexion, they may prevent the knee from fully flexing. However, you would expect
an equal restriction on both the left and right knees if the restriction were due to bulky
muscles. This would also be the case when assessing someone with a high body mass
index, where fat deposits around the knee may restrict flexion on both knees.
The prone and supine positions are the easiest positions in which to apply manual
resistance to the muscles and thus compare strength between the left and right muscle
groups. To do this, simply stand at the foot end of the plinth and cup your hand around
the client’s ankle. Then, ask your client to try to bend their knee or ‘bring the heel to
the buttock’ whilst you apply the resistance. As a therapist, you have strong leverage
in these positions, which are therefore good positions in which to test the knee flexors
of a client in whom you suspect these muscles are strong (a rugby player, for example).

Knee Flexor Strengthening

Strengthening of the knee flexors is important for people with osteoarthritis in the knee
and after surgery to the knee. It is also important for the recovery from a hamstring
strain. Knee flexors can be strengthened by adding resistance in the sitting (figure 8.3a)
or prone (figure 8.3b) positions using a rubber exercise band. Begin with a straight knee,
and slowly bend the knee against the resistance. Bending the knee against gravity (figure
8.4) is slightly more functional and may not require added resistance. Many clients
benefit from holding a tabletop or chair back for balance.

a b
Figure 8.3 Strengthening the knee flexors using a rubber exercise band in the (a) sit-
ting or (b) prone position.
Courtesy of Tim Allardyce, Rehabmypatient.com.

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 KNEE FLEXORS

a b
Figure 8.4 Strengthening the knee flexors in a standing position.
Courtesy of Tim Allardyce, Rehabmypatient.com.

TIP
The hamstrings tend to cramp when shortened. A quick way to overcome this is to contract
the quadriceps or the hip flexors, using the knee extension exercises shown in the next
section.

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KNEE EXTENSORS

Knee Extensors
Identifying Weakness in the Knee Extensors
Knee extension occurs when the leg is straightened. One of the simplest tests of knee
extension strength is the degree to which a client can straighten their leg when seated
(figure 8.5). This requires no added resistance but can require effort because the leg is
being lifted against gravity.

b
Figure 8.5 Testing knee extension in the sitting position.
Courtesy of Tim Allardyce, Rehabmypatient.com.

An easy way to test knee extension strength by adding manual resistance is to start
with your client in the prone position and with their knee flexed (figure 8.1); place
your hand on the anterior of the ankle and ask the client to try to straighten the knee,
bringing their ankle back down to the treatment couch.

TIP
In the early stages of recovery, it is rarely necessary to apply any resistance to the ankle
when using the exercise shown in figure 8.5. However, in later recovery stages, you could
add resistance by simply placing your hand on the anterior of the client’s ankle before
they begin to straighten the knee.

216
 KNEE EXTENSORS

Knee Extensor Strengthening

Knee extension exercises are important for regaining general knee strength but are
also useful for overcoming cramping in the hamstrings. This is because the quadriceps
(along with the hip flexors) are the antagonists to the hamstrings, and contraction of
the anterior thigh muscles reduces tone in the posterior thigh. These exercises are
important for people with osteoarthritis in the knee and after knee surgery. All of the
weight-bearing exercises illustrated in this section are also suitable as part of an ankle
strengthening programme – provided, of course, that there are no contraindications
(such as an unhealed fracture).
When your goal is strengthening the knee extensors, a useful exercise to begin with
is performed in the supine position with a small towel rolled up beneath the knee. The
aim of the exercise is to straighten the leg (figure 8.6). This requires the knee extensors to
work in a small range of movement. The value of this exercise is that it can be performed
when a person cannot sit or stand, perhaps due to weakness in the knee extensors,
and it is therefore especially helpful in the early stages of recovery from injury. With or
without the towel, this exercise is also helpful when trying to overcome genu flexum,
sometimes caused by contraction of the soft tissues at the back of the knee. Compare
this to figure 8.5. Notice how, in that figure, the knee is moved through a greater range.

b
Figure 8.6 Performing supine knee extension.
Courtesy of Tim Allardyce, Rehabmypatient.com.

If your client is able to flex their hip to approximately 90 degrees, they could prac-
tise knee extension in that position (figure 8.5). This requires lifting the foot through 90
degrees against gravity and can be a good way to progress knee extension exercises
when a client is unable to bear weight. With the hip flexed and the knee extended,
this exercise has the added advantage of helping to assist with lymphatic drainage, and
this could help reduce swelling in the knee. The exercise does, however, require good
hamstring flexibility.
If your client is able, resting in the prone position can also be used. In this position,
the knee is straightened against the resistance of a rubber exercise band (figure 8.7).
This requires your client to be able to hold an exercise band in one hand.

217
KNEE EXTENSORS

Figure 8.7 Knee extension against resistance in the prone position.

Courtesy of Tim Allardyce, Rehabmypatient.com.

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 FUNCTIONAL KNEE EXERCISES

Functional Knee Exercises

One of the exercises commonly overlooked is that of simply trying to stand, with or
without support. In standing, knee extensor strength is required simply to keep the leg
straight, and this can be very difficult after injury. This is a useful exercise if a person
does not yet have the strength or balance to walk far from a chair or bed. Also, because
this exercise requires weight bearing through both legs, the client can gradually increase
the amount of weight they place through the affected knee. Using the hands to press
up from a seated position is a good approach to start with, but eventually, the client
should be encouraged to stand without the aid of their arms. One way to encourage
this is to place the arms across the chest (figure 8.8).

a b c
Figure 8.8 Practising the sit-to-stand exercise.
Courtesy of Tim Allardyce, Rehabmypatient.com.

TIP
Sitting down from a standing position requires more effort than standing from a seated
position. This is because the quadriceps are required to work eccentrically as we lower our
body to a seat, and this is challenging. Therefore, one way to progress this exercise is to
stand quickly, then slowly lower down. A different way to progress the exercise is to place
more weight through the affected knee, rather than keeping the weight evenly distributed.
This has the effect of helping to strengthen that knee whilst performing an exercise that is
relatively stable. Even more challenging is a single-leg sit-to-stand movement.

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FUNCTIONAL KNEE EXERCISES

Once a client is able to stand, they could progress to performing small squats using a
wall for support (figure 8.9). For some people, this is more challenging than the simple
sit-to-stand exercise because it requires balance. The value of squatting in this manner
is that weight is distributed between both legs, making the exercise easier and more
stable than one-leg movements.

a b
Figure 8.9 Miniature squats using a wall for support.
Courtesy of Tim Allardyce, Rehabmypatient.com.

TIP
A way to progress the squatting exercise is to perform miniature squats without a wall,
deeper squats using a wall, and then deeper squats without a wall.

Once someone can perform miniature squats, they could also progress to a split
squat, with the affected knee foremost. Using a chair back or tabletop for support, the
client should place one leg in front of the other and then perform the squat (figure 8.10),
lowering the body only a little. Once the client can perform a small split squat, they
could progress by lowering more and deepening the lunge (figure 8.11). These small
lunges are a preferable starting point compared to full lunges, which require consider-
able strength and balance.

220
 FUNCTIONAL KNEE EXERCISES

a b
Figure 8.10 Performing a miniature split squat.
Courtesy of Tim Allardyce, Rehabmypatient.com.

Figure 8.11 Performing a full split squat.

Courtesy of Tim Allardyce, Rehabmypatient.com.

TIP
In the lunge position, it is important that the knee remains over the ankle and does not
advance farther forwards than the position of the ankle (figure 8.11). A way to encourage this
is to have the client drop the back knee towards the ground rather than lunging forwards.

221
FUNCTIONAL KNEE EXERCISES

Walking is a simple way to improve balance and strength in the knee. The value of
walking with an aid, such as a stick, should not be underestimated; an aid can provide
stability, which can increase the duration a person can walk. Many people are reluctant
to use walking aids, perhaps due to their association with aging. If you are working
with a client who does not want to use an aid outdoors, perhaps encourage them to
use it indoors at least. This could make the difference between the client remaining
predominantly sedentary or using the aid to move around within their home.
Practising small, single-leg bends is another functional exercise (figure 8.12). For
some clients, this may be too challenging because all of the weight is placed through
the knee. However, in later stages of rehabilitation, this may be exactly what is required.
Performing this exercise more slowly makes it more difficult. To progress this further,
the client could flex the knee to a greater degree.

Figure 8.12 Practising a single-leg bend.

Courtesy of Tim Allardyce, Rehabmypatient.com.

An obvious functional exercise is stepping up or stair climbing. In the early stages

of recovery, it is helpful to have a handrail (figure 8.13). This is a challenging exercise
because it requires lifting the entire body up against gravity using one knee at a time.
Therefore, to make the exercise easier, use steps that are small in height, and to make
it more difficult, use a higher step.

222
 FUNCTIONAL KNEE EXERCISES

a b
Figure 8.13 Stepping up with support.
Courtesy of Tim Allardyce, Rehabmypatient.com.

TIP
Stepping down is much harder than stepping up. This is because the extensors of the
supporting knee are required to work eccentrically when stepping down. Therefore, if
your aim is to make the exercise more difficult, encourage the client to step down slowly,
controlling the movement with the affected leg.

223
224 Soft Tissue Therapy for the Lower Limb

Water-Based Exercises
Knee strengthening can be performed in water by practising flexion and extension or
‘cycling’ types of movements. Exercise in water has the advantage of being non–weight-
bearing and therefore forms a valuable component of early rehabilitation. Exercising
in water can help make some of the movements accessible for people who would not
be able to perform them on land. Double-leg and single-leg squats can be performed
more easily in water than on land, for example.

Balance Exercises
Please refer to chapter 9 for balance exercises. Balance is commonly affected after an
injury to the knee and in people with conditions such as knee osteoarthritis. Balance
exercises are an important part of knee rehabilitation and can help maintain or improve
a person’s existing ability to balance.

Quick Questions
1. Other than weakness in the knee flexor muscles, what are three things that
might restrict knee flexion when it is tested actively?
2. When testing the strength of the knee extensors in either the sitting or prone
position, to which part of the lower limb would you apply gentle pressure to
add resistance?
3. What is one advantage and one disadvantage of performing an exercise to
strengthen the knee extensors in the supine position with the hip flexed to
approximately 90 degrees?
4. Why is the stand-to-sit exercise harder to perform than the sit-to-stand exercise?
5. Name three ways you could progress someone who is now able to perform a
miniature squat against a wall, still using a squat-type exercise.
 9
Feet and Ankles
Learning Outcomes
After reading this chapter, you should be able to do the following:
■ Demonstrate simple tests to determine the strength of the ankle flexor, exten-
sor, evertor and invertor muscles.
■ Teach simple exercises to strengthen the ankle flexors, extensors, evertors
and invertors.
■ Explain how to make any of the exercises in this chapter harder or easier.
■ Illustrate a safe, simple way to test balance.
■ Select and demonstrate exercises that are appropriate for common conditions
affecting the ankle.
■ Demonstrate ankle strengthening exercises in supine, sitting and standing
positions.
■ List examples of functional ankle strengthening exercises.
■ Tell which exercises in this chapter are also appropriate for the treatment of
common leg conditions: calf muscle strain, tight calf muscles, calf cramping,
shin splints, and tight tibialis anterior and peroneal (fibular) muscles.

T
he muscles of the ankle bring about different movements: plantar flexion, dorsiflex-
ion, eversion and inversion. The plantar flexors are much stronger than the other
muscles of the ankle because they need to be able to lift the entire body when
pushing off during walking or raising up onto the toes. The dorsiflexors, by contrast,
only have to raise the toes up a little to prevent their catching on the ground during
walking, and even less strength is required in the evertors and invertors. However, a
common mistake is to focus on strengthening only the plantar flexors, when it is in fact
important to strengthen all the muscles of the ankle. Together, these muscles provide
stability to the joint and are important for balance.
Weakness in all the ankle muscles is common after periods of immobilisation – for
example, when someone has sustained a lower limb injury or has been ill. The longer
a person has been unable to use their ankle, the greater the degree of muscle weakness

225
226 Soft Tissue Therapy for the Lower Limb

and the longer it will take to improve this. The exercises provided in this chapter are
useful for the treatment of the conditions described in chapter 6, predominantly ankle
sprains, Achilles tendinopathy, ankle fractures, stiff ankles, plantar fasciitis and stiff feet.
Chapter 6 also covered the postural conditions known as pes planus, pes cavus, pes
valgus and pes varus, and a few of the exercises in this chapter are relevant for those
conditions also.
Strengthening of the ankle muscles is important in the treatment of many conditions,
not only after an injury or immobilisation. For example, a quick way to overcome
cramping in the calf is to contract the antagonist muscle group – the dorsiflexors.
Therefore, you will find the section on how to strengthen ankle dorsiflexors useful if
you are treating people prone to calf cramping. The exercises presented in this chapter
are likely to be helpful in the treatment of the conditions described in chapter 5 – calf
muscle strain, tight calf muscles, calf cramping, shin splints and tight tibialis anterior
and peroneal (fibular) muscles.

Testing Ankle Strength

The easiest way to test ankle strength is to ask your client to perform one of the ranges
of movement – plantar flexion, dorsiflexion, eversion or inversion – against resistance.
Resistance could be in the form of the client’s own body weight, a resistance band, a
wall or even resistance provided by you. The form of resistance you use depends on fac-
tors such as the degree of weakness you suspect and the client’s overall state of health.
For example, to test the strength of the plantar flexors of someone recovering from
a severe ankle sprain, you might ask them to perform a toe raise whilst they are sitting
and let you know whether their ankle feels weak. You might also ask them to lie face
down or supine on a treatment plinth and to plantar flex as you apply resistance to the
foot whilst you assess for any strength deficits. You should not ask them to attempt to
perform a single-leg calf raise, because they will almost certainly lack the strength to
do this, which could be demotivating. They are also likely to lack balance.
The strengthening exercises in this chapter are presented in order from easiest to
hardest as much as possible. Therefore, to test a person’s strength, you could select the
very first exercise initially but would be unlikely to select the last. However, the degree
of difficulty in performing an exercise will depend on the condition you are treating
and the general health of the client. For example, a bilateral toe raise with straight legs
may be easier than a bilateral toe raise with bent knees if someone is recovering from a
torn soleus muscle, because the bent-knee position requires the soleus muscle to work
harder to bring about plantar flexion than does the straight-leg position.
 PLANTAR FLEXORS

Plantar Flexors
Plantar Flexor Muscle Strengthening
One of the easiest ways to strengthen
the plantar flexors is to lift the heels off
the ground whilst seated (figure 9.1).
This is the kind of exercise that might be
appropriate after a prolonged period of
immobilisation, when the ankle will be
especially weak and the person is likely
to have very poor balance. Because this
exercise involves lifting only the weight
of the lower legs and partial weight of
the thighs, the advantages are that it is
manageable for most people, does not
need to be performed bilaterally and
does not require balance. Therefore, it is Figure 9.1 Strengthening the plantar flex-
generally a safe exercise to use and a good ors using minimal resistance.
one with which to start. Courtesy of Tim Allardyce, Rehabmypatient.com.

TIP
To progress this exercise, the client could simply place their hands on their knees whilst
leaning forwards slightly, thus using their own body weight to apply some resistance.

Another way to strengthen the plantar

flexors is using a resistance band. In this
exercise, the client begins with their foot in
dorsiflexion (figure 9.2a) and then plantar
flexes against the resistance of the band
(figure 9.2b). This exercise can be performed
sitting on the floor or on a chair.
Using body weight as the resistance is
an effective way to strengthen the plantar
a flexors, but it can be challenging. A good
way for the client to start is by holding on
to a chair for balance and rising up onto
the toes bilaterally (figure 9.3a). Note that
the exercise may feel different if the feet are
turned in (figure 9.3b) or out (figure 9.3c).

Figure 9.2 Using a resistance band to

strengthen the plantar flexors: (a) Begin in
dorsiflexion and (b) gently plantar flex.
b
Courtesy of Tim Allardyce, Rehabmypatient.com.

227
PLANTAR FLEXORS

b c
Figure 9.3 Strengthening the plantar flexors when standing with the feet in a (a) neu-
tral, (b) toe-in or (c) toe-out position.
Courtesy of Tim Allardyce, Rehabmypatient.com.

TIP
A single-leg raise should be used only when a person can comfortably perform a bilateral
toe raise with no pain.

228
 PLANTAR FLEXORS

It is interesting to compare a straight-leg toe

raise with a bent-knee toe raise. In the bent-
knee position (figure 9.4), the soleus must work
harder than in the straight-leg position. This
exercise could be useful when working with
people recovering from a soleus strain. It can
also be useful to help determine if there is any
strength deficit in the soleus.
Eccentric calf training is a commonly used
exercise for ankle rehabilitation. It requires a
step or stair, preferably with a handrail for bal-
ance. It can be performed with a small towel
beneath the toes (see figure 9.5) or without. In
this exercise, the client begins on tiptoe (figure
9.5a) and slowly lowers their heels to beneath
the level of the step (figure 9.5b). This move-
ment requires eccentric contraction of the calf
and is more challenging than plantar flexion
(which involves concentric contraction). Figure 9.4 Strengthening the soleus.
Courtesy of Tim Allardyce, Rehabmypatient.com.

a b
Figure 9.5 Performing an eccentric calf contraction exercise (a) begins on tiptoe and
(b) ends in dorsiflexion.
Courtesy of Tim Allardyce, Rehabmypatient.com.

229
DORSIFLEXORS

Dorsiflexors
Dorsiflexor Muscle Strengthening
In either a sitting (figure 9.6) or lying position, a simple way to strengthen the ankle
dorsiflexors is for the client to apply resistance to the ankle using their other foot as they
attempt to dorsiflex. If this proves difficult, a resistance band can be used. This exercise
often works best in the supine position (figure 9.7) with the band wrapped around a
secure anchor or being held by someone else. Activation of the ankle dorsiflexors is a
quick way to overcome cramping in the calf. If a client can bear weight through the
ankle, then walking on the heels (figure 9.8) is another possibility.

Figure 9.6 (a) Applying resistance to the ankle dorsiflexors using the opposite foot
whilst (b) trying to raise the bottom foot.
Courtesy of Tim Allardyce, Rehabmypatient.com.

230
 DORSIFLEXORS

Figure 9.7 Using a resistance band to strengthen the ankle dorsiflexors.

Courtesy of Tim Allardyce, Rehabmypatient.com.

Figure 9.8 Heel walking to strengthen the dorsiflexors.

Courtesy of Tim Allardyce, Rehabmypatient.com.

231
EVERTORS

Evertors
Evertor Muscle Strengthening
Most people find eversion of the ankle more difficult than plantar flexion or dorsiflexion,
perhaps because eversion is a relatively small movement. Strengthening the evertors is
crucial after a lateral ankle sprain. In a systematic review, Wagemans and colleagues
(2022) concluded that exercise rehabilitation reduces the risk of reinjury after a lateral
ankle sprain but that there was insufficient evidence to determine the optimal content of
a rehabilitation programme. Although unilateral exercises could be used to strengthen
the evertors, bilateral exercises are preferable because they are simply much easier
to perform, irrespective of the amount of existing ankle strength. For example, when
lying or sitting (figure 9.9a), the client can cross the feet at the ankles and use the feet
to oppose eversion or can use a resistance band looped around the ankles (figure 9.9b)
to provide the resistance.

a b

Figure 9.9 Exercises to strengthen the ankle evertors using (a) self-resistance or (b) a
resistance band.
Courtesy of Tim Allardyce, Rehabmypatient.com.

232
 INVERTORS

Invertors
Invertor Muscle Strengthening
Similarly to eversion, inversion is a movement many people find difficult to perform
compared to plantar flexion or dorsiflexion because the ankle has less movement into
inversion than into plantar flexion or dorsiflexion. The invertors are important muscles
and contribute to balance; therefore, there is a good rationale for strengthening them.
An easy way to strengthen the invertors is by using a resistance band. The band is
placed around the foot, and the client inverts the ankle against the resistance (figure
9.10). This exercise could be performed sitting on the floor, as shown in figure 9.10,
or in a chair or bed.

Figure 9.10 Using a resistance band to strengthen the ankle invertor muscles.
Courtesy of Tim Allardyce, Rehabmypatient.com.

233
BALANCE

Balance Exercises
When someone stops using their lower limbs, whether this is due to illness or to an
injury affecting the hip, thigh, knee, ankle or foot, the muscles start to deteriorate,
and the person loses not only strength but balance. Poor balance increases the risk of
injury, and this is especially significant for older adults or those with osteoporosis, in
whom the risk of fracture from falls is significant. Fortunately, many exercises can be
used to improve balance, and the simplest and most effective of these are shown in
the following sections.

Testing Balance
The single-leg standing exercise (figure 9.11) can be used to both test and improve
balance.

Balance is impaired not only after an injury to the ankle but also when there are
issues affecting the knee or even the hip. Therefore, the material in this section will also
be useful when helping people to recover from hip and knee conditions.
To test or improve balance, ask your client to stand with their feet hip distance apart.
Next, ask them to shift their weight onto the non-affected lower limb, then to flex the
knee of that leg slightly. Once the knee is slightly
flexed, ask them to lift their other foot off the floor,
transferring all their weight onto the non-affected
side. They do not need to lift the affected limb
high off the floor, but they should prevent it from
touching the leg on which they are balancing (see
figure 9.11). Note the amount of time they can
remain in this position. You may wish to try this
three times and determine the average duration. It
can be helpful to ask your client to keep a diary,
noting improvements in the length of time they can
perform the one-leg balance exercise. This exercise
strengthens leg muscles, and it is normal for the
client to experience some aching in the leg in the
following 2 days, as with all strength training.
Because we use our eyes to help us balance,
practising the single-leg standing exercise with
the eyes closed creates more of a challenge. To
make balance exercises safer when the eyes are
closed, it is helpful to perform them where there
is a handhold nearby – a table surface or the back Figure 9.11 The single-leg stand
of a chair, for example. You need to determine for to test and improve balance.
yourself whether practising with the eyes closed Courtesy of Tim Allardyce,
will be safe for your client. Rehabmypatient.com.

234
 BALANCE

After the client performs the one-leg balance exercise on the non-affected side, have
them repeat it on the affected side. There are two ways to determine whether balance
is impaired in this position. In most cases, either your client will not be able to balance
on the affected side (or the length of time they can stand on that leg will be significantly
reduced) or they may be able to balance but with a lot of wobbling and use of the arms
to maintain the position. The simplest way to improve balance is to practise this exercise.
There are many ways that this exercise can be progressed. A common mistake is
to progress too quickly, such as by using a ‘wobble’ board – an unstable board that
wobbles when a person stands on it, thus challenging balance. However, if used too
soon, this increases the risk of reinjury. There are many other, safer ways to challenge
balance and improve strength in the ankle at the same time.
One of the best ways to progress the single-leg standing exercise is to have the client
practise it whilst standing on a sloped surface rather than flat ground. When we face
uphill or downhill or stand with our side towards the top or bottom of a hill, force
passes through different parts of the ankle.
An easy way to progress the balance exer-
cise is simply to have the client practise
it when standing on a gentle slope, facing
different directions.
Another way to challenge balance is to
stand on an uneven surface or a surface
with a different texture. For example,
standing on a wooden floor provides more
support than standing on a thick carpet or
on a rolled-up towel.
Items such as a wobble board should
only be used once a person can balance
on different static slopes and surfaces.
It is important to challenge balance
safely. One exercise you may wish to try
is the clock exercise. Have your client
imagine they are standing in the centre of
a clock that is drawn on the ground (figure
9.12). When standing on the affected limb,
have them use the toes of the non-affected
limb to point to where various numbers
would be on the clock. This requires move-
ment of the non-affected limb away from Figure 9.12 The ‘clock’ exercise to chal-
the midline, making it more challenging lenge balance.
to maintain balance. Courtesy of Tim Allardyce, Rehabmypatient.com.

235
FUNCTIONAL ANKLE EXERCISES

Functional Exercises to Strengthen the Ankle and Improve

Balance
Exercises that are more representative of everyday use of the ankle are those that
combine both strength and balance, such as standing on one leg whilst brushing one’s
teeth or hair. For some people, this may be too challenging. An easier exercise might
be to simply stand with one leg in front of the other and sway forwards and backwards,
placing weight first on the front leg and then on the back leg (figure 9.13). It is important
to alternate the leg that is in front, but it does not matter whether the affected or non-
affected leg is positioned in front to begin. This could be progressed to walking in a
straight line as if on a tightrope (figure 9.14).

a b a b

Figure 9.13 Weight transfer forwards Figure 9.14 Walking as if on a tightrope to

and backwards. challenge balance.
Courtesy of Tim Allardyce, Rehabmypatient.com. Courtesy of Tim Allardyce, Rehabmypatient.com.

236
 FUNCTIONAL ANKLE EXERCISES

Positioning the legs hip distance apart and transferring weight from side to side (figure
9.15) is another way to make strengthening exercises more functional.

a b
Figure 9.15 Weight transfer side to side.
Courtesy of Tim Allardyce, Rehabmypatient.com.

Finally, all kinds of exercises can be used to improve strength and balance simply
by introducing movement in different positions, such as leaning forwards on one leg.

237
TOES

Exercises to Strengthen the Feet and Toes

It is difficult to separate exercises for the feet and toes from those of the ankle, because
the toes contain not only small, intrinsic muscles but also muscles that attach to the
leg via the ankle: the long toe flexors and extensors and the evertors and invertors of
the ankle. Therefore, many of the preceding exercises will also help to strengthen the
feet and toes, and certain exercises may be helpful to strengthen the flexors of the toes
specifically. Whilst the exercises in this chapter may have little effect, if any, on pes
varus, pes valgus and pes cavus foot postures, the exercises that follow may be helpful
for people with pes planus (flatfoot).
One way to treat pes planus caused by faulty postural activity of the foot muscles is
to stand barefoot, with the feet hip distance apart, then consciously contract the but-
tock muscles. Notice how contraction of the buttocks lifts the medial arches of the feet.
To strengthen the tibialis posterior and the long toe flexors, toe flexion could be
performed against the resistance of an exercise band. One way to do this is to dorsiflex
the ankle, then place the flat band along the length of the foot (figure 9.16a). Whilst
holding the band taut, flex the toes against it (figure 9.16b).

a b

Figure 9.16 (a) Starting and (b) ending positions when using an exercise band to
strengthen the long toe flexors.

Some clients find it fun to try foot gymnastics, which are commonly prescribed for
flexible pes planus despite little evidence that they are effective. Examples of exercises
used in foot gymnastics are using the feet and toes to tie a knot in a rope, using the toes
to pick up and fasten a clothes peg to a line or to the edge of a cup, passing a stick or
pencil back and forth with a partner, holding a paper cup between the toes of one foot
whilst using the toes of the other foot to pick up small objects and deposit these in the
cup or using the toes to pick up small hoops and place them over a pole. A simple way
to begin might be to try picking up a facecloth or a small towel (figure 9.17).

238
 TOES

a b
Figure 9.17 Using the toes to pick up a small towel to strengthen the toe flexors.
Courtesy of Tim Allardyce, Rehabmypatient.com.

Quick Questions
1. List three advantages of a seated calf raise when treating someone with weak
ankles or poor balance.
2. Which ankle muscles does heel walking strengthen?
3. Why might it be preferable to perform ankle evertor exercises bilaterally?
4. When the single-leg standing test is used, what two things indicate that some-
one has poor balance?
5. Give examples of foot strengthening exercises used in foot gymnastics.

239
 App
ppendix
Lower Limb Postural Assessment Chart

U
se this lower limb postural assessment chart to document your observations,
recording these in the appropriate column depending on whether what you
observe affects the right or the left side of the body.

ANTERIOR VIEW
Right side Posture Left side
Stance

Lateral tilt of the pelvis

E8778/Johnson/F A.01/718734/pulled/R1

E8778/Johnson/F A.02/718735/pulled/R1

240
Appendix 241

ANTERIOR VIEW
Right side Posture Left side
Pelvic rotation

Muscle bulk and tone

E8778/Johnson/F A.03/718736/pulled/R1

Genu varum orA.04/718737/pulled/R1

E8778/Johnson/F genu valgum?

(continued)
E8778/Johnson/F A.05/718738/pulled/R1
242 Appendix

Lower Limb Postural Assessment Chart (continued)

ANTERIOR VIEW
Right side Posture Left side
Patellar position

Rotation of the lower limb

E8778/Johnson/F
E8778/Johnson/F
A.06/723393/pulled/R1
A.06/723393/pulled/R1

E8778/Johnson/F A.07a/718740/pulled/R1

E8778/Johnson/F A.07b/718761/pulled/R1
Appendix 243

ANTERIOR VIEW
Right side Posture Left side
Tibial torsion

Q angle
Anterior superior
iliac spine

E8778/Johnson/F A.08/718741/pulled/R1
Q angle

Midpoint of the
patella
Tibial tuberosity

Ankles

E8778/Johnson/F A.09/718742/pulled/R2

E8778/Johnson/F A.10/718743/pulled/R1 (continued)

244 Appendix

Lower Limb Postural Assessment Chart (continued)

ANTERIOR VIEW
Right side Posture Left side
Foot position

Other observations

E8778/Johnson/F A.11/718744/pulled/R1

POSTERIOR VIEW
Right side Posture Left side
Pelvic rim

E8778/Johnson/F A.12/7187454/pulled/R1
Appendix 245

POSTERIOR VIEW
Right side Posture Left side
Posterior superior iliac spines and
buttock crease

x x

Pelvic rotation
E8778/Johnson/F A.13/718746/pulled/R1

Internal rotation of the hip

E8778/Johnson/F A.15/718748/pulled/R1

(continued)
E8778/Johnson/F A.14/718747/pulled/R2
246 Appendix

Lower Limb Postural Assessment Chart (continued)

POSTERIOR VIEW
Right side Posture Left side
Muscle bulk and tone

Posterior knee

E8778/Johnson/F A.16b/718762/pulled/R1
E8778/Johnson/F A.16a/718749/pulled/R1

Calf midline

E8778/Johnson/F A.17/718750/pulled/R2

E8778/Johnson/F A.18/718751/pulled/R1
Appendix 247

POSTERIOR VIEW
Right side Posture Left side
Achilles tendon

Pes valgus or pes varus?

E8778/Johnson/F A.19/718752/pulled/R1

Foot position
E8778/Johnson/F A.20/718753/pulled/R2

Other observations
E8778/Johnson/F A.21/718754/pulled/R1

(continued)
248 Appendix

Lower Limb Postural Assessment Chart (continued)

LATERAL VIEW
Left side Posture Right side
Overall lower limb posture

Anterior or posterior pelvic tilt?

E8778/Johnson/F A.22/718755/pulled/R1

Genu recurvatum or genu flexum?

E8778/Johnson/F A.23/7187564/pulled/R1

E8778/Johnson/F A.24/718757/pulled/R1
Appendix 249

LATERAL VIEW
Left side Posture Right side
Ankles

Pes cavus or pes planus?

E8778/Johnson/F A.25/718758/pulled/R1

Other observations
E8778/Johnson/F A.26/718759/pulled/R1

From J. Johnson, Soft Tissue Therapy for the Lower Limb (Champaign, IL: Human Kinetics, 2025).
 Answers to Quick Questions

Chapter 1 Answers
1. When using the anterior view, it is useful to use the anterior superior iliac spines
(ASIS) when assessing someone for pelvic rotation.
2. It is more accurate to measure the Q angle with a client standing rather than
supine because when the client is standing, the patella is under the usual
weight-bearing stresses.
3. When someone has a pelvis that is laterally tilted upwards on the right, the
right hip is adducted and the left hip is abducted.
4. In the posterior view, the purpose of imagining or drawing a line down the
midline of the calf is to help determine whether there is rotation in the lower
limb, particularly the hip.
5. Key observations that might indicate someone has genu recurvatum posture
(knee hyperextension) are a large portion of the calf falling posterior to a plumb
line (in the side view), the popliteal space appearing prominent (in the posterior
view) and the patella appearing to be compressed and pointing downwards
(in the anterior view).

Chapter 2 Answers
1. A treatment aim is a general, overarching target, whereas a treatment goal is a
specific set of steps needed to reach that target.
2. Treatment aims listed in this chapter are the following:
Reduce pain
Reduce swelling
Improve balance
Overcome the sensation of muscle stiffness
Overcome or prevent muscle cramping
Regain normal movement in a joint
Improve weight bearing through the lower limb
Improve lower limb strength
Regain everyday lower limb function
Educate the client
Help correct postural imbalance
3. The pain measurement tools described in this chapter are the Visual Analogue
Scale (VAS) and the Numerical Pain Rating Scale (NPRS).

250
Answers to Quick Questions 251

4. Common lower limb muscle length tests are the prone knee bend test, straight-
leg raise test, Thomas test and Ober test.
5. The Lower Extremity Functional Scale is a measure of lower limb function. The
user is asked to score the level of difficulty they have, or would have, if attempt-
ing certain activities, irrespective of what lower limb condition they have.

Chapter 3 Answers
1. The sciatic nerve is affected in piriformis syndrome.
2. In a groin strain, the adductor muscles may be damaged by impact, sudden
contraction or overstretching.
3. When applying a gentle passive stretch in the supine position to someone
with tight left hip adductors, it is helpful for the clinician to stabilise the pelvis
by placing their right hand over the client’s right anterior superior iliac spine.
4. When treating someone with tight hip flexors, soft tissue release can be applied
to the iliacus with the client in the side-lying position.
5. To identify the tensor fasciae latae with a client in the supine position, ask the
client to lift their leg off the treatment couch and rotate the hip internally as
you palpate the muscle close to the posterior side of the iliac crest.

Chapter 4 Answers
1. Signs that may identify a hamstring strain include the following:
Pain on palpation
Pain on stretching of the muscle
Pain on resisted knee flexion
Pain on resisted hip extension
Bruising (severe cases)
Loss of strength in knee flexion or hip extension (severe cases)
2. When a client uses soft tissue release in the supine position, dorsiflexing the
ankle increases the stretch compared to when the ankle is plantar flexed.
3. When using a ball to deactivate trigger points in the sitting position, the ball
should be moved after about 30 seconds.
4. When stretching the quadriceps in the prone position, placing a towel beneath
the knee extends the hip and therefore enhances the stretch to one of the quad-
riceps muscles – the rectus femoris.
5. For some people, a foam roller is helpful for reducing sensations of quadriceps
tightness.

Chapter 5 Answers
1. Actively contracting the tibialis anterior helps reduce the sensation of cramp-
ing in the calf.
252 Answers to Quick Questions

2. A more accurate term for shin splints is medial tibial stress syndrome.
3. When preparing to work on trigger points in the peroneal (fibular) muscles,
it is important to be aware of the peroneal nerve in the region of the head of
the fibula.
4. When working with someone with osteoarthritis in the knee, soft tissue tech-
niques should be used in conjunction with therapeutic exercise because there
is not enough evidence to support the use of soft tissue techniques alone.
5. When applying tape for the treatment of genu recurvatum, the tape is applied
with the knee in a neutral knee posture.

Chapter 6 Answers
1. It is necessary to educate a client with regards to the importance of rehabilita-
tion after an ankle sprain because there is strong evidence that having had an
ankle sprain is a risk factor for subsequent re-sprain.
2. When working with someone who had their ankle immobilised after a fracture,
it is necessary to mobilise and stretch the joints of the foot and toes.
3. It useful to stretch the ankle joint to more than 90 degrees as part of treatment
for a stiff ankle because the ankle joint needs to dorsiflex to more than 90
degrees during normal walking.
4. In the pes valgus foot posture, there is compression of the soft tissues on the
lateral side of the ankle.
5. Massage is helpful when applied to the medial side of the leg, ankle and foot
when working with someone with the pes varus foot posture.

Chapter 7 Answers
1. When using the bridge exercise to test a client’s hip extensor strength, three
things that indicate weakness are (1) the exercise appearing difficult for the
person, (2) inability to keep the pelvis parallel to the floor and (3) shaking.
2. The two functional exercises described in the text to strengthen hip abductors
are sidestepping and side step-ups.
3. The advantage of testing the strength of hip adductors bilaterally in the frog-like
supine position is that you can compare the left and right hips and therefore
help determine what is normal hip strength for your client.
4. Whether performed in the standing or supine position, more strength is required
to perform hip flexion with the knee extended.
5. Water-based exercises are helpful for someone with a hip problem because they
can be used in the early stages of recovery to improve mobility and strength.

Chapter 8 Answers
1. Oedema, large thigh and calf muscles and fat deposits around the knee can
all restrict active knee flexion.
Answers to Quick Questions 253

2. When testing the strength of the knee extensors in either the sitting or prone
position, gentle pressure can be applied to the anterior of the ankle to add
resistance.
3. One advantage of performing an exercise to strengthen the knee extensors in
the supine position with the hip flexed to approximately 90 degrees is that this
helps to reduce swelling of the knee; one disadvantage is that it requires good
flexibility in the hamstrings.
4. The stand-to-sit exercise is harder to perform than the sit-to-stand exercise
because when we sit down, the quadriceps must work eccentrically, and this
requires more effort than a concentric contraction (as in the sit-to-stand move-
ment).
5. Once someone is able to perform a miniature squat against a wall, this could
be progressed to a miniature squat without a wall, a deep squat with a wall,
or a deep squat without a wall.

Chapter 9 Answers
1. Three advantages of a seated calf raise when treating someone with weak ankles
or poor balance are that (1) it is manageable by most people, (2) it does not
need to be performed bilaterally and (3) it does not require balance.
2. Heel walking strengthens the ankle dorsiflexor muscles.
3. It might be preferable to perform ankle evertor exercises bilaterally because
this is easier than performing them unilaterally, irrespective of ankle strength.
4. Poor balance is indicated in the single-leg standing test when the duration for
which a person can stand on their affected leg is reduced compared to the
non-affected leg or when there is a lot of wobbling and the person must use
their arms to maintain the position.
5. Examples of foot strengthening exercises used in foot gymnastics are using
the feet and toes to tie a knot in a rope, using the toes to pick up and fasten a
clothes peg to a line or to the edge of a cup, passing a stick or pencil back and
forth with a partner, holding a paper cup between the toes of one foot whilst
using the toes of the other foot to pick up small objects and deposit these in
the cup or using the toes to pick up small hoops and place them over a pole.
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 About the Author

Jane Johnson, PhD, MSc, BSc(Hons), BA(Hons), CSP,

HCPC, is a chartered physiotherapist specializing in
occupational health and massage. In this role she assesses
the posture of clients; performs manual assessments,
including that of the soft tissues; and determines whether
work, sport, or recreational postures may be contributing
Photo courtesy of Kathryn Faulkner.

to a person’s symptoms. She devises postural correction

plans that include both hands-on and hands-off tech-
niques. A key element of her work involves educating
each client in how to self-manage their condition.
Johnson has taught continuing professional develop-
ment workshops for organizations in the United Kingdom
and abroad. This experience has brought her into con-
tact with thousands of therapists of varying disciplines
and has informed her own practice. Johnson has a particular passion for inspiring and
supporting students and newly qualified therapists to gain confidence in the use of
assessment and treatment techniques.
Johnson is a member of the Chartered Society of Physiotherapy and is registered with
the Health and Care Professions Council. For many years she provided expert witness
reports on cases involving soft tissue therapies. Johnson is the author of six titles in
the Hands-On Guides for Therapists series: Postural Assessment, Postural Correction,
Therapeutic Stretching, Soft Tissue Release, Deep Tissue Massage and Soft Tissue and
Trigger Point Release. These titles have been translated into multiple different languages,
including Japanese, traditional Chinese, simplified Chinese, Korean, German, Italian,
Spanish and Portuguese. Postural Assessment has sold over 15,000 copies. Johnson is
also the author of The Big Back Book: Tips & Tricks for Therapists.
Johnson regularly delivers webinars on popular musculoskeletal topics as well as on
life working as a therapist. In her Facebook group, ‘Jane Johnson: The Friendly Physio’,
she shares tips and tricks in her usual friendly manner.
Johnson lives in the north of England in an unmodernized house, where she creates
books and webinars, keeps a sketchbook and nature journal, and rehomes big rescue
dogs. Her Instagram page is @janejohnson5047, ‘The physio who keeps a sketchbook’.

261
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