LOWER EXTREMITY:ARTICULATORY AND MUSCLE

ENERGY

Blackboard Copy

Articulatory Objectives Demonstrate 70% minimum competency of the following skills:

On a written exam Identify: Therapeutic goals of articulatory techniques Indications for performing articulatory techniques Absolute and relative contraindications to performing articulatory techniques The mechanism of action of articulatory techniques Correctly described techniques

On a practical exam: Verbally describe and correctly perform LE articulatory techniques if assigned

on a practical exam

Muscle Energy Objectives The osteopathic medical student will demonstrate a 70% minimum

competency/understanding of the following subject areas on a written and/or practical examination:

1. Define muscle energy technique2. Describe the different types of muscle energy technique3. State the principles and proposed mechanisms of muscle energy

technique4. Verbalize and perform the essential steps applicable to all muscle

energy techniques5. Identify the indications and contraindications for the use of muscle

energy technique in all body areas6. Demonstrate ability to use muscle energy technique treatment

principles in diagnosing and treating segmental motion restrictions7. Correctly identify descriptions of muscle energy mechanics, patient

positioning and treatments.

Disclaimer! In this lecture you will be learning muscle

energy and articulatory techniques. SOME of the techniques you’ll learn today are ONLY

articulatory or ONLY muscle energy. Give us your attention this hour so you can keep ‘em

straight! ATTENTION: treatments are named

differently...again. “-ion” = Articulatory technique, named by

restriction. “-ed” = Muscle energy technique, named by

position of ease

Do you know what this is? CPM (Continuous Passive Motion) Machine

Articulatory vs. ME ReviewArticulatory Muscle Energy

In/direct

Active vs Passive

Low velocity, moderate-high amplitude

No velocity, no amplitude

Frequency

5-50x 3-5 seconds, 3-5x

Principles “Stabilize, localize, articulate” “Control, balance, localization”

1° MOA Mobilize joints within their physiologic ranges of motion

Frequently uses postisometric relaxation and reciprocal inhibition to reset the stretch reflex to a decreased resting muscle tone and increases resting length of the muscle fibers.

Passive Active

Direct Direct

Articulatory Muscle Energy

Indications

Presence of a somatic dysfunction

Limited or lost articular motion and when a restrictive barrier is emanating from a joint itself or the respective periarticular tissue.

Presence of a somatic dysfunction

To reposition or mobilize an articulation to restores its normal arthrokinematics

Lengthen a shortened or spastic muscle

Strengthen a physiologic weak muscle or muscle group

Decrease edema and passive congestion

Contra-indications

Open wounds/infection Infection, hematoma, tear in involved muscle

Fracture/dislocation Fracture, avulsion, or dislocation of involved joint

Tendon/ligament avulsions

Severe osteoporosis

Severe osteoporosis Metastatic disease of bone or soft tissue

Bleeding disorders Rheumatologic conditions causing instability of the C-spine.

Articulatory vs. ME Review

Types of Muscle Energy Isometric Isotonic Eccentric or Isolytic Antagonistic Inhibition

Which type do we use primarily at COMP? Isometric

Lower Extremity Anatomy

Iliopsoas Piriformis/Gemelli/Quadratus Femoris Gluteal Muscles

Lower Extremity Anatomy

Quadriceps Hamstrings Gastrocnemius/Tibialis Anterior

Lumbar Plexus

Hip Flexion / Extension: 110° / 10° Abduction / Adduction: 30° Internal / External rotation: 40° Knee Flexion: 135° Ankle Dorsi / Plantarflexion: 20° / 40° Inversion / Eversion : 20° / 10° *Foundations of Osteopathic Medicine, ed. 3

AROM (perform bilaterally)

Hip (flex/extend, ab/adduction, int/ext rotation)

Knee (flex/ext)

Ankle/Foot (dorsi/plantarflexion, in/eversion)

REGIONAL EXAMINATION

PROM (perform unilaterally) - one area to be assigned by grader

Hip (flex/extend, ab/adduction, int/ext rotation)

Knee (flex/ext)

Ankle/Foot (dorsi/plantarflexion, in/eversion)

WHERE ARE YOUR RESTRICTIONS?…

Range of Motion

Hip Techniques

Articulatory Muscle Energy

Hip Flexion -----

Hip Extension Hip Flexed

Hip ABduction Hip ADducted

Hip ADduction Hip ABducted

Hip Internal Rotation Hip Externally Rotated

Hip External Rotation Hip Internally Rotated

Hip FlexionArticulatory

Flex the patients hip to the flexion restriction barrier while keeping the knee extended

The flexion restrictive barrier is repetitively engaged 10-50 times

Hip Extension//Hip Flexed Articulatory ME

Extend the patients hip to the extension restriction barrier off the table while stabilizing the contralateral ASIS

The extension restrictive barrier is repetitively engaged 10-50 times

stabilize

• Extend the patients hip on the table, stabilizing the right knee off the table.

• Pt instructed to flex and ER the hip against the physicians unyielding counterforce x 3-5 seconds, followed by relaxation x 2-3 seconds.

• Reposition into new restrictive barrier.• Repeat 3-5x; final stretch.

Alternate Set Up for MET

Hip ABduction//Hip ADductedArticulatory ME

ABduct the patients hip to the ABduction restriction barrier

The restrictive barrier is repetitively engaged 10-50 times

• ABduct the patients hip to the ABduction restriction barrier

• Pt instructed to adduct their leg against the physicians unyielding counterforce x 3-5 seconds, followed by relaxation x 2-3 seconds.

• Reposition into new restrictive barrier.• Repeat 3-5x; final stretch.

Hip ADduction//Hip ABductedArticulatory ME

ADduct the patients hip to the ADduction restriction barrier

The restrictive barrier is repetitively engaged 10-50 times

• ADduct the patients hip to the ADduction restriction barrier

• Pt instructed to abduct their leg against the physicians unyielding counterforce x 3-5 seconds, followed by relaxation x 2-3 seconds.

• Reposition into new restrictive barrier.• Repeat 3-5x; final stretch.

Hip Internal Rotation//Hip Externally RotatedArticulatory ME

Supine: Apply an internal rotation force through the patients ankle while stabilizing the patient’s distal thigh

The restrictive barrier is repetitively engaged 10-50 times

stabilize

• Prone: Pt is prone, knee flexed to 90°; physician stabilizes opposite PSIS.

• Internally rotate the patients hip to the restriction barrier

• Pt instructed to externally rotate their leg against the physicians unyielding counterforce x 3-5 seconds, followed by relaxation x 2-3 seconds.

• Reposition into new restrictive barrier.• Repeat 3-5x; final stretch.

*Can be performed supine or prone.

Supine set-up for Artic + ME Prone set-up for Artic + ME

Hip External Rotation//Hip Internally RotatedArticulatory ME

Supine: Support the patient’s heel and foot, flexing the hip and knee to 90°

Externally rotate the hip, engaging the restrictive barrier

The restrictive barrier is repetitively engaged 10-50 times

• Prone: Pt is prone, knee flexed to 90°; physician stabilizes opposite PSIS.

• Externally rotate the patients hip to the restriction barrier

• Pt instructed to internally rotate their leg against the physicians unyielding counterforce x 3-5 seconds, followed by relaxation x 2-3 seconds.

• Reposition into new restrictive barrier.• Repeat 3-5x; final stretch.

*Can be performed supine or prone.Supine set-up for

Artic + ME

Prone set-up for Artic + ME

MET & Articulatory: Hip

Hip Adducted (ME)/ Hip Abduction (Artic)

Hip Flexed (ME)/ Hip Extension (Artic) Hip Abducted (ME)/

Hip Adduction (Artic)

Hip Internally Rotated (ME)/ Hip External Rotation (Artic)

Hip Flexion (Articulatory ONLY)

Hip ExternallyRotated (ME)/ Hip Internal Rotation (Artic)

Knee and Ankle/Foot Techniques

Articulatory Muscle Energy

Knee Flexion Knee Extended

-------- Hamstring Restriction(2 ways)

Ankle Dorsiflexion Ankle Plantar Flexed

Ankle Plantar Flexion Ankle Dorsiflexed

Ankle (Talocalcaneal Motion) --------

Tarsometatarsal jt --------

Metatarsal-phalangeal jt --------

Knee Flexion//Knee ExtendedArticulatory ME

Apply a flexion force through the distal LE to the flexion restrictive barrier

The restrictive barrier is repetitively engaged 10-50 times without returning to neutral

• Pt instructed to extend their leg against the physicians unyielding counterforce x 3-5 seconds, followed by relaxation x 2-3 seconds.

• Reposition into new restrictive barrier.• Repeat 3-5x; final stretch.

Hamstring Restriction (knee flexed)Muscle Energy

Flex the patient’s hip into the restrictive barrier keeping the knee extended.

Pt instructed to extend their hip against the physicians unyielding counterforce x 3-5 seconds, followed by relaxation x 2-3 seconds.

Reposition into new restrictive barrier. Repeat 3-5x; final stretch.

Alternate method: Pt flexes right hip and knee Pt instructed to flex their knee against the

physicians unyielding counterforce…

MET/Articulatory Knee

Hamstring Restriction/Knee Flexed (2 ways)(ME only)

Knee Extended (ME)/Flexion Knee (Artic)

Ankle Dorsiflexion//Ankle Plantar FlexedArticulatory ME

Dorsiflex the foot into the restrictive barrier

The restrictive barrier is repetitively engaged 10-50 times never quite returning to neutral

• Supporting the heel, dorsiflex the foot into the restrictive barrier

• Pt instructed to plantar flex their ankle against the physicians unyielding counterforce x 3-5 seconds, followed by relaxation x 2-3 seconds.

• Reposition into new restrictive barrier.• Repeat 3-5x; final stretch.

Ankle Plantar Flexion//Ankle DorsiflexedArticulatory ME

Supporting the heel, plantar flex the foot into the restrictive barrier

The restrictive barrier is repetitively engaged 10-50 times never quite returning to neutral

• Supporting the heel, plantar flex the foot into the restrictive barrier

• Pt instructed to dorsiflex their ankle against the physicians unyielding counterforce x 3-5 seconds, followed by relaxation x 2-3 seconds.

• Reposition into new restrictive barrier.• Repeat 3-5x; final stretch.

Ankle Talocalcaneal MotionArticulatory

Grasp the heel and talus Apply and maintain a traction force

and articulate through full ROM (plantar/dorsiflexion, inversion/eversion)

The restrictive barrier(s) is repetitively engaged 10-50 times

Tarsometatarsal Joint Motion Articulatory

The physician contacts the tarsal bones and the appropriate metatarsal intended for treatment.

The physician performs a rhythmic articulatory motion, enhancing gliding motion between the bases of the metatarsal bones and the tarsometatarsal articulations.

Metatarsal Head MotionArticulatory

The physician stabilizes one metatarsal and then articulates the neighboring metatarsal through a dorsal/plantar glide

The Lateral hand then rotates medially and laterally increasing rotatory capacity of the metatarsal heads.

Each metatarsal head and shaft is evaluated and treated sequentially.

Metatarsal-Phalangeal JointArticulatory

The physician stabilizes the metatarsal and then articulates the corresponding proximal phalanx through flexion/extension, superior/inferior “glide” (translation), medial/lateral rotation, and medial/lateral “tilt” (translation)

Treat other interphalangeal joints in a similar fashion (stabilize proximal, move distal) until improved motion is noted

MET/Articulatory Ankle & Foot

Ankle Plantarflexed (ME)/Ankle Dorsiflexion (Artic)

Ankle Dorsiflexed (ME)/Ankle Plantarflexion (Artic)

Ankle Talocalcaneal Motion (Artic)

Tarsal-Metatarsal Joint(Articulatory)

Metatarsal-Phalangeal Joint(Articulatory)

Metatarsal Head Motion( Articulatory)

ROUND ONE 24-year-old male basketball player

complains of tight adductor muscles after intensive offseason training the last couple weeks. Please set your patient up in position to treat this patient with articulatory.

ROUND TWO A 19-year-old soccer player presents to

you complaining of ankle stiffness 3 months after a right ankle sprain. On exam you note significant restriction when you try to passively dorsiflex his right ankle. Please set up your patient correctly to treat this somatic dysfunction with muscle energy

SUDDEN DEATH 26yo medical student was found to have

a positive Thomas test during his OP&P class and his partner decided to treat the corresponding tight muscle. Please set your patient up in position to treat this patient with articulatory.

References WesternU/COMP, OP&P OMT Manual 2013-2014, ST and Artic

pp 24-27, 74-90; MET pp 3-11, 77-89.

Department of Neuromusculoskeletal Medicine/ Osteopathic Manipulative Medicine at Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. Osteopathic Principles and Diagnosis. 1st ed. Pomona, CA: 2013:pp, Chapter 13: The Lower Extremity Structural Examination.

Chila AG, executive ed, Carreiro, JE, Dowling DJ, et al. Foundations of Osteopathic Medicine. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011.