Articular disorders of the lower extremities are quite common, both as primary and secondary disorders, and may have far-reaching effects. For example, the hip works as a functional unit with the pelvis and indirectly the lumbar spine, as well as the knee, ankle, and foot, which have a direct influence on both adjacent segments and body structure as a whole.

The knee is the largest joint of the body, and it is fairly centered between long bones above and below. Thus, it is frequently subjected to strong leverage forces. Without much soft-tissue protection, the knee is easily subject to trauma; however, this same attribute offers helpful bony landmarks that are easily palpable.

Total body weight from above is transmitted downward to the leg, ankle, and foot in the upright position, and this force is greatly multiplied in locomotion. Thus, the ankle and foot are uniquely affected by trauma and static deformities infrequently seen in other areas of the body. For most clinical purposes, the lower leg, ankle, and foot can be considered to work as a dynamic unit.


Screening Tests for the Lower Extremity as a Whole

Human architecture is a complex design incorporating many vertebral and extra-vertebral articulations, all of which can function normally or abnormally. Gillet has found that when extra-vertebral articulations are fixated, they have a tendency to produce and reproduce spinal subluxations. Thus, the analysis and elimination of causes must consider the body a whole.

Most subluxations were considered by pioneer chiropractors to be the result of trauma. We now realize that this is not the case and that many subluxations can be the effect of various intrinsic stresses (eg, mechanical, chemical). In general, chiropractic authorities believe that these subluxations will continually recur if the reasons for their existence are not also eliminated. In fact, it can be generally considered that any subluxation that has been effectively normalized and which tends to recur should be considered as being secondary to some other spinal or extra-spinal cause.


Initial Considerations

During the evaluation of lower-extremity neuromusculoskeletal disorders, it is well to initially seek signs of atrophy, hypertrophy, fibrillations, and abnormal movements such as tremors, myoclonus, chorea, athetosis, tics, etc. Gross posture, structural attitude, and deformities should also be noted. The range of joint motion at each joint can be measured with a goniometer during the orthopedic part of the examination. Then voluntary power of each group of muscles can be tested against resistance and compared bilaterally. Abnormal tonus (flaccidity, spasticity) can be determined by passive movements.

      Lower Extremity Postural Balance

The gravity line passes slightly anterior to the S2 segment, behind the axis of the hip joint, slightly anterior to the transverse axis of rotation of the knee (slightly posterior to the patella), crosses anterior to the lateral malleolus, and through the cuboid-calcaneal junction to fall between the heel and metatarsal heads when viewed laterally during good postural balance. When viewed from the back, the lateral line of gravity passes through the spinous of L5 and the coccyx and bisects the knees and ankles. When viewed from the front, a line dropped from the anterior-superior iliac spine (ASIS) should bisect the patella and the web space between the 1st and 2nd toes.

      Leg Length Discrepancies

Bilateral differences because of anatomical discrepancies can arise from growth irregularities or severe fractures and gross pathology resulting in bone loss. Apparent discrepancies are usually due to adductor spasm causing pelvic tilt, unilateral rotatory misalignment of an ilium on the sacrum, knee distortion, or a fallen arch. Anatomical (true) leg lengths are bilaterally measured from the ASIS to a point on the medial malleolus of the respective tibia. It is usually preferred that the patient be in the nonweight-bearing supine position. In contrast, functional (apparent) leg lengths are measured bilaterally from the umbilicus to the respective medial malleolus when the patient is in the standing position.


Paralysis

True paralysis is invariably of a pathologic nature rather than the effect of a local malfunction (eg, transient circulatory insufficiency). For example, paralysis of one leg occurring in children is usually due to anterior poliomyelitis; in adults, it usually forms part of a hemiplegia or is of hysterical origin. Neuritis (eg, alcohol, lead, arsenic, diphtheria) may affect one leg predominantly, but both are usually involved. Cerebral monoplegia, due to cortical lesions of the leg area, are rare. Chorea may be associated with a limp half-paralyzed condition in one leg, usually with some involvement of the arm on the same side. The characteristic motions make the diagnosis clear. The differential diagnosis of the other varieties of monoplegia is usually made with the aid of a careful history and a thorough examination of the other parts of the body.

Several clues aid the gross differentiation of paralyses. For example, there are increased reflexes, anesthesia, usually loss of control of the bladder and anal sphincters, and pressure sores in diffuse or transverse myelitis. In spastic paraplegia of any type, the legs are stiff, the reflexes are increased, but sensation and the sphincters are normal. There is no atrophy or bed-sore formation. In multiple sclerosis, there are usually no disturbances of sensation or of the sphincters, and the paralysis is associated with nystagmus, intention tremor, and slow staccato speech. Tabes dorsalis shows ataxia but no paralysis until late in its course. The paralytic stage is preceded by a long period characterized by lightning pains, bladder symptoms, Argyll-Robertson pupil, and loss of knee-jerks. Hysteria may take on almost any type of paralysis and may deceive even the experienced examiner; but as a rule, other evidence of hysteria will guide the diagnosis.


Lower Extremity Circulatory Insufficiencies

Skin color of the lower extremities normally darkens in the weight-bearing position. An elevated pink foot that markedly deepens in color in the standing position suggests arterial insufficiency or vascular disease. The venous filling time on the dorsum of the foot should be noted at the same time. Collapsed veins should fill within 12 seconds on standing.

When pulses are absent in a limb, the examiner should return to the most distal palpable pulse and auscultate for an audible bruit suggesting the site of obstruction. Next, finger pressure should be applied to the medial dorsal area of the foot and the time noted for the white spot to disappear. Then the patient's weight can be rotated to the outer border of the foot and the test repeated. Blanching time is delayed in cases of pronation and arch weakness due to circulatory compromise. To evaluate the capillary filling time of the toes, a selected toe is compressed until it blanches white, and then the pressure is released quickly. Normal color should return within 6—10 seconds.

Lymphatic obstruction, venous disease, or acute arterial occlusion may result in ankle edema. Venous disease is the most common cause of pitting on pressure. Trauma or local disease is the usual cause for unilateral swelling, while cardiac or lymphatic disorders produce bilateral swelling.

Low-back pain is one of the most common entering complaints in a chiropractic office. Because of this, Wiehe points out the importance of recognizing associated problems of neurovascular stenosis in the large arteries of the leg due to L4–L5 irritation and differentiating them from other factors that can produce circulatory insufficiency. For example, thrombosis of the femoral artery can produce the same symptomatic picture as sciatic neuritis. Thus, diagnostic procedures might include, when indicated, unilateral-vertical and bilateral-horizontal blood pressure comparisons, Doppler ultrasound readings, plethysmography, and reactive hyperemia tests besides other clinical tests.

Positive signs of arterial insufficiency are often found by using Buerger's test. If claudication is suspected, the claudication test should be applied. Perthe's tourniquet test is an excellent test to use in differentiating the extent of superficial and deep lower limb varicosities. A variation of this is Pratt's tourniquet test, which can be used to evaluate the integrity of specific communicating veins. If a suspicion arises that something is interfering with the collateral circulation, Moskowicz's tourniquet test is helpful. Homan's sign is a strong indication that thrombophlebitis is present.

Buerger's Test.   The patient is placed supine with the knees extended in a relaxed position, and the examiner lifts a leg with the knee extended so that the lower limb is flexed on the hip to about a 45º angle. The patient is then instructed to move the ankle up and down (dorsiflex and plantar flex the foot) for a minimum of 2 minutes. The limb is then lowered, the patient is asked to sit up, the legs are allowed to hang down loosely over the edge of the table, and the color of the exercised foot is noted. Positive signs of arterial insufficiency are found if:

(1)   the skin of the foot blanches and the superficial veins collapse when the leg is in the raised position and/or
(2)   it takes more than 1 minute for the veins of the foot to fill and for the foot to turn a reddish cyanotic color when the limb is lowered.

Claudication Test.   If lower extremity claudication is suspected, the patient is instructed to walk on a treadmill at a rate of 120 steps/minute. If cramping, and sometimes a skin color change, occurs, the approximate level of the local lesion can be identified. The time span between the beginning of the test and the occurrence of symptoms is used to record the "claudication time," which is usually recorded in seconds.

Perthe's Tourniquet Test.   An elastic bandage is applied to the upper thigh of a standing patient sufficient to compress the long saphenous vein, and the patient is instructed to walk briskly around the room for approximately 2 minutes. The varicosities are then examined. This exercise with the thigh under pressure should cause the blood in the superficial (long saphenous) system to empty into the deep system by the communicating veins. Thus:

(1)   If the varicosities increase in their distention (become more prominent) and possibly become painful, it is an indication that the deep veins are obstructed and the valves of the communicating veins are incompetent.
(2)   If the superficial varicosities remain unchanged, the valves of both the long saphenous and communicating veins are incompetent.
(3)   If the superficial varicosities disappear, the valves of the long saphenous and the communicating veins are normal.

Pratt's Test.   This variation of Perthe's test is used to evaluate the integrity of specific communicating veins. The patient is placed in the supine position with the knees extended. The involved limb is raised to about 45º to empty the veins, placed on the examiner's shoulder or held by an assistant, and an elastic bandage is applied to the upper thigh sufficient to compress the long saphenous vein. A second elastic bandage is wrapped about the limb from the foot to the tourniquet on the thigh. The patient is then instructed to stand, and the examiner carefully observes the varicosities of the leg as the lower bandage is slowly unwrapped from above downward. The tourniquet on the thigh is left in place. As the lower bandage is untwined, the site of an incompetent communicating vein will be indicated by the appearance of a prominently bulging varicosity (blowout). When the first blowout is found, the spot is marked, and the upper bandage is extended to that point. Another bandage is then applied from that site downward, and the test is repeated again and again until all blowouts have been marked. Caution should be taken in this test because severe pain and swelling may arise in the calf if the deep veins are obstructed.

Moskowicz's Test.   The patient is placed supine with the knees extended in a relaxed position. The straight limb is then elevated by the examiner to about 45º, an elastic bandage is wrapped around the limb in an overlapping fashion from the ankle to the midthigh, and the elevated limb is supported in this position for 5 minutes. At the end of this time, the examiner quickly untwirls the bandage from above downward and notes how rapidly the skin blushes when the obstruction to the collateral circulation has been removed. If the normal blush is absent or lags far behind the unbandaged area, something (eg, an arteriovenous fistula) interfering with the collateral circulation should be suspected.

Homan's Sign.   The patient is placed supine with the knees extended in a relaxed position. The examiner, facing the patient from the involved side, raises the involved leg, sharply dorsiflexes the ankle with one hand, and firmly squeezes the calf with the other hand. If this induces a deep-seated pain in the calf, a strong indication of thrombophlebitis is found.

The hip is the most proximal joint of the lower extremity and is a near-perfect ball-and-socket joint. It provides stability for the body above and gross control for the extremity segments below.

Because the head of the femur articulates deeply within the acetabulum, the joint is highly stable; unfortunately, this asset excludes the advantages of direct palpation during examination. Therefore, most of the physical clues of osseous dysfunction must be analyzed indirectly from the effects expressed in the thigh as a whole during passive motion studies in the nonweight-bearing position, gait and upright postural analyses, muscle strength testing, subjective symptoms (eg, pain, tenderness), superficial signs (eg, skin characteristics and temperature changes), reflexes, etc.

Initial Considerations

From a biomechanical and kinesiologic viewpoint, the joint is one of the most complex joints of the body in its role of providing both large ranges of motion and large muscle torques in attempting to meet the requirements of imposed body weight during static and dynamic postures in the upright position.

Degenerative changes and fractures predisposed by structural changes (eg, osteoporosis, biomechanical failures) within the hip are common. This is likely because the hip is frequently subjected to heavy repetitive loading that must be tolerated during function.

Muscle and ligament shortening affecting the hip is common in the nonathletic individual, frequently producing complicating secondary effects in the musculoskeletal architecture above and below. Overstress imposed upon such fixations (added to the large muscle torques required for hip function) appears to encourage the development of acute and chronic subluxation syndromes. While chronic hip subluxations may exhibit themselves locally (in the hip), they can express themselves remotely in the kinematic chain (eg, lumbosacral area, feet, upper cervical spine).


Hip Pain

The common causes of hip pain are shown in Table 1.1. Soderberg points out that pain is a symptom common to most hip pathologies, regardless of etiology. "In such a circumstance, patients assume postures that diminish the force through the hip joint. During normal standing, the magnitudes of the forces are low and are usually tolerable. However, single limb stance during gait significantly increases the joint force due to the abductor muscle force required to keep the pelvis from dropping on the opposite side." Thus, overstressed fatigued muscles from an adductor lurch are the common cause of hip pain, and it should be recognized that this soft-tissue stress, and the pain associated, is usually a secondary condition.

The first priority during physical examination when hip pain is the primary complaint is to determine if joint motion is restricted and if certain passive motions conducted in a nonweight-bearing position (eg, supine, prone) aggravate or initiate the pain. Evaluation should include internal and external rotation, abduction and adduction, and flexion and extension. Branch feels that the loss of normal internal rotation is the most sensitive sign of hip disease.

Hip joint dysfunctions often refer pain more distally in the ipsilateral lower extremity, and while the lumbosacral region may refer pain to the area of the hip, rarely does a diseased hip joint refer pain to the lower back.


Common Differentiation Clues

In testing hip flexion with the knee locked (straight-leg test), sciatic neuritis would be aggravated. In testing full hip flexion with the knee relaxed, a sacroiliac lesion may be aggravated. However, testing internal and external rotation of the hip with the hip and knee flexed to 90º should not normally reproduce a low-back or sacroiliac lesion unless there is complicating psoas or piriformis spasm.


Hip Fixations

Mennell considers long-axis (downward) joint play to be the most important motion of the hip joint. The gross degree of distraction available can easily be determined by placing the patient supine, in a position of rest, stabilizing one foot against your thigh and then applying traction on the thigh to be examined. Many types of hip dysfunction will be associated with a limitation in joint distraction.

In osteoarthritic hip disease and certain adhesions, forced flexion of the thigh on the involved side towards the abdomen will cause the contralateral thigh to raise from the table. This occurs because the motion limitation in the involved socket forces the pelvis as a whole to rotate upward. This will suggest a restriction in hip flexion and point to a posterior adhesion or shortened tissues posteriorly (eg, hamstrings). The same procedure can be used when testing forced extension with the patient in the prone position. If the contralateral thigh raises before normal extension is reached, the examiner should suspect an anterior joint fixation or shortening of the quadriceps.

Note:   The maneuvers described below must be applied gently and not beyond patient tolerance, with special caution used with the elderly and very young. Too forceful an application, especially during forced extension, can produce a torsion fracture of the neck of the femur in the elderly or dislocate the head of the femur in a youngster. At the same time, it must be kept in mind that the hip joint is much more stable than the shoulder and requires a greater force to overcome larger muscle and ligamentous restrictions.

Releasing Inferior Distraction Fixations

Soft-tissue distraction (separation of intra-articular space) restrictions can be released simply by axial traction (manual or mechanical). Some type of belt or harness to stabilize the patient's pelvis is often helpful. Once long-axis joint play is restored, at least to a moderate degree, attention can be given to flexion, extension, abduction, and adduction fixations.

Straight distraction (inferior motion) can be achieved by holding the supine patient's leg distally with one hand and the proximal aspect of the leg with your other hand and applying a pulling force, thus directing a distraction force to the hip via the knee.


Releasing Flexion Fixations

To improve posterior glide with the patient supine, stand perpendicular to the involved thigh. Place your cephalad palm firmly on the most superior aspect of the anterior surface of the patient's thigh as possible, and grasp the underside of the patient's proximal thigh with your caudad hand. In this position, apply a slow pushing force directed to the floor with your cephalad hand (elbow locked) and a slight upward pull with your caudad hand.

To further improve flexion range of motion, stand on the opposite side of involvement perpendicular to the supine patient and approximately centered to the patient's knees. Flex the uninvolved knee and hip towards the patient's abdomen. Place your contact (cephalad) hand over the knee of the uninvolved side, and reach over the patient with your caudad hand and stabilize the distal aspect of the patient's thigh on the involved side. Flex the uninvolved limb toward the patient's abdomen just to the point where the contralateral (involved) femur begins to raise from the table. At this point, apply firm pressure against the involved limb as you continue to apply flexion pressure to the uninvolved hip.

Another technic is to place the patient supine with the hip and knee flexed at a right angle, and stand obliquely to the involved thigh. Grasp the patient's kneecap with your cephalad hand. Reach under the patient's leg with your caudad hand and place that hand on top of your other hand, thus supporting the patient's leg in the angle of your caudal arm and forearm. In this position, apply pressure toward the floor, which will be through the vertical axis of the femur.

Also with the supine patient, specific posteroinferior distraction of the hip can be applied in hip flexion and slight abduction by facing the patient, placing the patient's flexed knee over your medial shoulder, grasping the upper thigh of the patient anteriorly with both hands and fingers interlaced, and applying a pulling force that is directed to your chin.


Releasing Extension Fixations

To improve anterior glide with the patient prone, stand perpendicular to the involved thigh. Place your cephalad palm firmly on the most superior aspect of the posterior surface of the patient's thigh as possible, and grasp the patient's flexed knee with your caudad hand. In this position, apply a slow pushing force directed to the floor with your cephalad hand (elbow locked) and a mild upward pull with your caudad hand.

To further improve extension range of motion, stand on the opposite side of involvement perpendicular to the prone patient approximately centered to the patient's knee. Grasp under the uninvolved extended knee, and start to lift the limb upward. Reach over the patient with your caudad hand and stabilize the distal aspect of the patient's thigh on the involved side. Extend the uninvolved limb just to the point where the contralateral (involved) hip begins to raise from the table. At this point, apply firm pressure against the involved limb as you continue to apply extension pressure to the uninvolved hip.


Releasing Lateral Hip Fixations

A lateral fixation within the hip joint is not an uncommon finding. On the involved side, abduction and internal rotation will be restricted and the psoas muscle will frequently test weak. Psoas strength can be tested by having the supine patient lift the extended limb to 45º, externally rotate the foot, and resist your attempt to move the patient's foot laterally and towards the floor. Stand at the foot of the table so that your inactive hand can stabilize the patient's contralateral pelvis.

Place the patient supine with the involved hip and knee flexed so that the foot rests flat upon the table without strain. Stand at the foot of the table, and face the patient. Interlock your fingers over the patient's flexed knee, and lean forward so that your sternum is almost above the knee. With the medial aspect of your forearm, press the patient's leg laterally to internally rotate the femur approximately 25º. While holding this pressure, make a gentle thrust through the longitudinal axis of the femur. Check if the fixation has been freed by evaluating bilateral internal rotation of the hip and psoas strength.

In chronic cases, the following bed exercise is recommended. Have the patient assume the sidelying position with the involved side up. The patient's body should be positioned near the edge of the bed, with the patient facing away from the near edge. A small pillow should be placed between the upper thighs. The underlying uninvolved hip and knee should be moderately flexed. The patient then slightly extends the limb and allows the leg to drop over the edge of the bed, thus producing hip adduction in mild extension. The patient should then actively abduct the limb a few inches and let it drop by its own weight several times. This will help to stretch soft-tissue restrictions to external rotation and inferior distraction.


HIP SUBLUXATIONS

      Internally Subluxated Femur

This subluxation is commonly associated with restricted femoral external rotation, anterior pelvic tilting, external tibia rotation, and subtalar pronation. A degree of genu valgum and hip pain are usually associated.

Adjustment.   Place the patient supine with flexed knees so that the buttocks are near the end of the table. Stand medially, facing perpendicular to the thigh of the involved hip. Contact the medial aspect of the upper thigh, while your stabilizing hand grasps the patient's upper calf. Externally rotate the femur, apply traction with your stabilizing hand, and make a gentle thrust with your contact hand, directed towards further external rotation.

      Externally Subluxated Femur

This subluxation is related to restricted femoral internal rotation, internal tibia rotation and subtalar pronation. A degree of genu varum and hip pain are usually related.

Adjustment.   With the patient supine, stand lateral to the patient on the side of involvement, facing obliquely medial. Contact the superolateral aspect of the femur at midshaft with your cephalad hand, while your stabilizing hand is wrapped over the patient's leg so that your palm supports the patient's upper calf. Internally rotate the femur, apply caudal traction with your stabilizing hand, and make a gentle thrust with your contact hand that is directed towards further internal rotation.

      Superiorly Subluxated Femur

This situation is usually seen when nagging hip pain complicates low back pain. A degree of fixed internal or external rotation is often involved.

Adjustment.   With the patient supine, stand at the foot of the table and face the patient. Grasp the lower leg of the involved limb just above the ankle, and stabilize the patient's contralateral foot against your thigh. Apply traction, and make a gentle pull considering any internal or external rotation involved.

      Anteriorly Subluxated Femur

Occasionally one comes upon a lesser degree of an anterior (obturator) dislocation. The cause is usually a severe fall or being forced backward against an obstacle. On the involved side, the patient exhibits hip pain and an externally rotated limb that is lengthened. The head of the femur lies near the obturator foramen.

Adjustment.   With the patient supine, stand at the foot of the table, near the side of involvement, and face the patient. With your lateral hand, grasp the patient's posterior-distal leg just above the ankle. With your medial hand, reach across the patient's foot and grasp the heel. Both hands should be on the lateral aspect of the patient's ankle area. Apply gentle traction and medial rotation to the limb. Adduct the patient's involved limb across the patient's other leg, maintaining careful control. Constant traction, medial rotation, and adduction should reseat the displaced femoral head.

      Posteriorly Subluxated Femur

When the femur is subluxated backward, the patient has difficulty in extending the thigh. Measurement will indicate limb shortening. The mechanism of injury is usually a fall, long jump, or severe upper-thigh blow directed from the anterior.

Adjustment.   Place the patient supine. Stand on the side of involvement at a level near the patient's flexed knee, and face obliquely medial to the patient. Bring the patient's knee laterally so that it is firm against your upper abdomen. With your cephalad hand, stabilize the patient's contralateral ilium. With your caudad contact hand, grasp the patient's ankle from the anterior. Apply abduction to the flexed knee with your body weight, and simultaneously apply superior pressure with your contact hand to increase hip flexion and carry the patient's lower leg medially. This hip flexion, abduction, and external rotation should realign the displaced femoral head.

      Sciatic Displacement

This is a chronic postural disorder associated with pelvic tilt where weight balance is decidedly unilateral on the involved side. Acute trauma is rarely involved, but it may be in the patient's history. The patient presents with hip pain, internal limb rotation, and a shortened limb. The head of the femur is found near the lesser sciatic notch.

Adjustment.   This maneuver is essentially the opposite of adjusting an anteriorly subluxated femur. Place the patient supine, and stand at the foot of the table near the side of involvement. Face the patient. With your lateral hand, grasp the patient's posterodistal leg just above the ankle. With your medial hand, reach across the patient's foot and grasp the heel. Both hands should be on the lateral aspect of the patient's ankle area. Apply gentle traction and lateral rotation to the limb. Abduct the patient's involved limb. In this position, constant traction, lateral rotation, and abduction should reseat the displaced femoral head.

CHRONIC HIP DISLOCATION

      Posterior Dislocations

The most common hip luxation is posterior dislocation of the femoral head, exhibiting thigh adduction and internal rotation at the hip with leg shortening on the affected side. When dislocation takes place, the head of the femur may be driven into the posterior or central acetabulum creating acetabular comminution fragments. But posterior displacement may also be seen with a single major posterior acetabular fragment, with femoral head fracture, or without fracture. The cause is usually a force against the flexed knee with the hip in flexion and slight adduction. The most common complications are sciatic nerve stretching causing foot drop and numbness along the lateral calf.

      Anterior Dislocations

Anterior dislocation is relatively rare because Bigelow's ligament offers considerable protection against overstress. When found, the limb will be externally rotated and abducted, without leg shortening. Obturator, iliac, and pubic displacement may be seen, as well as those associated with femoral head fractures. These usually occur from a blow to the back while squatting, a fall where forced abduction occurs, or forced abduction of the extended hip.

      Central Dislocations

These luxations feature:

(1)   displacement toward the inner wall only with partial dome fractures or
(2)   central displacement with comminution of the dome. This type of dislocation-fracture commonly results from a severe force to the lateral trochanter and pelvis directed through the femoral head. Occasionally, they are produced by a force on the long axis of the femur when the hip is abducted.

      Trendelenburg's Hip Test

If the hip and its muscles are normal, the iliac crest and sacral dimple will be slightly low on the weight-bearing side and high on the elevated side when one knee is flexed. To test, have the patient with a suspected hip involvement stand on one foot (the side of involvement) and raise the other foot and leg in hip and knee flexion. If there is hip joint involvement and muscle weakness, the iliac crest and sacral dimple will be markedly high on the standing side and low on the side the leg is elevated. A positive sign suggests that the gluteus medius muscle on the supported side is weak. The gait will exhibit a characteristic lurch to counteract the imbalance caused by the descended hip.


ACUTE HIP DISLOCATION

Any type of hip pain encourages careful physical and roentgenographic evaluation of the soft tissues on the lateral and medial aspects of the hip. The author recommends that an overt hip dislocation with or without fracture should be considered a major injury and referred immediately without attempts of reduction. Roentgenographs will never indicate all soft-tissue damage present. Severe pain on motion is typical in both hip dislocations and fractures.

Allis' Knee Sign.   With the patient supine, knees flexed, and soles of feet flat on table, observe the heights of the knees superiorly from the foot of the table. If one knee is lower than the other, a unilateral hip dislocation or severe coxa disorder is suggested.

Langoria's Sign.   Relaxation of the extensor muscles of the thigh indicates intracapsular fracture of the femur.

      Roentgenographic Considerations

The most common hip injuries viewed on film are dislocations and fractures, both of which may lead to avascular necrosis of the femoral head. Femur fracture occurring above the intertrochanteric line are within the joint capsule. They heal, as a rule, without the formation of visible callus.

Evidence is clear that there is an association of certain forms of degenerative hip disease, often with osteophytic flanges on the femoral head, secondary to a rearranged femoral-acetabular articulation. Thus, recognition during the early years is most helpful. Slippage of the femoral capital epiphysis often occurs 1—2 years earlier in females because the most rapid growth in that area comes earlier.

Epiphyseal Slippage.   It is common for athletes in later years to exhibit degenerative disease of the hip, suggesting evidence of an old slipped capital femoral epiphysis. Even in minimal slip of this epiphysis, a chronic "tilt deformity" may result which exhibits the femoral head sitting eccentrically on the neck of the femur in a drooped or tipped position. When swelling and ecchymosis appear at the base of Scarpa's triangle following trauma and the patient is unable to raise the thigh while in the sitting position, acute separation at the epiphysis of the lesser trochanter is indicated (Ludloff's sign).

Shenton's line is frequently disturbed in hip fracture. A gracefully arching line is drawn connecting the inferior margin of the superior pubic ramus with the medial margin of the neck of the femur. With minimal hip displacement, normal landmarks will be altered when compared bilaterally.

Avulsions.   The trochanteric areas should be checked for possible injury of the gluteal insertion at the greater trochanter or avulsion of the iliopsoas insertion at the lesser trochanter. Any type of hip pain encourages careful evaluation of the soft-tissue structures in the area of the obturator internus.

Impactions.   It is often difficult to locate a fracture of the margin of the head of the femur after an impaction injury. When visible, such a fracture is shown by slight contour changes and unusual densities. Comparative views, oblique and stereoscopic views, tomography, or arthrography are frequently necessary to identify small fracture fragments.

The knee joint has been the subject of intensive study for decades because of the large variety of kinetic and kinematic events that occur at this site during dynamic activity and static postures. It is a unique joint because it is the largest joint in the body and located between the body's longest bony segments, thus is predisposed to trauma and often unequaled pathologies and biomechanical faults. As with spinal segments, the inclusion of cartilaginous pads between weight-bearing joint surfaces makes for an interesting study of biped load transmission, injuries, and sites of articular derangements.

Initial Considerations

The stability of the knee is provided almost fully by its ligamentous complex, especially those on the medial and lateral aspects. The normal biomechanical function of the knee is frequently altered by subluxation-fixations that may be the cause or the effect of pathologic changes. Any of the three joints of the knee may be involved: the femorotibial, the patellofemoral, or the proximal tibiofibular joint.

Even though passive nonweight-bearing flexion (essentially controlled by the hamstrings) and extension (essentially controlled by the quadriceps) of the knee may appear normal, restricted rotation of the tibia on the femur during flexion-extension can produce severe dysfunction during weight-bearing. The tibia rotates internally during knee flexion, externally during extension. These rotatory movements of the tibia are governed by the ligaments and menisci of the knee and the action of the patella.

Common causes of knee pain are shown in Table 1.2. The priority considerations during physical examination where knee pain is the chief complaint are pain and tenderness and their localization, heat, motion restrictions, swelling, and ligamentous stability.

Knee Posture

Injuries due to excessive stress appear especially on the short arm of a first-class-lever joint such as the knee and elbow. This can be witnessed with the mechanism of injury to the medial collateral ligament when the valgus knee is overstressed. During extension, a force (eg, body weight) is applied at a distance from the fulcrum several times that occurring between the fulcrum and the ligament.

      Genu Valgum: Physical Signs of Knock-Knee

If there is an abnormal space between the malleoli when the knees are touching when the patient is standing with the kneecaps straight ahead, a degree of genu valgum is present that may be more marked on one side than the other. There will also be:

(1)   excessive internal rotation of the femur and external rotation restriction,
(2)   excessive external rotation of the tibia and internal rotation restriction,
(3)   medial patella deviation due to femur rotation, and
(4)   foot pronation. This distortion results in a short leg causing pelvic imbalance if the condition is unilateral. Be aware, however, that people with a large degree of joint flexibility can hyperextend their knees along with femoral rotation which gives a false appearance of structural deformity.

Bilateral genu valgum is common in late childhood but typically corrects itself before the age of 8 or 9 years. Acquired causes include postural dysfunction and metabolic diseases. In adults, genu valgum is more common among females.

      Genu Varum: Physical Signs of Bowed-Leg

If the medial malleoli are touching and the knees are not when the patient is standing, the space between the knees determines the degree of genu varum. There will also be:

(1)   excessive external rotation of the femur and internal rotation restriction,
(2)   excessive internal rotation of the tibia and external rotation restriction,
(3)   lateral patella deviation due to femur rotation,
(4)   anteversion of the femoral neck, and
(5)   an in-toeing gait. One study has shown that angular deformity of only 10º will triple the weight-bearing per unit of force in the knee.

Bilateral genu varum is common in early childhood, and spontaneously corrects itself 95% of the time, states Mercier, during further growth and maturation. Acquired causes include postural dysfunction, rickets, Paget's disease, scurvy, fibroid dysplasia, Blount's disease, degenerative arthritis, and various other bone diseases. In adults, genu varum is more common among males.

      Mikulicz's Roentgenographic Line

In the frontal view of the adult lower extremity (from hip to ankle) in the standing position, Mikulicz's line connects the middle of the inguinal ligament to the center of the talocrural joint, passing through the head of the femur and the center of the patella. If the center of the knee joint is found to be medial to this line, genu valgum (knock knee) exists. When the center of the knee joint lies lateral to Mikulicz's line, genu varum (bowleg) is present.

      Therapeutic Considerations

Little can be accomplished once bone remodeling has occurred. However, much can be done in preventing further malformation by a long-term regimen of soft-tissue therapy, strengthening muscles showing weakness, stretching muscles and ligaments exhibiting shortening, maintaining fixation-free motion, nutritional concern, and assuring adequate innervation. Surgical reconstruction is rarely considered except in extreme cases.

      Genu Recurvatum

Genu recurvatum refers to exaggerated hyperextensibility. It is usually associated with a joint disorder that produces A-P instability of the knee. Contact sports, high jumping, or any activity that may induce anterior leg trauma or strenuous "take offs" from a locked knee would be contraindicated.

      Tibial Rotation and Torsion

If the patient's kneecaps are facing straight ahead and the feet point distinctly outward, a positive sign of lateral rotation of the tibia on the femur exists. This sign is usually more pronounced on one side than the other. If the feet appear normally positioned but the patellae appear rolled medially inward, it is a positive sign of tibial torsion.

Various causes have been shown to be at the root of tibial rotation or torsion. The most common etiologies are congenital defect, spastic paralysis, poliomyelitis, tibial subluxation, scurvy, and as a consequence of tibial fracture.


Knee Fixations

      Patellofemoral Joint Motion Restrictions

With the knee locked in full extension, joint-play motion of the patella should exhibit free excursion superiorly, medially, inferiorly, and laterally. Only superior (cephalad) excursion is under voluntary control. If any of these movements are lost, knee function is disabled. Thus, patella mobility must be assured before any attempt to therapeutically release a fixation or adjust a subluxation.

Evaluating Restricted Cephalad and Caudad Excursion.   With the patient in the relaxed supine position and the involved locked in extension, place the thumb and 1st finger of your cephalad hand around the superior aspect of the patient's patella and the thumb and 1st finger of your caudad hand around the inferior aspect of the patient's patella. To evaluate the degree of motion freedom caudally, apply pressure with your active (cephalad) hand longitudinally footward (along the line of the anterior surface of the leg). To evaluate the degree of motion freedom cephalad, apply pressure with your active (caudad) hand longitudinally headward (along the line of the anterior surface of the thigh).

Evaluating Restricted Medial and Lateral Excursion.   The doctor-patient positions are the same as those described above except contact is made on the medial and lateral aspects of the patient's patella rather than on the superior and inferior borders of the patient's patella.

Releasing Patella Motion Restrictions.   The procedure to release patellar fixations is simply to apply sustained pressure against the soft-tissue resistance and then follow this, after allowing a period for tissue adaptation, with a short, shallow, thrust directed in the line of normal motion. The patient position and the doctor's position and contact may remain the same as that used during the evaluation process. More strength can be utilized, however, if the cupped heel of the palm of the active hand is used rather than the thumb and 1st finger. The most common fixation found will be that of restricted inferior (caudad) motion due to a shortened, fibrotic quadriceps, which tend to subluxate the patella superiorly and lock it at the maximum of normal cephalad excursion.

      Femorotibial Joint Motion Restrictions

When examining joint motion in the knee, special care must be taken that normal motion is not confused with the exaggerated motion resulting from joint instability.

Releasing Distraction (Joint Separation) Fixation.   With the patient prone, stand perpendicular to the involved knee. Flex the patient's knee to a right angle, place your cephalad knee gently in the patient's popliteal space to stabilize the patient's femur, grasp the patient's leg distally (above the ankle) with both hands, and apply a short, sharp upward pulling force directed through the vertical axis of the tibia.

Evaluating Restricted A-P Glide.   To judge A-P motion glide of the knee, sit at the foot of the table obliquely facing the supine patient, flex the involved knee to approximately 45º, grasp the proximal aspect of the patient's leg with both hands (thumbs pointing upward and fingers interlocking at the posterior), and apply pressure posteriorly and anteriorly in a rocking motion. This is the same position that will be used to elicit a drawer sign. It usually helps to stabilize the patient's leg by placing the toes of the foot of the involved limb slightly under your cephalad thigh. Normal joint play will be perceived as a slight but distinct motion (about 1/8 inch) and is best felt when the knee is in midflexion. Weak or torn tissues should be suspected if A-P glide is felt during full flexion or extension.

Releasing Posterior Glide Restriction.   If the posterior glide of the femur on the tibia is restricted, place the patient supine. Insert about 2 inches of toweling under the distal aspect of the patient's femur. On the side of involvement, stand perpendicular to the patient's knee, grasp the anterior surface of the patient's thigh just above the patella with your cephalad hand, place the heel of your caudad (active) hand on the anterior surface of the patient's tibia (just below the patella), apply pressure and administer a short moderate thrust.

Releasing Anterior Glide Restriction.   With the patient supine, flex the involved hip and knee so that the plantar surface of the foot rests firmly on the table. Sit on the table, obliquely facing the patient, so that your cephalad thigh rests lightly against the patient's foot for stabilization. Grasp the patient's knee (proximal tibia and fibula) with both hands as to elicit a drawer sign, apply a pulling force directed toward your sternum, hold the traction for several seconds, and conclude by administering a short dynamic pull.

Another method to release anterior glide restriction is the reverse of the technic used to release posterior glide restrictions. With the patient prone, insert about 2 inches of toweling under the distal aspect of the patient's femur. On the side of involvement, stand perpendicular to the patient's knee, grasp the posterior surface of the patient's thigh just above the popliteal space with your cephalad hand, place the heel of your caudad (active) hand on the posterior surface of the patient's tibia (just below the popliteal space), apply pressure and administer a short moderate thrust.

A common home therapy is to have the sitting or supine patient bring the involved flexed knee toward the abdomen after inserting a rolled towel against the popliteal space, grasp the anterior surface of the leg distally with both hands, and apply firm pressure (directed toward the buttock) several times.

Evaluating Restricted Medial Tilt.   To evaluate medial (inside opening) tilt of the knee, stand perpendicular on the side of involvement of the supine patient. Grasp the anterior surface of the patient's leg distally on the involved side with your caudad hand for stabilization, and place the supinated heel of your cephalad hand against the lateral aspect of the patient's knee, just above the joint line (over the lateral femoral condyle). The fingers of your active hand (cephalad) should be curled under the knee against the popliteal space. As there is almost no perceptible femorotibial sideward tilt or rotational joint play when the knee is fully extended (locked) and the ligaments are intact, flex the patient's knee slightly by raising it 3—4 inches by lifting your contact hand, and apply lateral-to-medial pressure. This should elicit slight opening (about 1/8 inch) of the medial aspect of the femorotibial joint. If the joint is fixated at its medial aspect, medial tilt will be nonexistent. If the medial ligaments are torn or the vastus medialis muscle is extremely weak, exaggerated motion will be perceived and will also be noted when the knee is fully extended. Atrophy of the vastus medialis is an early sign in many knee pathologies and articular derangements.

Releasing Medial Tilt.   Place the patient supine, stand on the side of involvement, obliquely facing the patient, so that you can flex the patient's hip and knee to a right angle. Place your stabilizing cephalad hand on the patient's flexed knee, and reach around and under the patient's leg so that your caudad palm can support the proximal aspect of the patient's leg. The patient's leg should be resting on your caudad forearm and hip. While holding the patient's leg distally by elbow pressure, slowly abduct the patient's leg by shifting your trunk laterally away from the table. This will place a medial stretch upon the patient's knee. Once tension is achieved, apply a shallow thrust with your caudad hand directed medially. The application of a temporary wedge (1/8—1/4 inch) to the patient's shoe laterally may be helpful in stretching medial restrictions.

Evaluating Restricted Lateral Tilt.   To test lateral (outside opening) of the knee, the doctor-patient positions remain the same as described above but pressure of the contact hand is applied from the medial to the lateral to open the lateral aspect of the femorotibial joint. If the joint is fixated at its lateral aspect, lateral tilt motion will be lost. If the lateral ligaments are torn, exaggerated motion will be perceived and it will also be noted when the knee is fully extended.

Releasing Lateral Tilt.   Place the patient supine, stand on the side of involvement, obliquely facing the patient, so that you can flex the patient's hip and knee to a right angle. Place your stabilizing cephalad hand on the patient's flexed knee, and reach around and under the patient's leg so that your caudad palm can support the proximal aspect of the patient's leg. The patient's leg should be resting on your caudad forearm and hip. While holding the patient's leg distally by elbow pressure, slowly adduct the patient's leg by shifting your trunk medially over the table. This will place a lateral stretch upon the patient's knee. Once tension is achieved, apply a shallow thrust with your caudad hand directed laterally. The application of a temporary wedge (1/8—1/4 inch) to the patient's shoe medially may be helpful in stretching lateral restrictions.

Evaluating Restricted Rotation.   To appraise the rotatory ability of the knee, place the patient supine, stand perpendicular to the involved limb, and flex the patient's knee and hip to approximately 45º. Grasp the patient's knee with your cephalad (stabilizing) hand and just above the patient's ankle with your caudad (active) hand. In this position and with the patient fully relaxed, rotate the patient's leg clockwise and counterclockwise with your active hand by supinating and pronating your forearm. Slight motion should be felt that will normally be absent in full knee flexion or extension if the integrity of the ligaments of the knee and the quadriceps is intact.

Releasing Rotational Restrictions.   With the doctor-patient positions the same as during evaluation, apply clockwise or counterclockwise pressure (according to the restriction present), hold the pressure for several seconds, and conclude with a firm shallow twist to free the motion.

      Proximal Tibiofibular Joint Motion Restrictions

Gillet reports that superior tibiofibular fixation is quite common. Normally, the joint between the proximal heads of the tibia and fibula opens slightly when the foot is inverted. This gap can be palpated just inferolateral to the patellar tendon. In addition, the head of the fibula will shift slightly cephalad when the foot is actively dorsiflexed. These movements will not be felt if the joint is locked. Gillet feels fixation at this joint is often linked to an L5 or sacral subluxation.

Mennell states that the only joint-play movement at the tibiofibular joint is A-P glide: maximum at knee midflexion, minimal at full knee extension.

Evaluating Tibiofibular A-P Glide.   To judge this motion, sit at the foot of the table obliquely facing the supine patient as if you were to evaluate A-P glide of the femorotibial joint. With your lateral active hand, grasp the head of the patient's fibula between your thumb anteriorly and the tips of your index and middle fingers posteriorly. Your medial hand can be used to stabilize the proximal aspect of the patient's tibia. In this position, use your active hand contact to pull the head of the patient's fibula forward and then push it backward to appraise A-P glide motion.

Tibial Subluxations

When a subluxation exists between the distal femur and the proximal tibia, the malpositioning may be attributed to either the femur or the tibia. We have elected the tibia in the following descriptions, and the reader should realize that this has been an arbitrary decision. Thus, a listing for an externally rotated tibia may be described by another person as an internally rotated femur, for example, or a lateral tibia subluxation may be rightfully described as a medial femur subluxation.

Because the articulation between the femur and tibia is so complex, an array of subluxation possibilities exist. The tibia may be translated solely in one direction; eg, medially, laterally, posteriorly, or anteriorly on the femur. In addition, rotatory instability may produce a displacement in the anteromedial, anterolateral, posteromedial, or posterolateral direction. Therefore, astute evaluation of these displacement possibilities and the integrity of the associated soft tissues must be made before a corrective adjustment can be made.

      Medial Tibia Subluxation

Medial tibial subluxation is frequently consequent to medial collateral ligament sprain with restricted lateral motion. A history of trauma to the lateral upper tibia is usually involved.

Adjustment.   Place the patient supine with the involved knee extended and the ipsilateral hip flexed about 45º. Stand on the side opposite to involvement, and place your cephalad contact palm against the upper medial aspect of the patient's tibia. A pisiform contact is taken against the medial aspect of the tibial condyle. Wrap your caudad hand under the patient's calf to support the weight of the patient's leg. Slightly flex the patient's knee, apply traction to the leg, and simultaneously make a short thrust that is directed from the medial to the lateral to correct the malposition.

      Anterior Tibia Subluxation

The major features of anterior tibial subluxation include patellar tendon tenderness, an anterior drawer sign, anterior cruciate tenderness, patellar tendon hypertonicity or tendinitis, and restricted posterior tibial motion. The history often involves a blow to the back of the upper leg or falling backward over a low obstacle.

Adjustment.   Place the patient supine, and stand on the side of involvement. Take contact with your cephalad hand against the proximal anterior aspect of the patient's tibia. Place your caudad hand under the patient's calf to support the weight of the leg and to apply traction during the adjustment. As traction is made, simultaneously make a short A-P thrust to correct the malposition.

      Lateral Tibia Subluxation

Lateral tibia subluxation is frequently consequent to lateral collateral ligament sprain with restricted medial motion. A history of trauma to the medial upper tibia is frequently associated.

Adjustment.   Place the patient supine with the involved knee extended and the ipsilateral hip flexed about 40º. Stand on the side of involvement, and place your cephalad contact palm against the upper-lateral aspect of the patient's tibia. A pisiform contact is taken against the lateral aspect of the tibial condyle. Wrap your caudad hand under the patient's calf to support the weight of the patient's leg. Slightly flex the patient's knee, apply traction to the leg, and simultaneously make a short thrust that is directed from the lateral to the medial to correct the malposition.

      Posterior Tibia Subluxation

Physical indications include popliteal fossa tenderness, posterior cruciate ligament tenderness, posterior drawer sign, patella tendon hypotonicity and depression, and restricted anterior tibia motion. A history of anterior tibial trauma is usually involved.

Adjustment.   Place the patient prone with the involved knee flexed 70º. Squat at the end of the table, and place the patient's involved leg against your medial shoulder. Interlock both of your hands on the posterior aspect of the tibial condyles. Apply traction while simultaneously making a fairly strong adjustment that is directed to bring the tibia anterior, correcting the malposition..

      Internally Rotated Tibia

The typical physical features of an internally rotated tibia are lateral capsular pain and tenderness, genu varum, a prominent lateral tibial condyle and plateau, tightness of the iliotibial band and lateral hamstring tendons, chondromalacia patellae, and restricted external tibial rotation.

Patient Prone Adjustment Procedure.   Place the patient prone with the involved knee flexed about 70º. Stand facing away from the patient at the side of the table, opposite to the involved tibia, and place your medial knee on the distal aspect of the patient's involved femur for stabilization. Grasp the distal aspect of the patient's tibia and fibula, with your fingers interlocking on the anterior aspect. Apply upward traction to the leg, and make the adjustment by externally rotating the patient's leg to correct the malposition.

Patient Supine Adjustment Procedure.   Place the patient supine, and stand on the side of involvement facing the patient. Place your medial foot on the table, and place the patient's ankle in your axilla. Your lateral hand should grasp the anterior surface of the patient's leg just above the ankle, and your medial hand is moved under the patient's leg so that you can grasp your lateral arm. The patient's leg rests within your medial cubital fossa for support. Apply traction to the leg while simultaneously manipulating the leg into external rotation to correct the malposition.

      Externally Rotated Tibia

The physical features of an externally rotated tibia are medial capsular pain and tenderness, genu valgum, a prominent medial tibial condyle and plateau, tightness of the pes anserine tendons, chondromalacia patellae, and restricted internal tibial rotation.

Patient Prone Adjustment Procedure.   Place the patient prone with the involved knee flexed at about 70º. Stand at the side of the involved tibia, and set your cephalad knee on the distal aspect of the patient's femur to stabilize the patient's knee against the table. Grasp the patient's distal tibia and fibula with your fingers interlocking on the anterior aspect. Apply upward traction to the leg, and then make a firm but gentle internal rotation maneuver of the leg to correct the malposition.

Patient Supine Adjustment Procedure.   Place the patient supine, and stand on the side of involvement facing the patient. Place your medial foot on the table. It sometimes helps to place your knee against a pad in the patient's popliteal space for countertraction. Next, place the patient's leg against your hip for stabilization. Your medial hand grasps the anterior surface of the patient's leg just above the ankle, and your lateral hand is moved under the patient's leg so that you can grasp your medial forearm. The patient's leg rests within your cubital fossa for support. Apply traction to the leg while simultaneously manipulating the leg into internal rotation to correct the malposition.

Alternative Patient Supine Adjustment Procedure.   Stand on the side of involvement of the supine patient. The patient's hip should be flexed about 60º with the knee flexed about 110º. Grasp the patient's lower leg with your medial contact hand, and place your lateral hand on the patient's knee to stabilize the patella. The adjustment is made in this position by flexing and internally rotating the patient's leg to correct the malposition.

Fibular Subluxations

      Inferior Fibula Subluxation

An inferior fibula subluxation can be the result of inversion sprain and is often associated with tenderness about the collateral ligament of the fibula and restricted superior fibula motion.

Adjustment.   Place the patient in the lateral recumbent position with the affected side up and the medial aspect of the affected foot resting relaxed on the table. Stand at the foot of the table in line with the longitudinal axis of the patient's affected leg. Take a capitate contact with your medial hand against the inferior aspect of the lateral malleolus, with your lateral hand grasping your contact wrist for stability. Apply pressure, and simultaneously make a short thrust directed superiorly along the vertical axis of the fibula to correct the malposition.

      Superior Fibula Subluxation

A superior fibula subluxation is often consequent to eversion sprain. Typical features include tenderness about the fibular collateral ligament due to jamming, restricted inferior fibula motion, and a possible slight foot-drop sign.

Adjustment.   Place the patient supine with knee extended and hip flexed at about 45º. Stand at the end of the table with the patient's foot placed on the anterior aspect of your thigh. Grasp the patient's ankle with your lateral hand, and take a web or capitate contact at the proximal aspect of the lateral malleolus. With your medial hand, overlap the wrist of your contact hand for stability. Apply traction, and simultaneously make a short inferiorly directed thrust to correct the malposition.

      Anterolateral Fibula Subluxation

An anterolateral fibula subluxation is often the result of lateral hamstring strain, eversion sprain, or trauma to the posterolateral aspect of the knee. It is characterized by lateral hamstring tendon tenderness, genu varum, excessive pronation, and restricted posteromedial fibula motion.

Adjustment.   Place the patient prone with the involved knee flexed. Squat at the end of the table (facing the patient) so that the patient's leg can rest on your shoulder for stability. Grasp the involved leg and interlace your fingers around the posterior aspect of the patient's leg proximally. Take a specific pisiform contact with your cephalad hand against the anterolateral aspect of the fibular head. Apply traction, and simultaneously rotate the fibula posteromedially to correct the malposition.

      Posteroinferior Fibula Subluxation

The typical physical features of a posteroinferior subluxation of the fibula include pain at the fibula head, lateral collateral ligament pain at the ankle, lateral hamstring complaints, and restricted anterosuperior fibula motion. This type of subluxation is often the result of inversion ankle sprain.

Adjustment.   Place the patient supine with the affected knee flexed. Stand lateral to the involved limb with your cephalad hand within the popliteal fossa. Take a thenar-pad contact against the fibular head. For leverage, grasp the anterior aspect of the patient's lower leg with your caudad hand. Apply oblique pressure with your stabilizing hand to flex the knee and push the leg superiorly, while simultaneously sharply lifting the fibular head anteriorly with your contact hand to make the correction.

      Posteromedial Fibula Subluxation

A posteromedial subluxation of the fibula is often consequent to inversion sprain, violent hamstring pull, trauma to the anterolateral knee, and genu valgum. Severe anterolateral fibula motion is usually associated.

Adjustment.   Place the patient prone with the involved leg flexed. Squat at the end of the table (facing the patient) so that the patient's leg rests on your shoulder for stability. Grasp the involved leg and interlace your fingers around the posterior aspect of the patient's leg proximally. Take a specific pisiform contact with your lateral hand against the medial aspect of the involved fibular head. Apply traction, and simultaneously rotate the fibula anterolaterally to correct the malposition.

Patella Subluxations

The incidence of patella subluxation is secondary only to collateral ligament and meniscus injuries in athletic knee injuries.

      Superior Patella Subluxation

The major features of superior subluxation of the patella are an upward displacement during rest in the recumbent position, patellar tendinitis, quadriceps spasm, chondromalacia patellae, and restricted inferior patella motion.

Adjustment.   Place the patient supine with the affected knee extended. Stand on the side of involvement. Take a web contact with your cephalad hand against the superior aspect of the involved patella. Stabilize the patient's leg by your caudad hand grasping the patient's shin. Apply pressure with your contact, and make a short thrust directed inferiorly to correct the malposition.

      Superomedial and Superolateral Patella Subluxations

The physical features of these subluxations of the patella include unusual position during rest in the recumbent position, patellar tendinitis, quadriceps spasm, and chondromalacia patellae. Genu varum and restricted inferolateral patella motion are often associated with superomedial subluxations, while genu valgum and restricted inferomedial patella motion are associated with superolateral subluxations.

Adjustment.   Place the patient supine with the affected knee extended. Stand on the side of involvement. Take a web contact with your cephalad hand against the superomedial or superolateral aspect of the involved patella. Stabilize the patient's leg by your caudad hand grasping the upper shin. Apply pressure with your contact and make a short thrust directed obliquely (ie, inferomedially or inferolaterally) to correct the misalignment.

      Inferior Patella Subluxation

An inferior subluxation of the patella is typically associated with a patella that appears low during rest in the recumbent position, chondromalacia of the patella, blocked superior joint play, suprapatellar tendinitis, and restricted extension of the knee.

Adjustment.   The patient is placed supine with the involved knee extended. If full extension cannot be made comfortably, the popliteal space should be supported by one or more rolled towels. Stand on the side of involvement. Take a web contact with your caudad hand against the inferior aspect of the patella, deep against the patella tendon. Your cephalad hand should grasp the wrist of your contact hand for support and added strength. Apply pressure superiorly so that all joint play is removed, and then make a short thrust to stretch the patella tendon and normalize the position of the patella.

      Patella Dislocations

In patella dislocation, a fixed tilt or malposition of the patella or an osteochondral fracture may be noted. Motion will be restricted in all directions, and the surrounding tissues will be extremely tender. Secondary infection may occur. The typical acute case exhibits point tenderness, erythema, mild heat, edema, pain aggravated by motion, joint block, patella restriction, and limping. The patella apprehension and bounce-home tests are positive.

      General Considerations

The cause of a dislocated patella may be a congenital or traumatic decrease in the femoral intrapatellar groove, especially at the lateral lip; trauma tearing the ligamentous attachments; inflammation (traumatic or infectious) in the intrapatellar pad that produces an increase in synovial fluid; vastus medialis dystonia; torn collateral or cruciate ligaments; or femoral or tibial dislocation. The patella displaces laterally with vigorous quadriceps contraction. When the person strongly extends the flexed knee with the leg externally rotated, the patella may redislocate.

Roentgenographic Considerations.   Tangential views with the knee flexed about 50º are helpful in showing malposition. The most common patella dislocation is sideward, especially laterally, but proximal shifting may occur. In association with traumatic dislocations, fractures of the medial patellar margin and osteochondral fracture of the femoral condyles are quite common.

Patella Apprehension Test.   If a patella is prone to dislocation, any attempt to produce dislocation will be met with by immediate patient resistance. In seeking a positive sign, the patient is placed in the relaxed neutral supine position and the examiner applies increasing pressure against the patellar. If a chronic weakness exists, the patient will become increasingly apprehensive as the patella begins to dislocate.

The stability of the complex series of joints that comprise the ankle and foot is primarily maintained by an expansive network of ligaments. In comparison to the knee, little is known about the integrated biomechanical actions within the ankle and foot.

Initial Considerations

Where the ankle, essentially a hinge joint, leaves off and the foot begins is a matter of differing opinions. Most authorities, however, consider the ankle to be formed by the tibia, fibula, and talus, with the foot including all structures distal to the talus. Subtalar joint motion occurs about an axis that lies oblique to the three axes around which usual ankle flexion-extension, abduction-adduction, and rotation occur.

      Ankle Pain

The common causes of ankle pain are shown in Table 1.3. The history, localization of pain and tenderness, evidence of swelling, motion limitation, surface temperature, hemotologic findings, and associated systemic signs will aid differentiation.

      Ankle Fixations

Two major areas of possible motion restriction exist in the ankle area: above and below the talus. The key structure within the ankle is the talus, which superiorly supports the weight of the tibia, laterally articulates with the nonweight-bearing fibula, and inferiorly rests primarily on the anterior two-thirds of the calcaneus.

The only motions of joint play to be evaluated within the ankle mortise are long-axis extension and A-P glide. Within the subtalar joint, long-axis extension, talar rock on the calcaneus, medial tilt, and lateral tilt are the primary considerations.

      The Ankle Mortise

Being a hinge joint, the ankle mortise is designed essentially to allow plantar flexion and dorsiflexion. Only a slight amount of rotation is normally allowed.

Ankle Mortise Long-Axis Extension.   This is a subtle motion to perceive but necessary for complete evaluation of joint motion within the ankle. Place the patient in the supine position with the feet at the end of the table, and stand or squat facing the patient. The plantar surface of the patient's uninvolved extremity should be placed against knee (above or below) for stability. Encircle the ankle mortise at the level of the malleoli with the thumb and index fingers of each hand so that your index fingers are interlaced and firmed against the Achilles tendon posteriorly and your thumbs are centered over the anterior aspect of the tibiotarsal joint. Apply traction and simultaneously note the degree of joint play perceived by your thumbs. Care must be taken to avoid pressure against the malleoli during this maneuver.

Ankle Mortise A-P Glide.   This motion refers to the A-P motion of the talus between the malleoli. Place the patient supine with the hip and knee on the involved side flexed and the foot at a right angle to the leg (resting on the heel), and stand or sit facing perpendicular to the patient's ankle. With your cephalad hand, grasp the patient's lower leg anteriorly just above the malleoli, with your thumb laterally and your fingers on the medial surface of the patient's ankle. With your caudad hand, grasp the anterior surface of the patient's ankle just below the malleoli. In this position, you will be able to elicit ankle mortise A-P glide by alternately pushing downward and pulling upward with your active (cephalad) hand.

An alternative method to evaluate posterior glide of the talus on the tibia utilizes the same doctor-patient positions described above. With this technique, your cephalad hand grasps the underside of the patient's distal leg and applies an upward pressure while your caudad hand on the anterior surface of the patient's ankle just below the malleoli exerts a downward force.

      The Subtalar Joint

Subtalar Long-Axis Extension.   Place the patient in the supine position with the feet at the end of the table, and stand or squat facing the patient. The plantar surface of the patient's uninvolved extremity should be placed against your contralateral knee (above or below) for stability. Encircle the involved subtalar area with the thumb and index fingers of each hand so that your index fingers are interlaced and firmed against the heel and your thumbs are centered over the anterior aspect of the talonavicular and talocuboid joints. Apply traction and simultaneously note the degree of joint play perceived by your thumbs. This is the same technique described for evaluating ankle mortise long-axis extension except that the contacts are applied at a lower level.

Subtalar Rock.   The doctor-patient positions are the same as described above except that your hand contact is reversed so that the thumbs of your hands are firmed against the apex of the longitudinal arch of the patient's involved limb and your fingers are wrapped around the anterior surface of the ankle so that your index fingers are centered over the talonavicular joint anteromedially and the talocuboid joint anterolaterally. In this position, alternately dorsiflex and plantar flex the patient's foot by rotating your hands upward and downward and note the subtalar motion elicited under your index fingers.

Subtalar Medial and Lateral Tilt.   With the doctor-patient positions and contacts the same as described above for evaluating subtalar rock, alternately invert and evert the patient's ankle by rotating your hands clockwise and counterclockwise to evaluate subtalar medial and lateral tilt.

Ankle Subluxations

      Anterior Talus Subluxation

Indications of an anterior talus subluxation include pain and tenderness at the anterior aspect of the ankle, a history of inversion sprain that occurs with plantar flexion, roentgenographic signs of exostosis of the dorsal talonavicular articulation, and excessive postural pronation during weight bearing.

Adjustment.   Place the patient supine, and sit at the foot of the table (facing the patient). Interlock your fingers across the anterior aspect of the involved ankle with your thumbs placed on the plantar surface of the patient's foot and your elbows moderately flexed. Your third fingers should make specific contact over the anterior aspect of the involved talus. To make the articular correction, apply traction to separate the calcaneus and talus while simultaneously snapping your wrists and elbows inferiorly in a scooping fashion to move the talus from the anterior to the posterior.

      Lateral Talus Subluxation

The major features associated with a lateral subluxation of the talus are a history of inversion ankle sprain, excessive postural pronation during weight bearing, pain anterior to the lateral malleolus, and tenderness of the anterior talofibular ligament.

Adjustment.   Place the patient supine, and stand at the foot of the table (facing the patient). Place the 3rd and 4th finger of your medial contact hand over the anterolateral aspect of the involved talus with your thumb on the plantar surface of the patient's foot. Your lateral stabilizing hand supports the patient's heel. To make the corrective adjustment, apply traction with your stabilizing hand to separate the calcaneus from the talus while simultaneously making a lateral-to-medial torque maneuver by bringing the fingers of your active hand medially while thrusting laterally with the web between your thumb and 1st finger.

Alternative Adjustment Procedure.   In this procedure, the doctor-patient position is the same as that described above. Internally rotate the patient's leg, and take a double-thumb contact on the lateroanterior aspect of the involved talus. Your lateral hand grips the calcaneus, while your medial hand grasps the anterior surface of the tarsals. Apply pressure with your double-thumb contact, slightly invert the foot, apply traction, and simultaneously make a short, sharp pull towards yourself to correct the malposition.

      Medial-Inferior Talus Subluxation

Subluxation of the talus medioinferiorly is often found in association with eversion ankle sprain exhibiting tenderness at the deltoid ligament.

Adjustment.   This corrective maneuver is essentially the opposite of the adjustment for a lateral talus. The patient is placed supine. Sit at the foot of the table, facing the patient. Place the third finger of your lateral contact hand over the anteromedial aspect of the involved talus with your thumb on the plantar surface of the patient's foot. Your stabilizing hand supports the heel. To make the adjustment, apply traction with your stabilizing hand to separate the calcaneus from the talus while simultaneously making a medial to lateral torque maneuver towards yourself.

From an arbitrary anatomical viewpoint, the forefoot is composed of the five metatarsals and the phalanges; the midfoot consists of the cuneiform, navicular, and cuboid bones; and the hindfoot (rearfoot) includes the talus and calcaneus.

Initial Considerations

As the disruption of the mechanics of the kinematic chain leads to pathologic function, the foot and ankle must ideally combine a complex series of joints and controlling forces and so integrate as to meet the demands of static and dynamic situations. In addition, being the final links in the human kinematic chain and those which approximate the supporting surface, the segments of the foot and ankle must be flexible enough (free of fixation) to accommodate to different surfaces yet be stiff enough to provide the required torque for locomotion.

Descriptors of foot motion have yet to be standardized. Most authorities, however, use the following terminology: Plantar flexion and dorsiflexion are motions about a horizontal axis (through the ankle) that lies in the frontal plane. Eversion occurs about an axis running in the A-P direction of the foot. Adduction of the foot occurs around a vertical axis. Pronation refers to combined dorsiflexion, eversion, and abduction of the foot; and supination is the result of combined plantar flexion, inversion, and adduction of the foot.

The causes of foot pain may be traumatic, inflammatory, neuropathic, circulatory, or postural. Common etiologies are shown in Table 1.4.

      Foot Fixations

The bony complex of a foot (about 27 articulations) is a common site of single or multiple fixations that Gillet reports can frequently be linked to spinal fixations.

Fixation of the distal phalangeal joints are not common but those joints more proximal are. The metatarsophalangeal joint of the great toe is a common site, especially where plantar flexion is restricted. The intermetatarsal ligaments are frequently shortened. Partial or complete fixations are also found at the cuneiform-metatarsal, cuboid-metatarsal, cuneiform-navicular, intercuneiform, cuneiform-cuboid, navicular-cuboid, talus-navicular, and talus-cuboid articulations. Keep in mind that a high stiff arch that does not reduce somewhat during weight bearing is just as abnormal as a flattened arch.

Gillet looks to the feet as the functional base of the spine. He feels that the cause of many frequently recurring fixations in the spine or pelvis can be traced to a fixation in the feet. Several authorities agree with this observation. Gillet's studies showed a distinct relationship between phalangeal fixations and upper cervical fixations, metatarsal fixation and C3–C7 fixations, metatarsal-tarsal fixations and thoracic fixations, intermetatarsal fixations and costospinal subluxations, cuneiform-navicular or cuboid-calcaneus and lumbar fixations, and talus fixations and L5 fixations. These empirical findings are awaiting further confirmation.

The joint play motion to evaluate for possible fixations are midfoot (proximal metatarsal) and forefoot (distal metatarsal) A-P glide and rotation. Hindfoot mobility has been evaluated indirectly during the evaluation of ankle mortise and subtalar mobility.

      Midfoot Fixations

Proximal Metatarsal A-P Glide.   With the patient in the supine position, stand or sit facing perpendicular to the patient's foot. Grasp the patient's foot with your stabilizing cephalad hand so that you have firm contact on the cuneiforms and cuboid. With your active hand, grasp the patient's foot so that your thumb and index fingers are around the proximal aspect of the bases of the patient's metatarsals. While holding these contacts, alternately pull upward and push downward with your active hand to elicit proximal metatarsal glide.

Proximal Metatarsal Rotation.   With doctor-patient positions the same as described above, evaluate rotary motion of the proximal metatarsals by rolling your contact hand into pronation and supination so that the patient's foot is rotated medially and laterally.

      Forefoot Fixations

Distal Metatarsal A-P Glide.   Place the patient in the supine position with the feet at the end of the table, and stand or squat facing the patient. With your lateral hand, grasp the head of the 5th metatarsal anteriorly with your index finger and posteriorly with your thumb. With your medial hand, grasp the head of the 4th metatarsal in a similar manner. To evaluate A-P glide between the 5th and 4th metatarsal distally, alternately push with one hand while producing a pulling force with the other hand, thus alternately causing distal metatarsal flexion and extension. Continue to evaluate A-P glide between each digit by moving your contacts medially over the distal 4th and 3rd metatarsals, 3rd and 2nd metatarsals, and 2nd and 1st metatarsals.

Distal Metatarsal Rotation.   With the doctor-patient positions and contacts the same as described above, rotation is evaluated by trying to move one metatarsal hand over and under its neighbor by rotating your contact fingers clockwise and counterclockwise. Gross screening of forefoot rotational mobility can be evaluated by stabilizing the patient's heel with one hand while your contact hand grasps the patient's forefoot and performs a figure-8 maneuver by supinating and pronating your forearm.

Foot Subluxations

      Anterior Calcaneus Subluxation

The most obvious signs of an anterior calcaneus subluxation are excessive supination and pes cavus during weight bearing.

Adjustment.   Place the patient prone with the involved knee flexed. Stand on the side of involvement. Your caudad hand contacts the anterior plantar aspect of the involved calcaneus with a web contact, while your cephalad hand stabilizes the patient's talus, tibia, and fibula by grasping the posterior ankle with a web contact. To correct the malposition, apply pressure with your contact hand against the heel and simultaneously make a short sharp thrust that is directed from the anterior to the posterior.

      Posterior Calcaneus Subluxation

Subluxation of the calcaneus posteriorly is usually associated with tarsal tunnel syndrome, excessive pronation during weight bearing, and pain located inferior and slightly posterior to the medial malleolus.

Adjustment.   Place the patient prone, and stand at the foot of the table (facing the involved limb). With your medial hand, grasp the anterior aspect of the patient's involved ankle with your fingers and place your thumb firmly against the distal plantar calcaneus. With your lateral hand, cup the patient's heel and apply firm pressure against the posterior aspect of the calcaneus. The adjustment is made with a snapping force by the thumb of the contact hand superiorly while the stabilizing hand rotates the calcaneus towards your body. Both hands must act simultaneously, working in unison.

      Inferomedial Navicular Subluxation

An inferomedial subluxation of the navicular is typically associated with medial longitudinal arch pain, excessive pronation during weight bearing, and a history of inversion or eversion ankle sprain.

Adjustment.   Place the patient prone with the involved knee slightly flexed. Stand at the foot of the table on the side of involvement. Grasp the anterior surface of the patient's foot with your caudad hand so that your 2nd and 3rd fingers are hooked over the inferomedial aspect of the navicular. With your cephalad hand, take a pisiform contact over your contact fingers. To correct the malposition, apply traction and simultaneously thrust obliquely lateral towards the floor.

      Lateral Cuboid Subluxation

Subluxations of the cuboid are one of the most frequent subluxations found and frequently involved in a wide variety of noxious reflex manifestations. William Locke, MD, of Ontario, Canada built a world-wide reputation for aiding many arthritic and systemic conditions in the 1930s by correcting articular disorders of the feet, adjusting cuboid malpositions especially.

Lateral subluxation of the cuboid is usually associated with a history of inversion sprain, lateral longitudinal arch pain and tenderness, and excessive pronation during weight bearing.

Adjustment.   Place the patient supine, stand at the foot of the table centered to the involved limb, and face the patient. Grasp the anterior ankle with your medial hand so that your thumb is on the lateral aspect of the cuboid. Your stabilizing hand is placed palm up against the lateral ankle so the thumb of the contact hand is between the thenar and hypothenar pads of the stabilizing hand. While maintaining this contact, stand closer to the patient so that the foot is between your thighs, and assume a crouching position. To make the correction, apply traction by thigh pressure, and simultaneously make a thrust directed medially with the stabilizing palm against your contact thumb.

Alternative Adjustment Procedure.   The doctor-patient positions are the same as above. Contact is made on the patient's involved cuboid with the web of your lateral hand, with your fingers on the anterior surface of the patient's ankle and your thumb on the plantar surface of the patient's foot. Your medial hand stabilizes the metatarsocuneiform region of the patient's foot by grasping the medial aspect of the forefoot with your thumb on top and your fingers wrapped around the distal arch. To make the corrective adjustment, apply traction and simultaneously make a scissors-type adjustment by thrusting medially with your lateral contact hand and laterally with your stabilizing hand.

      Inferior Cuboid Subluxation

The typical clinical picture of an inferior cuboid subluxation is lateral longitudinal arch pains and excessive pronation or supination during weight bearing.

Adjustment.   Place the patient prone, and stand at the foot of the table facing laterally oblique to the involved limb. Locate the plantar aspect of the cuboid. A contact is made with the pisiform of your cephalad hand, with your fingers wrapping around the lateral aspect of the foot. The patient's anterior foot rests in the palm of your caudad stabilizing hand. To correct the malposition, apply traction to the patient's forefoot with your stabilizing hand with emphasis upon the 5th metatarsal and simultaneously make a short sharp thrust toward the floor.

Alternative Adjustment Procedure.   The doctor-patient positions are the same as described above. Locate the plantar aspect of the cuboid. A contact is made with the thumb of your medial hand with the fingers wrapping around the anterior aspect of the foot for support. Make pisiform pressure over your contact thumb with your cephalad hand. To correct the malposition, apply traction, and simultaneously make a thrust towards the floor with a drooping motion aided by bending your knees.

      Inferior Tarsal or Proximal Metatarsal Subluxation

The features of either an inferior tarsal or proximal metatarsal subluxation are arch pain, a history of ankle sprain, and excessive pronation or supination during weight bearing.

Patient Prone Adjustment Procedure.   Place the patient prone with the knee slightly flexed. Stand at the foot of the table (facing the patient), centered at the involved side. Take a double-thumb contact on the involved inferior tarsal or proximal metatarsal bone, with your fingers extending around to support the anterior aspect of the foot. To correct the malposition, apply steady plantar flexion to the foot and simultaneously make a snapping thrust with your contact thumbs directed towards the floor.

Patient Supine Adjustment Procedure.   Place the patient supine with the involved foot placed at a right angle to the leg. Stand at the foot of the table (facing the patient), centered at the involved side. Take a double-thumb contact on the involved inferior tarsal or proximal metatarsal bone with your fingers extending around to stabilize the anterior aspect of the involved foot. To correct the malposition, apply steady plantar flexion of the forefoot by finger pressure towards your body and simultaneously make a quick short adjustment by thrusting your thumb contacts cephalad by snapping your elbows forward. Your fingers, thumbs, wrists, and elbows must work in unison.

      Superior Tarsal or Proximal Metatarsal Subluxation

The major characteristics of either a superior tarsal or proximal metatarsal subluxation are pain on the dorsum of the foot, a history of inversion sprain resulting in a 1st metatarsal displaced superiorly, pronation syndrome with superior 1st and 5th metatarsals, and excessive supination during weight bearing.

Adjustment.   Place the patient supine. Stand at the foot of the table, and face the patient. Grasp the lateral aspect of the patient's involved foot with your lateral hand so that the superiorly subluxated bone is under the proximal or medial phalanx of your third finger and your thumb can stabilize the plantar surface of the patient's foot. Your medial hand is interlaced over the contact hand so that the third finger is on top of the contact hand's third finger and the thumb stabilizes against the plantar surface. Remove any foot inversion or eversion present. To correct the malposition, apply traction with firm contact pressure and simultaneously make a sharp pull towards yourself to move the subluxated bone caudally.

      Inferior Distal Metatarsal Subluxation

A distal metatarsal bone that has subluxated inferiorly is commonly associated with excessive callus formation across the metatarsal heads, a history of plantar forefoot pain, and excessive pronation during weight bearing.

Adjustment.   Place the patient supine. Stand at the foot of the table, and face the patient. Grasp the patient's involved foot with your medial hand so that the inferiorly subluxated bone is under your thumb and your fingers extend around the medial aspect. With the thumb and index finger of your lateral stabilizing hand, grasp the phalanges of the involved metatarsal. Remove any foot inversion or eversion present. To correct the malposition, apply traction to the phalanges, and simultaneously make a short thumb thrust cephalad to move the subluxated bone superiorly.

Common Toe Subluxations and Deformities

      Hallux Valgus

This is a state of lateral deviation of the great toe, usually found in conjunction with a hypermobile pronated foot and the prolonged wearing of pointed-toe shoes that produce abuse to the medial aspect of the front foot. The 1st metatarsal becomes fixed in abduction and the great toe (hallux) subluxates laterally. In time, the abductor hallucis becomes shortened, fixating the great toe in lateral displacement relative to the metatarsal head. The muscle becomes ineffective in maintaining abduction.

Adjustment.   With the patient supine, stand at the foot of the table and face the patient. With your lateral contact hand, grasp the great toe with your thumb anteriorly and your index finger on the plantar surface. Your medial stabilizing hand then grasps the wrist of your active hand for support. Apply traction, remove the valgus deviation, and make a short pull towards your body.

      Bunion

A bunion is an effect of prolonged hallux valgus where the great toe displaces laterally with rotation about the long axis so that the nail faces distinctly medially. The sesamoid enlarges because of chronic inflammation as do the soft tissues on the lateral aspect of the great toe. An adventitious bursa forms, which often becomes extremely tender and inflamed.

      Claw Toes

Claw toes, usually associated with pes cavus, feature flexed proximal and distal interphalangeal joints and hyperextended metatarsophalangeal joints. An early physical sign is the development of callosities over the dorsal surface of the toes, on the tips of the toes, and on the plantar surface under the metatarsal heads.

      Hammer Toe

A hammer toe presents with flexion deformity of the proximal interphalangeal joint and hyperextension deformity of the metatarsophalangeal and distal interphalangeal joints. It usually involves a singular toe and is typically associated with a callosity on top of the proximal interphalangeal joint. Predisposing factors include forceful plantar flexion of the metatarsal, pes cavus, a short metatarsal, forefoot valgus, a history of foot trauma, and/or pronation imbalance during weight bearing.

      Mallet Toe

A mallet toe reflects a distal interphalangeal joint flexion contracture, which usually occurs in the smaller toes. Its occurrence is less common than a hammer toe.