Clinical Notes in Physiotherapy

✅ Gait Dysfunctions

✅ McConnell Test for Chondromalacia Patellae

The patient is sitting with the femur laterally rotated. The patient performs isometric quadriceps contractions at 120°, 90°, 60°, 30°, and 0° with each contraction held for 10 seconds. If pain is produced during any of the contractions, the patient's leg is passively returned to full extension by the examiner. The patient's leg is then fully supported on the examiner's knee, and the examiner pushes the patella medially. The medial glide is maintained while the knee is returned to the painful angle, and the patient performs an isometric contraction, again with the patella held medially. If the pain is decreased, the pain is patellofemoral in origin. Each angle is tested in a similar fashion.

MET of Upper Hamstrings

- If the upper fibres are involved, then treatment is performed in the SLR position, with the knee maintained in extension at all times.
- The non-treated leg should be flexed at hip and knee or straight, depending on the hip flexor findings.
- In all other details the procedures are the same as for treatment of lower hamstring fibres except that the leg is kept straight.

MET of Lower Hamstrings (Fig. 5.14)

- The non-treated leg needs to be either flexed (if hip flexors are short) or straight on the table.
- The treated leg should be flexed at both the hip and knee, and then straightened by the practitioner until the restriction barrier is identified (one hand should palpate the tissues behind the knee for sensations of bind as the lower leg is straightened).
- Depending upon whether it is an acute or a chronic problem, the isometric contraction against resistance is introduced at this "bind" barrier (if acute) or a little short of it (if chronic).
- The instruction might be something such as "try to gently bend your knee, against my resistance, starting slowly and using only a quarter of your strength".
- Following the 7-10 seconds of contraction followed by complete relaxation, the leg should, on an exhalation, be straightened at the knee towards its new barrier with the patient's assistance.
- The slight stretch should be held for up to 30 seconds.
- Repeat the process until no further gain is possible (usually one or two repetitions achieve the maximum degree of lengthening available at any one session).

Hamstring Test B (Fig. 5.14)

Whether or not an 80° elevation is easily achieved, a variation in testing is needed to evaluate the lower hamstring fibres.
- To achieve this assessment the tested leg is taken into full hip flexion (helped by patient holding upper thigh with both hands). The knee is then straightened until resistance is felt, or bind is noted by palpation of the lower hamstrings.
- If the knee cannot straighten with the hip flexed, this indicates shortness in the lower hamstring fibres, and the patient will report degrees of pull behind the knee and lower thigh. MET treatment of this is carried out in the test position.

Hamstring Test A

- The patient lies supine with non-tested leg either flexed or straight, depending on previous test results for hip flexors.
- The tested leg is taken into a straight-leg raised (SLR) position, no flexion of the knee being allowed, with minimal force employed.
- The first sign of resistance (or palpated bind) is assessed as the barrier of restriction.
- If straight leg raising to 80° is not easily possible, then there exists some shortening of the hamstrings and the muscles can be treated in the straight leg position (see below).

✅ Assessment and Treatment of Hamstrings

MET Treatment of gastrocnemius and soleus (Fig. 5.1A,B)

- If the condition is acute (defined as a dysfunction/injury of less than 3 weeks' duration) the area is treated with the foot dorsiflexed to the restriction barrier.
- If it is a chronic problem (longer duration than 3 weeks) the barrier is assessed and the muscle treated in a position of ease, slightly towards the mid-range, away from the restriction barrier.
- Starting from the appropriate position, at the restriction barrier or just short of it, based on the degree of acuteness or chronicity, the patient is asked to exert a small effort (no more than 20% of available strength) towards plantarflexion, against unyielding resistance, with appropriate breathing.
- This effort isometrically contracts either gastrocnemius or soleus (depending on whether the knee is unflexed or flexed).
- The contraction is held for 7-10 seconds.
- On slow release, on an exhalation, the foot/ankle is dorsiflexed to its new restriction barrier if acute, or slightly and painlessly beyond the new barrier if chronic, with the patient's assistance.
- If chronic, the tissues should be held in slight stretch for up to 30 seconds, to allow a slow lengthening of tissues.
- This pattern is repeated until no further gain is achieved.

Figure 5.2 illustrates an alternative treatment position for gastrocnemius which can also be used for assessment. Flexion of the knee would allow this position to be used for treating soleus.