LOWER EXTREMITY:

ARTICULATORY AND MUSCLE

ENERGY
Blackboard Copy

Articulatory Objectives

Demonstrate 70% minimum competency of the following skills:

On

a written exam Identify:

Therapeutic goals of articulatory techniques
Indications for performing articulatory techniques
Absolute and relative contraindications to performing articulatory
techniques
The mechanism of action of articulatory techniques
Correctly described techniques

On

a practical exam:

Verbally describe and correctly perform LE articulatory techniques if

assigned on a practical exam

Muscle Energy Objectives

1.
2.
3.
4.

5.

6.

7.

The osteopathic medical student will demonstrate a 70% minimum

competency/understanding of the following subject areas on a written
and/or practical examination:
Define muscle energy technique
Describe the different types of muscle energy technique
State the principles and proposed mechanisms of muscle energy technique
Verbalize and perform the essential steps applicable to all muscle energy
techniques
Identify the indications and contraindications for the use of muscle energy
technique in all body areas
Demonstrate ability to use muscle energy technique treatment principles in
diagnosing and treating segmental motion restrictions
Correctly identify descriptions of muscle energy mechanics, patient
positioning and treatments.

Disclaimer!

In this lecture you will be learning muscle energy

and articulatory techniques.

SOME of the techniques youll learn today are ONLY

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

ATTENTION: treatments are named

differently...again.
-ion = Articulatory technique, named by restriction.
-ed = Muscle energy technique, named by position
of ease

Do you know what this is?

CPM (Continuous Passive Motion) Machine

Articulatory vs. ME Review

Articulatory

Muscle Energy

In/direct

Direct

Direct

Active vs
Passive

Passive

Active

Low velocity, moderate-high

amplitude

No velocity, no amplitude

Frequenc
y

5-50x

3-5 seconds, 3-5x

Principles

Stabilize, localize, articulate

Control, balance, localization

1 MOA

Mobilize joints within their

physiologic ranges of motion

Frequently uses postisometric

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

Articulatory vs. ME Review

Indication
s

Articulatory

Muscle Energy

Presence of a somatic
dysfunction

Presence of a somatic dysfunction

Limited or lost articular

motion and when a
restrictive barrier is
emanating from a joint
itself or the respective
periarticular tissue.
Contraindication
s

To reposition or mobilize an articulation to restores its normal

arthrokinematics
Lengthen a shortened or spastic muscle
Strengthen a physiologic weak muscle or muscle group
Decrease edema and passive congestion

Open wounds/infection

Infection, hematoma, tear in involved muscle

Fracture/dislocation

Fracture, avulsion, or dislocation of involved joint

Tendon/ligament
avulsions

Severe osteoporosis

Severe osteoporosis

Metastatic disease of bone or soft tissue

Bleeding disorders

Rheumatologic conditions causing instability of the C-spine.

Types of Muscle Energy

Isometric
Isotonic
Eccentric or Isolytic
Antagonistic Inhibition

Which type do we use primarily at COMP?

Isometric

Lower Extremity Anatomy

Iliopsoas
Piriformis/Gemelli/QuadratusFemoris
GlutealMuscles

Lower Extremity Anatomy

Quadriceps
Hamstrings
Gastrocnemius/TibialisAnterior

Lumbar Plexus

Range of Motion
AROM (perform bilaterally)
HipFlexion/Extension:110/10
Hip
(flex/extend, ab/adduction, int/ext rotation)
Knee
Abduction/Adduction:30
(flex/ext)

Ankle/Foot
(dorsi/plantarflexion, in/eversion)
Internal/Externalrotation:40

REGIONAL
EXAMINATION
KneeFlexion:135
PROM (perform unilaterally) - one area to be assigned by grader
AnkleDorsi/Plantarflexion:20/40
Hip
(flex/extend, ab/adduction, int/ext rotation)
Inversion/Eversion:20/10
Knee
(flex/ext)

*FoundationsofOsteopathicMedicine,ed.3
Ankle/Foot (dorsi/plantarflexion, in/eversion)

WHERE ARE YOUR RESTRICTIONS?

Hip Techniques
Articulatory

Muscle Energy

Hip Flexion

-----

Hip Extension

Hip Flexed

Hip ABduction

Hip ADducted

Hip ADduction

Hip ABducted

Hip Internal Rotation

Hip Externally Rotated

Hip External Rotation

Hip Internally Rotated

Hip Flexion
Articulatory

Flex the patients hip to the

flexion restriction barrier
while keeping the knee
extended
The flexion restrictive barrier
is repetitively engaged 10-50
times

Hip Extension//Hip Flexed

Articulatory

Extend the patients hip to

the extension restriction
barrier off the table while
stabilizing the
contralateral ASIS
The extension restrictive
barrier is repetitively
engaged 10-50 times
stabilize

ME

Extend the patients hip on the

table, stabilizing the right knee
off the table.
Pt instructed to flex and ER
the hip against the physicians
unyielding counterforce x 3-5
seconds, followed by relaxation
x 2-3 seconds.
Reposition into new restrictive
barrier.
Repeat 3-5x; final stretch.

Alternate Set Up for

MET

Hip ABduction//Hip ADducted

Articulatory

ABduct the patients hip

to the ABduction
restriction barrier
The restrictive barrier is
repetitively engaged 1050 times

ME
ABduct the patients hip to the
ABduction restriction barrier
Pt instructed to adduct their leg
against the physicians unyielding
counterforce x 3-5 seconds,
followed by relaxation x 2-3
seconds.
Reposition into new restrictive
barrier.
Repeat 3-5x; final stretch.

Hip ADduction//Hip ABducted

Articulatory

ADduct the patients hip

to the ADduction
restriction barrier
The restrictive barrier is
repetitively engaged 1050 times

ME
ADduct the patients hip to the
ADduction restriction barrier
Pt instructed to abduct their leg
against the physicians unyielding
counterforce x 3-5 seconds,
followed by relaxation x 2-3
seconds.
Reposition into new restrictive
barrier.
Repeat 3-5x; final stretch.

Hip Internal Rotation//Hip Externally Rotated

Articulatory

Supine: Apply an internal

rotation force through the
patients ankle while
stabilizing the
patients distal thigh
The restrictive barrier is
repetitively engaged 1050 times

ME

Prone: Pt is prone, knee flexed to 90;

physician stabilizes opposite PSIS.
Internally rotate the patients hip to the
restriction barrier
Pt instructed to externally rotate their
leg against the physicians unyielding
counterforce x 3-5 seconds, followed by
relaxation x 2-3 seconds.
Reposition into new restrictive barrier.
Repeat 3-5x; final stretch.

stabilize

*Can be
perform
ed
supine
Supine set-up for Artic + ME or

Prone set-up for Artic + ME

Hip External Rotation//Hip Internally Rotated

Articulatory

ME

Supine: Support the

Prone: Pt is prone, knee flexed to 90;
patients heel and foot,
physician stabilizes opposite PSIS.
Externally rotate the patients hip to the
flexing the hip and knee
restriction barrier
to 90
Pt instructed to internally rotate their
Externally rotate the hip,
leg against the physicians unyielding
engaging the restrictive
counterforce x 3-5 seconds, followed by
relaxation x 2-3 seconds.
barrier
Reposition into new restrictive barrier.
The restrictive barrier is
Repeat 3-5x; final stretch.
repetitively engaged 10*Can be
50 times

Supine set-up for

Artic + ME

performed
supine or
prone.

Prone set-up for Artic + ME

MET & Articulatory: Hip

Hip Flexion
(Articulatory
ONLY)

Hip Adducted (ME)/

Hip Abduction

Hip Flexed (ME)/ Hip

Extension (Artic)

Hip
ExternallyRotated
(ME)/ Hip Internal

Hip Abducted (ME)/

Hip Adduction
(Artic)

Hip Internally
Rotated (ME)/ Hip
External Rotation

Knee and Ankle/Foot Techniques

Articulatory

Muscle Energy

Knee Flexion

Knee Extended

--------

Hamstring Restriction
(2 ways)

Ankle Dorsiflexion

Ankle Plantar Flexed

Ankle Plantar Flexion

Ankle Dorsiflexed

Ankle (Talocalcaneal Motion)

--------

Tarsometatarsal jt

--------

Metatarsal-phalangeal jt

--------

Knee Flexion//Knee Extended

Articulatory

ME

Apply a flexion force

Pt instructed to extend their leg
through the distal LE to
against the physicians
the flexion restrictive
unyielding counterforce x 3-5
barrier
seconds, followed by relaxation
x 2-3 seconds.
The restrictive barrier is
repetitively engaged 10-50 Reposition into new restrictive
times without returning to
barrier.
neutral
Repeat 3-5x; final stretch.

Hamstring Restriction (knee flexed)

Muscle Energy

Flex the patients hip into the

restrictive barrier keeping the
knee extended.
Pt instructed to extend their hip
against the physicians
unyielding counterforce x 3-5
seconds, followed by relaxation
x 2-3 seconds.
Reposition into new restrictive
barrier.
Repeat 3-5x; final stretch.
Alternate method:

Pt flexes right hip and knee

Pt instructed to flex their knee

MET/Articulatory Knee

Knee Extended
(ME)/
Flexion Knee
(Artic)

Hamstring Restriction/Knee Flexed (2

ways)
(ME only)

Ankle Dorsiflexion//Ankle Plantar Flexed

Articulatory

Dorsiflex the foot into the

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

ME

Supporting the heel, dorsiflex

the foot into the restrictive
barrier
Pt instructed to plantar flex their
ankle against the physicians
unyielding counterforce x 3-5
seconds, followed by relaxation x
2-3 seconds.
Reposition into new restrictive
barrier.
Repeat 3-5x; final stretch.

Ankle Plantar Flexion//Ankle Dorsiflexed

Articulatory

Supporting the heel,

plantar flex the foot into
the restrictive barrier
The restrictive barrier is
repetitively engaged 10-50
times never quite
returning to neutral

ME

Supporting the heel, plantar flex

the foot into the restrictive
barrier
Pt instructed to dorsiflex their
ankle against the physicians
unyielding counterforce x 3-5
seconds, followed by relaxation x
2-3 seconds.
Reposition into new restrictive
barrier.
Repeat 3-5x; final stretch.

Ankle Talocalcaneal Motion

Articulatory

Grasp the heel and talus

Apply and maintain a traction
force and articulate through
full ROM
(plantar/dorsiflexion,
inversion/eversion)
The restrictive barrier(s) is
repetitively engaged 10-50
times

Tarsometatarsal Joint Motion

Articulatory

The physician contacts the

tarsal bones and the
appropriate metatarsal
intended for treatment.

The physician performs a

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

Metatarsal Head Motion

Articulatory

The physician stabilizes one

metatarsal and then
articulates the neighboring
metatarsal through a
dorsal/plantar glide
The Lateral hand then
rotates medially and
laterally increasing rotatory
capacity of the metatarsal
heads.
Each metatarsal head and

Metatarsal-Phalangeal Joint
Articulatory

The physician stabilizes the

metatarsal and then
articulates the corresponding
proximal phalanx through
flexion/extension,
superior/inferior glide
(translation), medial/lateral
rotation, and medial/lateral
tilt (translation)
Treat other interphalangeal
joints in a similar fashion
(stabilize proximal, move
distal) until improved motion

MET/Articulatory Ankle & Foot

Ankle Plantarflexed (ME)/ Ankle Dorsiflexed (ME)/

Ankle Dorsiflexion (Artic) Ankle Plantarflexion
(Artic)

Ankle Talocalcaneal Motion

(Artic)

Tarsal-Metatarsal Joint Metatarsal Head Motion

(Articulatory)
( Articulatory)

Metatarsal-Phalangeal Joint
(Articulatory)

ROUND ONE

24-year-old male basketball player

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

ROUND TWO

A 19-year-old soccer player presents to

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

SUDDEN DEATH

26yo medical student was found to have

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

References

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

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

Department of Neuromusculoskeletal Medicine/ Osteopathic

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

Chila AG, executive ed, Carreiro, JE, Dowling DJ, et al.

Foundations of Osteopathic Medicine. 3rd ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2011.