DECEMBER, 1974 P H Y S I O T H E R A P Y 11 DIE W ERKING VAN DIE QUADRICEPS-SPIER en ’ n FUNKSIONALE BENADERING T O T S Y HEROPLEIDING (Miss) L. M . D A V ID S/SEN IO R LEC T U R E R : T R A IN IN G B.Sc. (Physio) Rand., B.A. Hons. (U .O.F.S.), Dip.Ed. Physiother. Pret. D isfunksie van die Quadriceps-spier is een van die mees aig e m e n e verskynsels in traum a van die onderste ledemaat. Enige besering in die omgewing van die kniegewrig sal ’n v e rra in d e rin g in die effektiewe werking van hierdie spiergroep v e r o o rs a a k en ’n erger graad van besering en/of chirurgie kan ’n totale inhibisie veroorsaak. D it is veral in laasgenoemde geval dat die pasient na Fisioterapie verwys word vir ‘Quadriceps driF. D ie sukses o f m islukking van hierdie ‘dril’ hang a f van ’n goeie begrip van die werking van die spier- -oroep. Anatomies word die quadriceps beskou as ’n knie 'isten so r— d.w.s. m et die voet vry word die knie van die gebuigde posisie to t die reguit posisie gebring. D it is natuurlik die aksie van hierdie spier, m aar w aarom moet die spierbou so massief wees vir so ’n ligte werk ? Ekstensie van die knie met ’n vry voet is nie die primere funksie van die quadriceps nie. Let us first consider its structure. The quadriceps is an extremely bulky muscle which covers th e whole of the front of the thigh. Morphologically it can be divided into four distinct com ponents:— (i) Rectus Femoris which is fusiform in shape, arises from the anterior inferior iliac spine and inserts into th e base of the patella. I t forms the superficial central part of the quadriceps tendon. Rectus femoris is a two-joint muscle i.e. it acts on both the hip and the knee joints. (ii) Vastus lateralis is the largest com ponent o f quadriceps femoris. I t arises from the intertrochanteric line, the, anterior and inferior borders of the greater trochanter and the upper h alf of the lateral lip o f the linea aspera. It inserts principally into the lateral border o f the patella and into the quadriceps femoris tendon. (iii) Vastus medialis arises from the lower p art o f the inter­ trochanteric line, spiral line, medial lip of the linea aspera and upper p art of the medial supracondylar line etc. Its fibres pass dow nward and forw ard and are chiefly attached to the medial border o f the patella and the quadriceps tendon. The lowest fibres are alm ost horizontal and form the bulge on the medial side o f the knee th at is distinctive in a well-developed muscle. The fibres o f vastus medialis run thus in tw o distinct direc­ tions and one w ould expect the function o f the two parts to differ. (iv) Vastus intermedius arises from the anterior and lateral surfaces o f the upper tw o thirds o f the shaft of the femur. In its upper p a rt it is frequently fixed w ith the upper fibres of vastus medialis. Its insertion forms the deep part of the quadriceps tendon and it is also attached to the lateral border of the patella. (1 1 ) D uring the last ten years a fair am ount of work has been done on the action of the individual parts o f the the quadri­ ceps. In a mechanical study using am putation specimens, Lieb and Perry (17) established th a t:— (a) Vastus intermedius is the m ost efficient extensor. W ith various combinations the total force com bination was very close to th at o f vastus interm edius alone. Vastus medialis alone could not extend the knee. (b) Full knee extension and term inal rotation were attained only when the prim ary extensor was vastus lateralis. The horizontal fibres o f vastus medialis failed to produce extension. F ull extension was obtained when the extension load was on any of th e other long heads. (c) W hen a weight was applied to the horizontal fibres o f vastus medialis sufficient to keep the patella centred in the femoral groove, th e force required fo r the vastus lateralis to extend th e knee fully, was decreased by 13%. (d) As the knee became progressively straighter, a greater force was required. They came to the conclusion th a t:— (i) The only selective function attributable to the horizontal fibres of vastus medialis is patellar alignment. (ii) The extensor lag accompanying knee lesions is a function o f the loss in mechanical advantage of the quadriceps during the last 15° o f extension, a 60 per cent increase in force being necessary to complete extension. (iii) The clinical prom inence of vastus medialis is related to th e m arked obliquity o f its distal fibres, th e lowness o f its insertion and the thinness of the fascial covering o f this part o f the muscle. (iv) Early atrophy o f the vastus medialis and lack o f terminal extension after injury are indicative o f general quadriceps weakness. These findings are borne out by other investigators per­ forming electrom yographic studies on both norm al and recently injured knee joints. (4 ,1 5 ,1 8 , 24) One is able to infer from available studies th at no individual com ponent o f the quadriceps perform s consistently in any specific p art o f the range. The muscle com ponents act as a whole with con­ siderable variation. There is consensus o f opinion th a t the action o f the horizontal fibres of vastus medialis during the terminal phase o f extension, is to retain patella in its groove on the patellar surface of th e femur, helping to counteract the natu ral tendency to lateral displacement. ( 1 1 , 26) All these studies have been perform ed with the quadriceps acting as a knee extensor with the foot free. Insofar as they establish the necessity to re-educate the muscle as a whole and not to concentrate on one com ponent alone viz vastus medialis, they can assist in the planning of a rehabilitation program. However, in order to obtain the optim um perform ­ ance in the minim um time, one must consider the function of the quadriceps in the living body. The quadriceps is a postural muscle which fact is the reason for its bulk. Its function is to counteract gravity in a m ultitude o f different postures. Its function is n o t so much to m aintain a standing posture as to perform the powerful movements required for th e changes o f posture such as sitting to standing, crouching to standing, etc. (3) In the erect position the line of gravity falls slightly in front of the knee joint so th at quadriceps action is slight, if n o t entirely absent. According to Basmajian (3) during walking on the level, the quadriceps contracts as extension o f the knee is being completed, early extension being principally passive (this principle is used in the construction o f the free knee jo in t in an above-knee prosthesis), and it continues to act during the early p a rt of the supporting phase while the line o f gravity is behind the knee joint. A strong quadriceps is thus n o t a requirem ent for walking on the level. Patients with a paralysed quadriceps use their hand to lock the knee at the heel strike, and otherwise m anage very well. Thus, as soon as the line of gravity falls behind the knee and if there is any degree o f flexion, the quadriceps will be R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) F I S I O T E R A P I E DESEMBER 1974 ■ i n■ F o r m u la : D ie th y la m in e S a lic y la te 10 g N o p o x a m in e 1 g E x c ip ie n t q .s .a d . 100 g ■ ■ s H■Nil 1. R heum atic pains in jo in ts an d m uscles 3. M uscle cram ps an d stiffness gllf 2. Fibrositis 4. Other local pains and aches pain is our scene. analgen ointment Formulation: T w o p a i n -k i l lin g ingredients, diet I n I a m i n e sal i c \ l a t e a n d n o p o x a m i n e , in a special oin tm ent b as e to sp e ed sul - c u t a n e o u s p e n e t r a t i o n . Indications: R h e u m a t i c pa in s in joint', a n d m u s c l e s , l o w b a c k a c h e , f i b r o s i t i s , s p r a i n s a n d b r u is es , m u s c u l a r cra mps a n d stiffness, n e u r a l g i c pai ns. Action: S o o t h i n g , dee p -p en et ra ti n g , r a p i d p a i n re li ef w ith local anaesthetic effect. Application: M a s s a g e g e n t k into the sk in a r o u n d t h e af fec ted a'e.i u n til c o m p l e t e l y a b ­ s o r b e d . A p p l y a s o f t e n a s r e q u ir e d . . , Another pain-fighting product in the A N ALG EN tradition @ jNoristan L a b o r a to r ie s (Pty) Ltd, Silverton, Pretoria. Form ula: Latema, Paris. For full prescribing information, contact Noristan Laboratories direct. 9 l 6 4 / « R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) DECEMBER, 1974 P H Y S I O T H E R A P Y 13 thrown into action. In walking up and down an incline the muscle works more strongly than on a level surface. Walking up and down steps is impossible without an adequately functioning quadriceps on the supporting leg—the higher the step the greater the muscle activity. The m ajor action of this muscle is, therefore, to straighten the knee with the foot fixed on the ground i.e. to help support the body weight, or to allow the knee to bend (by means o f a lengthening reaction), again with a fixed foot. In this fashion it performs its postural function and it is in order to support the weight of the body that the quadriceps is so massive in structure. The re-education of quadriceps function poses several problems:— (1) A fter injury o r surgery there is a reflex inhibition which is thought to be a result of pain. In the studies performed on knee injuries, most investigators come to the conclu­ sion that the inhibition is central and that pain and not soft tissue stretching is the m ajor factor concerned. (8, 9, 13, 22, 23, 27, 28, 30) (2) With most patients who have undergone knee surgery, flexion of the knee is not allowed for approximately 10 Q days to avoid the possibility o f a haemarthrosis. In fact the knee joint is generally splinted in full extension. (3) Immediate weight-bearing is not usually permitted. (4) The last being most im portant from the point of view of re-education— the principle function of the quadriceps is not to lift the leg up straight and this combined with the previously mentioned factors, impedes re-education. It must be understood th at re-education or therapy does not comprise the m otor act alone. N orm al m otor activity is always a response to stimuli and therapy should therefore consist of the application of stimuli to activate the m otor response in such a way as to stim ulate norm al m otor functions. According to Prof. Rood (29) m otor development takes place in four steps;— (i) In a non-weight-bearing reciprocal pattern moving the small lever e.g. the foot in a mass flexion pattern. This is seen in the supine infant kicking. (ii) In a weight-bearing co-contraction pattern e.g. in the stabilizing action seen in stance patterns i.e. all muscle groups around a joint are active. (iii) In a weight-bearing pattern moving the larger lever e.g. in the action of bringing the body over the foot the calf muscles are thrown into strong contraction. (iv) In a co-ordinate pattern e.g. at the heel strike phase of walking there is dorsiflexion of the foot with knee extension and hip flexion. y Q These patterns o f movement are presented in order of -complexity and are found to occur in this order during the developmental process. If functions such as stabilizing are lost as a result o f reflex inhibition they must be restored before progressing to the more complex skills. Rood also classifies muscles into two m ajor functional groups viz. mobilizing and stabilizing. M ost muscles in the body comprise both these elements, but it is possible to consider some muscles to be predom inantly mobilizers and others to be predom inantly stabilizers. This classification is not only functional, but histological and neurological as well. Histologically, mobilizing muscles have a high concentration of white muscle fibres, stabilizers having more red. M obili­ zing muscles are usually fusiform in shape, they cross two or more joints and belong generally to the flexor and adductor groups. They tend to perform light work with the distal part of the limb free. Rectus femoris falls into this category. Stabilizers are commonly bipennate or irregular in shape, they cross one joint and are found to be extensors and abductors. Their action is to move the body over the fixed limb i.e. heavy work. The other components of quadriceps are stabilizers. The muscle spindles of single joint extensors are richly supplied with secondary afferents whose activity Facilitates a co-contraction. (2 1 ) The nerve supply is thus also functionally arranged. It is not only the peripheral innervation which is functionally orientated, but the central nervous system as well. Buchwald (7) states that “ Central mechanisms upon which postural maintenance is primarily dependent would seem to reside in those pathways term inating most densely around the axial and extensor interneurons and m otoneurons i.e. the vesti­ bulospinal and reticulospinal tracts . . . Central control of limb movements and actions of fine co-ordination would seem to descend through those pathways terminating most heavily around the interneurons and m otoneurons inner­ vating the distal and flexor musculature i.e. pyram idal and rubrospinal tracts.” p. 150. It would seem then that in order to obtain the optimum response from any muscle group, irrespective of the specific movement technique employed, one must take into account its physiological function as well as its anatom ical action. T o return to the quadriceps—this is a bi-functional muscle. The rectus femoris part is a mobilizer working principally with the light lever i.e. straight leg raising, while the other three components are stabilizers whose principal function is to move the body weight. Now, we have the patient with a reflex inhibition of the quadriceps, a splinted straight knee and he is not allowed to weight-bear. Before he is able to lift his leg (a co-ordinate pattern or skilled function) the patient must regain the stabilizing function o f the quadriceps. If one attem pts re-education without considering the functional level o f the patient, therapy, if not completely unsuccessful, is certainly greatly hindered. One must thus as far as possible simulate weight-bearing conditions without putting any strain on the joint. This is not as difficult as it sounds. Stretch of the interosseus muscles of the foot has a facilitating effect on the postural muscles of the lower limb. Joint compression is facilitatory to extensor muscles. If a quick, alternate rotation o f the hip in a very small range, is applied together with other superimposed facilitatory methods, a co-contraction of the muscle groups of the lower limb is elicited and the quadriceps contracts as a stabilizer. Stretch by gravity can be superimposed by placing the patient in the prone position. Once the quadriceps is able to function as a stabilizer, one can progress to using it in a co­ ordinate pattern i.e. straight leg raising; Effective re-education of quadriceps function is most difficult in the immediate post-operative stage. Once movement of the knee and weight-bearing are allowed, the problems are fewer. N orm al function need not be simulated. The limb can be subjected to the natural facilitatory effects of changes in the centre of gravity, weight-bearing, walking, etc. as an essential part of the re-education program. The action o f the quadriceps is extremely complex and many aspects must be taken into consideration by the therapist so lth at she can provide the most favourable con­ ditions for rehabilitation. F rom experience it has been found that the application o f a functional, developmental approach to rehabilitation can dynamically influence the musculo­ skeletal system. REFERENCES 1. Barnett, C. H .: Locking at the knee joint. J. A nat. 87: 91-95, 1953. 2. Basmajian, J. V .: G rant’s Method of Anatomy, 8th ed. Baltimore, Williams & Wilkins, 1971. 3. Basmajian, J. V.: Muscles Alive, 2nd ed. Baltimore, Williams & Wilkins, 1967. 4. Basmajian, J. V., H arden, T. P. & Regenos, E. M .: Integrated actions of the four heads of quadriceps femors: An electromyographic study. A nat. Rec. 172: 15-20, 1972. 5. B runnstrom , S.: Clinical kinesiology, 3rd ed. rev. by D ickinson, R. Philadelphia, F. A. Davis, 1972. 6. Buchwald, J. S.: Proprioceptive Reflexes and Posture. Am. J. Phys. M ed. 46: 104-113, 1967. 7. Buchwald, J. S .: A functional concept o f m otor control. Am. J. Phys. Med. 46: 141-150, 1967. 8. C arlsoo, S. & N ordstrand, A .: The co-ordination of the knee muscles in some voluntary movements and in the R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 14 F I S I O T E R A P I E d e s e m b e r 19?4 gait in cases with and w ithout knee joint injuries. Acta Chir. Scand. 134: 423-426, 1968. 9. D e A ndrade, J. R ., G rant, C. & Dixon, A. St. J . : Joint distension and reflex muscle inhibition in the knee. J. Bone Joint Surg. 47A: 313-322, 1965. 10. G ardner, E., G ray, D . J. & O ’Rahilly, R .: Anatomy, 3rd ed. Philadelphia, W. B. Saunders, 1969. 11. G ray’s Anatomy—ed. Warwick, R. & Williams, P. L., 35th ed. Edinburgh, Longman, 1973. 12. H all, M. C .: The Locomotor System: Functional Anatomy. Springfield, Charles C. Thomas, 1965. 13. H allen, L. G. & Lindahl, O .: R otation in the knee joint in experimental injury to the ligaments. A cta O rthop. Scand. 36: 400-407, 1965. 14. H allen, L. G. & Lindahl, O .: The ‘screw-home’ move­ ment in the knee joint. Acta O rthop. Scand. 37: 97-106, 1966. 15. H allen, L. G. & Lindahl, O .: Muscle function in knee extension: an electrom yographic study. A cta O rthop. Scand. 38: 434-444, 1967. 16. Licht, S., ed.: Therapeutic Exercise, 2nd ed. rev. Balti­ more, Licht, E., 1965. 17. Lieb, F. J. & Perry, J . : Quadriceps function: an anatom ­ ical and mechanical study using am putated limbs. J. Bone Joint Surg. 50A: 1535-1548, 1968. 18. Lieb, F. J. & Perry, J.: Quadriceps function: A n electro­ m yographic study under isometric conditions. J. Bone Joint Surg. 53A. N o. 4: 749-758, 1971. 19. Lindahl, O. & M ovin, A .: The mechanics o f extension of the knee joint. Acta O rthop. Scand. 38: 226-234,1967. 20. M acConaill, M. A. & Basmajian, J. V.: Muscles & Movements. Baltimore, Williams & Wilkins, 1969. 21. O ’Connell, A. L. & G ardner, E. B.: Understanding the Scientific Bases of Human Movement. Baltimore, Williams & Wilkins, 1972. 22. Palmer, I . : Pathophysiology of the medical ligamn the knee joint. A cta Chir. Scand. 115: 312-318, 1953 23. Petersen, I. & Stener, B .: Experimental evaluation nf . hypothesis o f ligamento-muscular protective refle 111 A Study in m an using the medial collateral lioal Xes- of the knee. Acta Physiol. Scand. 48 Supp. 166, 1 9 5 9 * 24. Pocock, G. S .: Electromyographic study of the quad ■ ceps during resistive exercise. J. Amer. Phys tk Assoc. 43: 427-434, 1963. ' "er- 25. Rasch, P. J. & Burke, R. K . : Kinesiology and anni.vj anatomy, 4th ed. Philadelphia, Lea & Febiger, 1971 26. Steindler, A .: Kinesiology of the human body. SnrinefiAij Charles C. Thomas, 1955. s eid- 27. Stener, B. & Petersen, I.: Electromyographic investing tion of reflex effects upon stretching the partial] ruptured medial collateral ligament o f the knee ininf Acta Chir. Scand. 124: 396-411, 1962. J nt- 28. Stener, B.: Reflex inhibition o f the quadriceps elicited from a subperiosteal tum our o f the femur. Acta Orthnn Scand. 40: 86-91, 1969. L 29. Stockmeyer, S. A .: An interpretation of the approach oT Rood to the treatm ent o f neurom uscular dysfunction' Am. J. Phys. Med. 46: 900-956, 1967. 30. Swearingen, R. L. & Dehne, E .: A study of pathological muscle function following injury to a joint. J. Bone Joint Surg. 46A: 1364, Sept. 1964 (Proceedings). 31. Tokizane, T. & Shimazu, H .: Functional differentiation of human skeletal muscle. Tokyo, University of Tokyo press, 1964. 32. Wells, K . F .: Kinesiology, 5th ed. Philadelphia, W. B. Saunders, 1971. 33. Williams, M. & Lissner, H. R .: Biomechanics of human motion. Philadelphia, W. B. Saunders, 1962. F O R S A L E PRIVATE PRACTICE Fully equipped P hysio th erap y P ractice fo r sale a t coastal resort. Easy, c o m fo rta b le living as is or scope fo r en larg em en t. Enquiries: P.O. Box 11151, J O H A N N E S B U R G . A „ C . PJeS L L E R & C O . ORTHOPAEDIC MECHANICIANS © Technicians registered w ith S.A. Medical and r Dental Council specialising in the following: ORTHOPAEDIC APPLIANCES, SURGICAL CORSETS, CERVICAL COLLARS, CHILDREN'S SHOES AND BOOTS,- ARTIFICIAL LIMBS, LATEST IN PLASTIC MODIFICATION. HIRING AND SELLING OF HOSPITAL EQUIP­ MENT AND SICK ROOM REQUISITES, e.g. WHEEL CHAIRS, COMMODES, HOSPITAL BEDS, WALKING AIDS, TRACTION APPARATUS, etc. Telephone P.O. Box 3412 23-24 96 275 Bree Street Johannesburg R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )