D. Combined Extension in Hip and Knee.

Half-lying (really Half-crook-half-lying) Leg-outstretching (Fig. 63). - The gymnast stands at the side of the patient and grasps with one hand the dorsum of the foot; with the other the heel from below. At the same time he leans his shoulder against the patient's knee, and during the movement resists partly with the shoulder, partly with the hand which holds the heel, while the hand which grasps the dorsum of the foot guides the movement.

The patient stretches the leg against the resistance of the gymnast, who then carries it back to the starting position while the patient is either quite passive or gives a little resistance. Repeated four to eight times.

Fig. 62.

If the movement is given with slight resistance a similar grasp is used as for Leg-updrawing and -downdrawing. The working muscles are :

(a) Extensors of hip (concentrically, then eccentrically). (N.B. - Semi-tendinosus, Semi-membranosus, and Biceps do not work.)

(b) Extensors of knee (concentrically, then eccentrically).

(c) Lower part of extensors of back (statically to fix pelvis). Effects and Uses. - (a) Depleting from head and upper part of body. (b) Used in general gymnastic treatment as a good leg exercise, and after massage of thigh and region of hip to cause increased supply of blood to the muscles worked upon.

Wing-Knee-Sitting Raising And Downpressing

Knee-sitting position is derived from Knee-standing by bending hip and knee joints till the buttocks rest on the heels.

The patient takes up the position on a plinth; the gymnast, standing behind him, places his hands on the patient's hips (iliac crests) and gives resistance while the patient raises himself to Knee-standing position. Then the gynmast presses down the patient again to starting position, while he in his turn resists. Repeated four to six times. (N.B. - Trunk should be kept upright throughout.)

The working muscles are the same, as in the previous exercise, but their attachments are reversed.

Effects And Uses

Are naturally also similar, but the exercise is not much used because it cannot be so well moderated (is always double; resistance can never be less than the weight of the patient's own body).

Fig. 63.

E. Combined Extension in Hip, Knee, and Ankle.

Reach-grasp-standing

Reach-grasp-instep-support-standing

Wing-standing

Neck-rest-standing

Stretch-standing

Stretch-instep-support-arch-standing

Heel-raising Knee-bending.

Reach-grasp-standing Heel-raising Knee-bending (Fig. 64). - After having taken the position, the patient first performs

"Toe-heaving," or more correctly "Heel-raising," then "Knee-bending" to a right angle between thigh and leg, then "Upward-stretching" to Toe-standing, and finally "Sinking" to starting position.

The exercise is performed at the command of the gymnast ("heels raise, knees bend, upward stretch, sink "); and he must observe that the carriage of the body is carefully maintained throughout. Repeated four to five times.

Sometimes the exercise is combined with "abdominal and lumbar pressure." This is given with the gymnast's one hand placed on the patient's sacrum, the other just above the symphysis pubis. In stretching, which is usually combined with a marked arching forward of the pelvis while the patient's arms are kept fully extended, the gymnast presses both hands firmly towards each other. In this it must be carefully observed, especially with women patients, that the palmar surface of the front hand is turned slightly upwards and that pressure with this is exerted straight backwards, not in the slightest degree down towards the true pelvis, otherwise dangerous pressure on the genital organs may occur.

Reach-Grasp-Instep-Support-Standing Heel-Raising Knee-Bending

Like the preceding; repeated three to four times on each leg. May be combined with abdominal and lumbar pressure.

Wing-Standing And Neck-Rest-Standing Heel-Raising Knee-Bending

Performed like Reach-grasp-standing, but in Free-standing position.

Stretch-Standing Heel-Raising Knee-Bending

The gymnast stands in front of or behind the patient, grasping his wrists, and resists the upward stretching.

Fig. 64.

Fig. 65.

Stretch-instep-support-arch-standing Heel-raising Knee-bending (Fig. 65). - The gymnast stands behind the patient on a stool. The patient holds one leg stretched backwards as straight as possible, with the foot supported on a stool. Otherwise like the preceding, except that the patient on stretching upward pushes forward the pelvis so that a strongly arched position arises.

The working muscles are: -

(a) Extensors of hip.

(b) Extensors of knee.

(c) Plantar flexors of ankle (calf muscles). They all work eccentrically and concentrically. (N.B. - Really the calf muscles work first concentrically, then eccentrically, concentrically, and finally eccentrically.)

Effects And Uses

Chiefly like Leg-outstretching, but Heel-raising and Knee-bending is in all respects stronger. It can only be moderated to a certain extent, because the weight of the body must always be overcome. It also repletes the pelvis (according to Brandt), probably because the common iliac arteries are enlarged to make possible the increased supply of blood necessary to the working muscles of the lower extremity.