The techniques are described outside the context of integrating the whole. They must not be used this way but only if properly indicated by that context. They can otherwise introduce disorder into the structure instead of order.
Standard Torsion of the Right Lower Leg
Not much is known yet about the configuration of the fascial net which holds the right lower leg in standard torsion. Working on the superficial fascia membranacea and organizing the hamstring tendons and the iliotibial tract often does not normalize the situation significantly. Apparently, “deeper” parts of the fascial net are involved. Certainly the proximal membrana interossea plays a role. It must be assumed to be “narrow”. Widening it in the frontal plane should help to detach tibia and fibula from each other, but it cannot be reached easily.
Of course, one should not expect “absolute normalization”. Torsion seems to be a biological constant, and an “ossary factor” must be presumed to sustain it. But improvement to some degree can sometimes be achieved by affecting the “deep” parts of the fascial net if one has a clear mental picture of “normal”. Various techniques offer themselves to this end. One of them which is easy and quick is presented.
The method is indirect but specific. Sitting at the foot end of the table the Rolfer influences torsion from the ankle. The client is supine, with the heels over the edge of the table so the feet are free. This reduces the tendency of the legs to rotate externally when the client lies on the back and makes it easy to prevent the knees from going into hyperextension, which must be avoided.
I take the heel in my left hand with the thumb on the outside, the other fingers on the medial side of the calcaneus and Achilles tendon. The thumb of the right hand is on the sole of the foot, the other fingers go into the ankle joint from anterior. From this vantage point the hands control the whole leg optimally. I have two objectives in mind. One is to get length in all compartments of the leg, the other is no bring the ankle in its normal position.
I first make sure that the pelvis is free by pulling slightly distal. The pelvis should detach a little from the thorax and tend to go in the direction of a very slight anterior tilt. Then the hip is checked to be free by rotating the leg in and out softly under permanent light tension. Following this, the knee is attended to. It should be minimally flexed because in hyperextension, and even approaching it, the whole fascial net around the knee loses length and tension, or it is displaced sideways as far as its parts on the backside are concerned.
Finally, I pull the foot a little off the lower leg by taking the heel distal. The fingers of my right hand press down and distal on the dorsum of the foot to prevent the ankle joint from closing in front when the heel comes down. The foot is so dorsiflexed passively, but it is not necessary and not advisable at this point to attain a 90° angle.
Now the exact transverse orientation of the rotational axis through the ankle is established. The knee now points clearly medial. My left hand keeps the heel aligned while pulling it distal and posterior a little, the other hand holds the forefoot anterior.
Sometimes it is favorable to exceed normal with the ankle axis and bring it some way into internal rotation. Flexing and extending the leg slightly and passively, prepares the ground optimally.
With the leg loose and under constant distal traction, I ask the client to let the knee rotate out. There should be no muscle activity which pulls the knee proximal, nor should the muscles in back of the hip be contracted. The right side of the pelvis should stay flat on the table and remain wide. A further slight flexion of knee and hips may occur but must be in the extension mode. I sometimes suggest that the knee should turn out as if by itself, as if there were a small motor in it.
I resist the force of the knee turning out from the ankle. My left hand still pulls distal, while the fingers of the right hand in the joint push up a little on the tibia with the intention of rotating it medial at the knee. When the distal femur turns out the tibia stays behind. There should still be some distal traction in the knee joint.
The leg is held as if suspended between the active force from the knee and the passive counterforce I exert from the ankle until there is a sense of the interosseous membrane giving way, loosening. The caput fibulae should tend to go lateral and posterior with the femur. If the alignment described is just right, active external rotation of the knee contributes a little to that, perhaps via biceps femoris. Sometimes I help this with the thumb of my left hand which has gone to the anterior side of the fibula just above the lateral malleolus. The effect is sometimes more marked if I dorsiflex the foot strongly now, keeping the ankle open, and pulling it decisively distal and pushing it posterior.
Lengthening the Extensor Sling of the Knee in a Special Sitting Position
The extensor sling of the knee is in the narrowest view formed by the fasciae of the vasti, the patella, and the patellar tendon inserting on the tuberositas tibiae. It contains the forward thrust of the flexed knee and helps to straighten the leg bent in the knee by increasing its tension. Because muscles which cross more than one joint should not “work” but only modify and control movement and posture, the rectus femoris should not play an active role in this.
Shortness of the extensor sling is most marked in locked-knee internals. With hyperextension of the knee, the anteriorly slanted thigh and the posterior slant of the lower leg produce a concave front contour. In standing, gravity pushes the knee back into the sleeve behind and the extensors have no function. They are extremely relaxed, and by adapting to it, the tissue becomes primary short.
Below, the tissue of the dorsal extensors of the foot between tibia and fibula is strongly in primary shortness, especially when the posterior slant of the lower leg is marked. This seems to contribute to the general shortness above probably via fascia membranacea, including the periostium of the tibia.
The extensor sling can be considered to have two “adjuncts”. Medially, the three strands of fascia which insert as the pes anserinus on the tibia have taken a shortcut and lie more anterior. Laterally, the part of the fascia lata which often impresses as the iliotibial tract has also come around and forward. Both are displaced anteriorly and are usually markedly short.
I ask the client to sit on the edge of the table with the lower legs hanging down. The feet should not touch the floor; so she should sit relatively far back. If the mattress is a little farther out than the table, pressure in the back of the knees is avoided and the table will not inhibit the movement that I ask her to do.
Fig.1 – Front and side view before and after the two techniques described.
First I check that the body is in a variation of normal sitting. Generally I ask the client to support herself on her hands which are placed forward toward the edge of the table. The midline of the trunk is anterior convex, it “hangs through”. Chest and belly are completely reIaxed, the back is passively extended, the ischial tuberosities are far back. Clients who are familiar with normal function are able to extend, i.e. to let their tuberosities slide back by pressing down with their hands.
I ask the client to let the foot of the leg I am working on swing back under the table. She should imagine that the heel goes back and pulls the foot and the lower leg along. The foot should stay straight. Usually it tends to rotate externally or internally, which must not be allowed. Often the medial side of the foot is pulled up. This is prevented by asking the client to lower the medial arch, and to hold up the lateral toes a little, without producing rotation. The supinators are then relaxed and long, the peroneals are active.
The most difficult part of the movement is the knee. It should initially slide forward a little before the foot goes back (extension mode). For this to happen all muscles of the thigh, front and back, must reduce their tonus first. Care must be taken that the knee is not pushed forward from the hip. The whole movement looks like this: The upper body stays hanging forward supported by the arms; the ischial tuberosities go back a little and out; at the same time the knee extends forward slightly; only then the heel goes back without retracting the knee or pulling forward the ischial tuberosity. The movement observed at these points of reference is often minimal which is sufficient, however.
It is also advantageous to keep the thigh slightly adducted and rotated internally. The ischial tuberosity is then far lateral, the pelvic floor is open. Abduction and external rotation of the thigh result quickly in a considerable loss of length and passive tension on both the medial and lateral side of the distal thigh.
If the movement described above is done well, I then generally work with both hands from the patella on up. The fingers slide under both edges of the rectus femoris, and it is often necessary to lift it off and separate it from the tissue underneath. Then I lengthen this, under the rectus first, then more lateral with special attention to the septa intermuscularia. Working with both hands provides excellent control over the position of the thigh so all the tissue stays long. Focusing on the ischial tuberosity through the hands helps to keep it back and lateral. When movement is not optimal I work with one hand on the medial or lateral side while the other gives direction to the thigh from the knee. When the client pulls the foot back, the tissue is pulled long and allows to lengthen it more. When she lets the foot come forward, the tissue relaxes and permits me to slide into place with my fingers. The alternating movement from the foot is used to work my way up as far as necessary.
I also usually work on the side of the patella, this time in the distal direction. With the foot moving back, the tissue wants to go wide. Holding it medially from both sides and away from the bone makes it lengthen. The patellar ligament can be lengthened this way from the sides, even a little from behind, or from in front by pressing into it just above the rim of the tibia.
When the movement is too difficult for the client something can still be gained by passive motion. I take the foot back with one hand while the other works.
One will often notice that with this lengthening of the extensor sling, the ipsilateral side of the pelvis with the hip sinks down and back. It appears that the short sling when tensed by the flexed knee pulls the pelvis forward and onto the thigh. Part of the pull is probably by the rectus, but also the fascia membranacea (fascia lata) and perhaps especially the two septa seem to be responsible for it. The method is favorable as far as the pelvis of locked-knee internals is concerned considering its anterior shift on the thighs in sleeve-supported stance and the usually marked anterior tilt in internal free stance.
The technique can also be used with other structural types although with symmetrical externals it may produce disintegration.