The rest position for the quadriceps is secured by keeping the leg in full extension; that for the flexors by placing the knee in flexion at a right angle or less.

For the sake of brevity, training of the muscles supplied by the external popliteal nerve will be considered in toto, that of the muscles supplied by the internal popliteal being the exact reverse. Variation in individual cases will be required according to the relative strength of the muscles supplied by the anterior tibial and the musculo-cutaneous nerves respectively. Gravity assists the dorsi-flexors to the greatest possible extent when the patient is prone and the knee flexed to a right angle. In this position, therefore, the antagonists are taught to relax. The zero position is reached when the patient lies upon his side. If the patient lies with the injured leg next the couch, the tibialis anticus and posticus muscles can be trained against gravity; if on the opposite side, then the evertors can be dealt with in similar manner (see Fig. 47, p. 92). Gravity resists the muscular action of the dorsi-flexors slightly when the patient is recumbent (or sitting) with the foot projecting slightly over the end of the couch. The resistance increases with increase in dependency of the limb, till it is greatest when the leg hangs vertically downwards. In this position gravity antagonises equally both evertors and invertors in movement away from the rest position, and can render assistance in return to it. The maximum assistance (or resistance) is afforded when the leg is placed upon one side, the foot projecting from above the ankle over the side or end of the couch.

The rest position for the dorsi-flexors is found in the sitting position when the feet are drawn well under the chair and the weight of the leg rests upon the toes (cf. Fig. 108, p. 269). The plantar-flexors are relaxed when the feet are moved forward till the weight rests solely on the heels. The invertors are relaxed and their antagonists maintained in a state of tension when the patient sits with feet crossed and the weight of the leg resting on the outer borders of the foot (cf. Fig. 110, p. 271), while the evertors are usually rested quite adequately when the sole of the foot rests quite flat upon the floor, the inclination of the tibia being slightly directed forwards.

The training of the muscles of the foot is similar to that used when dealing with a hand, the general plan of the muscle action being very similar. But if, as we have seen, the opponens pollicis is probably the most important individual muscle in the hand, so the adductor transversus must be awarded a high place when considering the foot. The actual foot-drill will be considered later (see Chapter XXXI (The Treatment Of Deformities).).

The question is often raised as to when muscle re-education should begin if a muscle has been completely paralysed. The answer is simple: it cannot be begun too soon once acute symptoms (if such are present at all) have subsided. It is common knowledge how rapidly skill in movement deteriorates in the absence of practice. Experience tends to show that complete inability to move a muscle rapidly leads the patient to forget what it feels like to move it, and this leads in turn to forgetfulness as to how to use it. Whenever paralysis is present there is a block somewhere which effectually prevents the passage of the volitional impulse past a certain point. Very soon disuse will tend to inhibit the passage of impulses even up to this point, and further ground is lost. In the absence of mobility the joint sense deteriorates and, in the absence of mobility and of the function of contraction and active relaxation, the muscle sense of the antagonists (as well as their function) is rapidly affected deleteriously. Thus, in quite a short space of time, all that remains in the part that is capable of function deteriorates, and the ultimate recovery is thereby prolonged. Our duty is to retain the whole part as nearly intact as may be, and not to let the undamaged tissues and senses suffer merely because some of their fellows have been disorganised.

Some argue that, if we tell a patient to attempt to contract a paralysed muscle before regeneration has taken place, we shall merely succeed in disheartening him. Of course we shall, if we do not explain how and why we expect his unproductive effort to help him. But given this knowledge, there is no fear of a disheartening element creeping in, and the fact that the part retains some evidence of vitality is far less discouraging than to allow it to be useless and often motionless month after month. Nothing can possibly more powerfully convey to the mind the impression of complete uselessness and disability, particularly as absence of movement promotes loss of power and decrease of mobility throughout the limb. The slow but steady decrease in bulk of the uninjured muscles, the steady loss of ordered sensation due to lack of movement, and the general decrease in vascular supply are all disheartening in the extreme. Well may these patients gain the idea that recovery is remote and well-nigh impossible. If on the other hand we maintain mobility, sensation and appearance unaltered save for the actual area involved, we are surely doing much to keep alive the hope of ultimate recovery.

In the treatment of all weak and paralysed muscles we must remember that patients are not made of muscle, just as after fracture we must remember that they are not made of bone. If we neglect to treat the other structures that have suffered or fail to maintain the condition of those that have escaped damage, we are not treating our patient to the best of our ability.

Then, too, without training a time will come when we shall be able to tell our patient that the path is again open for the passage of nerve impulses. Why should he believe it? He can see no change, he has forgotten from months of disuse how to send down his impulses. He fails to secure the expected movement, try how he may, largely because he does not know how to control the antagonists. Here, then, is a fertile source of functional paralysis being added to the organic. Lieut.-Col. A. F. Hurst, in a lecture to the members of the Incorporated Society of Trained Masseuses,1 said that the unexpected early recoveries after nerve-suture occasionally reported are quite possibly the normal cases in reality, and that delay in recovery is often attributable to a "functional" element having been grafted on to the organic. That this does occur is undoubtedly true, and it is the fault of the treatment the patient has received and not of the patient. As Col. Hurst hints, a functional element can easily be rubbed into the mind during massage treatment.