chiropractic-technique-bergmann-thomas

238 | Chiropractic Technique Gluteal 60��30� muscles NEUTRAL relax Erector spinal muscles relax Gluteal Erector NEUTRAL muscles spinal contract to muscles stabilize contract A pelvis Gluteal muscles contract Figure 5-213â•… Observation of lumbopelvic alignment and posture with palpation of the posterior iliac spines and iliac crests. B Figure 5-212â•… Flexion of the trunk. A, The first 60 degrees of flexion involve eccentric contraction of the lumbar paraspinal muscles, followed by an additional 30 degrees of hip flexion after relaxation of the gluteal muscles. B, In extension, the converse occurs. forces in extension. Extension is limited by the ALL and ante- Figure 5-214â•… Posterior plumb line observation, demonstrating pelvic rior annulus and most significantly by bony impact of the spinous unleveling low on the right, with a right convex curve in the lumbar spine. Âp

Chapter 5â•… The Spine: Anatomy, Biomechanics, Assessment, and Adjustive Techniques | 239 common in the lumbar spine, and any noted deviations should be To assess flexion, the patient bends forward, and any limi- followed up with an assessment of leg length. tations, painful arcs, or alterations in normal sequencing are observed. With normal range, the patient should be able to come Sagittal plane orientation of the hips, pelvis, and lumbar spine within several inches of the floor with the fingertips, and the lum- is evaluated from the side. The lumbosacral angle in large part bar curve should reverse (Figure 5-216). determines the angle of the lumbar curve and is often mirrored by the positioning of the pelvis. Anterior or posterior tilting of the pelvis usually results from alterations in the hip angle. Anterior pelvic tilt results from bilateral hip flexion, and posterior pelvic tilt results from bilateral hip extension (Figure 5-215). Anterior pelvic tilt increases the lumbosacral angle and lum- bar curve; posterior pelvic tilt reduces the lumbosacral angle and curve. The lumbar curve also alters its angle relative to sÂ

240 | Chiropractic Technique C D Figure 5-216—Cont’dâ•… C, Lateral flexion. D, Rotation. After the patient returns to neutral, the doctor should stabi- Static Palpation lize the patient’s hips while extension is performed. Extension is To evaluate the bony and soft tissue structures of the lumbar spine, significantly more limited than flexion, and mild midline lum- the patient is placed in the prone position and scanned for areas of bosacral discomfort is commonly associated with full extension. potential tenderness, misalignment, or asymmetry. Lateral bending is evaluated by instructing patients to bend to To scan the bony landmarks, use the pads of the fingers or one side while running their fingers down the lateral surface of thumbs and palpate the spinous processes, interspinous spaces, and the leg. It is important to ensure that the patient does not Âa

Chapter 5â•… The Spine: Anatomy, Biomechanics, Assessment, and Adjustive Techniques | 241 AB Figure 5-217â•… Palpation of lumbar interspinous alignment and sensitivity (A) and paraspinal muscle tone, texture, and sensitivity (B). 5-218 AB Figure 5-218â•… Lumbar joint play evaluation for posterior-to-Âa

242 | Chiropractic Technique 5-219 Figure 5-219â•… Counter-rotational joint play 5-221 Figure 5-221â•… Side-posture evaluation for lÂ

Chapter 5â•… The Spine: Anatomy, Biomechanics, Assessment, and Adjustive Techniques | 243 5-222 Figure 5-222â•… Segmental ROM and end-feel Figure 5-224â•… Movement evaluation of lumbar flexion, with fingertip evaluation for left rotation at the L2–3 articulation, contacts in the L2–3 and L3–4 interspace. using a thumb contact across the left L2–3 interspace. 5-22Â3

244 | Chiropractic Technique 5-225A, B AB Figure 5-225â•… A, End-play evaluation for flexion at the L2–3 motion segment, using a thumb contact over the inferior tip of the L2 spinous process. B, Lumbar extension end play, with a reinforced interphalangeal joint contact over the L2–3 interspace. A B 5-226B Figure 5-226â•… A, Side-posture movement evaluation for flexion. B, Extension of the L4–5 motion segment, using a fingertip contact over the L4–5 interspace. 5-227 Figure 5-227â•… Side-posture movement Âe

Chapter 5â•… The Spine: Anatomy, Biomechanics, Assessment, and Adjustive Techniques | 245 AB 5-22 8A Figure 5-228â•… Side-posture movement evaluation of rotation at the L3–4 motion segment. A, Evaluation of right rotation mobility. Caudal hand establishes fingertip contacts over the L3–4 spinous process while the cephalad hand induces posterior trunk rotation. B, Evaluation of left rotation, using fingertip contacts over the left lateral surface of the L3 spinous process and right lateral surface of the L4 spinous process with counterrotation of shoulders and pelvis. superior spinous process rotates away from the inferior spinous A process in the direction of trunk rotation (toward the table). When movement is initiated with the pelvis, the inferior spinous process B rotates away from the superior spinous process in the direction of pelvic rotation (away from the table). C Figure 5-229â•… Side-posture patient positioning. A, Development Adjustments of the Lumbar Spine of segmental flexion and distraction of the posterior joint by flexing the patient’s upper knee and hip. B, Development of lateral flexion by placing Side-Posture Adjustments a pillow under the lumbar spine and pulling the patient’s shoulder down Side-posture lumbar adjustments are the most frequently applied and forward. C, Counter-rotation of the pelvis and shoulders to induce adjustments for lumbar spinal dysfunction. They offer freedom of gapping distraction in the up-side (left) facet joint. movement to alter patient position and adaptability to methods that methods for positioning and contacting the patient’s shoulders improve the doctor’s leverage and mechanical advantage. Although and pelvis are pictured in Figures 5-231, 5-232, and 5-233. they are difficult adjustments to perfect, doctors can reduce frustra- tion by understanding their mechanical principles and effects. Proper use of body weight and leverage is also critical to the effective application of side-posture adjusting. Side-posture adjust- The level of segmental tension is regulated by patient position- ments often demand the added force that is produced by incorpo- ing and the degree of induced lumbar flexion, lateral flexion, and rating the doctor’s body weight in the development of preadjustive the amount of counter-rotation induced between the shoulders tension and adjustive thrusts.64 and pelvis (Figure 5-229). The direction of adjustive thrust in rela- tion to the direction of torso movement and pelvic movement is also important in localizing the adjustive. Adjustments that direct the adjustive thrust in the same direction as torso movement but opposite pelvic movement are defined as assisted adjustments. Adjustments that direct the adjustive thrust in a direction opposite the torso movement and in the same direction as pelvic movement are defined as resisted adjustments (Figure 5-230). Assisted adjustments are applied to develop maximal Âp

5-23 0A, B Figure 5-230â•… Side-posture positioning for rotational dysfunction. A, Resisted positioning, with contact applied to the inferior vertebra to induce gapping in the joints superior to the contact. B, Assisted positioning, with contact applied to the superior verte- bra to induce gapping in the joints inferior to the contact. Arrows indicate adjustive vectors and direction of shoulder and pelvic rotations. AB 5-23 1 Figure 5-231â•… Movement of the patient’s lower arm to assist in the development of lateral flexion. A, Lateral flexion away from the table, induced by pulling the arm headward to place the patient on the lateral surface of the shoulder to produce left lateral flex- ion (LLF). B, Lateral flexion toward the table, induced by pulling the arm footward to place the patient on the posterolateral surface of the shoulder to produce right lateral flexion (RLF). Elevation of the pelvic and lumbar sections or a pillow placed under the lumbar spine will assist in the development of lateral flexion toward the table. AB 5-23 2 Figure 5-232â•… Optional patient arm positioning for side-posture adjusting. A, Forward positioning of the upper arm applied with flexible individuals to maintain neutral trunk positioning. B, Midline positioning of the upper arm to accommodate neutral positions or positions incorporating slight posterior trunk rotation. (Continued)

Chapter 5â•… The Spine: Anatomy, Biomechanics, Assessment, and Adjustive Techniques | 247 C Prone and Knee-Chest Adjustments Figure 5-232—Cont’dâ•… C, Posterior positioning of the upper arm Prone and knee-chest adjustments are applied with specific short- applied with large patients or specifically to induce posterior movement lever contacts (Figure 5-234). They are especially suited to the treat- of the trunk. ment of extension restrictions or adjusting situations in which it is desirable to minimize rotation. Extension is easily induced in the prone or knee-chest positions, and the lumbar sagittal facet facings do not conflict with anteriorly directed adjustive VECs. The doctor also has the advantage of centering their body over the contact. Because the knee-chest positions are especially helpful in maxi- mizing lumbar extension, the patient is vulnerable to hyperexten- sion in this position. Therefore, the doctor must be skilled in the application of this procedure and deliver the adjustive thrust in a shallow and nonrecoiling manner. AB CD 5-233A, B, C Figure 5-233â•… Optional leg contacts that may be used in the application of side-posture pelvic and lumbar adjustments. A, Lateral thigh-to-thigh contact. B, Square stance shin-to-knee contact. C, Straddle thigh contact. D, Straddle flexed-knee contact.

248 | Chiropractic Technique LR Approximation Separation Superior vertebra LR 5-234 Figure 5-234â•… Prone unilateral hypothenar Figure 5-236â•… Illustration of right rotation, demonstrating gapping mammillary adjustment. of the right articulation and anterior glide and approximation of the left articulation. 5-235 Figure 5-235â•… Sitting mammillary push either joint is potentially detrimental to joint function. Fixation adjustment. in the joint on the side of rotational restriction may produce a loss of facetal separation (Figure 5-236). Fixation in the joint on the Sitting Lumbar Adjustments side opposite the rotational restriction (compression facets) may Sitting lumbar adjustments (Figure 5-235) conform to the same theoretically produce a loss of anterior glide of the inferior facet mechanical principles previously discussed for sitting thoracic relative to the superior facet (see Figure 5-236). The facet joints adjustments. They use assisted methods and are applied to develop on the side opposite the direction of trunk rotation act as a major maximal tension in the motion segments below the level of con- barrier to axial rotation. Bony impact of these structures is largely tact. They are typically applied for lumbar rotation or combined responsible for limiting lumbar rotation. As a result, functional rotation and lateral flexion dysfunction. The most frequent and changes in the periarticular soft tissues of these joints are unlikely effective site of application occurs at the thoracolumbar region. to significantly affect the range of axial rotation. In contrast, the Critical to their application is an understanding of the thora- joints on the side of trunk rotation are not limited by bony impact. columbar transition to sagittal facet orientation and the effect this Therefore, functional changes in these articulations may have a has on axial rotation and facet movements. significantly greater potential to limit joint movement. Rotational Adjustments Rotational dysfunction of the lumbar spine theoretically may Rotational dysfunction leading to a loss of gapping on the side of result from decreased mobility in the posterior joints on the side of restricted rotation may be treated with side-posture assisted or resisted rotational restriction or on the side opposite rotational restriction. methods. With both patient positions, the affected joint is placed up Although the movements on each side are small, reduced play in (away from the table) and the patient is flexed, laterally flexed toward the table, and counter-rotated at the level of dysfunction. With resisted methods, the contact is established on the up- side mammillary process or the down-side of the spinous process of the inferior vertebra. The thrust is delivered in the direction opposite the shoulder rotation. This method is applied to induce rotation and gapping in the facet joints superior to the point of contact (Figure 5-237). With assisted methods, the contact is established on the spinous process of the superior vertebra and the thrust is delivered in the direction of shoulder rotation. This method is also applied to induce facet gapping, but the point of distraction is directed to the articulations below the contact (Figure 5-238). To incorporate forces applied in each of the previous two methods, apply a com- bination spinous push-pull adjustment (Figure 5-239). To induce rotation and facet gapping in the sitting position, use patient postures that are identical to those used with side-Âp

Chapter 5â•… The Spine: Anatomy, Biomechanics, Assessment, and Adjustive Techniques | 249 L2 L3 L4 L5 A B 5-237 Figure 5-237â•… Resisted position with a hypothenar contact applied to the right L4 mammillary process to induce right rotation and gapping of the right L3–4 articulation. L2 L3 L4 L5 A B 5-238 Figure 5-238â•… Assisted position, with a hypothenar contact applied to the right L3 spinous process to induce right rotation and gapping of the right L3–4 articulation. the superior spinous process on the side of rotational restriction the side of facet approximation contralateral to the side of facet (side of spinous rotation) or over the mammillary process on the gapping. Therefore, they may be less effective at inducing joint side opposite the rotational restriction. Laterally flex the patient gapping then the previous methods described, which establish away from the side of desired facet gapping and rotate the torso in contacts on the same side of the desired joint gapping. the direction of restriction (Figure 5-240). In the side-posture method, take care to maintain the patient’s Rotational restrictions may also be treated with assisted side- relatively neutral shoulder position. Excessive posterior shoulder posture mammillary push adjustments or assisted sitting mam- rotation opposes the direction of adjustive thrust and may place millary push adjustments. The contacts are applied to the superior unwanted distractive tension at the joint above the desired level. vertebra of the involved motion segment on the side of Âp

A B 5-239 Figure 5-239â•… Digital contacts applied to the right lateral surface of the L3 spinous process and left lateral surface of the L4 spinous process to induce right rotation and gapping of the right L3–4 articulation. 5-240 AB Figure 5-240â•… Assisted method, with a hypothenar contact applied to the right lateral surface of the L3 spinous process to induce right rotation and gapping of the right L3–4 articulation. Anterior glide 5-241 Figure 5-241â•… Assisted method, with a hypothenar contact applied to the right L3 mammillary process (dot) to induce left rotation.

Chapter 5â•… The Spine: Anatomy, Biomechanics, Assessment, and Adjustive Techniques | 251 Anterior glide 5-242 Figure 5-242â•… Assisted method, with a hypothenar contact applied to the left L3 mammillary (dot) to induce right rotation or right lateral flexion. 5-24 3 Figure 5-243â•… Illustration of right lateral Âf

252 | Chiropractic Technique may be placed under the patient to assist in the development the patient is prestressed and allowed to move in the direction of of distraction. The contacts are established on either the upper lateral flexion restriction (Figure 5-246). The use of rolls, wedges, or lower vertebra. With a contact on the superior vertebra, the and articulating tables can assist in this capacity. thrust is delivered anteriorly and superiorly in the direction of Flexion and Extension Adjustments trunk bending to distract the joints below the contact (Figure Flexion dysfunction is commonly treated in the side-posture posi- 5-245). With an inferior vertebra contact, the thrust is directed tion, with contacts established over the spinous processes. The spine anteriorly and inferiorly to distract the joints above the contact. is flexed at the level of dysfunction, and contacts are applied to Upper vertebra contacts are much more commonly applied and the superior or inferior vertebra of the involved motion segment easier on the doctor’s wrist and shoulder. to induce separation of the interspinous space and posterior joints. With assisted methods, the contact is established on the superior When mammillary contacts are applied to accentuate disc clo- vertebra, and the thrust is directed anteriorly and superiorly (Figure sure, the patient is placed with the side of lateral flexion restric- 5-247). With resisted methods, the contact is applied to the inferior tion up. The patient is laterally flexed away from the table, and the vertebra and the thrust is directed anterior and inferiorly. Resisted doctor thrusts posteriorly to anteriorly, laterally to medially, and methods are not commonly applied, except at the lumbosacral junc- superiorly to inferiorly to induce approximation of the facets and tion, where the contacts are established on the sacral apex. disc closure (Figure 5-246). This procedure is not commonly used unless lateral flexion restrictions are also coupled with opposite- Extension dysfunction is also treated in side-posture Âp

Chapter 5â•… The Spine: Anatomy, Biomechanics, Assessment, and Adjustive Techniques | 253 Distraction 5-247 Distraction Figure 5-247â•… Assisted method, with hypothenar contact applied over the L5 spinous process to induce distraction in the L5–S1 motion segment. Approximation Approximation 5-248 Figure 5-248â•… Resisted method, with a hypothenar contact applied to the L5 spinous process (dot) to induce extension in the L4–5 motion segment. distraction of the anterior elements (Figure 5-248). The resisted BOX 5-9 Lumbar Adjustments method may be the procedure of choice because of the associated slight I-S VEC that minimizes stress to the doctor’s shoulder. • Side posture • Hypothenar/mammillary push (Figure 5-249) It is unlikely that adjustive VECs directed up or down the spine in a • Hypothenar/spinous push (Figure 5-250) patient positioned in a neutral position will induce flexion or eÂ

254 | Chiropractic Technique AB CD E 5-249AÂ, B, C,

Chapter 5â•… The Spine: Anatomy, Biomechanics, Assessment, and Adjustive Techniques | 255 the segmental contact by sliding laterally over the superior verte- and D). Establish the contact on the superior vertebra or on the bra on the side of posterior body rotation. For example, if the L4 inferior vertebra. At tension, deliver an impulse thrust anteriorly, body is rotated posteriorly on the right (left rotation restriction), medially, and inferiorly with a superior vertebral contact (see the contact should be established over the right L4 mammillary Figure 5-249, C) and anteriorly, medially, and superiorly with an (see Figure 5-249, A). At tension, deliver an impulse thrust ante- inferior vertebral contact (see Figure 5-249, D). Simultaneously riorly and superiorly, parallel to lumbar facetal planes. gently pulling down on the patient’s shoulder with IH contact Resisted method: To effect rotation with a resisted method, place effectively assists in the production of lateral flexion (see Figure the patient on the side opposite the rotational restriction and 5-249, D). This superior vertebral contact method is commonly contact the mammillary of the inferior vertebra on the side applied in the Gonstead technique to treat rotational restrictions of rotational restriction. For example, when treating an L3–4 coupled with opposite-side lateral flexion restrictions (PRI, PLI right rotation restriction (L3 left posterior body rotation), place listings). the patient on the left side and establish a contact over the right L4 mammillary (see Figure 5-249, B). When contacting the closed-wedge side, place the patient on the side of lateral flexion restriction and laterally flex the To develop preadjustive tension, rotate the patient’s shoul- patient toward the table. The thoracolumbar section of the ders posteriorly, laterally flex the trunk toward the adjusting adjustive bench may be elevated or a roll may be placed under bench, and counter-rotate the patient’s pelvis anteriorly. This the patient’s lumbar spine to assist in the development of lat- should induce gapping distraction in the motion segment ipsi- eral flexion (see Figure 5-249, E). Deliver the adjustive thrust lateral superior to the point of contact. superiorly and posterior to anterior. Hypothenar/Spinous Push (Figure 5-250) Shoulder rotation and lateral flexion are induced by pull- IND: Restricted flexion, extension, rotation, and lateral flexion, ing the patient’s down-side arm anteriorly and inferiorly (see L1–S1. Rotation, flexion, extension, and lateral flexion mal- Figure 5-231, B and C). Lateral flexion of the patient may be positions, L1–S1. assisted by elevating the thoracolumbar section of an articulat- PP: The patient lies in the basic side-posture position. ing adjustive bench or by placing a roll under the patient’s lum- DP: Stand in a fencer stance, angled approximately 45 degrees bar spine. Forward rotation of the patient’s pelvis is aided by to the patient. Support the patient’s pelvis by contacting the downward traction along the patient’s flexed thigh and hip by patient’s thigh with your caudad thigh. the doctor’s anterolateral thigh (see Figure 5-223, A) or lower CP: Hypothenar of inferior hand, with fingers angled across the spine. abdomen (see Figure 5-233, C and D). SCP: Lateral margin of the superior spinous process. IH: The patient’s up-side shoulder and overlapping hand. The degree of shoulder rotation depends on the area being VEC: L-M and P-A. treated. It is greater in the upper lumbar spine as compared with P: Ask the patient to lie on the appropriate side and to straighten the lower lumbar spine. Excessive counter-rotation through the the down-side leg. Position the patient’s shoulders and flex the shoulders may be unnecessarily uncomfortable to the patient upper thigh to distract the interspinous space of the Âd

256 | Chiropractic Technique AB CD E 5-250A, B, C, D, E Figure 5-250â•… A, Assisted method, with a hypothenar contact applied to the right lateral surface of the L3 spinous process to induce right rotation in L3- motion segment. B, Assisted method, with a hypothenar contact applied to the right lateral surface of the L3 spinous process to induce right lateral flexion in the L3–4 motion segment. C, Resisted method, with a hypothenar contact applied to the sacral apex to induce flexion in the L5–S1 motion segment. D, Resisted method, with a hypothenar contact applied to the spinous process of L5 to induce extension in the L4–5 motion segment. E, Assisted spinous push adjustment, with contact established over the right lamina of the L4 spinous process to induce L4–5 right rotation and right lateral flexion. Lateral flexion restrictions: When treating pure lateral flexion dys- spinous process. Develop preadjustive tension by transferring function, place the patient on the side opposite the lateral flex- additional weight through your trunk into the spinous contact. At ion restriction and laterally flex the patient away from the table. tension, deliver an impulse thrust through the body and contact Induce lateral flexion by pulling headward on the patient’s down- arm. Simultaneously gently pulling down on the patient’s shoul- side shoulder. Placing a triangular pillow under the patient’s head der with IH contact effectively assists in the production of lateral and shoulder or placing a patient on an articulating bench and flexion (Figure 5-250, E). lowering and releasing the thoracolumbar section may aid lateral Flexion restrictions: To treat flexion dysfunction, place the patient flexion positioning (Figure 5-250, B). Establish the adjustive contact and remove superficial tissue on either side and induce flexion in the lumbar spine. Establish the segmental contact with the proximal midline calconal or slack by sliding medially onto the lateral surface of the superior hypothenar contact on your caudal hand. When using an

Chapter 5â•… The Spine: Anatomy, Biomechanics, Assessment, and Adjustive Techniques | 257 assisted method, slide superiorly to contact the inferior tip of the IH: Your IH contacts the patient’s up-side shoulder and overlap- superior spinous process and thrust superiorly and anteriorly. ping hand. When using a resisted method, slide inferiorly to contact VEC: L-M pulling movement to induce axial rotation. the inferior vertebra and thrust anteroinferiorly. The resisted P: Ask the patient to lie on the appropriate side and to straighten approach is commonly applied only when treating lumbosacral flexion restriction with a sacral contact (see Figure 5-250, C). the down-side leg. Flex the patient’s upper thigh to distract Extension restrictions: To treat extension dysfunction, use the interspinous space of the dysfunctional motion segment. the same contacts as described for flexion dysfunction, but Then establish contacts on the spinous process, lateral hip and allow the lumbar spine to move into extension. With an the patient’s flexed leg. The spinous contacts are established by assisted approach, contact the superior vertebra and thrust hooking the down side of the spinous process with the second, Âa

258 | Chiropractic Technique Resisted method: With a resisted method, place the patient on the inferior spinous process while the forearm contacts the the side opposite the restriction (side opposite spinous rota- patient’s posterolateral buttock and thigh. tion) and establish the segmental contact on the down-side SCP: Adjacent spinous processes. of the inferior spinous process. For example, when treat- VEC: The superior hand thrusts (pushes) laterally to medially and ing a right rotation restriction (left posterior body rotation) inferiorly to superiorly. The inferior hand thrusts (pulls) later- at the L3–4 motion segment, place the patient on the left ally to medially in the opposing direction. side and contact the left side of the L4 spinous process (see P: Place the patient in side posture. Flex the patient’s upper thigh Figure 5-251, B). to distract the interspinous space of the dysfunctional motion Develop preadjustive tension by rotating the patient’s shoul- segment. Rotate the patient’s shoulder posteriorly in the direc- ders posteriorly in the direction of segmental restriction as you tion of segmental restriction and flex the trunk laterally toward rotate the patient’s pelvis anteriorly with your leg and forearm. the adjusting bench. Induce posterior shoulder rotation and lateral flexion of the patient’s trunk toward the table by pulling the patient’s down- The doctor establishes appropriate contacts on the adjacent arm anteroinferiorly. spinous process and develops local joint tension by counter- Resisted spinous pull adjustments may also be applied for rÂ

Chapter 5â•… The Spine: Anatomy, Biomechanics, Assessment, and Adjustive Techniques | 259 5-253 Figure 5-253â•… Bilateral thenar contacts applied SCP: Mammillary process. to the mammillary processes of L3 to induce exten- IH: Your IH reinforces the contact or reaches around to grasp the sion at the L3–4 motion segment. anterior ilium or rib cage on the side of adjustive contact. P: The patient lies prone. Establish bilateral thenar contacts and VEC: P-A and S-I or I-S, depending on the restriction being develop joint tension by transferring additional body weight into the contacts. At tension, deliver a combined impulse thrust treated. through the arms, trunk, and body. Releasing and lowering the P: The patient lies prone, with the thoracic section released and low- thoracic section of an articulating table may assist in the devel- opment of segmental extension (see Figure 5-253). The thrust ered to assist in the development of segmental extension. Remove may be applied with a lumbar drop section. The thrust should superficial tissue slack and establish adjustive contact. Develop be shallow to avoid hyperextension of the back. preadjustive tension by transferring additional body weight into the contact. Deliver an impulse thrust through the arms, trunk, Hypothenar/Mammillary Push (Figure 5-254) and body. The thrust may be applied with a lumbar drop section. IND: Restricted lateral flexion or rotation coupled with restricted The contact may be reinforced with the IH, or the IH may extension, L1–L5. Rotation or lateral flexion malpositions cou- contact the ipsilateral anterior ilium. When applying a reinforc- pled with flexion malpositions, L1–L5. ing contact, stand on the side of adjustive contact (see Figure PP: The patient lies prone. 5-254, A). If the IH contacts the ilium, stand on the side oppo- DP: Stand in a fencer stance or square stance on the side of site the adjustive contact (see Figure 5-254, B). adjustive contact. CP: Hypothenar (pisiform), with arched hand and fingers rÂ

260 | Chiropractic Technique 5-25 5 Figure 5-255â•… Hypothenar contact applied to Knee-Chest the left L2 spinous process to induce extension, left Hypothenar/Spinous Push (Figure 5-256) lateral flexion, and left rotation of the L2–3 motion segment. IND: Restricted extension, coupled with lateral flexion, or rota- CP: Mid-hypothenar. tion restrictions, L1–L5. Flexion, rotation, or lateral flexion SCP: Lateral proximal surface of the spinous process of the supe- malpositions, T4–T12. PP: Position the patient in the knee-chest position, with the rior vertebra. chest support placed so that the patient’s pelvis is even with IH: Your IH supports the contact hand on the dorsal surface, with or slightly lower than the thoracic spine. The patient’s femurs should be angled between 95 and 110 degrees. the fingers wrapped around the wrist. DP: Stand at the side of the table in a square stance, typically on VEC: P-A, L-M, and S-I. the side of the contact. You may also stand in a fencer stance, P: The patient lies prone, with the thoracolumbar section of the facing caudad. CP: Mid-hypothenar. table released and lowered to assist in the development of seg- SCP: Lateral surface of the spinous process. mental extension. Establish a fleshy hypothenar contact against IH: Your IH supports the contact hand on the dorsal surface, with the spinous process on the side of rotation restriction (side of the fingers wrapped around the wrist. spinous rotation). The contact is developed by sliding medially VEC: P-A, L-M, and S-I. onto the spinous process while inducing a slight clockwise or P: The IH first raises the patient’s abdomen to make the spinous counterclockwise torquing movement, depending on the side processes more prominent and available for establishing the of contact. The torquing movement is applied to assist in the contacts (see Figure 5-256, A). The patient is then instructed development of a firm contact. to allow the abdomen to drop and, at tension, an impulse thrust is delivered (see Figure 5-256, B). The patient is vul- Develop preadjustive tension by transferring additional body nerable to hyperextension in this adjustment, and the thrust weight into the contacts. At tension, deliver an impulse thrust must be shallow and nonrecoiling. Prestressing the patient through the arms, trunk, and body. The thrust should be shal- into lateral flexion and inducing lateral flexion during the low to avoid hyperextension of the patient’s back. The thrust delivery of the adjustment may assist in the production of may be applied with a lumbar drop section. This adjustment is lateral flexion. commonly applied in the treatment of coupled restrictions in Bilateral Thenar/Mammillary Push (Figure 5-257) rotation and same-side lateral flexion (PRS, PLS listings) IND: Restricted extension, L1–L5. Flexion malpositions, L1–L5. PP: Position the patient in the knee-chest position, with the chest support placed so that the patient’s pelvis is even with or slightly lower than the thoracic spine. The patient’s femurs should be angled between 95 and 110 degrees. DP: Stand in a fencer stance on either side of the patient. CP: Bilateral thenar contacts parallel to the spine, with the fingers fanned and running medially to laterally. SCP: Mammillary processes. VEC: P-A. AB 5-25 6 Figure 5-256â•… Knee-chest adjustment. A, Development of the adjustive contact and use of an adjusting bench in circumstances in which a knee-chest table is not available. B, Hypothenar contact applied to the left L1 spinous process to induce extension, left lateral flexion, and left rotation of the L1–2 motion segment.

Chapter 5â•… The Spine: Anatomy, Biomechanics, Assessment, and Adjustive Techniques | 261 5-257 Figure 5-257â•… Bilateral thenar contacts eÂ

262 | Chiropractic Technique DP: The doctor may sit behind the patient, straddle the bench, PELVIC JOINTS or stand at the caudal end of the bench. In the standing Âp

Chapter 5â•… The Spine: Anatomy, Biomechanics, Assessment, and Adjustive Techniques | 263 LR Superior articular facet Sacral tubercle Sacral foramen Sacral Sacral B cornua A hiatus Second sacral Sacral base tubercle Sacroiliac facet surface C Figure 5-261â•… A, Sacrum viewed from the posterior is triangular and serves as a keystone (B) in the arch between the two columns formed by the lower extremities. C, Lateral view of the sacrum. two Âs

264 | Chiropractic Technique Figure 5-263â•… Forces from gravity above meet with forces from the The morphologic configuration of the sacroiliac joints is not lower extremities at the sacroiliac and hip articulations. static and is extremely variable from individual to individual.72,73 At birth, the joints are undeveloped, smooth, and flat. Only after an individual becomes ambulatory do the joints begin to take on their adult characteristics. In the teenage years, the joint surfaces begin to roughen and develop their characteristic grooves and ridges. In the third to fourth decades, this process is well estab- lished, and by the fifth and sixth decades, the joint surfaces may be very eroded. In later years, a high percentage of male patients will have developed interarticular adhesions across the sacroiliac joints and will have lost sacroiliac joint motion.72,73 A number of strong ligaments aid in stabilizing the pelvic mech- anism (Figure 5-264). The posterior sacroiliac ligaments run from the sacrum to the iliac tuberosity and posterosuperior iliac spine (PSIS). They continue laterally with the sacrotuberous ligament and medially with the thoracolumbar fascia. The sacrotuberous ligament extends from the lower portion of the sacrum obliquely downward to the ischial tuberosity. It continues caudally with the tendon of the long head of the biceps femoris. The anterior sacroiliac ligament consists of numerous bands attaching from the lateral edge of the sacrum to the auricular surface of the ilium. The sacrospinous liga- ment is triangular and extends from the lower lateral edge of the sacrum and the upper edge of the Âc

Chapter 5â•… The Spine: Anatomy, Biomechanics, Assessment, and Adjustive Techniques | 265 Superior pubic flexion and extension. He suggests that as one innominate flexes ligament (the PSIS moves posteriorly and inferiorly), the ipsilateral sacral base moves anteriorly and inferiorly, and as the other innominate extends Hyaline cartilage (moves anteriorly and superiorly), the sacral base on that side moves Fibrocartilaginous posteriorly and superiorly (Figure 5-266). If the described actions of the sacrum are envisioned as one continuous motion, a picture of an disc oblique and horizontal, figure-eight–shaped rocking movement of Nonsynovial the sacrum becomes apparent (Figure 5-267). cavity Illi82 further postulates that alternating movements of flexion act through the iliolumbar ligament to dampen motion at L5 and Inferior pubic hence the whole spine.78 As the ilium moves posteriorly, L5 is ligament pulled posteriorly and inferiorly through tension in the iliolumbar ligament, and the rest of the lumbar spine undergoes coupled Figure 5-265â•… Pubic symphysis: anterior joint of the sacroiliac three- motion in slight rotation and lateral flexion (type I movement). joint complex. There has been a tendency in the chiropractic profession to The sacrotuberous and sacrospinal ligaments limit posterior refer to the complementary ipsilateral anterior and inferior and movement of the sacral apex; the posterior sacroiliac ligament lim- posterior and superior sacral movements as extension and flexion. its anterior movement of the sacral base. Anteriorly, the pubic bones This has led to the confusing situation in which the same restric- are joined by the symphysis pubis, a cartilaginous joint containing tion in sacroiliac movement may be referred to interchangeably a fibrocartilaginous interpubic disc (Figure 5-265). The superior pubic ligament connects the pubic bones superiorly; the inferior RL pubic ligament connects the lower borders of the symphysis pubis, forming the upper boundary of the pubic arch. Anteriorly, there AB is evidence of connective tissue layers passing from one bone to Figure 5-266â•… Movements of the pelvic joints during gait. A, Posterior another. They are interlaced with fibers of the external oblique view, illustrating left hip and sacroiliac (SI) joint flexion and right hip and aponeuroses and the medial tendons of the rectus abdominious SI joint extension. B, Anterior view, illustrating reciprocal movements of muscles. Posteriorly, there is also some fibrous tissue that is con- the innominate and sacrum during SI joint flexion and extension. As the tinuous with the periosteum of both pubic bones. The inguinal left innominate moves posteriorly, a pivoting motion occurs at the pubic ligament, the lower reflected aponeurotic margin of the external symphysis, and the left sacral base moves anteroinferiorly. As the right oblique muscle, extends from the ASIS to the pubic tubercle. innominate moves anteriorly, the sacral base moves posterosuperiorly. Although some of the strongest muscles of the body surround Left Right the sacroiliac joint, none are intrinsic to it or act upon it directly.67 oblique oblique However, the surrounding muscle mass may influence the mechan- axis ical behavior of the joint or respond to the stresses applied to it. axis Sacroiliac Motions Inferior lateral Although it has become accepted that the sacroiliac is a truly mov- axis able joint, there is still controversy as to exactly how it moves, how much it moves, and where axes of motion might be located. Figure 5-267â•… The proposed axes of motion in the sacroiliac articula- A number of different hypotheses and models of pelvic mechan- tion allow a “gyroscopic” figure-eight movement. ics have been proposed.71,74-80 Recent models reinforce the reality of sacroiliac motion but also stress the sacroiliac joint’s impor- tant role in maintaining stability during the transverse of forces between the lower extremity and the spine.81 The sacroiliac joint is most active during locomotion, with movement occurring primarily in the oblique sagittal plane. During locomotion the sacroiliac joints flex and extend in unison with the corresponding hip joint. In the process of ambulating, each sacroiliac joint goes through two full cycles of alternating flexion and extension. Movements of flexion or extension in one joint are mirrored by the opposite movement at the other joint. Illi’s model of sacroiliac motion82 proposes that compensatory movements at the sacrum and lumbosacral junction occur to help absorb the pelvic torsion induced by these opposing movements of

266 | Chiropractic Technique as flexion and extension restrictions. For example, during sacroil- It is also important to understand and appreciate that with flex- iac flexion, if the PSIS is the point of reference and perceived to ion and extension movements at the posterior sacroiliac joints, be limited in its PI movement, the restriction is described as a motion of the pubic symphysis in rotation about a transverse axis sÂ

Chapter 5â•… The Spine: Anatomy, Biomechanics, Assessment, and Adjustive Techniques | 267 Static Palpation between the second sacral tubercle and the PSIS should be evalu- The palpatory assessment of pelvic bony and soft tissue structures ated on each side and compared (see Figure 5-269). is primarily conducted in the prone position. To evaluate the bony landmarks, establish bilateral contacts with the thumbs or finger- Flexion (PI) or extension (AS) malpositions of one innomi- tips and compare the contour and alignment of the iliac crests, nate as compared with the other are possible indications of pelvic PSISs, sacral base, and sacral apex (Figure 5-269). The palpatory dysfunction. These positions of distortion may be identified with depth of the sacral base just medial to the PSIS and the distance the aid of palpation and observation. Table 5-9 lists the clinical findings that have been empirically reported by the cÂ

268 | Chiropractic Technique profession to reflect each distortion. However, remember that Âd

AB Figure 5-271â•… Prone evaluation of leg length. A, Knees extended. B, Knees flexed. A B Lying Leg A Leg B Leg B Leg A Sitting Leg B Leg B Leg A Leg A C Figure 5-272â•… Supine evaluation of leg length. A, Lying supine. B, Sitting. C, Changes in leg length observed from the lying to the sitting position may indi- cate a sacroiliac dysfunction. On the side of the relative posterior innominate (leg A), the acetabulum is displaced anteriorly, creating a leg deficiency in the supine position, which lengthens on sitting. (Modified from Gatterman MI: Chiropractic management of spine related disorders, Baltimore, 1990, Williams & Wilkins.)

270 | Chiropractic Technique to detect sacroiliac dysfunction and determine the side and nature 5-273 Figure 5-273â•… Thumb contact applied to the right of the dysfunction. 85,86 The reliability of DPLC as a separate diag- posterosuperior iliac spine to evaluate joint play of the nostic procedure has not been evaluated. The€validity of the DPLC right sacroiliac articulation. to ascertain pelvic dysfunction has not been evaluated. 5-274 Figure 5-274â•… Anterior-to-posterior pressure The test is based on the premise that pelvic dysfunction is asso- applied to the right ilium and digital contacts applied ciated with misalignment of one ischium as compared with the to the right sacroiliac joint assess for the presence of flexion joint play. other, and that pelvic misalignment will be reflected in functional unleveling of the legs. The relative short-leg side is envisioned to palpate for posterior glide of the ilium. Counterpressure asserted be associated with a PI malposition of the ischium. The relative against the sacral base through the doctor’s thenar or hypothenar long-leg side is associated with an AS malposition of the ischium. may also be applied to induce more shear across the joint. Pain indicates that the sacroiliac joint may be dysfunctional and con- The DPLC is performed in a prone position and incorporates tributing to the patient’s LBP. the evaluation of leg length in a knee-extended position, followed by an evaluation in 90 degrees of knee flexion (see Figure 5-271). Sacroiliac Extension.╇ To assess extension, contact the sacral If leg length inequality is noted in the knee-extended position, apex with the caudal hand and a contact on the ipsilateral PSIS the knees are flexed to 90 degrees to observe for a change in com- with the hypothenar of the cephalic hand (Figure 5-275). Apply parative length. A Derifield positive response (D+) is observed anterior and superior pressure against the ilium and anterior and when the comparative short leg gets longer. A Derifield negative inferior movement against the sacral apex. Normal movement is response (D−) is observed when the short leg remains short or appears even shorter. A D+ indicates that the sacroiliac dysfunc- tion is on the side of the short leg and a D− response indicates that the dysfunction is on the side of the long leg.85 The DPLC is theorized to detect pelvic dysfunction as a result of associated reactive hypertonicity in the anterior thigh muscles on the side of sacroiliac dysfunction. When the reactive ante- rior thigh muscles are stretched in the knee-flexed position, they contract, firming up the thigh and increasing its A-P diameter. The€net effect is to elevate the leg of the table on the dysfunctional side. Therefore, on the D+ side, the short leg gets longer, decreas- ing or reversing the inequality. On the D− side, the long leg gets longer, increasing the inequality. 85 Joint Play A variety of different joint provocation techniques have demonstrated their reliability and validity for identifying the sacroiliac joint as a source of LBP. Many of these procedures can be classified as JP pro- cedures and include compression, distraction, torsion, and shear tests. Palpatory localization of pain to the sÂ

Chapter 5â•… The Spine: Anatomy, Biomechanics, Assessment, and Adjustive Techniques | 271 5-275 Figure 5-275â•… Counterpressure applied through 5-277 Figure 5-277â•… Hypothenar contact applied to a hypothenar contact over the right posterosuperior the right inferior margin of the sacrum exerts pres- sure superiorly against counterpressure applied by a calcaneal contact over iliac spine and a hypothenar contact over the sacral apex to assess extension the right iliac crest to assess superior sacral glide. joint play in the right sacroiliac joint. reflected by a sense of give and separation into extension. Pain Motion Palpation indicates that the SI joint may be dysfunctional and contribut- ing to the patient’s LBP. Sitting Mobility Test Sacral Push. The patient is asked to sit with the arms relaxed Inferior Sacral Glide.╇ The patient is placed in the prone posi- tion, and the doctor reaches across the patient with the heel of the on the thighs. The doctor sits behind the patient and establishes caudal hand to contact the patient’s lower ischium. The ulnar side bilateral thumb contacts across the patient’s sacroiliac joints and of the cephalic hand contacts the superior dorsal surface of the sacral ala (Figure 5-278). The patient is then asked to extend back sacrum, also on the contralateral side (Figure 5-276). To execute and rotate around the doctor’s thumbs. With proper sacroiliac and the procedure, apply caudal pressure against the sacrum as coun- lumbosacral joint motion, the doctor’s thumbs should move sym- terstabilizing pressure is maintained against the ischium. Pain dur- metrically forward with the patient’s sacral base. Restricted ante- ing the test may indicate sacroiliac dysfunction. rior gliding of the sacral base may indicate sacroiliac dysfunction. Superior Sacral Glide. The patient is placed in the prone posi- tion. The doctor reaches across the patient with the ulnar side of the caudal hand to contact the inferior and lateral mÂ

272 | Chiropractic Technique Standing Sacroiliac Tests relative to the sacral apex (see Figure 5-280, A). Extension of the Upper Sacroiliac Mobility. The patient is asked to stand, support- lower sacroiliac joint is evaluated by elevating the opposite leg ing himself or herself by reaching out to contact the wall or a chair. to a level above 90 degrees. Normal extension of the lower joint The doctor stands or sits behind the patient and establishes thumb is demonstrated by separation of the sacral and ischial contacts contacts on the patient’s PSIS and second sacral tubercle or ipsi- (Figure 5-280, B). lateral sacral base (Figure 5-279). The patient is then instructed to flex his or her ipsilateral hip. This induces flexion of the hip and The standing sacroiliac mobility tests (Gillet tests) have demon- sacroiliac joint. This procedure may be done with the patient’s strated poor to mixed reliability and have not been subjected to sig- knee either flexed or straight. If the patient is instructed to keep nificant validity testing. They may assist the doctor in refining his or his or her knee bent during hip flexion, instruct the patient to raise her adjustive approach, but should not be used as a stand-alone pro- the hip to approximately 90 degrees. If the patient is instructed to cedure for determining whether a patient has pÂ

Chapter 5â•… The Spine: Anatomy, Biomechanics, Assessment, and Adjustive Techniques | 273 AB 5-280 Figure 5-280â•… Standing sacroiliac joint evaluation for right lower joint movement. After thumb contacts are established over the right sacral apex and the soft tissue lateral to the sacral apex in line with the posterosuperior iliac spine, the patient flexes the ipsilateral hip to assess SI joint flexion (separation of thumbs) (A) and the contralateral hip to assess SI joint extension (separation of thumbs) (B). Pubic Symphysis Dysfunction Once the superior margins of the pubic bone are located, the doc- The symphysis is not a synovial joint and, as such, does not dem- tor may palpate the anterior aspect of each pubic bone with the onstrate significant movement. However, some degree of shifting thumbs or index fingers of both hands (Figure 5-281). and shearing movement at the symphysis is probably present with locomotion and occurs by virtue of its fibrocartilaginous structure. After locating the pubic bone, the doctor should proceed to As a result, dysfunction at this joint may contribute to pelvic dys- evaluate alignment and the joints’ response to gentle provocation. function and pain. The question then remains: If the sÂ

274 | Chiropractic Technique AB Figure 5-281â•… Palpation of the pubic symphysis for pain and displacement. A, Anterior-to-posterior pressure is applied to assess anterior displacement and posterior glide. B, Superior-to-inferior and inferior-to-superior pressure is applied to assess for superior or inferior displacement and glide. restrictions, or tenderness of myofascial attachments to its ante- Prone Pelvic Adjustments rior and lateral surfaces. Misalignment with tenderness or loss of Prone pelvic adjustments can be appropriate alternatives to side- JP is cÂ

Chapter 5â•… The Spine: Anatomy, Biomechanics, Assessment, and Adjustive Techniques | 275 BOX 5-10 Pelvic Adjustments CP: Hypothenar of caudal hand. SCP: Medial margin of the PSIS. • Side posture IH: Your IH contacts the patient’s up-side shoulder and overlap- • Hypothenar/ilium push (PI ilium) (Figure 5-282) • Hypothenar/sacral base push (PS sacrum) (Figure 5-283) ping hand. • Hypothenar/ischium push (AS ilium) (Figure 5-284) VEC: P-A, M-L, and I-S. • Hypothenar/sacral apex push (AI sacrum) P: Place the patient in side posture, with the involved side up. • Prone Flex the upper thigh to between 60 and 80 degrees. Establish • Hypothenar/ilium sacral apex push (PI ilium or AI the ilial and leg contacts and develop preadjustive tension by sacrum) (Figure 5-285) Âd

276 | Chiropractic Technique Dysfunctional side up: The patient lies on the side opposite the DP: Stand in a low fencer stance, straddling the patient’s flexed dysfunctional sacroiliac joint. Induce sacroiliac flexion by push- upper knee. Support the patient’s flexed leg against the Âp

Chapter 5â•… The Spine: Anatomy, Biomechanics, Assessment, and Adjustive Techniques | 277 At tension, a body-centered thrust is delivered anteriorly nodding and rotation of the sacral base on the down-side and along the shaft of the femur through the trunk and lower extension of the down-side sacroiliac joint. Induce anterior pel- extremities. Your lower abdomen may impact the patient’s pos- vic rotation by dropping the patient’s flexed thigh toward the terior lateral buttock and hip. A slight variation of this proce- floor and by lowering your body weight against the patient’s dure involves using a forearm contact instead of a hypothenar flexed hip. Induce posterior nodding of the sacral base by pull- contact (Figure 5-284, B). Optional doctor stances and leg con- ing inferiorly with the contact hand against the sacral apex as tacts may also be used in this adjustment (Figure 5-284, C). you push cephalically against the patient’s flexed leg with your Hypothenar/Sacral Apex Push (AI Sacrum) (Figure 5-285) caudal leg. IND: Restricted sacroiliac extension or unilateral anteroinferior malposition of the sacrum. At tension, deliver a body-centered thrust anteriorly through PP: The patient lies in the basic side-posture position. the trunk, lower extremities, and shoulder. Your lower abdo- DP: Stand in a low fencer stance, straddling the patient’s flexed men may impact the patient’s posterolateral buttock and hip. upper knee. Support the patient’s flexed leg against the proxi- A€ slight variation of this procedure involves using a forearm mal anterior thigh of your caudal leg. contact instead of a hypothenar contact (Figure 5-285, B). CP: Hypothenar of the caudal hand, with the fingers pointing Prone cephalad (Figure 5-285, A). Hypothenar/Ilium Sacral Apex Push (PI Ilium or AI Sacrum) SCP: Apex of the sacrum. (Figure 5-286) IH: Your superior hand stabilizes the patient’s upper shoulder, IND: Restricted sacroiliac extension. Posteroinferior malposition of maintaining spinal flexion. the ilium or unilateral anteroinferior malposition of the sacrum. VEC: P-A. PP: The patient lies prone. P: Place the patient in side posture, with the involved side down. Slightly flex the patient’s trunk and flex the upper thigh above 90 degrees. Establish a broad soft contact along the up-side of the sacral apex. Develop preadjustive tension by inducing lumbosacral flex- ion and forward rotation of the pelvis. This produces posterior A A B B 5-28Â6A, B

278 | Chiropractic Technique DP: Stand in a modified fencer stance on the side opposite the When using this adjustment with a drop table, place the dysfunction. patient’s ASISs in the break between the adjusting table’s pelvic and lumbar sections. The adjustive thrust should not CP: Hypothenar contacts of both hands. be delivered until appropriate drop-piece tension has been SCP: Medial superior margin of the PSIS and sacral apex (see established. Figure 5-286, A). If desired, a PI ilium or sacroiliac extension restriction may VEC: P-A, I-S, and M-L with the PSIS contact. P-A, S-I, and be treated with a unilateral contact on the PSIS. With this method, you may stand on either side of the patient (Figure M-L with the sacral apex contact. 5-286, B). P: Position the patient in the prone position. Reach across the Hypothenar/Ischium Sacral Base Push (AS Ilium or PS SÂ

Chapter 5â•… The Spine: Anatomy, Biomechanics, Assessment, and Adjustive Techniques | 279 CP: Proximal palmar surface of the caudal hand for ischial con- P: Position the patient in the prone position. Reach across the tact and thenar or hypothenar eminence of cephalic hand patient with the cephalic hand and establish a hypothenar for sacral base contact (Figure 5-287, A and B). Âc

280 | Chiropractic Technique hip on the side of the posterior innominate to develop sacro- iliac flexion. No thrust is given; gravity provides the force applied over time. This procedure does not fit the definition of an HVLA adjustment because of the lack of a high-velocity thrust. Pubic Symphysis Adjustments (Box 5-11) Box 5-11 Pubic Symphysis Adjustments 5-291 Figure 5-291â•… Right anterior pubis adjustment; also an alternative for a right superior pubis adjustment. • Supine • Hypothenar/Thigh (Figure 5-290) Hypothenar/Pubis (Anterior Pubis) (Figure 5-291) • Hypothenar/Pubis (Figure 5-291) IND: Restricted posterior glide and anterior malposition of the • Hypothenar/Ilium, Palmar/Ischium (Figure 5-292) • Pubic Distraction (Figure 5-293) pubis (alternate procedure for superior pubis). PP: The patient lies supine, with the uninvolved knee and hip Supine Hypothenar/Thigh (Superior Pubis) (Figure 5-290) flexed and the foot flat on the table. IND: Restricted inferior glide and superior malposition of the pubis. DP: Stand on the uninvolved side, facing obliquely caudad. PP: The patient lies supine, with the side of involvement at the CP: A hypothenar knife-edge contact of the cephalad hand. SCP: Anterior aspect of the involved pubic ramus (superior aspect edge of the table. The corresponding leg hangs off the table. The PSIS is just on the table. for superior pubis). DP: Stand on the involved side, facing caudad in a fencer’s stance. IH: The caudal hand either reinforces the contact hand with the CP: A palmar contact of the caudal hand. SCP: Distal femur of the leg on the involved side. fingers wrapped around the wrist or establishes a palmar con- IH: The cephalad hand establishes a palmar contact over the ASIS tact over the distal thigh of the uninvolved leg and applies on the uninvolved side. additional flexion stress. VEC: S-I. VEC: A-P. P: While stabilizing the pelvis with the IH, the contact hand P: At tension, deliver a quick and shallow impulse thrust A-P to applies an A-P stress on the patient’s thigh. Ask the patient to the involved pubis. This technique is best done with the use of attempt to raise the thigh against the resistance and after 4 to a pelvic drop section. 5€seconds, deliver a slight and shallow impulse thrust down- Hypothenar/Ilium, Palmar/Ischium (Inferior Pubis) (Figure ward to the distal thigh. After the adjustment is applied, the 5-292) patient should relax, maintaining the adjustive position for IND: Restricted superior glide of the pubis. Inferior malposition approximately 1 to 2 minutes. of the pubis. 5-290 Figure 5-290â•… Left superior pubis adjustment. 5-292 Figure 5-292â•… Right inferior pubis adjustment.

Chapter 5â•… The Spine: Anatomy, Biomechanics, Assessment, and Adjustive Techniques | 281 PP: The patient lies supine, with the knee and hip on the involved Coccyx Adjustments (box 5-12) side fully flexed. Box 5-12 Coccyx Adjustments DP: Stand on the side of the table opposite the side of involve- ment, leaning over the patient, with your upper body contact- • Prone ing the anterior aspect of the patient’s tibia. • Thumb/External Coccyx Push (Figure 5-294) • Index/Internal Coccyx Pull (Figure 5-295) CP: The caudal hand grasps the patient’s lower ischium while the cephalad hand reaches over the patient and contacts the ASIS Prone on the side of involvement. Thumb/External Coccyx Push (Figure 5-294) IND: Restricted coccyx movement, malposition of the coccyx, VEC: P-A and I-S with the caudal hand. A-P with the cephalic hand. and coccygodynia. PP: The patient lies in the prone position, with the thoracic and P: Develop preadjustive tension by applying body weight to the patient’s flexed leg. At tension, deliver a thrust with the caudal pelvic pieces raised or a Dutchman roll placed under the ASIS. hand while the cephalic hand thrusts posteriorly through your The buttocks should be appropriately draped. torso while generating a pulling thrust. DP: Stand at the side of the table, assuming a fencer’s stance and facing cephaladly. Pubic Distraction (Figure 5-293) CP: The thumb contact of the cephalad hand. IND: Pubic dysfunction, pubic symphysis pain with palpation, SCP: The base of the coccyx (skin to skin). IH: The pisiform-hypothenar contact of the caudad hand is estab- and joint provocation. lished over the thumbnail of the contact hand, with the fingers PP: The patient lies supine, flexing both knees and hips and rest- lying loosely over the dorsum of the contact hand. VEC: I-S. ing the feet flat on the table, close to one another. P: Draw tissue slack out in a cephalad direction with both hands. DP: Stand at or kneeling on the foot end of the table, facing the At tension, deliver a cephalad and slightly P-A impulse thrust over the coccygeal base, producing a mixed tissue pull and patient. osseous adjustive technique. CP: Palmar contacts of both hands. SCP: Medial aspects of both knees. VEC: M-L. P: Separate the patient’s knees and grasp the medial aspects of the patient’s knees. With crossed forearms between the knees, ask the patient to squeeze the knees together for several seconds or until sufficient adductor muscle fatigue occurs. Then deliver a shallow impulse thrust to both knees. A B 5-293 Figure 5-293â•… Pubic distraction. 5-294 Figure 5-294â•… External coccyx adjustment. A, Tissue pull, with thumb contact taken. B, Reinforced contact, with thrust headward.

282 | Chiropractic Technique AB Figure 5-295â•… A, Simulation of an internal coccyx adjustment. B, Illustration of contacts. Index/Internal Coccyx Pull (Figure 5-295) SCP: The anterior surface of coccyx, intrarectally. IND: Restricted coccyx movement, malposition of the coccyx, IH: A palmar-calcaneal contact of the cephalad hand over the and coccygodynia. upper half of the sacrum. PP: The patient lies in the prone position, with the thoracic and VEC: S-I. P: The intrarectal contact applies tension to the coccyx inferi- pelvic pieces raised or a Dutchman roll placed under the ASIS. DP: Stand at the side of the table, assuming a fencer’s stance and orly and slightly posteriorly. Deliver a gentle impulse thrust through the contact on the sacrum while simultaneously facing cephaladly. delivering a very gentle and shallow posterior thrust against CP: A digital contact, with a gloved and lubricated middle finger the coccyx. of the caudad hand. A palmar-calcaneal contact of the cephalad hand over the upper half of the sacrum.

c0030 Extraspinal Techniques Chapter 6 OUTLINE 283 ELBOW 315 Evaluation 344 283 Functional Anatomy 316 Adjustive Procedures 346 ROLE OF THE PERIPHERAL 284 Biomechanics 317 KNEE 349 JOINTS 286 Evaluation 319 Functional Anatomy 350 288 Adjustive Procedures 322 Biomechanics 353 TEMPOROMANDIBULAR JOINT 291 326 Evaluation 354 Functional Anatomy 294 WRIST AND HAND 326 Adjustive Procedures 358 Biomechanics 294 Functional Anatomy 327 ANKLE AND FOOT 364 Evaluation 298 Biomechanics 329 Functional Anatomy 365 Adjustive Procedures 298 Evaluation 333 Biomechanics 367 302 Adjustive Procedures 337 Evaluation 368 SHOULDER 337 Adjustive Procedures 371 Functional Anatomy HIP 341 Biomechanics Functional Anatomy Evaluation Biomechanics Adjustive Procedures ROLE OF THE PERIPHERAL JOINTS Reflex-triggered functional syndromes occur through a series of dÂ

284 | Chiropractic Technique Condylar process Coronoid process Neck Mylohyoid line TMJ Ramus Angle Body Mental Mental foramen protuberance Hyoid Figure 6-2â•… The osseous components of the mandible. (Modified bone from Hertling D, Kessler RM: Management of common musculoskeletal disorders: Physical therapy principles and methods, ed 2, Philadelphia, 1990, JB Lippincott.) Sternum Clavicle form an inferior palpable angle. Each ramus has two processes: the 1st Rib coronoid process, serving as a point of attachment for muscles, and the condylar process, for articulation with the temporal bone via the intra-articular disc. Lines drawn through the axis of each condyle intersect just anterior to the foramen magnum, the significance of which is in visualizing a line of correction for manipulative proce- dures (Figure 6-3). The temporal bone has a concave mandibular fossa, with the convex articular eminence just anterior to it. Figure 6-1â•… Biomechanical relationship necessary to stabilize the head Foramen magnum and the cervical spine segments. Arrows indicate direction of muscle pull. (Modified from Grieve G: Common vertebral joint problems, ed 2, Figure 6-3â•… Line drawn through the axes of the mandibular condyles will Edinburgh, 1988, Churchill Livingstone.) intersect just anterior to the foramen magnum. (Modified from Hertling D, have clinical relationships with neck pain, headache, orofacial pain, Kessler RM: Management of common musculoskeletal disorders: Physical and abnormalities of chewing and swallowing. An association is tÂ

Chapter 6â•… Extraspinal Techniques | 285 Functionally, the mandibular fossa serves as a receptacle for mandible during opening movements of the jaw. It also prevents the condyles when the joint is in a closed-packed position (teeth excessive forward, backward, and lateral movements. The stylo- approximated). During opening, closing, protrusion, and retru- mandibular ligament prevents excessive anterior movement of the sion, the convex surface of the condyle must move over the convex mandible and, as such, serves as a stop for the mandible in extreme surface of the articular eminence (Figure 6-4). The existence of the opening. The sphenomandibular ligament functions as a suspen- intraarticular disc compensates functionally for the incongruity sory ligament for the mandible during wide opening of the joint. of the two opposing convex surfaces.3 The disc also separates the joint into an upper and lower portion or compartment, each with A mandibular-malleolar ligament connecting the neck and synovial linings. The outer edges of the disc are connected to the anterior process of the malleus to the medioposterior aspect of joint capsule. the joint capsule has been reported.4,5 The clinical significance Ligamentous Structures of this structure lies in making an anatomic connection between Four ligaments serve as secondary stabilizers for the joint. They are the TMJ and the middle ear. The mandibular malleolar ligament the articular capsule, temporomandibular ligament, stylomandib- passes through the petrotympanic fissure to connect the malleolus ular ligament, and sphenomandibular ligament (Figure 6-5). The to the meniscus and the capsular ligament of the TMJ. The ante- primary function of the joint capsule is to enclose the joint, but rior tympanic artery, which is responsible for supplying blood to because the disc is tethered to it, the joint capsule also causes the the tissue around the tympanic membrane, and the chorda tym- disc to move forward when the condyle moves forward. The tem- pani nerve, which gives pain sensation to the tongue, also travel poromandibular ligament is the main suspensory ligament of the through this fissure. Irritation to these structures can cause symp- toms such as ear pain, tinnitus, vertigo, subjective hearing loss, hyperacusis, tongue pain, and muscle pain. Synovial Mandibular Articular membrane fossa eminence Upper joint Fossa Cartilage Disc Upper joint compartment Temporal compartment bone Lower joint Articular disc Lateral Condyle Lower joint compartment collateral compartment Fibrocartilage ligament Medial collateral Lateral pole ligament Medial pole Condylar process AB Figure 6-4â•… A, Coronal (frontal) section through the temporomandibular joint (TMJ) in the closed position. B, Sagittal section through the TMJ in the open position. Articular Sphenomandibular capsule ligament Temporomandibular Articular ligament capsule Stylomandibular ligament Styloid process Stylomandibular ligament AB Figure 6-5â•… Lateral view of the left temporomandibular joint (TMJ) (A) and medial view of the right TMJ (B), showing the ligamentous structures.

286 | Chiropractic Technique Musculature attaches to the mandibular condyle and the intraarticular disc, The primary movers of the mandible in elevation are the thereby serving as a significant stabilizer of the joint. It is the Ât

Chapter 6â•… Extraspinal Techniques | 287 Mandible shifted Original to left position Anterior middle and posterior fibers of temporalis Pull of left Pull of left Pull of right temporalis muscle lateral pterygoid lateral pterygoid Lateral pterygoid Masseter Medial B Axis of opening rotation Right condyle pterygoid moved forward A Figure 6-7â•… The directions of muscular pull in the temporomandibular joint. A, Opening, closing, and anterior glide. B, Left lateral deviation. Suprahyoid Posterior belly of The position of the mandible when the teeth are fully occluded muscles digastric muscle is termed the intercuspal position and is directly influenced by the state of the dentition. In this position, the condylar location is also Stylohyoid affected by the dentition, which may differ from that imposed by muscle muscle action. Furthermore, the intercuspal position may have an effect on the mandibular resting posture by disturbing the bal- Hyoid bone ance of the musculature, which in turn can affect the head posture and cervical spine function. Therefore, the state of the dentition Thyrohyoid should not be ignored in patients who have chronic neck pain. muscle The TMJ undergoes the coupled motions of rotation and Infrahyoid Omohyoid Anterior belly of translation. Rotational movement of the condyle occurs about muscles muscle digastric muscle a transverse axis between the condyle and the intraarticular disc. This movement causes the first 12 to 15 mm of mandibular open- Sternohyoid ing and closing. Translational movement of the condyle consists muscle of a downward and forward gliding movement of the disc-Âc