chiropractic-technique-bergmann-thomas

288 | Chiropractic Technique TABLE 6-2 Arthrokinematic and Osteokinematic Movements of the Temporomandibular Joint Osteokinematic Movements Arthrokinematic Movements Mandibular elevation and 40 to 60 mm of incisor Combination of spin and glide occurring in the depression separation upper and lower joint compartments Mandibular retraction 5 to 10 mm of incisor separation Glide movement occurring in the upper joint and protrusion compartment 5 to 10 mm of incisor separation Mandibular lateral Glide, spin, and angulation occurring mostly in the deviation upper compartment but also in the lower joint space cervical muscles must contract to prevent neck flexion and per- BOX 6-1 C lose-Packed and Loose-Packed (Rest) mit the mandible to drop away from the cranium. The first few Positions for the Temporomandibular degrees of opening are rotational movements about a transverse Joint axis. Then the condyle and disc complex must translate for- ward over the articular eminence, allowing condylar rotation to CLOSE-PACKED POSITION continue. The closing sequence is the reverse. The condyle and The maximal intercuspal position, in which all teeth make disc complex translate posteriorly with condylar rotation, which full contact with one another (clenched) brings the joint to its resting position, or intercuspal position. The masseter, medial pterygoid, and temporalis muscles are respon- LOOSE-PACKED POSITION sible for this action. Table 6-2 lists the osteokinematic and arthro- The “freeway space” position of slight mandibular opening, kinematic movements of the TMJ. which occurs because of equilibrium between jaw-opening and jaw-closing muscles Lateral glide of the mandible involves a pivoting rotation of the condyle on the side to which the mandible is moving and a BOX 6-2 Classification of Problems Affecting the translation of the other condyle. For lateral glide to the right, the left lateral pterygoid and the anterior bellies of both the digastrics Temporomandibular Joint contract, causing the left condyle to move downward, forward, and medially. Meanwhile, contraction of the right temporalis and DEVELOPMENTAL ABNORMALITIES the right lateral pterygoid rotates the right condyle in the fossa and Hypoplasia displaces the mandible to the right. Box 6-1 identifies the close- Hyperplasia packed and loose-packed positions for the TMJ. Impingement of the coronoid process Chondromas Evaluation Ossification of ligaments (e.g., Eagle syndrome) Problems affecting the TMJ can be broadly classified into devel- INTRACAPSULAR DISEASES opmental abnormalities, intracapsular diseases, and dysfunc- Degenerative arthritis tional conditions (Box 6-2). Developmental abnormalities Osteochondritis include hypoplasia, hyperplasia, impingements of the coronoid Inflammatory arthritis (rheumatoid and psoriatic arthritis process, chondromas, and ossification of ligaments, such as the stylohyoid ligament (Eagle syndrome). The intracapsular dis- and gout) eases include degenerative arthritis, osteochondritis, rheumatoid Synovial chondromatosis arthritis, psoriatic arthritis, synovial chondromatosis, infections, Infections steroid necrosis, gout, and metastatic tumors.6 Developmental Metastatic tumors abnormalities and intracapsular diseases must be ruled out by using appropriate evaluative procedures, including diagnostic DYSFUNCTIONAL CONDITIONS imaging and clinical laboratory studies. The focus here is on the Extracapsular Conditions dysfunctional conditions affecting the TMJ, which are catego- Myofascial pain syndrome rized as extracapsular (myofascial pain syndromes and muscular Muscular imbalance (strain or spasm) imbalance); capsular (sprain, hypomobility and hypermobility, and synovial folds); and intracapsular (disc displacement and Capsular conditions disc adhesions). Sprain, capsulitis, synovitis Hypomobility Inspect the face and jaw, looking for bony or soft tissue Hypermobility Âa

Chapter 6â•… Extraspinal Techniques | 289 AB Figure 6-10â•… Intercuspal alignment. A, Normal alignment. B, Left lateral deviation. AB Figure 6-12â•… Generally, and only as a screen, three of the patient’s fin- Figure 6-11â•… Mandibular gait pattern. A, Normal pattern. B, C-shaped gers should fit between the incisors when fully opened. deviation. BOX 6-3 Accessory Joint Movements of the fÂ

290 | Chiropractic Technique A B C Figure 6-13â•… Intra-auricular palpation of the temporomandibular joint. A, Finger is placed in external auditory meatus. B, Movement of condyle is palpated on opening and closing. C, Asymmetric joint movement. AB Figure 6-14â•… External palpation of the temporomandibular joint space. A, Jaw closed. B, Jaw open.

Chapter 6â•… Extraspinal Techniques | 291 Figure 6-15â•… Palpation of pterygoid muscles with intraoral contact. Figure 6-17â•… Double-thumb intraoral contact on mandible. BOX 6-4 Temporomandibular Adjustive Techniques Supine bilateral thumb/mandible distraction; long-axis distraction (Figure 6-19) Seated or supine bimanual thumb/lower molars; plica entrapment reduction (Figure 6-21) Seated reinforced palmar/distal mandible; anterior-to-posterior glide (Figure 6-22) Supine reinforced thumb/proximal mandible; lateral-to-medial glide (Figure 6-24) Seated thenar/proximal mandible; lateral-to-medial glide (Figure 6-25) Figure 6-16â•… Intraoral palpation of the pterygoid muscles. IND: Reduce an acutely dislocated disc, treat loss of accessory joint movements, and influence disc nutrition. Adjustive Procedures PP: The patient is supine, with the mouth slightly open. A The manipulative techniques used to treat TMJ disorders aim to head belt or an assistant may be used to stabilize the patient’s restore normal joint mechanics, which will then ideally allow full head. pain-free functioning of the mandible. Two basic types of adjus- tive procedures are used for the different forms of TMJ dysfunc- DP: With gloved hands, stand at the side of the table, facing the tion: distraction and translation techniques (Box 6-4). See Box 5-3 patient on the side of the joint dysfunction. for abbreviations used in illustrating techniques. Distraction Techniques SCP: Lower teeth on the involved side. Distraction procedures create a slow and controlled joint gap- CP: Use your cephalic hand, with a thumb contact on the lower teeth ping or separation of the joint surfaces. Typically, they require an intraoral contact, making the use of rubber gloves necessary. of the affected side. Wrap your fingers around the mandible exter- TMJ Supine: Bilateral Thumb/Mandible; Long Axis nally, with the index fingers along the body of the mandible. IH: Use your caudal hand, if jaw excursion allows, to reinforce the Distraction3,7,8 (Figure 6-19) CP with a thumb contact on top of the CP. If this is not pos- sible, place the thumb on the lower teeth of the other side. VEC: Long-axis distraction. P: Ask the patient to swallow, and then apply distraction to the caudal joint surfaces. For an acute anterior dislocation of the disc (Figure 6-20), tip the condyle anteriorly to position it under the disc and add a posterior-to-anterior (P-A) force. For an acute posterior dislocation of the disc, tip the Âc

292 | Chiropractic Technique 6-19 Figure 6-19â•… Long-axis distraction manipulation of the temporomandibular joint. 6-18 Figure 6-18â•… Accessory joint movement evalua- with the addition of lateral glide movements, dorsal-ventral tion for the temporomandibular joint. glide movements, or both. The TMJ is prone to plica formation (synovial fold) especially with pÂ

Chapter 6╅ Extraspinal Techniques | 293 6-22 Figure 6-22╅ Anterior-to-posterior translational manipulation for the right temporomandibular joint. 6-21 Figure 6-21╅ Manipulation for plica entrapment IND: Release intracapsular discal adhesions, restricted anterior to of the left temporomandibular joint. posterior glide accessory joint movements, anterior misalign- ment of the mandibular condyle. SCP: Lower teeth on the involved side. CP: Establish the thumb contact over the lower teeth, with the PP: The patient is seated. DP: Stand behind the patient, with a rolled towel or pillow placed fingers grasping the mandible. VEC: Long-axis distraction. between you and the patient to support the cervical spine. P: Apply a long-axis distraction force while maintaining the man- SCP: Ramus of the mandible. CP: Your ipsilateral hand takes a knife-edge palmar contact over dible in lateral deviation away from the problem. Then ask the€ patient to move the mandible (contracting the deep fibers the ramus of the mandible while the fingers cradle the chin. of the masseter) toward the affected side, against the applied IH: Your contralateral hand reinforces over the CP. resistance. VEC: A-P, along the line of the articular eminence (Figure 6-23). P: First apply a compressive loading force (inferior-to-superior Translation Techniques Translational adjustive techniques use a line of correction parallel [I-S]), and then deliver the thrust as an impulse anteriorly to to the plane of the joint surfaces. In addition, a compressive load- ing force may be applied. The primary effect of this procedure is to Articular fossa move the disc posteriorly, which is specifically indicated for releas- Eminence ing minor disc adhesions (intracapsular adhesions). Translational techniques use extraoral contacts, and gloves are not necessary. EAM Caution must be the rule when using translational techniques, because they carry a higher risk of complication than distraction Slope of techniques. If a translational technique is applied to a joint in the eminence which the disc is displaced anterior to the condyle, it is possible to injure the retrodiscal tissue or produce a hemarthrosis (blood in Figure 6-23╅ The slope of the articular eminence must first be estab- the joint) resulting in a medical emergency. lished because this will determine or influence the direction of a transla- TMJ Seated: Reinforced Palmar/Distal Mandible; Anterior-to- tional thrust. External palpation of the eminence is used to determine the slope. (Modified from Curl D: Acute closed lock of the temporomandibular Posterior Glide7,9 (Figure 6-22) joint: Manipulative paradigm and protocol, J Chiro Tech 3[1]:13, 1991.)

294 | Chiropractic Technique 6-24 Figure 6-24â•… Supine lateral-to-medial translation 6-25 Figure 6-25â•… Seated lateral-to-medial translation manipulation of the right temporomandibular joint. manipulation of the right temporomandibular joint. posteriorly and along the line of the articular eminence. To joint compartment; therefore, care must be taken when using distract the patient’s attention and to prevent jamming of the intraoral contacts. teeth, have the patient open his or her mouth and slowly close it; make the adjustment when he or she is closing the mouth. SHOULDER TMJ Supine; Reinforced Thumb/Proximal Mandible: Lateral- to-Medial Glide3,7 (Figure 6-24) The primary role of the shoulder is to place the hand in a func- IND: Restricted lateral to medial glide accessory joint movements, tional position. To achieve this function, a great deal of joint lateral misalignment of the mandibular condyle. mobility is necessary, which requires complex anatomy and biome- PP: The patient is supine, with the head turned slightly and the chanics. The shoulder is not one joint, but rather is a relationship affected side up. of anatomic and physiologic joints, forming a four-joint complex. DP: Stand at the side of the table toward the side of contact. The glenohumeral joint is a true anatomic joint and forms the SCP: Neck of the mandible. shoulder proper. The sternoclavicular and acromioclavicular joints CP: Establish a reinforced double-thumb contact over the neck of the are also true anatomic joints formed between the manubrium of mandible. the sternum, the clavicle, and the acromial process of the scap- VEC: Lateral-to-medial (L-M). ula, respectively. The scapulocostal joint lacks a joint capsule and P: Deliver an impulse thrust in an L-M direction. is therefore considered a physiologic joint, necessary to allow the TMJ Seated: Thenar/Proximal Mandible; Lateral to Medial smooth gliding of the scapula over the ribs (Figure 6-26). Glide (Figure 6-25) IND: Restricted lateral to medial glide accessory joint movements, These joints provide for an extensive range of active move- lateral misalignment of the mandibular condyle. ment for the upper extremity. Many muscles work together syn- PP: The patient is seated. ergistically to produce coordinated actions across multiple joints. DP: Stand behind the patient and slightly to the side of involvement. Dysfunction from trauma or pathologic processes to any of the SCP: Proximal mandible. articulations can cause a significant reduction in the effectiveness CP: With your ipsilateral hand, establish a thenar contact over the of the entire upper limb. proximal aspect of the mandible, just distal to the joint space. IH: Use the contralateral hand to apply a broad palmar contact on Functional Anatomy the uninvolved side of the face and head. Osseous Structures P: With the patient’s jaw relaxed (teeth not clenched), deliver an impulse thrust in an L-M direction. The convex articular surface of the proximal humerus is directed One of the greatest difficulties encountered when adjusting the slightly posteriorly, medially, and superiorly, and is met by the TMJ is the patient’s inability to adequately relax the jaw muscles. articular surface of the glenoid fossa of the scapula (Figure 6-27). Furthermore, it is detrimental to the joint to overstretch the upper A 45-degree angle is formed between the articular surface and the shaft of the humerus. The glenoid fossa is not a deep iÂ

Chapter 6â•… Extraspinal Techniques | 295 Acromioclavicular Sternoclavicular Acromioclavicular joint joint joint Glenohumeral Scapulocostal Glenohumeral joint articulation joint AB Figure 6-26â•… The four joints that make up the shoulder complex. A, Anterior view. B, Posterior view. Acromion process Coracoid process Glenoid fossa Figure 6-27â•… The proximal humerus articulates with the shallow Glenoid labrum Âg

296 | Chiropractic Technique Distal Costoclavicular provide some reinforcement to the joint capsule anteriorly while Interclavicular clavicle ligament helping to check external rotation and possibly abduction. The cora- Intraarticular disc cohumeral ligament runs from the coracoid process to the greater ligament tubercle, reinforces the superior aspect of the capsule, and checks Joint capsule Manubrium external rotation and possible extension. The transverse humeral ligament attaches across the greater and lesser tubercles and serves Figure 6-29â•… A coronal section through the sternoclavicular joints. to contain the tendon of the long head of the biceps muscle. 60° The acromioclavicular ligament strengthens the superior 30° aspect of the joint capsule. It is intrinsically weak, however, and 30° gives way when a force is applied to the acromion process or gle- nohumeral joint from above (Figure 6-32). The major stabilizing Figure 6-30â•… Apical view of the right shoulder complex showing the ligaments of the acromioclavicular joint are the coracoclavicu- relationship between the scapula and clavicle. lar ligaments, which include the conoid and trapezoid ligaments. The conoid ligament twists on itself as it connects between the coracoid process and clavicle. It prevents excessive superior move- ment of the clavicle on the acromion, as well as retraction of the scapula, by not allowing the scapuloclavicular angle to widen. Furthermore, the conoid ligament tightens on humeral abduc- tion, causing axial rotation of the clavicle that is necessary for full elevation of the arm. The trapezoid ligament also connects between the coracoid process and the clavicle, but lies distal to the conoid ligament. Its role is to check lateral movement of the clavicle, thereby preventing overriding of the clavicle on the acromion process. The trapezoid ligament also prevents excessive scapular protraction by not allowing the scapuloclavicular angle to narrow. The sternoclavicular joint capsule is reinforced anteriorly and posteriorly by the anterior and posterior sternoclavicular liga- ments, respectively (see Figure 6-32). The interclavicular ligaments reinforce the capsule superiorly. Lying just lateral to the joint, the costoclavicular ligament attaches between the clavicle and first rib and serves to check elevation of the clavicle. Its posterior fibers prevent medial movement, and the anterior fibers pÂ

Chapter 6â•… Extraspinal Techniques | 297 Musculature TABLE 6-3 Actions of the Muscles of the Because of the high degree of mobility and the numerous muscles Shoulder Joint Complex necessary to provide stability to the joint, eight or nine bursae are found about the shoulder joint to reduce friction between the Action Muscles moving parts. Irritation to the bursae, leading to an inflamma- tory response, is a common clinical occurrence. Of specific clini- Flexion Anterior deltoid, cal significance are the subscapular bursae and the subacromial or coracobrachialis, and subdeltoid bursae (see Figure 6-31). The subscapular bursa lies Extension pectoralis major (clavicular) beneath the subscapularis muscle and overlies as well as commu- Abduction nicates with the anterior joint capsule. Distension of this bursa Latissimus dorsi, teres major, occurs with articular effusion. The subacromial or subdeltoid Adduction and posterior deltoid bursa extends over the supraspinatus tendon and under the acro- External rotation mion process and deltoid muscle (Figure 6-33). It is susceptible to Internal rotation Middle deltoid, supraspinatus, impingement beneath the acromial arch, and inflammation often and serratus anterior follows supraspinatus tendinitis. Scapular (scapular stability) stabilization A review of the location and function of the numerous mus- Pectoralis major and latissimus cles that stabilize and supply the force for performing the var- Scapular retraction dorsi ied movements of the shoulder is necessary to understand the (medial glide) dysfunctional conditions that affect the shoulder joint complex Infraspinatus, teres minor, and (Table 6-3). Although muscle tendons tend to lend stability to the Scapular elevation posterior deltoid joint, they do not prevent downward dislocation. The rotator cuff is composed of the supraspinatus, infraspinatus, teres minor, and Subscapularis, pectoralis subscapularis muscles. It is most notably the horizontal running major, latissimus dorsi, teres fibers that prevent dislocation as they check the lateral excursion major, and anterior deltoid of the glenoid cavity, which in turn allows downward movement of the humerus. The factors preventing downward dislocation Trapezius, serratus anterior, include the slope of the glenoid fossa, which forces the humerus and rhomboids laterally as it is pulled down; tightening of the upper part of the capsule and of the coracohumeral ligament; and the activity of Rhomboid major and minor the supraspinatus muscle working with the posterior fibers of the deltoid. Trapezius and levator scapulae The tendon of the long head of the biceps is unique in its rela- tionship to the joint in that it originates from within the joint capsule. It arises from the upper margin of the glenoid fossa as a continuation of the glenoid labrum. It penetrates the capsule and passes through the intertubercular groove, which has been Subacromial bursa Acromion Subacromial (subdeltoid) bursa Deltoid Supraspinatus muscle muscle and tendon Joint capsule Joint capsule Triceps muscle Figure 6-33â•… Subacromial bursa. A, With humerus pendulous. B, With humerus abducted. (Modified from Hertling D, Kessler RM: Management of common musculoskeletal disorders: Physical therapy principles and methods, ed 2, Philadelphia, 1990, JB Lippincott.)

298 | Chiropractic Technique converted to a tunnel by the transverse humeral ligament. The Acromioclavicular Joint passage through the capsule, over the humeral head and between Arm abduction also requires axial rotation of the clavicle. For the two tubercles, is facilitated by a tubular sheath of synovial every 10 degrees of arm abduction, the clavicle must elevate membrane. 4 degrees. After 90 degrees of arm abduction (60 degrees of humeral abduction and 30 degrees of scapular rotation), the clavicle rotates Shoulder abduction can be artificially divided into two phases to accommodate the scapula through its full 60 degrees of motion. of movement, each involving different muscles to a greater or This is achieved through the S-shape of the clavicle.16 The acro- lesser degree. Shoulder movement is fluid, however, and the vari- mioclavicular joint usually has a meniscus that functionally divides ous muscular actions and motions run into one another. The first the joint. Rotational movements occur through the conoid liga- phase of movement, from 0 to 90 degrees of abduction, involves a ment and between the acromion and the meniscus. Hinging move- coupling of the deltoid and supraspinatus muscles that draws the ments occur between the meniscus and the clavicle.17 humerus up. To go farther, the scapula and shoulder girdle must also move. In the second phase, the serratus anterior, along with Glenohumeral Joint the upper and lower trapezius, tip the scapula so that the inferior The rotator cuff muscles pull the humerus inferiorly (depression), angle moves laterally and the acromion process is elevated. This and the glenohumeral joint capsule creates external rotation dur- allows movement between 90 and 180 degrees. ing abduction to permit the greater tuberosity to pass under the acromion and coracoacromial ligament (Figure 6-35). Carefully Forward flexion of the shoulder begins with the contraction of evaluate patients complaining of loss of full abduction with the anterior fibers of the deltoid, coracobrachialis, and clavicular or without pain to determine whether the humerus is displaced division of the pectoralis major muscles. Up to 60 degrees of flex- superiorly or has lost inferior glide movements because of capsular ion can occur before the scapula and shoulder girdle must move. ligament fibroadhesions or improper functioning of the rotator Again, the serratus anterior and the upper and middle trapezius cuff muscles. contract, tipping the scapula, raising the acromion process, and causing axial rotation at the acromioclavicular and sternoclavicu- During shoulder movements away from the body (flexion, lar joints. abduction, and extension), the superior aspect of the glenohumeral joint capsule becomes lax, so that it can no longer maintain joint Internal (medial) rotation is accomplished by contraction of integrity against external forces. The rotator cuff muscles carry the subscapularis, teres major, pectoralis major, latissimus dorsi, and responsibility for keeping the humerus oriented to the glenoid the anterior deltoid muscles. For extreme ranges of internal rota- fossa. Table 6-4 identifies the normal ranges of motion (ROMs) tion, the scapula will abduct from the pull of the serratus anterior for the shoulder joint complex, and Table 6-5 describes the close- and the pectoralis minor muscles. packed and loose-packed positions of the shoulder joints. The external (lateral) rotator muscles, in comparison with The minimally constrained ball-and-socket glenohumeral joint the internal rotators, are quite weak but are still very important allows for a significant amount of movement, but is also suscep- to normal function of the upper limb. Clinically, they are easily tible to injury and instability. Rotational movements are the most strained. The infraspinatus, teres minor, and to a lesser degree, frequent surface motion, although combinations of gliding and posterior deltoid muscles are responsible for external rotation of rolling also occur.17 For other movements, the humeral ball must the humerus, with the rhomboids and trapezius muscles adduct- displace with respect to the glenoid fossa. ing the scapula for extreme movement. Sternoclavicular Joint Considerable gliding movements occur at the sternoclavicular Shoulder extension is accomplished by contraction of the latis- joint, with the costoclavicular ligament serving as a fulcrum dur- simus dorsi, teres major, and posterior deltoid muscles, with some ing shoulder motion. Similar to the acromioclavicular joint, in adduction of the scapula from contraction of the middle trapezius the sternoclavicular joint, the meniscus divides the joint into two and rhomboid muscles. Adduction of the humerus is accomplished functional units. A-P gliding occurs between the sternum and the by contraction of the latissimus dorsi, teres major, and pectoralis meniscus, and superior-to-inferior (S-I) gliding occurs between major muscles, with the rhomboids adducting the scapula. the clavicle and the meniscus.12 Rotation of the clavicle about its long axis is possible. A reciprocal motion occurs between the stern- Biomechanics oclavicular joint and acromioclavicular joint during glide motions Scapulohumeral Rhythm but not during rotational motions. For the arm to be abducted from the side to overhead, motion of Evaluation the scapula must be simultaneous and synchronous. During the first 30 degrees of abduction, the scapula seeks a stable position The acromioclavicular joint is relatively weak and inflexible for on the rib cage through contraction of the trapezius, serratus ante- the constant burden and repeated stresses it bears. A force applied rior, and rhomboid muscles (Figure 6-34). Beyond 30 degrees, to the acromion process or the glenohumeral joint from above 2 degrees of glenohumeral movement occur for every 1 degree causes the scapula to rotate around an axis located at the coracoid of scapulocostal movement. Thus, 15 degrees of arm abduction process. The acromioclavicular ligament, being intrinsically weak, results from 10 degrees of glenohumeral joint movement and 5 degrees of scapulocostal joint movement. Rotation of the scap- ula during abduction also enhances mechanical stability by bring- ing the glenoid fossa directly under the humeral head.

Chapter 6â•… Extraspinal Techniques | 299 A 0� 0� 2 0� 30� 90� 60� 31 B 120� 5 30� 4 180� Posterior rotation 45� 60� C Figure 6-34â•… Scapulohumeral rhythm. A, Shoulder at 0-degree abduction, with the scapula, humerus, and clavicle in neutral positions. The weight of the extremity (1) is balanced by a force couple comprising an upward pull from the deltoid muscle (2) and a downward pull from rotator cuff muscles plus the pressure and friction of the humeral head (3). B, Shoulder at 90-degree abduction, with 30-degree scapular rotation and 60-degree humeral abduction; clavicle elevates 30 degrees; serratus anterior muscle (4) and upper trapezius muscle (5) force couple balance and rotate scapula. C, Shoulder at 180-degree abduction, with 60-degree scapular rotation and 120-degree humeral abduction; clavicle rotates 45 degrees to reach an additional 30-degree elevation. (Modified from Wadsworth CT: Manual examination and treatment of the spine and extremities, Baltimore, 1988, Williams & Wilkins.) gives way, and the joint disrupts. A second mechanism of injury repetitive stresses to a compromised tendon. Most injuries are to comes with a downward force of greater intensity, which lowers the supraspinatus tendon. the clavicle on the first rib, with the rib becoming a fulcrum. Both the acromioclavicular and coracoclavicular ligaments tear, caus- Because of the relatively poor blood supply near the inser- ing a complete acromioclavicular separation. This usually happens tion of the supraspinatus, nutrition to this area may not meet with a fall on the point of the shoulder or a fall on the hand of an the demands of the tendon tissue. An inflammatory response outstretched arm. The sternoclavicular and costoclavicular liga- arises in the tendon, creating a tendinitis that probably is a ments also may be sprained during shoulder trauma. result of the release of enzymes and resultant dead tissue acting as a foreign body. The body may react by laying down scar tis- Rotator cuff muscle strains are caused by falls on an outstretched sue or even calcific deposits. This is then referred to as calcific arm, impingement against the coracoacromial arch, and minor or tendinitis.

300 | Chiropractic Technique Deltoid Supraspinatus Bursitis, as a primary condition resulting from local trauma, is rare. As a secondary progression from tendinitis, however, it is Subscapularis very common. Acute bulging of the tendon compresses the bursa and infraspinatus against the coracoacromial arch, resulting in inflammation and swelling of the bursa. This produces severe limitation of motion, Figure 6-35â•… The actions of the rotator cuff muscles to depress the as well as severe pain. The subacromial and subdeltoid bursae are humeral head during shoulder abduction. most frequently involved. TABLE 6-4 Arthrokinematic and Capsulitis (adhesive capsulitis or “frozen shoulder”) is a further Osteokinematic Movements of the progression of tendinitis-bursitis clinical phenomenon, with resul- Shoulder Joints tant adherence of the bursal walls, causing the supraspinatus and deltoid muscles to become “stuck together.” Continued immo- Osteokinematic Arthrokinematic bility leads to capsular tightening and eventual capsular fibrosis. Movements Degrees Movements Degenerative joint disease, rheumatoid arthritis, immobilization, and reflex sympathetic dystrophy also cause capsular tightening Glenohumeral flexion 120 Rotation and glide that may lead to capsulitis. Glenohumeral 55 Rotation and glide Roll and glide The shoulder and arm are common sites for referred pain from extension 120 Roll and glide the cervical spine, myocardium, gallbladder, liver, diaphragm, and Glenohumeral 45 Rotation breast. Usually the patient’s history suggests the origin of pain. 90 Rotation Moreover, many of the muscles responsible for shoulder move- abduction 90 Rotation ment and proper function receive innervation from the C5 or C6 Glenohumeral 10 Roll and glide nerve root (NR), again signifying the importance of Âe

Chapter 6â•… Extraspinal Techniques | 301 TABLE 6-6 Accessory Joint Movements of the Shoulder Joint Complex Joint Movement 6-37 Figure 6-37â•… Assessment of anterior-to-posterior Glenohumeral humeral joint. and posterior-to-anterior glide of the right glenoÂ

302 | Chiropractic Technique 6-39 Figure 6-39â•… Assessment of external rotation of the right Âg

A C D 6-42 Figure 6-42â•… Assessment of the right sternoclavicular joint. A, Superior-to-inferior glide. B, Inferior-to-superior glide. C, Anterior-to-posterior glide. D, Posterior-to-anterior glide. B C A D 6-43 Figure 6-43â•… Assessment of the right acromioclavicular joint. A, Posterior-to-anterior glide. B, Anterior-to-posterior glide. C, Superior-to-inferior glide. D, B Inferior-to-superior glide.

304 | Chiropractic Technique 6-46 Figure 6-46â•… Assessment of the right scapulocostal articulation for counterclockwise rotation, gÂ

Chapter 6â•… Extraspinal Techniques | 305 BOX 6-5 Shoulder Adjustive Techniques BOX 6-5 Shoulder Adjustive Techniques—Cont’d Glenohumeral Supine: Sternoclavicular Sitting: Thumb web/axilla with knee extension; long-axis Reinforced thenar/proximal clavicle; inferior-to-superior distraction (Figure 6-48) glide (Figure 6-70) Bimanual thumb thenar grasp/proximal humerus with knee Digital/proximal clavicle, thenar/manubrium; long-axis extension; anterior-to-posterior glide (Figure 6-49) distraction (Figure 6-71) Interlaced digital/proximal humerus; superior-to-inferior Scapulocostal Side Posture: glide in flexion (Figure 6-50) Bimanual thumb thenar/lateral scapula; lateral-to-medial Index/proximal humerus; superior-to-inferior glide in glide (Figure 6-72) abduction (Figure 6-51) Crossed bilateral mid-hypothenar (knife-edge)/scapula; Bimanual thumb thenar grasp/proximal humerus with knee medial-to-lateral glide (Figure 6-73) extension; internal or external rotation (Figures 6-52 and Bimanual digital thenar grasp/scapula; rotation—inferior 6-39) Bimanual thumb thenar grasp/proximal humerus; angle lateral to medial (Figure 6-74) mobilization with distraction (Figure 6-53) Bimanual digital thenar grasp/scapula; rotation—inferior Bimanual grasp/hand; pendular abduction mobilization (Figure 6-54) angle medial to lateral (Figure 6-75) Glenohumeral Prone: 6-48 Figure 6-48â•… Adjustment for long-axis distrac- Bimanual thumb thenar grasp/proximal humerus with knee tion of the left glenohumeral joint. extension; posterior-to-anterior glide (Figure 6-55) 6-49 Figure 6-49â•… Adjustment for anterior-to- Bimanual thumb thenar grasp/proximal humerus; supine position. posterior glide of the left glenohumeral joint in the mobilization with distraction (Figure 6-56) Glenohumeral Standing: Interlaced digital/proximal humerus; superior-to-inferior glide in flexion (Figure 6-57) Interlaced digital proximal humerus; superior-to-inferior glide in abduction (Figure 6-58) Glenohumeral Sitting: Reinforced palmar/olecranon; anterior-to-posterior glide (Figure 6-59) Acromioclavicular Supine: Index/distal clavicle; superior-to-inferior glide (Figure 6-60) Covered thumb/distal clavicle; inferior-to-superior glide (Figure 6-60) Hypothenar/distal clavicle with distraction; anterior- to-posterior glide (Figure 6-62) Digital/distal clavicle with distraction; posterior-to-anterior glide (Figure 6-63) Acromioclavicular Sitting: Web/distal clavicle; superior-to-inferior glide (Figure 6-64) Sternoclavicular Supine: Hypothenar/proximal clavicle with distraction; anterior- to-posterior glide (Figure 6-65) Covered thumb/proximal clavicle; superior-to-inferior glide (Figure 6-66) Covered thumb/proximal clavicle with knee extension; inferior-to-superior glide (Figure 6-67) Digital/proximal clavicle with distraction; posterior-to- anterior glide (Figure 6-68) Thenar/distal clavicle, thenar manubrium; long-axis distraction (Figure 6-69)

306 | Chiropractic Technique DP: Stand at the side of the table and straddle the affected arm so Index/Proximal Humerus; Superior-to-Inferior Glide in that the patient’s epicondyles are held between your knees. Abduction (Figure 6-51) SCP: Proximal humerus. IND: Loss of accessory movements in inferior glide in abduction, CP: With both hands, grasp the proximal humerus with thumbs/ superior misalignment of the humerus. thenars together in the midline. PP: The patient is supine, with the involved arm abducted to 90 VEC: A-P. degrees. P: With your knees, provide slight distraction while applying an DP: Stand on the involved side at the head of the table, facing caudal. impulse thrust anteriorly to posteriorly with both hands. SCP: Superior aspect of the proximal humerus. Interlaced Digital/Proximal Humerus; Superior-to-Inferior CP: Establish a web contact over the superior aspect of the proxi- Glide in Flexion (Figure 6-50) mal humerus with the cephalic hand. IND: Loss of accessory movements in inferior glide in flexion, IH: With your caudal hand, grasp the distal aspect of the patient’s superior misalignment of the humerus. humerus. PP: The patient is supine, with the involved arm raised to 90 degrees VEC: S-I. P: Your IH serves as a pivot point, stabilizing the distal humerus flexion and the elbow bent so that the hand rests on the shoulder. DP: Stand on the involved side in a lunge position, facing cephalad and elbow, and your cephalic hand removes articular slack, fÂ

Chapter 6â•… Extraspinal Techniques | 307 6-52 Figure 6-52â•… Adjustment for internal rotation of the left glenohumeral joint with distraction. External rotation is done with the same procedure, using external rotation prestress and thrust. DP: Stand on the involved side, facing cephalad and straddling 6-53 Figure 6-53â•… Glenohumeral mobilization in the the patient’s affected arm so that your knees can squeeze the supine position. distal humerus just above the epicondyles. IH: With your outside hand, make a palmar contact on the poste- SCP: Proximal humerus. rior aspect of the shoulder and scapula to provide support and CP: Grasp the patient’s proximal humerus with interlaced fingers lift during the mobilization. of both hands. VEC: Circumduction and distraction. VEC: Rotational-internal rotation. P: Use your body weight to assist in producing a mild distraction P: Your hand contacts first turn the humerus into internal rotation, and circumduction movement of the shoulder in all directions. removing articular slack. Simultaneously straighten both knees, applying a long-axis distraction to the glenohumeral joint. Bimanual Grasp/Hand; Pendular Abduction Mobilization Bimanual Thumb Thenar Grasp/Proximal Humerus with Knee (Figure 6-54) Extension; External Rotation (see Figures 6-52 and 6-39) IND: Restricted external rotation accessory joint movement, IND: Intracapsular adhesions in the glenohumeral joint, mobili- internal rotation misalignment of the humerus. zation of the shoulder, and adhesive capsulitis. PP: The patient is supine, with the affected arm abducted slightly away from his or her body and the edge of the table, holding PP: The patient is supine, with the affected arm slightly abducted the arm in external rotation. and the forearm flexed to 90 degrees, pointing upward. DP: Stand on the involved side, facing cephalad and straddling the patient’s affected arm so that your knees can squeeze the DP: Stand at the side of the table on the involved side, facing the distal humerus just above the epicondyles. patient. SCP: Proximal humerus. CP: With your hand, grasp the patient’s proximal humerus with SCP: The hand. interlaced fingers. CP: With both hands, grasp the patient’s hand. VEC: Rotational-external rotation. VEC: S-I with passive rocking. P: Use both hands to turn the humerus into external rotation. P: Instruct the patient to relax the arm as much as possible. Raise the Simultaneously straighten both knees to create a long-axis dis- traction to the glenohumeral joint. arm away from the table so that it can swing freely. Induce a pendular Bimanual Thumb Thenar Grasp/Proximal Humerus Grasp; motion in the glenohumeral joint by rocking the forearm cephalad Mobilization with Distraction (Figure 6-53) and caudal, increasing the arc of abduction motion as tolerated. IND: Intracapsular adhesions in the glenohumeral joint and Prone: mobilization of the shoulder. Bimanual Thumb Thenar Grasp/Proximal Humerus with PP: The patient is supine, with the affected arm outstretched. Knee Extension; Posterior-to-Anterior Glide (Figure 6-55) DP: Stand in a lunge position on the affected side, facing the head of the table. SCP: Humerus. CP: With your inside hand, grasp the patient’s arm to hold the patient’s forearm against your thoracic cage.

308 | Chiropractic Technique IND: Loss of P-A accessory movements; or posterior misalign- ment of the humerus. PP: The patient lies in the prone position, with the involved arm in slight abduction and the glenohumeral joint positioned off the edge of the table. DP: Stand at the side of the table and straddle the patient’s affected arm, with the epicondyles held between your knees. SCP: Proximal humerus. CP: With both of your hands, grasp the proximal humerus with thumbs together in the midline. VEC: P-A. P: With your knees, provide slight distraction while applying an impulse thrust posteriorly to anteriorly with both hands. Bimanual Thumb Thenar Grasp/Proximal Humerus; Mobilization with Distraction (Figure 6-56) IND: Intercapsular adhesions and mobilization of the shoulder. PP: The patient lies prone, with the affected arm hanging down and off the side of the table. DP: Kneel at the side of the table, facing the patient. SCP: Proximal humerus. CP: Grasp the patient’s proximal humerus with both hands, with your thumbs together on the posterior aspect of the humerus while your fingers wrap around and into the axilla on the underside of the humerus. VEC: Circumduction. P: Using both hands, first distract the glenohumeral joint in the long axis of the humerus, and then move the humerus toward and away from you, cephalad and caudal, in a figure-8 motion. Standing: Interlaced Digital/Proximal Humerus; Superior-to-Inferior Glide in Flexion (Figure 6-57) 6-54 Figure 6-54â•… Glenohumeral mobilization using pendular abduction. 6-55 Figure 6-55â•… Adjustment for posterior-to- 6-56 Figure 6-56â•… Glenohumeral mobilization in the prone position. anterior glide of the right glenohumeral joint in the prone position.

Chapter 6â•… Extraspinal Techniques | 309 6-57 Figure 6-57â•… Adjustment for inferior glide in Figure 6-58â•… Adjustment for inferior glide in ing position. flexion of the right glenohumeral joint in the stand- abduction of the right glenohumeral joint in the IND: Loss of accessory movements in inferior glide in flexion; 6-58 superior misalignment of the humerus. standing position. PP: The patient stands, with feet spread at least shoulder-distance IND: Loss of A-P accessory movement, anterior misalignment of apart (or farther if the patient is taller than the doctor). The the humerus. involved arm is flexed to 90 degrees, and the elbow is flexed so that the hand rests on the patient’s shoulder. PP: The patient sits with the arm in forward flexion, the elbow bent, and the hand resting on the opposite shoulder if internal DP: Stand in front of the patient and to the affected side. Your rotation is also desired or on the same shoulder if external rota- legs should be spread appropriately for balance, as well as to tion is also desired. align to the patient’s height. DP: Stand behind the patient, slightly to the side of involvement, SCP: Proximal humerus. stabilizing the patient’s shoulder girdle against the torso. CP: First place the patient’s elbow on your shoulder, then, using 6-59 Figure 6-59â•… Adjustment for anterior-to- both hands, grasp the proximal humerus with your fingers sitting position. posterior glide of the right glenohumeral joint in the interlaced on the superior aspect of the joint capsule while your thumbs wrap into the axilla. VEC: S-I. P: First draw away from the patient, creating a joint separation, and then apply a downward pressure to remove articular slack. Give a thrust in the S-I direction. Interlaced Digital/Proximal Humerus; Superior-to-Inferior Glide in Abduction (Figure 6-58) IND: Loss of accessory movements in inferior glide in abduction; superior misalignment of the humerus. PP: The patient stands with legs at least shoulder-distance apart, with the involved arm abducted to 90 degrees and the elbow flexed so that the hand rests on the patient’s shoulder. DP: Stand with legs apart so that the patient’s elbow can rest on your shoulder. SCP: Proximal humerus. CP: Grasp the proximal humerus, with interlaced fingers on the superior aspect and thumbs in the axilla. VEC: S-I. P: Back away from the patient to distract the joint while applying a downward pressure with the hands to remove articular slack. Give an impulse thrust in the S-I direction. Sitting: Reinforced Palmar/Olecranon; Anterior-to-Posterior Glide (Figure 6-59)

310 | Chiropractic Technique SCP: The olecranon process. 6-61 Figure 6-61â•… Adjustment for inferior-to-superior CP: With your ipsilateral hand, use a palmar contact to cup the glide of the right acromioclavicular joint. patient’s elbow. IH: With your inside hand, place a pisiform contact over the IH: With your other hand, reinforce the CP. thumbnail of the contact hand. VEC: A-P. P: Using both hands, remove the articular slack and give a very VEC: I-S. P: As you straighten your knees to create a long-axis distraction quick and shallow thrust primarily in the axis of the humerus. Acromioclavicular Joint of the shoulder joint, use both hands to deliver an I-S impulse Supine: thrust to the distal clavicle. Index/Distal Clavicle; Superior-to-Inferior Glide (Figure 6-60) Hypothenar/Distal Clavicle with Distraction; Anterior- IND: Restricted S-I accessory movement of the distal clavicle, to-Posterior Glide (Figure 6-62) IND: Restricted A-P accessory joint movement of the distal clavi- superior misalignment of the distal clavicle. cle, anterior misalignment of the distal clavicle. PP: The patient is supine, with the affected arm abducted to PP: The patient is supine, with the affected arm straight and fÂ

Chapter 6â•… Extraspinal Techniques | 311 6-63 Figure 6-63â•… Adjustment for posterior-to-ante- rior glide of the right acromioclavicular joint. 6-62 Figure 6-62â•… Adjustment for anterior-to-poste- rior glide of the right acromioclavicular joint. deliver a very quick and shallow P-A impulse thrust to the dis- 6-64 Figure 6-64â•… Adjustment for superior-to- tal clavicle (lifting the distal clavicle). inferior glide of the right acromioclavicular joint in Sitting: the seated position. Web/Distal Clavicle; Superior-to-Inferior Glide (Figure 6-64) IND: Restricted S-I accessory movement of the distal clavicle, Sternoclavicular Joint superior misalignment of the distal clavicle. Supine: PP: The patient sits, with the affected arm abducted. Hypothenar/Proximal Clavicle with Distraction; Anterior- DP: Stand behind the patient and to the side of the affected arm. SCP: Superior aspect of the distal clavicle. to-Posterior Glide (Figure 6-65) CP: With your inside hand, apply a web contact over the superior IND: Restricted A-P accessory movement of the proximal clavi- aspect of the distal clavicle. IH: With your outside hand, grasp the patient’s distal forearm. cle, anterior misalignment of the proximal clavicle. VEC: S-I. P: While your IH uses the patient’s forearm as a lever to distract and abduct the shoulder joint, deliver an S-I impulse thrust with your contact hand.

312 | Chiropractic Technique 6-66 Figure 6-66â•… Adjustment for superior-to-infe- rior glide of the left sternoclavicular joint. Covered Thumb/Proximal Clavicle with Knee Extension; Inferior-to-Superior Glide (Figure 6-67) IND: Loss of I-S accessory joint movement of the proximal clavi- cle, inferior misalignment of the proximal clavicle. PP: The patient is supine, with the affected arm slightly abducted. DP: Stand on the affected side, straddling the patient’s arm and Figure 6-65â•… Adjustment for anterior-to-poste- grasping the distal humerus between your knees. 6-65 rior glide of the right sternoclavicular joint. SCP: Inferior aspect of the proximal clavicle. PP: The patient is supine, with the involved arm flexed forward to 6-67 Figure 6-67â•… Adjustment for inferior-to-superior approximately 60 degrees. position. glide of the left sternoclavicular joint in the supine DP: Stand on the side of the table on the side of involvement, Âf

Chapter 6â•… Extraspinal Techniques | 313 CP: With your outside hand, place a thumb contact on the infe- IH: Grasp the patient’s distal forearm with your outer hand. rior aspect of the proximal clavicle. VEC: P-A. P: With your IH, distract the shoulder anteriorly and while main- IH: With your inside hand, place a pisiform-hypothenar contact over the thumb contact for reinforcement. taining distraction, flex the arm, raising it past 90 degrees. As the articular slack is taken out, use your contact hand to deliver VEC: I-S. a very quick and shallow P-A impulse thrust to the proximal P: Use your knee contact on the patient’s distal humerus to dis- clavicle (lifting the proximal clavicle). Thenar/Distal Clavicle,Thenar/Manubrium; Long-Axis Distraction tract the shoulder girdle caudally. When articular slack has (Figure 6-69) been removed, apply an impulse thrust through both hands in IND: Generalized decrease in movement of the sternoclavicular an I-S direction on the proximal clavicle. joint, and displacement of the intraarticular meniscus. Digital/Proximal Clavicle with Distraction; Posterior-to-Anterior PP: The patient is supine, with a rolled towel or small cylindrical Glide (Figure 6-68) pillow placed under the upper thoracic spine. The affected arm IND: Loss of P-A accessory joint movement of the proximal clavi- is abducted to approximately 90 degrees. cle, posterior misalignment of the proximal end of the clavicle. DP: Stand on the affected side in a lunge position, facing cephalad. PP: The patient is supine. SCP: Distal clavicle. DP: Stand at the side of the table on the affected side, facing CP: With your outside hand, place a thenar contact over the distal cephalad. clavicle and grasp the deltoid area. SCP: Posterosuperior aspect of the proximal clavicle. IH: With your inside hand, place a thenar contact over the manu- CP: With your inside hand, apply the digital contact of the index brium of the sternum, with the thumb pointing cephalad and and middle fingers over the posterosuperior aspect of the proxi- the fingers pointing laterally across the contralateral clavicle. mal clavicle. VEC: Distraction. P: With your IH, stabilize the patient’s manubrium and opposite shoulder against the table, applying a downward pressure. The pillow or rolled towel serves as a fulcrum as you apply a shal- low impulse thrust to the distal clavicle and shoulder to distract the proximal clavicle from the manubrium. Alternatively, the clinician can use crossed arms, applying hypothenar knife-edge contacts on the clavicle and manubrium. Sitting: Reinforced Thenar/Proximal Clavicle; Inferior-to-Superior Glide (Figure 6-70) IND: Loss of I-S accessory joint movement of the proximal clavi- cle, inferior misalignment of the proximal clavicle. PP: The patient sits, with arms relaxed. DP: Stand behind the patient. Figure 6-68â•… Adjustment for posterior-to-infe- 6-69 Figure 6-69â•… Distraction of the right rior glide of the left sternoclavicular joint. sternoclavicular joint in the supine position. The patient lies on a sternal roll or rolled towel, which serves as a fulcrum for 6-68 distraction.

314 | Chiropractic Technique 6-70 Figure 6-70â•… Adjustment for inferior-to-superior CH: With your ipsilateral hand, reach under the patient’s affected position. glide of the right sternoclavicular joint in the seated arm to support the patient’s arm on your forearm. Make digital contact with the index and middle fingers on the proximal end SCP: Inferior aspect of the proximal clavicle. of the clavicle. CP: With your contralateral hand, establish a thenar contact on IH: With your contralateral hand, make a thenar contact over the the inferior aspect of the proximal clavicle. manubrium of the sternum, with the forearm lying across the IH: With your ipsilateral hand, take a calcaneal contact over the contralateral clavicle. thenar contact for reinforcement. VEC: Distraction. VEC: I-S. P: With your IH, stabilize the manubrium and opposite shoulder P: Stabilize the patient’s torso against the back of the chair or girdle against the back of the chair or your body while your your body. Deliver an impulse thrust with both hands in an contact hand draws the affected clavicle medially to laterally I-S direction. and your arm draws the patient’s affected shoulder slightly Digital Proximal/Clavicle, Thenar/Manubrium; Long-Axis anteriorly to posteriorly. When articular slack is removed, give Distraction (Figure 6-71) a quick and shallow impulse thrust, separating the proximal IND: Generalized decrease in movement of the sternoclavicular clavicle from the manubrium. joint, and displacement of the intra-articular meniscus. Scapulocostal Articulation PP: The patient sits, with the affected arm abducted to approxi- Side posture: mately 90 degrees. Bilateral Thumb Thenar/Lateral Scapula; Lateral-to-Medial DP: Stand behind the patient and slightly to the side of Glide (Figure 6-72) involvement. IND: Loss of L-M glide movement of the scapulocostal articulation, SCP: Proximal clavicle. dysfunctional scapulohumeral rhythm, subscapular adhesions. PP: The patient is in a side-lying position, with the affected side up and the arm resting on the side. DP: Stand at the side of the table, facing the patient. SCP: Lateral border of the scapula. CP: With both hands, establish a thumb, thenar, and calcaneal contact over the axillary (lateral) border of the scapula, with the fingers pointing toward the spine. VEC: L-M. P: Draw the scapula laterally to medially, and when the end of passive movement is reached, give an L-M impulse thrust. Crossed Bilateral Mid-Hypothenar (Knife-Edge)/Medial Scapula; Medial-to-Lateral Glide (Figure 6-73) IND: Loss of medial-to-lateral glide movement of the scapulo- costal articulation, dysfunctional scapulohumeral rhythm, sub- scapular adhesions. 6-71 Figure 6-71â•… Distraction of the right 6-72 Figure 6-72â•… Manipulation for lateral-to-medial sternoclavicular joint in the seated position. The cli- glide of the right scapulocostal articulation. nician’s body is used as a fulcrum for separation.

Chapter 6â•… Extraspinal Techniques | 315 6-73 Figure 6-73â•… Manipulation for medial-to-lateral 6-75 Figure 6-75â•… Manipulation for rotation of the glide of the right scapulocostal articulation. right scapulocostal articulation, moving the inferior angle in an medial-to-lateral direction (counterclockwise). PP: The patient is in a side-lying position, with the affected arm PP: The patient is in a side-lying position, with the affected side hanging forward in front of the table. up and the affected arm placed behind the back, with the fist in the small of the back. DP: Stand at the side of the table and to the front of the patient in a lunge position (fencer stance), facing cephalad. DP: Stand at the side of the table, facing the patient. SCP: Lateral aspect of the inferior angle of the scapula. SCP: Medial (vertebral) border of the scapula. CP: With your caudal hand, apply a thenar contact on the lateral CP: Use your caudal hand to apply a metacarpophalangeal (MP) aspect of the inferior angle of the scapula, with the fingers lying (knife-edge) contact over the vertebral (medial) border of the across the scapula and pointing toward the spine. affected scapula, with the fingers over the spine and body of IH: With your cephalic hand, place a thenar contact on the supe- the scapula. rior aspect of the spine of the scapula, with the fingers pointing IH: With your cephalic hand, establish a calcaneal contact over toward the inferior angle. the vertebral border of the other scapula, with the fingers over VEC: Rotational. the body of the scapula. P: Use both hands to induce a rotational, twisting action, using VEC: M-L. an impulse-type thrust to drive the inferior angle of the scapula P: Use both hands in opposing directions to draw passive move- laterally to medially. ment medially to laterally and administer an impulse thrust Bimanual Digital Thenar Grasp/Scapula; Rotation—Inferior primarily through the contact hand medially to laterally. Angle Medial to Lateral (Figure 6-75) Bimanual Digital Thenar Grasp/Scapula; Rotation—Inferior IND: Loss of rotational movement of the scapulocostal articu- Angle Lateral to Medial (Figure 6-74) lation, dysfunctional scapulohumeral rhythm, subscapular IND: Loss of rotational movement of the scapulocostal articu- adhesions. lation, dysfunctional scapulohumeral rhythm, subscapular PP: The patient is in a side-lying position, with the affected side adhesions. up and the affected arm abducted, with the hand behind the head. DP: Stand at the side of the table, facing the patient. SCP: Medial aspect of the inferior angle of the scapula. CH: With your caudal hand, establish a pisiform-hypothenar con- tact on the medial aspect of the inferior angle of the scapula, with the fingers pointing toward the axilla. IH: With your cephalic hand, grasp the spine of the scapula. VEC: Rotational. P: Use both hands to create a rotational, twisting action, using an impulse-type thrust to drive the inferior angle medially to laterally. 6-74 Figure 6-74â•… Manipulation for rotation of the ELBOW right scapulocostal articulation, moving the inferior angle in an lateral-to-medial direction (clockwise). Although outwardly the elbow appears to be a simple singular joint, it is actually an intricate mechanism that depends on the integrated action of three bones that form four distinct articula- tions. This peripheral joint complex must work together to enable

316 | Chiropractic Technique the movements of flexion and extension (humeroulnar and humer- The superior surface of the radial head is concave to accept the oradial joints), as well as pronation and supination (proximal and spherical capitulum. The radial or bicipital tuberosity protrudes distal radioulnar joints) of the forearm and hand. Performance of anteriorly and medially, just distal to the head of the radius. the unique manual skills of the upper extremity depends largely Ligamentous Structures on the proper functioning of the bones, ligaments, and muscles Besides the joint capsule that encloses the three-joint complex around the elbow joint. (humeroulnar joint, radiohumeral joint, and radioulnar joint), three primary ligaments stabilize the elbow. The annular ligament Functional Anatomy encircles the head of the radius and maintains its contact with the Osseous Structures ulna. It is lined with articular cartilage so that the radial head has an articular surface with the ulna, humerus, and annular ligament The cylindrical shaft of the humerus becomes flattened and (Figure 6-78). The medial and lateral collateral ligaments reinforce spreads out distally to form the medial and lateral epicondyles. the joint capsule of the elbow. They restrict medial and lateral angu- The distal end of the humerus contains two articular surfaces: lation and glide of the ulna on the humerus. Each collateral liga- the trochlea, which resembles an hourglass on its side, and ment spreads from its respective epicondyle attachment to reinforce the capitulum, which is spherical (Figure 6-76). The radial the annular ligament anteriorly while providing medial and lateral fossa and coronoid fossa on the anterior surface and the ole- stability through attachments to the radius and ulna, respectively. cranon fossa on the posterior surface allow an increased range Musculature of flexion and extension by delaying impact of the respective Several significant muscle groups cross the elbow joint and, bony prominences on the humeral shaft.16 The proximal end tÂ

Chapter 6â•… Extraspinal Techniques | 317 5–15° Articular capsule Lateral collateral ligament Annular ligament A Medial collateral ligament Annular ligament Figure 6-77â•… Carrying angle, a valgus angle ranging from 5 to 15 B degrees. Figure 6-78â•… Ligaments of the right elbow. A, Lateral view. B, Medial view. bÂ

318 | Chiropractic Technique Brachialis muscle Joint capsule Joint capsule Olecranon bursa Axis of rotation Figure 6-79â•… Sagittal section through the elbow, showing the olecra- non bursa. joint cavity lie the hinged (ginglymus) humeroulnar articulation, Figure 6-80â•… The axis of movement for flexion and extension of the the gliding (plane) humeroradial articulation, and the pivotal elbow. (trochoid) superior radioulnar articulation.15 Table 6-8 shows the normal ROMs for the elbow joint. The mechanical axis for forearm pronation and supination movements is a line passing from the center of the radial head to Flexion and extension movements occur around an axis that near the styloid process of the ulna distally. Normally, between passes through the centers of arcs described by the trochlear 175 and 180 degrees of movement occur from pronation to supi- Âs

Chapter 6â•… Extraspinal Techniques | 319 TABLE 6-9 Close-Packed and Loose-Packed Subluxation of the radial head can occur in a young person (Rest) Positions for the Elbow Joints who is forcibly pulled up from the floor by grabbing the wrist. This action creates traction on the annular ligament on one side Articulation Close-Packed Loose-Packed by the pull of the arm and on the other side by the pull of the Position Position body. This condition, called pulled elbow or nursemaid’s elbow, results in a limitation of supination and tenderness over the radial Humeroulnar Full extension 70 degrees of head. The patient will usually refuse to use the arm, and it will in supination flexion with hang limp at the side, with the hand in pronation. Humeroradial 10 degrees of 90 degrees of supination Trauma to the posterior aspect of the elbow, either by a fall on Proximal flexion with the flexed elbow or by recurrent irritation, can lead to inflamma- radioulnar 5 degrees of Full extension tion of the olecranon bursa. Swelling will be visible and palpable supination and supination and will result in pain on palpation and movement. Olecranon bursitis is frequently seen in individuals such as students who 5 degrees of 35 degrees of lean on their elbows on a hard surface for long periods. The liga- supination supination with mentous stability of the elbow can be breached, causing an elbow 70 degrees of sprain in hyperextension, hyperabduction, and hyperadduction. flexion The ulnar nerve is vulnerable to trauma as it passes through lateral epicondylar fracture and may cause a delayed nerve palsy, the ulnar groove at the medial aspect of the elbow. It can be con- which presents as an ulnar nerve distribution in the hand. tused by a direct blow, stretched by a valgus force to the elbow, A decrease in the carrying angle, called a gunstock deformity, trapped in scar tissue after trauma to the elbow, and irritated by is often the result of trauma, such as a supracondylar fracture bone spurs. Any or all of these processes can create a peripheral in childhood. entrapment of the ulnar nerve known as cubital tunnel syndrome. Elbow pain may or may not be associated with this problem. The Arthrokinematics of the elbow are dictated by the spiral shape cardinal symptoms of ulnar nerve injury are tingling and burning of the articular surface of the trochlea. Flexion and extension of the little finger and ulnar half of the ring finger. Motor func- movements are impure swing movements that couple adduction tion of the opponens digiti minimi and interosseous muscles also with flexion and abduction with extension. The close-packed may be impaired. and loose-packed positions for the elbow joints are identified in Table 6-9. The effective treatment and management of patients with elbow problems obviously depends on first establishing the nature Evaluation and extent of the lesion, being aware of which anatomic structures have been potentially injured. The elbow is largely derived from The elbow is exposed to numerous traumatic events that can lead C6 and C7 and may therefore be a site of referred pain, as well as a to joint injury and dysfunction. A common cause of elbow prob- source for referral of pain to other structures from these segments lems is a result of muscle activity across the joint. Lateral epicon- (Figure 6-82). dylitis results from such activity of the wrist extensors. The extensor mass, and especially the deeply located extensor carpi radialis, rubs To begin the evaluation of the elbow, observe the elbow for evi- and rolls over the lateral epicondyle and radial head during forced dence of swelling, asymmetry of contours, posture, and attitude. contraction of the muscle. The forced contractions of the muscle Also note functional use of the arm during gait, position chang- group produce tugs on the origin, resulting in microtears in the ing, and other activities. Evaluate the carrying angle by having the tendon and a pulling away of the periosteum. This, coupled with patient straighten his or her supinated elbows (anatomic position) the irritation of soft tissue rubbing over bony prominences, results and measuring the angle from the junction of the longitudinal axis in a painful elbow condition. Typically, a pain pattern extend- of the upper arm and forearm. ing down the forearm, following the extensor muscle group, and point tenderness over the lateral epicondyle both occur. The pain Identify osseous symmetry and pain production through static is intensified by resisted extension of the wrist and fingers, as well palpation of the radial head, medial epicondyle, lateral epicon- as by shaking hands. The pain may progress to the point that the dyle, olecranon process, and fossa. Structural integrity of the elbow patient has difficulty picking up a coffee cup or turning a door- joint can be evaluated through the relationship of the olecranon knob. The action of the backhand stroke in tennis has been a process to the humeral epicondyles. With the elbow extended and Âf

320 | Chiropractic Technique AB Figure 6-84â•… Palpational relationship between the epicondyles and ole- cranon process. A, Flexion landmarks form an isosceles triangle. B, Extension landmarks form a straight line. Deviations indicate a structural problem. Figure 6-82â•… The elbow may be the site of referred pain, as well as the BOX 6-6 A ccessory Joint Movements of the source of referral. (From Magee DJ: Orthopedic Physical Assessment, ed 5, St Louis, 2008, Saunders.) Elbow Joint determine the presence of joint dysfunction. Assess long-axis dis- traction, primarily of the humeroulnar joint, with the patient sit- Long-axis distraction ting or supine and his or her elbow bent slightly. Stand to the side Medial-to-lateral glide of involvement, facing the patient, and use your inside hand to Lateral-to-medial glide stabilize the humerus while your outside hand grasps the distal Posterior-to-anterior glide in extension Anterior-to-posterior glide (radioulnar joint) Posterior-to-anterior glide (radioulnar joint) Posterior-to-anterior glide (radioulnar joint in pronation) forearm. Then stress the forearm along its long axis, feeling for a springing end feel (Figure 6-85). Evaluate M-L glide of the humeroradial and humeroulnar joints with the patient seated and the affected arm extended at the elbow and flexed at the shoulder. Stand and face the patient on the medial side of the affected arm. Stabilize the patient’s arm against your body with your outer arm while your inside hand takes a calcaneal contact over the medial aspect of the elbow joint. With the forearm stabilized, stress the elbow from medial to lat- eral, assessing for the presence of a springing joint play movement (Figure 6-86). Assess L-M glide of the humeroradial and humeroulnar joint with the patient in a seated position and the affected arm extended at the elbow and flexed at the shoulder. Stand and face the patient on AB 6-85 Figure 6-85â•… Assessment of long-axis distrac- Figure 6-83â•… Palpational relationship between the epicondyles and tion of the right humeroulnar joint. olecranon process in a normal elbow.

Chapter 6â•… Extraspinal Techniques | 321 6-86 Figure 6-86â•… Assessment of medial-to-lateral of the affected arm. Form a ring with your thumb and index fin- glide of the right humeroulnar joint. ger of your outside hand and place it over the posterior aspect of the olecranon process. Rest your other hand on the anterior aspect the lateral aspect of the affected arm. Stabilize the patient’s forearm, of the distal forearm. With very little downward pressure on the using the inside arm to hold the patient’s arm against your body. distal forearm, apply a gentle P-A stress to the olecranon process, Your outside arm takes a calcaneal contact over the lateral aspect of looking for a springing joint play movement (Figure 6-88). the elbow joint. With the patient’s forearm stabilized against your body, stress the elbow laterally to medially, determining the pres- Assess A-P and P-A glide of the radioulnar joint, with the ence of a springing joint play movement (Figure 6-87). patient in the seated position and the affected arm extended at the elbow and flexed at the shoulder. Stand and face the patient on Evaluate P-A glide of the humeroulnar joint in extension, with the lateral aspect of the affected arm. With your inside arm, sta- the patient sitting and the affected arm extended at the elbow and bilize the patient’s forearm against your body and grasp the distal flexed at the shoulder. Stand and face the patient on the lateral side humerus and proximal ulna. With your outside hand, hold the radial head between the thumb and index finger. While stabilizing the ulna and humerus, stress the radial head from anterior to pos- terior and from posterior to anterior, determining the presence of a springing joint play movement (Figure 6-89). Evaluate P-A glide of the radioulnar joint in pronation with the patient in the seated position and the affected arm extended at the elbow and flexed at the shoulder. Stand and face the lateral aspect of the affected arm. With your outside hand, grasp the distal fore- arm, with digital contacts of the index, middle, and ring fingers on the posterior aspect of the radius. With your inside hand, place a thumb contact on the posterior aspect of the radial head. Use your outside hand to pronate the forearm. At the contact over the 6-88 Figure 6-88â•… Assessment of posterior-to-anterior glide of the right humeroulnar joint. 6-87 Figure 6-87â•… Assessment of lateral-to-medial 6-89 Figure 6-89â•… Assessment of anterior-to-posterior glide of the right humeroulnar joint. joint. and posterior-to-anterior glide of the right radioulnar

322 | Chiropractic Technique 6-90 Figure 6-90â•… Assessment for posterior-to-ante- Elbow rior glide in pronation of the right radial head. Sitting: Web/Distal Humerus, Forearm Grasp Pull; Long-Axis DistraÂ

Chapter 6â•… Extraspinal Techniques | 323 PP: The patient sits, with the affected arm flexed at the shoulder. 6-94 Figure 6-94â•… Adjustment for anterior-to-poste- DP: Stand and face the patient at the medial aspect of the patient’s rior glide of the right radial head. affected arm. CP: Using your forward hand, establish a pisiform-hypothenar SCP: Medial aspect of the proximal ulna. contact on the anterior aspect of the radial head. CP: With your inside hand, establish a calcaneal contact over the IH: Reinforce your contact hand with your posterior hand. medial aspect of the proximal ulna, just distal to the medial VEC: A-P. aspect of the elbow joint space. The fingers will rest in the ante- P: The patient’s body weight on the patient’s hand stabilizes the cubital fossa and over the proximal anterior forearm. IH: With your outside hand, contact the lateral aspect of the fore- upper extremity while the doctor delivers an A-P impulse thrust arm so that your arm can stabilize the patient’s forearm against with both hands to the radial head. The patient can be asked to your body. hold the end of the table for torso stabilization as needed. VEC: M-L. Thumb/Radius Push, Distal Forearm Grasp; Posterior- P: As your IH stabilizes the forearm, drawing it into slight distrac- to-Anterior Glide in Pronation (Figure 6-95) tion and elbow extension, induce an M-L impulse thrust with IND: Loss of P-A accessory joint movement of the radial head in your contact hand. pronation, posterior misalignment of the radius. Calcaneal/Proximal Radius Forearm Stabilization; Lateral-to- PP: The patient sits, with the affected arm flexed at the elbow and Medial Glide (Figure 6-93) pronated. IND: Loss of L-M accessory joint motion, olecranon process DP: Stand on the affected side of the patient. Âd

324 | Chiropractic Technique deliver a very shallow but quick impulse thrust in a P-A direc- 6-97 Figure 6-97â•… Adjustment for posterior-to-ante- tion against the radial head with your contact hand. rior glide of the right radial head. Mid-Hypothenar (Knife-Edge)/Proximal Ulna Elbow Flexion; Anterior-to-Posterior Glide (Figure 6-96) Thumb Index/Olecranon Push; Posterior-to-Anterior Glide in IND: Decreased A-P movement of the humeroulnar joint, ante- Full Extension (Figure 6-98) rior misalignment of the radius. PP: The patient sits, with the affected arm flexed at the shoulder IND: Loss of P-A glide of the humeroulnar joint. and at the elbow. PP: The patient sits, with the affected arm extended at the elbow DP: Stand and face the patient. SCP: Proximal ulna. and flexed at the shoulder. CP: With your inside hand, establish a mid-hypothenar (knife- DP: Stand and face the patient on the lateral side of the affected edge) contact over the proximal ulna in the antecubital fossa. IH: Grasp the proximal forearm with your outer hand. arm. VEC: A-P. SCP: The olecranon process. P: Using your IH, flex the patient’s elbow over your contact hand CP: Form a ring with the thumb and index finger of your outside until articular slack is removed. Accomplish the thrust with your IH, moving the forearm toward the patient’s shoulder hand and place it over the posterior aspect of the olecranon while your contact hand delivers an A-P thrust over the proxi- process. mal ulna. IH: Rest your other hand on the anterior aspect of the distal Hypothenar/Radius Push Ulnar Stabilization; Posterior-to- forearm. Anterior Glide in Supination (Figure 6-97) VEC: P-A. IND: Loss of P-A accessory joint movement of the radial head, P: With very little downward pressure on the distal forearm, apply posterior misalignment of the radius. a gentle P-A stress to the olecranon process, finishing with a PP: The patient sits on a chair or on the edge of an adjusting table, very shallow impulse thrust. sitting on the palmar aspect of the hand on the affected side. DP: Either straddle the table, facing the patient on the affected side, or squat next to the patient, who is seated on a chair. SCP: Posterior aspect of the radial head. CP: With your forward hand, establish a pisiform-hypothenar contact on the posterior aspect of the radial head. IH: Grasp the proximal ulna with your posterior hand. VEC: P-A. P: The patient’s body weight on the patient’s hand stabilizes the upper extremity. While your IH stabilizes the ulna, deliver a P-A impulse thrust to the radial head with the contact hand. 6-96 Figure 6-96â•… Adjustment for anterior-to-poste- 6-98 Figure 6-98â•… Adjustment for posterior-to-ante- rior glide of the right ulna. rior glide of the right ulna in extension.

Chapter 6â•… Extraspinal Techniques | 325 Supine: IND: Loss of M-L accessory joint movement, olecranon process Bimanual Grasp/Distal Humerus with Knee Extension; Long- displaced toward the medial epicondyle. Axis Distraction (Figure 6-99) PP: The patient is supine, with the affected arm abducted IND: Loss of joint separation in the long axis. slightly. PP: The patient is supine, with the affected arm slightly DP: Stand at the side of the table facing cephalad and straddling abducted. the patient’s affected arm so that your knees can grasp the DP: Stand on the affected side, facing cephalad, and straddle the patient’s distal forearm. patient’s forearm so that your knees can grasp the patient’s SCP: Lateral aspect of the proximal ulna. Âd

326 | Chiropractic Technique WRIST AND HAND Phalanges An intricate interaction of numerous structures in the wrist and Capitate Metacarpals hand is necessary to produce the remarkable dexterity and pre- cision that characterizes this joint complex.15 The entire upper Hamate Trapezoid limb is apparently subservient to the hand in its use as a tac- Pisiform Trapezium tile organ, a means of expression, and a weapon. The study of Triquetrum Scaphoid the hand is inseparable from that of the wrist and the forearm, Radius which function as a single physiologic unit, with the wrist being Lunate the key joint.3 The wrist serves as a flexible spacer between the forearm and hand and is critical in setting the length-tension Ulna relationship for the extrinsic finger muscles. By far the most important musculoskeletal function of the hand is its ability to Figure 6-102â•… Palmar view of the osseous structures of the right grasp objects. However the hand is also an important sensory wrist and hand. organ (kinesthetic) and helps to express emotion though gestures, touch, and art. Because of it biomechanical complexity, the func- Âc

Chapter 6â•… Extraspinal Techniques | 327 Pisohamate and Radial collateral Ulnar pisometacarpal ligament collateral ligament ligaments Palmar radiocarpal Intercarpal ligament (radiate) Dorsal ligaments radiocarpal Ulnar collateral ligament ligament Figure 6-103â•… Ligaments of the wrist. A, Palmar view. B, Dorsal view. (Modified from Hertling D, Kessler RM: Management of common musculosk- eletal disorders: Physical therapy principles and methods, ed 2, Philadelphia, 1990, JB Lippincott.) Common Trapeziometa- Biomechanics carpometacarpal carpal joint Midcarpal joint The complex movements of the wrist are accomplished by the joint Radial collateral distal radioulnar joint, the radiocarpal joint, and the midcar- Interosseous ligament pal joint. The radiocarpal and midcarpal joints produce the motion at the wrist joint. Wrist flexion and extension, as well as ligaments Radiocarpal joint radial and ulnar deviation, are thought to occur around an axis Inferior radioulnar of movement that passes through the capitate (Figure 6-108). Ulnar collateral joint However, the multiplicity of wrist articulations and the com- ligament plexity of joint motion make it difficult to calculate the precise Radius instantaneous axis of motion.12 The close-packed position for Triangular the wrist is full extension (Table 6-11). The wrist can undergo fibrocartilage approximately 160 degrees of flexion and extension, with exten- sion being slightly greater. Radial and ulnar deviation are pos- disc sible to 60 degrees, and ulnar deviation is almost twice as great Ulna Metacarpal head Figure 6-104â•… Coronal section through right wrist, showing inter- carpal joints and ligaments. Head of proximal phalanx Check ligament Lateral collateral ligament Volar plate Volar plate Check ligament Accessory collateral Accessory collateral Lateral collateral ligament ligament ligament Figure 6-105â•… Lateral view of the ligaments of the finger.

328 | Chiropractic Technique TABLE 6-10 A ctions of the Muscles of the Flexor digitorum Wrist and Hand profundus tendons Actions Muscles Fibrous digital Flexor digitorum sheaths superficialis tendons Wrist flexion Flexor carpi radialis, abductor Palmar (volar) Flexor retinaculum pollicis longus, palmaris carpal ligament (transverse carpal Wrist extension longus, flexor pollicis longus, ligament) flexor carpi ulnaris, and flexor Wrist adduction digitorum superficialis and Palmaris longus (ulnar deviation) profundus tendon Wrist abduction Extensor carpi radialis, extensor Figure 6-107â•… Palmar view of the left hand, showing flexor tendons. (radial deviation) digitorum, extensor carpi ulnaris, and extensor pollicis 40% 33.5% Finger flexion longus 60% Finger extension Extensor carpi ulnaris and flexor Finger abduction carpi ulnaris Extensor carpi radialis, abductor pollicis longus, and extensor pollicis longus and brevis Flexor digitorum superficialis and profundus Extensor digitorum, extensor digiti minimi, and extensor indicis Interosseous muscles Terminal tendon 66.5% Lateral bands Flexion Extension Central slip of Joint exposed extensor digitorum Figure 6-108â•… Most wrist flexion occurs at the intercarpal joint, and by removal of most wrist extension occurs in the radiocarpal joint. Sagittal bands central slip Dorsal expansion moving more with respect to the radius while the lunate and tri- Juncturae quetrum relate to the ulna. Furthermore, when moving from flex- tendinae Extensor pollicis ion to dorsiflexion, the distal row of carpals becomes close-packed brevis tendon with respect to the scaphoid first. This results in the scaphoid mov- Interosseous Extensor pollicis ing with the distal row into dorsiflexion, necessitating movement muscles longus tendon between the scaphoid and lunate as full dorsiflexion is approached. Extensor Extensor retinaculum digitorum tendons Figure 6-106â•… Dorsal view of the left hand, showing the location of TABLE 6-11 Close-Packed and Loose-Packed extensor tendons and dorsal interosseous muscles. (Rest) Positions for the Wrist and Hand Joints Closed-Packed Loose-Packed Position Position as radial deviation (Figure 6-109). Radial deviation is limited by Wrist Full dorsiflexion Palmar flexion with slight contact of the scaphoid against the radial styloid process. ROMs Hand Full extension ulnar deviation for the wrist and hand are listed in Table 6-12. Flexion with slight ulnar With dorsiflexion of the wrist, a supinatory rotation of the deviation carpal bones also occurs, which is mostly a result of the scaphoid

Chapter 6â•… Extraspinal Techniques | 329 TP H TP S H Proximal Distal transverse arch TZ TZ C TQ transverse arch Longitudinal arch C TQ L S L AB Figure 6-110â•… The three physiologic arches of the wrist and hand. Figure 6-109â•… Dorsal view of the right wrist. A, With ulnar devia- (Modified from Nordin M, Frankel VH: Basic biomechanics of the muscu- tion, some extension of proximal carpals occurs. B, With radial deviation, loskeletal system, ed 2, Philadelphia, 1989, Lea & Febiger.) some flexion of the proximal carpal occurs. C, Capitate; H, hamate; L, distally, the metacarpal arch is formed by the metacarpal heads. lunate; S, scaphoid; TP, trapezium; TQ, triquetrum; TZ, trapezoid. Longitudinal arches are formed along each finger by the corre- sponding metacarpal bone and phalanges. Obliquely, arches are TABLE 6-12 A rthrokinematic and formed by the thumb during opposition with the other fingers. Osteokinematic Movements of the These arches allow coordinating synergistic digital flexion and Wrist and Hand Joints opposition of the thumb and little finger. Osteokinematic Degrees Arthrokinematic The wrist provides a stable base for the hand, and its position con- Movements Movements trols the length of the extrinsic muscles to the digits. The muscles sta- bilize the wrist, as well as provide for the fine movements of the hand, Wrist flexion 80 Roll and glide to place it in its functioning position. The positioning of the wrist has Wrist extension 70 Roll and glide a significant influence on the strength of the fingers. For most effec- Ulnar deviation 30 Roll and glide tive action of the extrinsic muscles of the fingers, the wrist usually Radial deviation 20 Roll and glide must move in a direction opposite the movement of the fingers. MCP flexion 90 Roll and glide MCP extension 30–45 Roll and glide The naturally assumed position of the hand to grasp an object, PIP flexion 100 Roll and glide or the position from which optimal function is most likely to PIP extension 0 Roll and glide occur, is termed the functional position (Figure 6-111). The func- DIP flexion 90 Roll and glide tional position occurs when the wrist is extended 20 degrees and DIP extension 10 Roll and glide the ulna is deviated 10 degrees, the fingers are flexed at all of their Finger abduction 20 Roll and glide joints, and the thumb is in a midrange position, with the MP joint moderately flexed and the interphalangeal joints slightly flexed. DIP, Distal interphalangeal joint; MCP, metacarpophalangeal joint; PIP, proximal interphaÂ

330 | Chiropractic Technique Transverse carpal ligament (flexor retinaculum) Flexor tendons within Median nerve common sheath Carpals AB Extensor Figure 6-112â•… The fundamental patterns of prehensile hand func- tendons tion. A, Power grip. B, Precision maneuver. Figure 6-113â•… Cross-section of the wrist, showing the relationship the lunate. Occasionally, the scaphoid can be felt slipping as the wrist between the carpal bones, tendons, flexor retinaculum, and median is moved, or a painful click may be perceived. A space of more than nerve. 3 mm between the scaphoid and lunate may be seen on a closed-fist clinical picture may be defined as carpal tunnel syndrome, the nerve supinated radiographic view of the wrist. compression may not necessarily be at the wrist but may be at the elbow, shoulder, or neck. This syndrome occurs more often Trauma to an outstretched hand that is forcefully flexed or in women, with onset commonly between 40 and 50 years of extended may cause a fracture to the radius. A Colles fracture age. Slight paresthesias may precede the onset of the acute symp- occurs when the wrist is in dorsiflexion and the forearm is in toms for several months. Then, paroxysms of pain, paresthesia, pronation. Local pain and tenderness to palpation and vibration and numbness occur in the area of the median nerve distribution. are important physical findings; however, the radiograph is the The patient is often awakened at night by numbness or pain that most important tool for determining the presence of a fracture. can be described as burning, aching, prickly, or pins-and-needles. Manipulative therapy to this area is then contraindicated. Motor weakness of the thumb adductor or opposer may be found. The patient may describe relief from dangling the hand over the Singular trauma, such as a fall, or repetitive activities may lead side of the bed, shaking the hand vigorously, or rubbing it. to a sprain of the ligaments of the wrist. Moreover, when the wrist is subjected to sudden increases in workload, such as in gripping Because the wrist structures are innervated primarily from or lifting, or racquet games that require flexion and extension of segments C6 through C8, lesions affecting structures of similar the wrist, the tendons crossing the wrist can become inflamed, derivation may refer pain to the wrist and vice versa. Symptoms resulting in tendinitis. In addition, a possible response to repeated experienced at the wrist and hand must always be suspected as twisting and straining is a localized nodular swelling, called a gan- possibly having a more proximal origin (Figure 6-114). glion. Likely a defense mechanism, the ganglion is characterized by a fibrous outer coat that covers a thick gelatinous fluid derived Observe the wrist and hand for general posture and attitude. In from the synovium lining the tendon sheaths. the resting attitude of the hand, the MP and interphalangeal joints are held in a position of slight flexion. Observe the arm and hand Undoubtedly, the most noted condition affecting the wrist for natural swing when the patient walks. Also, note functional and hand is carpal tunnel syndrome, a peripheral entrapment activities of the hand and wrist, including the firmness of the per- neuropathy involving the median nerve. The median nerve lies son’s handshake, as well as temperature and moisture of the hand. superficial to the flexor tendons beneath the tense transverse car- The dominant hand should be determined. Sometimes this can be pal ligament (flexor retinaculum), making the carpal tunnel just done by noting the hand with more developed musculature, but is barely adequate to accommodate these structures. In the act of most easily done simply by asking the patient. grasping an object, particularly with the wrist in flexion, the flexor tendons are displaced forward and can compress the nerve against To begin the evaluation of the wrist and hand, osseous symme- the unyielding ligament. Narrowing of the carpal tunnel can occur try, bony relationships, and pain production are identified through through bony deformity after fracture, degenerative joint disease, static palpation of the wrist and hand (Figure 6-115). Palpate the synovial swelling of a tendon or of the wrist joint ligaments, and radius and ulna distally, identifying each of their styloid processes. thickening of the transverse carpal ligament (Figure 6-113). Most Just distal to the radial styloid and in the anatomic snuffbox, the often, however, no definitive local cause for nerve compression scaphoid can be palpated. Wrist flexion will facilitate the palpation can be detected. Moreover, Upton and McComas20 has identified of the lunate, which lies next to the scaphoid. The triquetrum and the possibility that peripheral nerves can be compressed at more pisiform overlie one another and are just distal to the ulnar styloid. than one spot along their course, creating “double-,” “triple-,” and The trapezium can be identified at the base of the first metacarpal. “quadruple-crush” syndromes. Therefore, although the patient’s The trapezoid lies at the base of the second metacarpal. The cap- itate is found between the base of the third metacarpal and the lunate. The hook of the hamate, and hence the hamate, can be

Chapter 6â•… Extraspinal Techniques | 331 Figure 6-114â•… Symptoms in the hand and wrist must be suspected found on the palmar surface, just distal and to the thumb side of of€having a more proximal origin. (From Magee DJ: Orthopedic Physical the pisiform. Then palpate the metacarpals through the palm of Assessment, ed 5, St Louis, 2008, Sauders.) the hand, with the fingers along the shaft of the metacarpal on the palmar surface while the thumb is over the dorsal surface. Finally, palpate the 14 phalanges (2 for the thumb and 3 for each finger). Identify tone, texture, and tenderness changes through soft Ât

332 | Chiropractic Technique TABLE 6-13 A ccessory Joint Movements of the Wrist and Hand Joints Joint Movement Distal radioulnar A-P glide 6-117 Figure 6-117â•… Assessment of medial-to-lateral P-A glide compression of the distal left radioulnar joint. Intercarpal M-L compression Long-axis distraction Individual carpals M-L tilt Intermetacarpal M-L glide Metacarpophalangeal and A-P glide P-A glide interphalangeal A-P glide P-A glide A-P glide P-A glide Long-axis distraction M-L glide L-M glide A-P glide P-A glide Internal rotation External rotation A-P, Anterior-to-posterior; L-M, lateral-to-medial; M-L, medial-to-lateral; P-A, posterior- to-anterior. 6-118 Figure 6-118â•… Assessment of long-axis distrac- tion of the left intercarpal joint. 6-11 6 Figure 6-116â•… Assessment of anterior-to-posterior oulnar joint. and posterior-to-anterior glide of the distal left radi- 6-119 Figure 6-119â•… Assessment of medial-to-lateral and lateral-to-medial glide of the left intercarpal joint. both hands to create opposing forces, creating a shearing stress (M-L glide) (Figure 6-119) and radial and ulnar deviation stress (M-L Assess A-P and P-A glide of the individual carpal bones with tilt) (Figure 6-120). the patient seated and the affected arm raised in forward flexion. Stand and face the patient. Use your thumb and index or middle Assess A-P and P-A glide of the intercarpal joint, with the fingers to contact the anterior and posterior surfaces of the car- patient seated and arm raised in forward flexion. Stand on the pal bone to be evaluated while using your other hand to stabilize affected side. Grasp the distal radius and ulna with your proxi- the rest of the wrist. Apply an A-P and P-A stress to each indi- mal hand while grasping the patient’s distal wrist with your distal vidual carpal bone, looking for a springing joint play movement hand. Using both hands to create opposing forces, stress the inter- (Figure 6-122, A and B). carpal joints in an A-P and P-A glide, looking for a springing joint play movement (Figure 6-121).

Chapter 6â•… Extraspinal Techniques | 333 6-120 Figure 6-120â•… Assessment of medial-to-lateral and lateral-to-medial tilt of the left intercarpal joint. Figure 6-123â•… Assessment of anterior-to-posterior and posterior-to- anterior glide of the left intermetacarpal joints. 6-121 Figure 6-121â•… Assessment of anterior-to-posterior Evaluate the MP and interphalangeal joints in a similar fash- joint. and posterior-to-anterior glide of the left intercarpal ion. With the patient seated, grasp the proximal member of the joint to be tested with one hand while grasping the distal mem- Assess A-P and P-A glide of the intermetacarpal joints with ber of the joint being tested with the other hand. Then stress each the patient seated and the affected arm raised in forward flex- MP or interphalangeal joint with long-axis distraction, A-P and ion. Stand and face the patient, grasp the adjacent metacar- P-A glide, L-M and M-L glide, and internal and external rotation pals with both hands, and stress them in an A-P and P-A glide (Figures 6-124 and 6-125). (Figure 6-123). Adjustive Procedures The application of an impulse thrust often can be performed using the accessory joint motion test procedure and adding the impulse thrust at the end. Although this is true of any joint in the body, fewer adjustive procedures are unique or different from the testing procedure for the wrist and hand. Box 6-8 identifies the adjustive procedures for the joints of the wrist and hand. A B 6-122 Figure 6-122â•… Assessment of posterior-to-anterior (A) and anterior-to-posterior (B) glide of the individual carpals of the left wrist.

334 | Chiropractic Technique 6-12 4 Figure 6-124â•… Assessment of long-axis distraction, BOX 6-8 Wrist and Hand Adjustive Techniques internal and external rotation, and anterior-to-poste- rior, posterior-to-anterior, lateral-to-medial, and medial-to-lateral glide of Wrist Supine or Sitting: the left metacarpophalangeal joints. Bimanual thumb index/radius and ulna shear; anterior-to- posterior or posterior-to-anterior glide (Figure 6-126) Wrist Sitting: Reinforced hypothenar/radius; medial-to-lateral compression (Figure 6-127) Hand-grasp pull with forearm stabilization; long-axis distraction (Figure 6-128) Bimanual palmar grasp/hand with arm axillary stabilization; long-axis distraction (Figure 6-129) Bimanual grasp/distal forearm hand; medial-to-lateral or lateral-to-medial glide; medial-to-lateral or lateral-to- medial tilt (Figure 6-130) Bimanual grasp/distal forearm hand; anterior-to-posterior or posterior-to-anterior glide (Figure 6-131) Reinforced thumbs/carpal; anterior-to-posterior or posterior- to-anterior glide (Figure 6-132) Hand Sitting: Bimanual thumbs digits/metacarpals; anterior-to-posterior or posterior-to-anterior glide (Figure 6-133) Thumb index grasp/metacarpophalangeal (or interphalangeal) with hand stabilization; long-axis distraction; internal or external rotation; anterior-to- posterior or posterior-to-anterior glide; lateral-to-medial or medial-to-lateral glide (Figure 6-134) 6-12 5 Figure 6-125â•… Assessment of long-axis distraction, internal and external rotation, and anterior-to-poste- rior, posterior-to-anterior, lateral-to-medial, and medial-to-lateral glide of the left interphalangeal joints. Wrist 6-12 6 Figure 6-126â•… Adjustment for anterior-to-posterior Supine or sitting: Âr

Chapter 6â•… Extraspinal Techniques | 335 6-128 Figure 6-128â•… Adjustment for long-axis distrac- tion of the right intercarpal joint. 6-127 Figure 6-127â•… Adjustment for lateral-to-medial compression of the distal right radioulnar joint. P: With both arms, deliver an extension thrust, creating an impulse 6-129 Figure 6-129â•… Manipulation for sustained long- movement and compressing the radius and ulna. This procedure axis distraction of the right intercarpal joint. can be augmented with the use of a mechanical drop headpiece. Hand Grasp Pull with Forearm Stabilization; Long-Axis Distraction (Figure 6-128) IND: Loss of long-axis accessory movements. PP: The patient is seated, with the affected arm raised in forward flexion. DP: Stand and face the patient. SCP: The hand. CP: Using your inside hand, grasp the patient’s hand as though to give a handshake. IH: Grasp the distal forearm with your outside hand. VEC: Long-axis distraction. P: While you stabilize the forearm with your IH, distract the wrist in the long axis with your contact hand. Bimanual Palmar Grasp/Hand with Arm Axillary Stabilization; Long-Axis Distraction (Figure 6-129) IND: Loss of long-axis accessory movements. PP: The patient is seated, with the affected arm slightly flexed at the shoulder and slightly flexed at the elbow. DP: Stand or sit on the affected side. SCP: Proximal to the hypothenar and thenar eminences. CP: Position your inside arm so that the inferior aspect of your arm rests in the patient’s antecubital fossa and a calcaneal con- tact can be placed just proximal to the patient’s hypothenar and thenar eminences. IH: With your outside hand, place a calcaneal contact over the dorsal aspect of the metacarpal heads, with a palmar contact over the back of the patient’s hand. VEC: Long-axis distraction. P: Squeeze both the contact hand and the IH together to maintain contact while flexing the patient’s elbow. The lever action will create and maintain a long-axis distraction at the wrist.

336 | Chiropractic Technique A B 6-130 Figure 6-130â•… Adjustment for medial-to-lateral and lateral-to-medial glide (A) and medial-to-lateral and lateral-to-medial tilt (B) of the left intercarpal joint. Bimanual Grasp/Distal Forearm Hand; Medial-to-Lateral 6-131 Figure 6-131â•… Adjustment for anterior-to- or Lateral-to-Medial Glide; Medial-to-Lateral or Lateral- intercarpal joint. posterior and posterior-to-anterior glide of the left to-Medial Tilt (Figure 6-130) CP: With your proximal hand, grasp the distal radius and ulna. IND: Decreased M-L or L-M glide movements. IH: With your distal hand, grasp the patient’s distal wrist over the PP: The patient sits, with the affected arm raised in forward metacarpal-carpal joints. flexion. P: Using both hands to create opposing forces, deliver an impulse DP: Stand on the affected side, facing the lateral aspect of the thrust, stressing the intercarpal joints in either an A-P or P-A arm. direction. SCP: Distal radius and ulna. CP: Using your proximal hand, grasp the distal radius and ulna. IH: With your distal hand, grasp the patient’s distal wrist. P: Use both hands to develop opposing forces and deliver an impulse thrust, creating a shearing stress (M-L glide) or radial and ulnar deviation stress (M-L tilt). Bimanual Grasp/Distal Forearm Hand; Anterior-to-Posterior or Posterior-to-Anterior Glide (Figure 6-131) IND: Loss of A-P and P-A accessory joint movements. PP: The patient sits, with the affected arm raised in forward flexion. DP: Stand on the affected side. SCP: Distal radius and ulna. A B 6-132 Figure 6-132â•… Adjustment for anterior-to-posterior (A) and posterior-to-anterior (B) glide of the individual carpals of the left wrist.

Chapter 6╅ Extraspinal Techniques | 337 ReinforcedThumbs/Carpal; Anterior-to-Posterior or Posterior- 6-13 4 Figure 6-134╅ Adjustment for long-axis distraction, to-Anterior Glide (Figure 6-132) internal and external rotation, and anterior-to-posterior, posterior-to-anterior, lateral-to-medial, and medial-to-lateral glide of the left IND: Restricted glide motions of the carpals, anterior or posterior metacarpophalangeal joints (interphalangeal joints are adjusted in the misalignment of the individual carpals. same€way). PP: The patient is seated, with the affected arm raised in slight IND: Lack of accessory joint movement in the finger joints, mis- forward flexion. alignment of the finger joints. DP: Stand and face the patient. PP: The patient is seated. SCP: Carpal bone. DP: Stand and face the patient. CP: Establish a thumb contact over the affected carpal. SCP: Distal component of the affected joint. IH: Using your other hand, apply a thumb contact over the con- CP: Grasp the distal member of the joint to be adjusted with tact thumb to reinforce it. either hand. VEC: A-P or P-A. IH: With your other hand, grasp the proximal member of the P: Use both hands to remove articular slack and deliver an impulse joint being adjusted. thrust with both thumbs to create A-P or P-A glide. VEC: Long-axis distraction, A-P and P-A glide, L-M and M-L Hand Sitting: glide, and internal and external rotation. Bimanual Thumbs Digits/Metacarpals; Anterior-to-Posterior P: Apply an impulse thrust to the affected MP or interphalangeal or Posterior-to-Anterior Glide (Figure 6-133) joint, using long-axis distraction, A-P and P-A glide, L-M and IND: Restricted intermetacarpal glide movements. M-Lglide, and internal and external rotation. PP: The patient is seated, with the affected arm in forward flexion HIP and the elbow flexed so that the palm of the hand faces outward. DP: Stand and face the patient. The hip joint is one of the largest and most stable joints in the SCP: Metacarpal bone. body.17 In contrast to the other extremity joints and, specifically, CP: Establish a thumb contact on the palmar aspect of a metacar- its counterpart in the upper extremity, the shoulder, the hip has intrinsic stability provided by its relatively rigid ball-and-socket pal bone. With your fingers, hold the same metacarpal shaft on configuration (Figure 6-135) and an extensive set of capsular the dorsal surface of the hand. ligaments. Although dysfunction of the hip is not as frequently IH: Make the same contacts on the adjacent metacarpal. encountered as dysfunction in the spine and other extremity joints, VEC: A-P or P-A. its identification and treatment are very important and often over- P: Use both hands to create an A-P and P-A shear between the looked. A pathologic or traumatized hip can create a wide range two metacarpals. of functional limitations, including difficulty in walking, dressing, ThumbIndexGrasp/Metacarpophalangeal(orInterphalangeal) driving a car, climbing stairs, and lifting and carrying loads. The with Hand Stabilization; Long-Axis Distraction; Internal hip joint must accommodate the great deal of mobility necessary or External Rotation; Anterior-to-Posterior or Posterior- for gait and the performance of daily activities. Furthermore, the to-Anterior Glide; Lateral-to-Medial or Medial-to-Lateral hip joint is a multiaxial articulation that must form a stable link Glide (Figure 6-134) between the lower limb and the spine and pelvis. Figure 6-133╅ Adjustment for anterior-to-posterior and posterior- Functional Anatomy to-anterior glide of the left intermetacarpal joints. Osseous Structures The hip is a deep ball-and-socket joint with a spherical convex surface on the head of the femur and a concave articular sur- face formed by the acetabulum of the pelvis. The acetabulum is