chiropractic-technique-bergmann-thomas

["338\t |\t Chiropractic Technique Posterior superior iliac spine Iliac crest Ilium Anterior superior iliac spine Acetabulum Superior pubic ramus Ischium Pubis Ischial tuberosity Obturator foramen Inferior pubic ramus Figure 6-136\u00e2\u2022\u2026 Structures of the innominate and acetabulum. Figure 6-135\u00e2\u2022\u2026 Ball-and-socket configuration of the hip joint. the impact of the femoral head in forceful movements. Hyaline formed by a fusion of the three bones that make up the innomi- cartilage lines the horseshoe-shaped surface of the acetabulum. nate: the ilium (superior), the ischium (posteroinferior), and the The center of the acetabulum is filled in with a mass of fatty tis- pubic bone (anteroinferior) (Figure 6-136). A fibrocartilaginous sue covered by a synovial membrane. The cavity of the acetabulum acetabular labrum surrounds the rim of the acetabulum, effec- is directed obliquely anteriorly, laterally, and inferiorly. The infe- tively deepening it and serving to protect the acetabulum against rior component is important because of the transference of weight from the upper body through the sacroiliac joints into the head of the femur and down its shaft. The femur is the longest bone in the body, as well as one of the strongest. It must withstand not only weight-transmission forces but also those forces developed through muscle \u00c2c","Chapter 6\u00e2\u2022\u2026 Extraspinal Techniques\t |\t 339 (90 to 135 degrees). This angle offsets the femoral shaft from the femoral head. Aging produces degenerative changes that gradu- pelvis laterally and facilitates the freedom of motion for the hip ally cause the trabeculae to resorb, predisposing the femoral neck joint. An angle of more than 125 degrees produces a coxa valga, to fracture. whereas an angle of less than 125 degrees results in coxa vara. A Ligamentous Structures deviation either way can alter the force relationships of the hip The hip joint is completely covered by an articular capsule that joint. The angle of anteversion is the second angle associated with attaches to the rim of the acetabulum, to the femoral side of the the femoral neck and is formed as a projection of the long axis of intratrochanteric line, and to parts of the base of the neck and the femoral head and the transverse axis of the femoral condyles. adjacent areas. The joint capsule is a cylindrical structure resem- This angle should be approximately 12 degrees but has a great bling a sleeve running between its attachment around the periph- deal of variation, of which 10 to 30 degrees is considered within eral surface of the acetabular labrum to the femoral neck (Figure normal limits. Any increase in this anterior angulation is called 6-139). It therefore encloses not only the head of the femur but excessive anteversion and results in a toe-in posture and gait. An the neck as well. From its femoral attachments, some of the fibers angle that is less than ideal produces a retroversion and an exter- are reflected upward along the neck as longitudinal bands, termed nally rotated leg posture (toe-out) and gait. retinacula. The capsule is thicker toward the upper and ante- rior part of the joint, where the greatest amount of resistance is The atmospheric pressure holding the head of the femur in the required. Some deep fibers of the distal portion of the capsule are acetabulum is approximately 18 kg. This could support the entire circular, coursing around the femoral neck and forming the zona limb without ligamentous or muscular assistance, although capsular orbicularis. They form somewhat of a sling, or collar, around the ligament and muscular tension do help keep the head of the femur neck of the femur. stable in the acetabulum. The joint capsule is reinforced and supported by strong lig- A unique trabecular pattern corresponding to the lines of aments named for the bony regions to which they are attached force through the pelvis, hip, and lower extremity are developed (Figure 6-140). The iliofemoral ligament lies anteriorly and superi- through the course of the femoral neck (Figure 6-138). Tension orly and forms an inverted Y from the lower part of the anteroin- trabeculae are more superior and run from the femoral head to ferior iliac spine to the trochanteric line of the femur. It prevents the trochanteric line. Compression trabeculae are inferior and posterior tilt of the pelvis during erect standing, limits extension run from the trochanteric area to the femoral head. The epiphy- of the hip joint, and is responsible for the so-called \u201cbalancing seal plates are at right angles to the tension trabeculae, which on the ligaments\u201d maneuver that occurs in the absence of muscle likely places them perpendicular to the joint reaction force on the contraction. The ischiofemoral ligament consists of a triangular band of strong fibers extending from the ischium below and behind the acetabulum to blend with the circular fibers of the joint capsule and attaching to the inner surface of the greater trochanter. It reinforces the posterior portion of the capsule and limits excessive medial rotation, abduction, and extension. Tension Longitudinal trabeculae Oblique Compression Arcuate trabeculae Circular Figure 6-138\u00e2\u2022\u2026 Hip joint, showing tension and compression trabe- Figure 6-139\u00e2\u2022\u2026 Diagrammatic representation of the cylindrical joint culation, as well as the forces transmitted from the ground and gravity. capsule, showing the orientation of fibers to resist stresses. (Modified from Kapandji IA: The physiology of the joints, ed 2, vol 1, Edinburgh, 1970, Churchill Livingstone.)","340\t |\t Chiropractic Technique Pubofemoral Ischiofemoral ligament ligament Iliofemoral ligament AB Figure 6-140\u00e2\u2022\u2026 The ligamentous structure of the right hip. A, Anterior view. B, Posterior view. The pubofemoral ligament is attached above to the obturator stability is provided by the iliopsoas, sartorius, and rectus \u00c2f","Chapter 6\u00e2\u2022\u2026 Extraspinal Techniques\t |\t 341 the tensor fascia lata, and to a lesser extent, the piriformis create hip abduction. Hip adduction is the primary role of the adductor mus- cles, the gracilis, and the pectineus, with some influence from the hamstrings. External rotation of the hip occurs through contrac- tion of the piriformis, obturators, gemelli, and quadratus femoris muscles. Internal rotation of the hip is accomplished by the tensor fascia lata, gluteus medius, gluteus minimus, and gracilis muscles. Several of the muscles that act at the hip joint also act with equal or greater effectiveness at the knee joint. These are known as two-joint muscles of the lower extremity. The location and line of pull or action of the muscles make it relatively easy to understand the mechanics of testing any individual muscle. Transverse Biomechanics acetabular The movements of the femur are similar to those of the humerus ligament but not as free because of the depth of the acetabulum. In the Ligamentum standing position, the shaft of the femur slants somewhat in a medial direction and is not vertically straight. This places the teres center of motion of the knee joint more nearly under the center of motion of the hip joint. Therefore, the mechanical axis of the Figure 6-141\u00e2\u2022\u2026 Ligamentum teres and transverse acetabular ligaments femur is almost vertical. The degree of slant of the femoral shaft are not true supportive ligaments. depends on both the angle between the neck and the shaft and the width of the pelvis. Seen from the side, the shaft of the femur TABLE 6-14\t \u0007Actions of the Muscles of the bows forward. These orientations of the femur are provisions for Hip Joint resisting the stresses and strains sustained in walking and jump- ing and for ensuring proper weight transmission. Action Muscles Pelvic rotation about the hip accounts for a significant portion Extension Gluteus maximus, gluteus of forward bending. Trunk flexion from the erect posture through Flexion medius, and hamstrings approximately the first 45 to 60 degrees involves primarily the lumbar spine, with further forward bending occurring because Abduction Iliopsoas, sartorius, rectus of the pelvis rotating about the hip (Figure 6-142). The iliofem- femoris, tensor fascia lata, oral and ischiofemoral ligaments twist as they go from the pel- Adduction gracilis, and pectineus vic attachment to the femur. In the erect neutral position, these External rotation ligaments are under moderate tension. Thigh extension \u201cwinds\u201d Internal rotation Tensor fascia lata, gluteus these ligaments around the neck of the femur and tightens them. medius and minimus, and piriformis Figure 6-142\u00e2\u2022\u2026 Trunk flexion begins with lumbar spine flexion, \u00c2f","342\t |\t Chiropractic Technique Neutral BOX 6-9\t C\u0007 lose-Packed and Loose-Packed (Rest) Ischiofemoral Acetabulum Positions for the Hip Joint ligament Posterior Anterior CLOSE-PACKED POSITION Iliofemoral Full extension, internal rotation, and abduction Head of ligament femur LOOSE-PACKED POSITION 30 degrees of flexion, 30 degrees of abduction, and slight external rotation A Extension During flexion, a forward movement of the femur occurs in the sagittal plane. If the knee is straight, the movement is restricted B by the tension of the hamstrings. In extreme flexion, the pel- vis tilt supplements the movement at the hip joint. Extension Flexion is a return movement from flexion. Hyperextension, however, is a backward movement of the femur in the sagittal plane. This C movement is extremely limited. In most people, this is possible Figure 6-143\u00e2\u2022\u2026 Diagrammatic representation of the effects of flexion only when the femur is rotated outward. The restricting factor and extension on the ischiofemoral and iliofemoral ligament. A, Right is the iliofemoral ligament at the front of the joint. The advan- hip in the neutral position. B, Extension tightens ligaments. C, Flexion tage of restriction of this movement is that it provides a stable slackens ligaments. joint for weight-bearing without the need for strong muscular Furthermore, during posterior tilting of the pelvis, these ligaments contraction. The movements are mostly rotary actions. Abduction are taut and therefore are responsible for maintaining optimal pel- is described as a sideward movement of the femur in the fron- vic position (Figure 6-143). Anterior hip and thigh pain may tal plane, with the thigh moving away from the midline of the occur as a result of tension in these ligaments from excessive pos- body. A greater range of movement is possible when the femur terior pelvic tilting. In contrast, flexion of the hip \u201cunwinds\u201d these is rotated outward. Adduction is a return movement from abduc- ligaments. Moreover, anterior pelvic tilting is not prevented by tion, whereas hyperadduction is possible when the other leg is these ligaments, and the hip extensors must play an important role moved out of the way. Abduction and adduction motions are a in stabilizing the pelvis in the anteroposterior direction. The twist- combination of roll and glide. Internal rotation and external rota- ing of these ligaments, as well as the twisting that occurs within tion are rotary movements of the femur around its longitudinal the joint capsule, draws the joint surfaces into a close-packed posi- axis, resulting in the knee turning inward and outward, respec- tion through a \u201cscrew-home\u201d movement of the joint surfaces. The tively (Figure 6-144). Circumduction is a combination of flexion, close-packed position of the hip is in extension, abduction, and abduction, extension, and adduction performed sequentially in internal rotation (Box 6-9). According to Kapandji,21 erect pos- either direction (Table 6-15). ture tilts the pelvis posteriorly, relative to the femur, causing these ligaments to become coiled around the femoral neck. When the hip is externally rotated, the anterior ligaments become taut while the posterior ligaments relax. The converse is true when the hip is internally rotated (Figure 6-145). During adduction the inferior part of the joint capsule becomes slack while the superior portion becomes taut. The opposite is true dur- ing abduction; the inferior part of the capsule becomes taut, and the superior portion relaxes and folds on itself (Figure 6-146). During abduction the iliofemoral ligament becomes taut, and the pubofemoral ligament and ischiofemoral ligament slacken. Again, during adduction, the opposite occurs; the pubofemoral ligament and the ischiofemoral ligament become taut, and the iliofemoral ligament slackens. Pelvic stability in the coronal plane is secured by the simulta- neous contraction of the ipsilateral and contralateral adductors and abductors. When these antagonistic actions are properly bal- anced, the pelvis is stabilized in the position of symmetry (Figure 6-147). If, however, an imbalance exists between the abduc- tors and the adductors, the pelvis will tilt laterally to the side of adductor predominance. If the pelvis is supported by only one limb, stability is provided only by the action of the ipsilat- eral abductors. An insufficiency in the abductor muscles and,","Chapter 6\u00e2\u2022\u2026 Extraspinal Techniques\t |\t 343 Flexion Extension Abduction Adduction External rotation Internal rotation Figure 6-144\u00e2\u2022\u2026 Hip joint movements. TABLE 6-15\t A\u0007 rthrokinematic and specifically, the gluteus medius results in the body weight not Osteokinematic Movements of being counterbalanced, resulting in a pelvic tilt to the opposite the Hip Joint side. The severity of \u00c2m","344\t |\t Chiropractic Technique Gluteus Adductors medius Abductors Tensor fasciae latae Figure 6-148\u00e2\u2022\u2026 Hip pain can be referred from the knee or lumbar spine, and hip disorders can refer pain to the lumbar spine and knee. Figure 6-147\u00e2\u2022\u2026 Pelvic stability in the coronal plane is produced by a Entrapment of several peripheral nerves can occur in association balance between the abductors and adductors. with hip dysfunction. The femoral nerve lies close to the femoral head, and trauma or hematoma may produce entrapment, causing Evaluation weakness of the hip flexors and local tenderness in the groin. The sciatic nerve, which passes deep to or through the piriformis muscle, Although the hip joint exhibits 3 degrees of freedom of motion may be compressed with contraction of the piriformis muscle. A and is analogous to the glenohumeral joint, the hip is intrinsically sciatic radiculopathy with concomitant motor and sensory changes a much more stable joint. The hip, however, is still quite prone may result. The lateral femoral cutaneous nerve is prone to entrap- to pathomechanic changes and, as such, is often overlooked as a ment near the anterior superior iliac spine (ASIS), where the nerve source for mechanical joint dysfunction. Clinically, pain originat- passes through the lateral end of the inguinal ligament. Entrapment ing in the hip joint is primarily perceived as involving the L3 seg- creates a condition called meralgia paresthetica and is characterized ment, although derivation of the hip joint is from segments L2 by a burning pain in the anterior and lateral portions of the thigh. to S1. Hip pain can be the result of referral from the facets of the The condition may be associated with a biomechanical dysfunction lower lumbar spine. Moreover, the knee also refers pain to the hip of the lumbopelvic complex and postural unleveling of the pelvis.22 area, and the hip can refer pain to the knee (Figure 6-148). Use radiographic examination of children with hip pain The muscles working across the hip joint are subject to strain, (anteroposterior and frog leg) to evaluate the integrity of the cap- either through overuse (chronic strain) or overstress (acute strain ital femoral epiphysis. A slipped capital femoral epiphysis may or trauma). Tenderness is usually localized to the involved mus- occur, creating hip or knee pain. On examination, the hip will cle, and the pain increases with resisted contraction. Commonly tend to swing into external rotation instead of flexion. A referral strained muscles include the sartorius, rectus femoris, iliopsoas, for a surgical consult is indicated. hamstrings, and adductors. An unrecognized or improperly treated slipped capital femo- Trochanteric bursitis, a result of overuse or direct injury, pres- ral epiphysis or a reactive synovitis may occlude the blood supply ents as pain felt primarily over the lateral hip region, which is to the femoral head, and part or all of the femoral head may die often aggravated by going up stairs. The pain is usually described as a result of avascular necrosis. These avascular changes usually as deep and aching pain that began insidiously. Getting in and out involve the superoanterolateral weight-bearing part of the femo- of a car is sometimes listed as a precipitating factor. Point tender- ral head, and in later stages, this area becomes irregular, collapsed, ness is found over the inflamed bursa at the posterolateral aspect and sclerotic. Examine radiographs for rarefaction of the femoral of the greater trochanter. head, characteristic of Legg-Calv\u00e9-Perthes avascular necrosis. To begin evaluation of the hip, observe the joint for the pres- ence of any skin lesions associated with trauma, signs of inflamma- tion, and the presence of pelvic obliquity. Observe gait patterns, although usually a pathomechanic hip dysfunction will not be severe enough to create a noticeable change in gait. However, t\u00c2","Chapter 6\u00e2\u2022\u2026 Extraspinal Techniques\t |\t 345 BOX 6-10\t A\u0007 ccessory Joint Movements of the Determine A-P and P-A glide movement, with the patient supine and the involved leg slightly abducted. Straddle the Hip Joint patient\u2019s thigh just above the knee. Grasp the proximal thigh with both hands and induce an A-P and P-A stress, feeling for the Long-axis distraction presence of a springing joint play movement (Figure 6-151). Anterior-to-posterior glide Posterior-to-anterior glide Internal rotation External rotation Inferior glide in flexion Note osseous symmetry and relationships between the greater A trochanters, ASIS and posterior superior iliac spine, iliac crests, ischial tuberosities, and pubic symphysis. Identify tone, texture, and tenderness changes through soft tissue palpation of the bursa, inguinal ligament, hip flexors, hip extensors, hip adductors, and hip abductors. Evaluate accessory joint motions for the hip joint for the pres- ence of joint dysfunction (Box 6-10). Evaluate long-axis distraction of the iliofemoral joint, with the patient supine and the affected side close to the edge of the table. Straddle the patient\u2019s distal thigh, grasping the area just proximal to the epicondyles with your knees. With your outside hand, palpate the greater trochanter while you stabilize the pelvis at the ASIS with your inside hand. By straight- ening your legs, you can induce a long-axis distraction into the hip joint and perceive a springing joint play movement with the con- tact on the greater trochanter (Figure 6-149). Evaluate internal and external rotation, with the patient supine with the affected hip flexed to 90 degrees and the knee flexed to 90\u00c2\u20acdegrees. Stand on the affected side, facing cephalad and using your outside hand to palpate the hip joint and greater trochanter while grasping the patient\u2019s calf and thigh area with your inside arm. Then induce internal and external rotational stresses while evaluating for the presence of a springy end feel\u2013type motion (Figure 6-150). \t\t6-149 \t Figure 6-149\u00e2\u2022\u2026 Referred pain around the hip. Right B Figure 6-150\u00e2\u2022\u2026 Assessment of external (A) and side demonstrates referral to the hip. Left side shows 6-150 internal (B) rotation of the left hip joint. referral from hip. (Modified from Magee DJ: Orthopedic physical assessment, ed 5, St Louis, 2008, Saunders.)","346\t |\t Chiropractic Technique A 6-152 Figure 6-152\u00e2\u2022\u2026 Assessment of inferior glide in flexion of the left hip joint. B Figure 6-151\u00e2\u2022\u2026 Assessment of anterior-to-posterior BOX 6-11\t Hip Adjustive Techniques 6-151 (A) and posterior-to-anterior (B) glide of the left hip joint. Hip Supine: Bimanual grasp\/distal tibia pull; long-axis distraction Evaluate inferior glide of the hip in flexion, with the patient supine and the involved knee flexed to 90 degrees and the hip (Figure 6-153) flexed to 90 degrees. Stand on the involved side, facing the Towel wrap grasp\/distal tibia pull; long-axis distraction patient and bending over so that the patient\u2019s calf can rest over your shoulder. Grasp the anterior aspect of the proximal thigh (Figure 6-154) and create a caudal stress toward the foot end of the table, Bimanual grasp\/proximal femur; internal rotation evaluating for the presence of a springing end-feel movement (Figure 6-152). (Figure\u00c2\u20ac6-155) Bimanual grasp\/proximal femur; external rotation Adjustive Procedures (Figure\u00c2\u20ac6-156) The manipulative techniques used to treat hip disorders aim to Hypothenar\/proximal femur, palmar distal femur grasp; restore normal joint mechanics, which will then ideally allow full pain-free functioning of the hip joint. Box 6-11 identifies the anterior-to-posterior glide (Figure 6-157) adjustive procedures for the hip. Bimanual grasp\/proximal femur; inferior glide in flexion (Figure 6-158) Hip Side Posture: Hypothenar\/trochanter push; long-axis distraction (Figure\u00c2\u20ac6-159) Hip Prone: Hypothenar\/proximal femur, palmar distal femur grasp; posterior-to-anterior glide (Figure 6-160)","Chapter 6\u00e2\u2022\u2026 Extraspinal Techniques\t |\t 347 6-153 Figure 6-153\u00e2\u2022\u2026 Adjustment for long-axis distraction of the left hip joint. Hip A Supine: Bimanual Grasp\/Distal Tibia Pull; Long-Axis Distraction B (Figure 6-153) \t\t6-15\u00c24","348\t |\t Chiropractic Technique 6-157 Figure 6-157\u00e2\u2022\u2026 Adjustment for anterior-to-poste- rior glide of the left hip joint. 6-155 Figure 6-155\u00e2\u2022\u2026 Adjustment for internal rotation Bimanual Grasp\/Proximal Femur; Inferior Glide in Flexion of the left hip joint. (Figure 6-158) IND: Loss of inferior glide in flexion accessory joint movements of the hip joint. PP: The patient is supine, with the involved knee flexed to 90 degrees and the hip flexed to 90 degrees. 6-156 Figure 6-156\u00e2\u2022\u2026 Adjustment for external rotation of the left hip joint. IH: With your caudal hand, grasp the distal femur with the \u00c2f","Chapter 6\u00e2\u2022\u2026 Extraspinal Techniques\t |\t 349 \t\t6-159 \t Figure 6-159\u00e2\u2022\u2026 Adjustment for long-axis distraction, as well as inferior glide in flexion or internal rotation, of the left hip joint in the side-posture position. Figure 6-160\u00e2\u2022\u2026 Adjustment for posterior-to- DP: Stand on the involved side, facing the patient, flexed forward, 6-160 anterior glide of the left hip joint. with the patient\u2019s calf resting over your shoulder. IH: With your caudal hand, grasp the distal femur from the medial SCP: Anterior aspect of the proximal femur. aspect (the patient\u2019s knee can be bent and cradled against your CP: Grasp the anterior aspect of the proximal thigh with both IH and forearm). hands. VEC: P-A. VEC: S-I. P: With your IH, draw the hip into extension by raising the knee off P: With both hands, deliver an impulse thrust caudal. Side Posture: the table. Deliver a P-A impulse thrust with your contact hand. Hypothenar\/Trochanter Push; Long-Axis Distraction (Figure KNEE 6-159) IND: Loss of long-axis distraction accessory movement of the hip The distal end of the femur and the proximal end of the tibia are con- nected by numerous ligaments and stabilized by strong muscles to joint. form the very complicated knee joint. This joint is situated between PP: The patient lies in a basic side-posture position, with the the body\u2019s two longest lever arms and therefore must be able to trans- mit significant loads as it sustains high forces through upright posture involved side up, the hip flexed to approximately 60 degrees, and gait. Three articular complexes are typically discussed in conjunc- and the knee bent to 90 degrees, with the dorsum of the foot tion with the knee: the tibiofemoral, patellofemoral, and tibiofibu- in the popliteal fossa of the other leg. lar articulations. However, only the tibiofemoral and patellofemoral DP: Stand in front of the patient, straddling the patient\u2019s involved leg. articulations participate in knee joint activity. The tibiofibular articu- SCP: Posterosuperior aspect of the greater trochanter. lation does not actually contribute to the actions of the knee. Instead it CP: With your caudal hand, establish a pisiform hypothenar con- is part of the ankle joint complex, moving with i\u00c2","350\t |\t Chiropractic Technique Functional Anatomy Lateral femoral Trochlear groove Osseous Structures condyle The femoral shaft lies in oblique alignment with the lower leg, B which produces a physiologic valgus angle of approximately 170 to 175 degrees (Figure 6-161). The distal end of the femur Femur is expanded to form a large, convex, U-shaped articular surface (Figure 6-162). The medial and lateral femoral condyles lie on the Adductor Medial femoral end of the U shape and are separated by the intercondylar fossa. tubercle condyle Anteriorly, the articular surface of the femoral condyles forms the Patella patellar groove. The proximal end of the tibia is flattened to cre- Intercondylar fossa ate a plateau with a bifid, nonarticulating intracondylar eminence, dividing the plateau into medial and lateral sections to accommo- Tibial tuberosity Intercondylar eminence date the medial and lateral femoral condyles. The tibial tuberosity projects from the anterior surface of the tibia, serving as the point Tibia of insertion of the quadriceps tendon (Figure 6-163). The patella, the largest sesamoid bone in the body, lies embedded within the Fibular head Medial tibial quadriceps tendon. It is triangular in shape, with its apex directed inferiorly. The anterior surface is nearly flat, and a longitudinal A Lateral tibial condyle condyle C Tibial tuberosity Figure 6-162\u00e2\u2022\u2026 Osseous structures of the right knee. A, Anterior view. B, Articular surface of the distal femur. C, Articular surface of the proxi- mal tibia. ridge divides the posterior surface into medial and lateral articu- lating facets. The longitudinal ridge fits into the patellar groove of the femur. The proximal head of the fibula is expanded and con- tains a single facet that corresponds with a facet on the posterolat- eral aspect of the rim of the tibial condyle. Femur Q angle (10\u201315\u00b0) Physiologic Patella Femoral Quadriceps valgus Tibia condyles muscle Fibula (170\u2013175\u00b0) Patella Fibula Patellar tendon Tibial condyles Figure 6-161\u00e2\u2022\u2026 The physiologic valgus tilt of the lower extremity Figure 6-163\u00e2\u2022\u2026 Lateral view of the knee. places the knee under the hip.","Ligamentous Structures Anterior cruciate Chapter 6\u00e2\u2022\u2026 Extraspinal Techniques\t |\t 351 Internal to the joint are the cruciate ligaments, arranged in a criss- ligament cross manner, providing A-P, as well as M-L, stability at the knee. Tibial tuberosity They prevent excessive medial rotation of the tibia and help main- tain contact between the articular surfaces of the tibia and femur (Figures 6-164 to 6-167). The anterior cruciate ligament extends from the anterior aspect of the intercondylar eminence of the tibia and runs posteriorly and superiorly to the medial side of the l\u00c2","352\t |\t Chiropractic Technique help in preventing anterior displacement of the tibia on the femur. TABLE 6-16\t \u0007Actions of the Muscles of the The lateral, or fibular, collateral ligament attaches from the lateral Knee Joint epicondyle of the femur to the head of the fibula. This ligament becomes taut on extension, adduction, and external rotation of Action Muscles the tibia on the femur. The tendon of the biceps femoris almost completely covers the lateral collateral ligament, and the popliteus Extension Quadriceps tendon runs beneath it and separates it from the meniscus. Flexion Hamstrings, gracilis, sartorius, Internal rotation Surrounding the external aspect of the joint is the fibrous joint tensor fascia lata, and popliteus capsule attaching at the margins of the articular cartilage. The infe- External rotation Sartorius, gracilis, rior portion of the capsule has been referred to as the coronary liga- ment. A substantial thickening in the medial portion of the joint semitendinosus, capsule has fibrous attachments to the periphery of the medial semimembranosus, and meniscus, thereby binding it firmly to the femur and loosely to the popliteus tibia. The lateral aspect of the joint capsule has a similar thicken- Biceps femoris and tensor fascia ing and has fibrous attachments to the lateral meniscus. lata (iliotibial tract) The posterior fibers of the medial collateral ligament blend with Musculature the joint capsule and the attachments to the medial meniscus. The Stabilizing the knee are the many muscles that cross it (Table patellofemoral ligaments form as thickenings of the anterior joint 6-16). Laterally, the iliotibial band attaches to the lateral condyle capsule and extend from the middle of the patella to the medial of the tibia, providing anterolateral reinforcement and stabiliza- and lateral femoral condyles. Their function is to stabilize the tion against excessive internal rotation of the tibia on the femur. patella in the patellar groove. The posterior thickening of the joint Crossing the anterior aspect of the knee is the quadriceps tendon. capsule arches over the popliteus tendon, attaches to the base of the It is formed by the junction of the four heads of the quadriceps \u00c2f","Chapter 6\u00e2\u2022\u2026 Extraspinal Techniques\t |\t 353 Vastus medialis Gastrocnemius Iliotibial Medial patellar retinaculum Popliteus tendon tract Semimembranosus Lateral meniscus Medial collateral ligament Lateral Gracilis tendon Biceps tendon collateral Semitendinosus tendon ligament A Sartorius B tendon Figure 6-169\u00e2\u2022\u2026 Lateral (A) and medial (B) aspects of the right knee, demonstrating muscular attachments. Rectus BOX 6-12\t C\u0007 lose-Packed and Loose-Packed (Rest) femoris tendon Positions for the Knee Joint Femur CLOSE-PACKED POSITION Suprapatellar Full extension with full external rotation bursa LOOSE-PACKED POSITION Articular 25 degrees flexion cartilage Joint capsule Flexion and extension of the knee are combinations of roll, slide, and ligaments and spin movements, which effectively shift the axis of movement Menisci posteriorly as the knee moves from extension into flexion (Figure Prepatellar 6-171). Similar to elbow flexion, knee flexion is limited by soft bursa tissue of the calf and posterior thigh, and extension is limited by Tibia the locking of the joint from bony and soft tissue elements in the Infrapatellar joint\u2019s close-packed position. Moreover, the so called screw-home bursa mechanism, which is a combination of external rotation of the tibia occurring with knee extension, further approximates the osseous Fibula structures and tightens the ligamentous structures to stabilize the joint (Figure 6-172). The marked incongruent positions of the Figure 6-170\u00e2\u2022\u2026 Sagittal section through the knee, demonstrating tibiofemoral joint are reduced by the fibrocartilaginous menisci. numerous bursae. These also help to distribute the forces of compressive loading over a greater area and reduce compressive stresses to the joint sur- become inflamed with prolonged kneeling activities. The deep and faces of the knee. ROMs of the knee are listed in Table 6-17. \u00c2s","354\t |\t Chiropractic Technique TABLE 6-17\t Arthrokinematic and Osteokinematic Movements of the Knee Joint Osteokinematic Degrees Arthrokinematic Movements Movements Flexion 130 Roll and glide Extension 10 Roll and glide Internal rotation 10 Rotation External rotation 10 Rotation Medial Lateral Roll and slide A Extension Tibial extension B Flexion \ufffd90\u00b0 Spin Figure 6-173\u00e2\u2022\u2026 The relationship of the patella to the femur in exten- sion (A) and flexion (B) of the knee. Figure 6-171\u00e2\u2022\u2026 Flexion and extension movements are combinations of roll, slide, and spin. Q\u00c2\u20ac angle is 10 to 15 degrees, being slightly greater in females. Muscle imbalance and rotational disrelationships of the tibia and Figure 6-172\u00e2\u2022\u2026 \u201cScrew-home\u201d mechanism of the knee, combining femur produce changes in the Q angle. external rotation with extension, which maximally approximates the joint surfaces. (Modified from Nordin M, Frankel VH: Basic biomechanics of The superior tibiofibular joint is mechanically linked to the the musculoskeletal system, ed 2, Philadelphia, 1989, Lea & Febiger.) ankle, but a dysfunctional process in this joint presents clinically d\u00c2","Chapter 6\u00e2\u2022\u2026 Extraspinal Techniques\t |\t 355 30\u00b0 Femur A Q angle B (10\u201315\u00b0) Patella Figure 6-174\u00e2\u2022\u2026 Identification of the position of the patella. If A\u2013B is Fibula greater than 1 cm, a low (baja) patella exists; if B\u2013A is greater than 1 cm, a high (alta) patella exists. Figure 6-175\u00e2\u2022\u2026 Q angle, the angle formed from the intersection of lines from the center of the patella to the anterior superior iliac spine and After traumatic injuries to the knee causing ligamentous injury, along the quadriceps tendon. joint instabilities are likely. The knee can undergo translational or femoris. This condition is called Osgood-Schlatter\u2019s disease and is rotational instabilities. Orthopedic stress tests are performed to more common in boys. identify the presence of joint instability. The knee joint is innervated by segments L3\u2013S1, and therefore The menisci are another site of possible injury. A trauma that in cases of pain of nontraumatic onset, lesions situated elsewhere couples rotation or violent extension of the knee may cause an in segments L3\u2013S2 must be ruled out. The lumbar spine, hip, and i\u00c2","356\t |\t Chiropractic Technique TABLE 6-18\t \u0007Accessory Joint Movements of Joint the Knee Joint Figure 6-176\u00e2\u2022\u2026 The ankle and hip can refer pain to the knee. Tibiofemoral Movement Patellofemoral Tibiofibular Long-axis distraction A-P glide P-A glide Internal rotation External rotation M-L glide L-M glide S-I glide I-S glide L-M glide M-L glide A-P glide P-A glide I-S glide S-I glide A-P, Anterior-to-posterior; I-S, inferior-to-superior; L-M, lateral-to-medial; M-L, medial- to-lateral; P-A, posterior-to-anterior; S-I, superior-to-inferior. the collateral ligaments, the pes anserine tendons, the peroneal nerve, the tibial nerve, the popliteal artery, the hamstring muscles, and the gastrocnemius and soleus muscles. Evaluate accessory joint motions for the knee articulations to determine the presence of joint dysfunction (Table 6-18). Assess long-axis distraction with the patient supine and the affected leg slightly abducted. Stand and face the patient, straddling the affected leg so that your knees can grasp the patient\u2019s distal leg just proxi- mal to the malleoli. Use both hands to palpate the knee joint at its medial and lateral aspects and use your legs to create a long-axis distraction while palpating with your hands for a springy end feel (Figure 6-178). Alternatively, one hand may stabilize the patient\u2019s femur on the table while the other hand palpates for end feel. Evaluate A-P and P-A glide with the patient supine and the involved knee flexed to 90 degrees with the foot flat on the table. Either kneel or sit on the patient\u2019s foot for stability while grasping the proximal tibia with both hands. Stress the proximal tibia in an A-P and P-A direction, looking for a springing end feel (Figure 6-179). Figure 6-177\u00e2\u2022\u2026 Patterns of referred pain to and from the knee. 6-178 Figure 6-178\u00e2\u2022\u2026 Assessment of long-axis distrac- (Modified from Magee DJ: Orthopedic physical assessment, ed 5, St Louis, tion of the left tibiof\u00c2","Chapter 6\u00e2\u2022\u2026 Extraspinal Techniques\t |\t 357 \t\t6-179 \t Figure 6-179\u00e2\u2022\u2026 Assessment of anterior-to- posterior and posterior-t\u00c2","358\t |\t Chiropractic Technique 6-184 Figure 6-184\u00e2\u2022\u2026 Assessment of lateral-to-medial glide of the left patellofemoral joint. 6-182 Figure 6-182\u00e2\u2022\u2026 Assessment of medial-to-lateral glide of the left tibiofemoral joint. 6-185 Figure 6-185\u00e2\u2022\u2026 Assessment of superior-to-inferior glide of the left patellofemoral joint. 6-183 Figure 6-183\u00e2\u2022\u2026 Assessment of medial-to-lateral glide of the left patellofemoral joint. Adjustive Procedures 6-186 Figure 6-186\u00e2\u2022\u2026 Assessment of inferior-to-superior glide of the left patellofemoral joint. The manipulative techniques used to treat knee disorders aim to restore normal joint mechanics, which will then ideally allow full pain-free functioning of the knee joints. The three joints associated with the knee should be evaluated for characteristics of dysfunc- tion when there are knee symptoms present. Box 6-13 identifies the adjustive procedures for the joints of the knee. Femorotibial Joint Supine: Bimanual Grasp\/Proximal Tibia with Knee Extension; Long- Axis Distraction (Figure 6-191)","Chapter 6\u00e2\u2022\u2026 Extraspinal Techniques\t |\t 359 6-190 Figure 6-190\u00e2\u2022\u2026 Assessment of inferior-to-superior glide of the left tibiofibular joint. 6-187 Figure 6-187\u00e2\u2022\u2026 Assessment of posterior-to- IND: Loss of long-axis distraction accessory movements of the 6-188 anterior glide of the left tibiofibular joint. femorotibial joint. Figure 6-188\u00e2\u2022\u2026 Assessment of anterior-to-\u00c2","360\t |\t Chiropractic Technique BOX 6-13\t Knee Adjustive Techniques \t\t6-192 \t Figure 6-192\u00e2\u2022\u2026 Adjustment for anterior-to- posterior glide of the right tibiofemoral joint. Femorotibial Supine: Bimanual grasp\/proximal tibia with knee extension; long- CP: Use your cephalic hand to apply a web contact over the ante- rior aspect of the proximal tibia. axis distraction (Figure 6-191) Reinforced web\/proximal tibia push; anterior-to-posterior IH: With your caudal hand, place a knife-edge contact, reinforc- ing the contact hand. glide in flexion (Figure 6-192) Bimanual gasp\/proximal tibia with knee extension; internal VEC: A-P. P: Use both hands to create an A-P impulse thrust on the proxi- or external rotation in extension (Figure 6-193) Hypothenar\/proximal tibia with leg stabilization; medial- mal tibia. Bimanual Grasp\/Proximal Tibia with Knee Extension; Internal to-lateral glide (Figure 6-194) Hypothenar\/proximal tibia with leg stabilization; or External Rotation in Extension (Figure 6-193) IND: Loss of rotational accessory movements of the tibia, internal lateral-to-medial glide (Figure 6-195) or external misalignment of the proximal tibia. Femorotibial Prone: PP: The patient is supine, with the affected leg abducted off the Reinforced mid-hypothenar (knife-edge) proximal tibia edge of the table. pull; posterior-to-anterior glide in flexion (Figure 6-196) DP: Stand and face the patient, straddling the affected leg and Bimanual grasp\/distal tibia with knee thigh grasping the patient\u2019s ankle between the knees. stabilization; internal or external rotation in SCP: Proximal tibia. flexion (Figure 6-197) CP: Using both hands, grasp the proximal tibia with the thumbs Patellofemoral Supine: along the sides of the tibial tuberosity. Bimanual web\/patella; superior medial-to-inferior lateral VEC: Rotation. glide; superior lateral-to-inferior medial glide; inferior medial-to-superior lateral glide; inferior lateral-to-superior medial glide (Figure 6-198) Tibiofibular Supine: Index\/proximal fibula, palmar ankle push; posterior-to- anterior glide in flexion (Figure 6-199) Reinforced thumbs\/proximal fibula; anterior-to-posterior glide in flexion (Figure 6-200) Tibiofibular Prone: Reinforced mid-hypothenar (knife-edge)\/proximal fibula pull; posterior-to-anterior glide in flexion (Figure 6-201) Tibiofibular Side Posture: Reinforced mid-hypothenar (knife-edge)\/proximal fibula push; inferior-to-superior glide in eversion (Figure 6-202) Reinforced mid-hypothenar (knife-edge)\/proximal superior fibula push; superior-to-inferior to glide in inversion (Figure 6-203) \t\t6-191 \t Figure 6-191\u00e2\u2022\u2026 Adjustment for long-axis distraction \t\t6-193 \t Figure 6-193\u00e2\u2022\u2026 Adjustment for external and internal of the left tibiofemoral joint. position. rotation of the left tibiofemoral joint in the supine","Chapter 6\u00e2\u2022\u2026 Extraspinal Techniques\t |\t 361 \t\t6-194 \t Figure 6-194\u00e2\u2022\u2026 Adjustment for medial-to-lateral glide of the left tibiofemoral joint. P: Extend your knees and hop caudal to create some long-axis \t\t6-195 \t Figure 6-195\u00e2\u2022\u2026 Adjustment for lateral-to-medial distraction while simultaneously twisting the proximal tibia, glide of the right tibiofemoral joint. either internally or externally, with your hands. CP: Using your cephalic hand, apply a pisiform-hypothenar con- Hypothenar\/Proximal Medial Tibia with Leg Stabilization; tact on the lateral aspect of the proximal tibia. Medial-to-Lateral Glide (Figure 6-194) IH: Use your caudal arm to grasp the proximal tibia and hold it IND: Loss of M-L glide movement, medial misalignment of the against your torso. proximal tibia. VEC: L-M. PP: The patient is supine, with the involved hip flexed to approxi- P: Using your contact hand as a pivot, tilt the distal tibia with your mately 45 degrees. indifferent arm to remove articular slack, and then use the contact DP: Stand on the side opposite the involved leg, grasping the hand to deliver an L-M impulse thrust to the proximal tibia. d\u00c2","362\t |\t Chiropractic Technique \t\t6-197 \t Figure 6-197\u00e2\u2022\u2026 Adjustment for external rotation of the left tibiofemoral joint in the prone position. \t\t6-196 \t Figure 6-196\u00e2\u2022\u2026 Adjustment for posterior-to- Patellofemoral Joint anterior glide of the left tibiofemoral joint. Prone: Bimanual Web\/Patella; Superior Medial-to-Inferior Lateral IH: Using your outside hand, reinforce the contact hand. VEC: P-A. Glide; Superior Lateral-to-Inferior Medial Glide; Inferior P: Use both hands to remove articular slack and thrust in the Medial-to-Superior Lateral Glide; Inferior Lateral-to- Superior Medial Glide (Figure 6-198) long axis of the femur, creating a P-A glide of the proximal IND: Patellar tracking problems, restricted patellar movements. tibia. PP: The patient is supine, with the involved knee in relaxed extension. Bimanual Grasp\/Distal Tibia with Knee Thigh Stabilization; DP: Stand on the involved side. Internal or External Rotation in Flexion (Figure 6-197) SCP: Patella. IND: Loss of rotational accessory movements of the tibia, internal CP: Use both hands to apply thumb web contacts over the borders or external rotation misalignment of the proximal tibia. of the patella. PP: The patient is prone, with the affected leg flexed to just less VEC: Inferolateral, inferomedial, superolateral, and superomedial. than 90 degrees. P: Depending on the direction of dysfunctional movement DP: Stand at the side of the table on the affected side, placing and involved soft tissues, give a thrust to the patella in a your cephalic proximal tibia on the patient\u2019s distal femur. down-and-in, down-and-out, up-and-in, or up-and-out SCP: Distal tibia. direction. CP: Using both hands, grasp the patient\u2019s distal tibia with your fingers interlaced. Tibiofibular Joint VEC: Rotation. Supine: P: Stabilize the patient\u2019s thigh on the table, use both hands to Index\/Proximal Fibula, Palmar Ankle Push apply long-axis distraction, and then impart an impulse thrust, IND: Loss of P-A fibular movement, posterior misalignment of creating internal or external rotation of the tibia. the fibula. (Figure 6-199) PP: The patient is supine, with the involved leg flexed at the hip and knee.","Chapter 6\u00e2\u2022\u2026 Extraspinal Techniques\t |\t 363 A B 6-198 Figure 6-198\u00e2\u2022\u2026 Adjustment for superior and medial (A) or inferior and lateral (B) glide of the right patellofemoral joint. P: Use your IH to flex the leg, pushing the heel toward the \u00c2b","364\t |\t Chiropractic Technique \t\t6-202 \t Figure 6-202\u00e2\u2022\u2026 Adjustment for inferior-to- superior glide of the left tibiofibular joint. \t\t6-201 \t Figure 6-201\u00e2\u2022\u2026 Adjustment for posterior-to- IND: Loss of I-S fibular movement, inferior misalignment of prone position. anterior glide of the left tibiofibular joint in the the fibula. Prone: PP: The patient is side-lying, with the affected leg up and posi- Reinforced Mid-Hypothenar (Knife-Edge)\/Proximal Fibula tioned anterior to the unaffected side. Both knees should be slightly flexed. Pull; Posterior-to-Anterior Glide in Flexion (Figure 6-201) IND: Loss of P-A fibular movement, posterior misalignment of DP: Stand at the foot end of the table so that the patient\u2019s involved foot rests against your thigh, maintaining the the fibula. patient\u2019s ankle in eversion. PP: The patient is prone, with the knee flexed to just less than SCP: Lateral and inferior aspect of the proximal fibula. 90 degrees. CP: Using your anterior hand, establish a knife-edge contact on DP: Stand at the foot end of the table, flexed at the waist so the the inferior aspect of the proximal fibular head. dorsum of the patient\u2019s foot can rest on your inside shoulder. IH: With your posterior hand, reinforce the contact hand. SCP: Posterior aspect of the proximal fibula. VEC: I-S. CP: With your outside hand, establish a pisiform-hypothenar P: While maintaining the ankle in eversion, deliver a thrust to contact on the posterior aspect of the proximal fibula. the proximal fibula in an I-S direction. This movement can IH: Use your inside hand to reinforce the contact. be achieved in a similar fashion by placing a thenar contact VEC: P-A. under the inferior aspect of the lateral malleolus, reinforc- P: Using both hands, deliver a P-A impulse thrust to the proxi- ing the contact with the other hand, and delivering an I-S thrust. mal fibula. Reinforced Mid-Hypothenar (Knife-Edge)\/Proximal Superior Side Posture: Fibula Push; Superior-to-Inferior to Glide in Inversion Reinforced Mid-Hypothenar (Knife-Edge)\/Proximal Fibula (Figure 6-203) IND: Loss of S-I fibular movement, superior misalignment of Push; Inferior-to-Superior Glide in Eversion (Figure 6-202) the fibula. PP: The patient is side-lying, with the involved side up and involved leg resting on the table behind the uninvolved leg so that the ankle of the involved leg can hang in inversion off the edge of the adjusting table. DP: Stand at the side of the table behind the patient, facing caudal. SCP: Posterosuperior aspect of the proximal fibula. CP: With your outside hand, establish a knife-edge contact over the posterosuperior aspect of the proximal fibula. IH: Using your inside hand, reinforce the contact hand. VEC: S-I. P: Using both hands, apply an S-I impulse thrust to the fibular head. ANKLE AND FOOT The ankle and foot can be discussed together because they are intimate components of a very intricately functioning unit. Together they make up a significant component in a kinetic chain r\u00c2","Chapter 6\u00e2\u2022\u2026 Extraspinal Techniques\t |\t 365 Medial malleolus Lateral malleolus Dome of talus Sustentaculum Neck of talus Calcaneus tali Peroneal Sinus tarsi Talar head tubercle Navicular Cuboid First cuneiform Styloid A process First metatarsal Fifth First MP joint metatarsal Fifth MP joint B Figure 6-204\u00e2\u2022\u2026 Osseous structures of the right foot and ankle. A, Medial aspect. B, Lateral aspect. 6-20\t\t 3 Figure 6-203\u00e2\u2022\u2026 Adjustment for superior-to-inferior with the fourth and fifth metatarsals distally (Figure 6-204). It also glide of the left tibiofibular joint. articulates with the navicular and third cuneiform medially. The first, or medial, cuneiform articulates with the first metatarsal; the viewed as initial supports for the musculoskeletal frame, because second, or intermediate, cuneiform articulates with the second they form the base on which all other osseous and muscular mech- metatarsal; and the third, or lateral, cuneiform articulates with the anisms reside. To the contrary, these joints may also be viewed as third metatarsal. Two phalanges complete the structure of the great a terminal segment, in that they must translate and carry out the toe, and three phalanges complete the bony structures of each of messages from the central nervous system through the hip and the other four toes. The function of the tibia is to transmit most of knee. This joint complex must attenuate weight-bearing forces, the body weight to and from the foot, and although the fibula plays support and propel the body, and maintain equilibrium.15 The a very important role in ankle stability, it is not directly involved in feet and ankles must therefore provide the two paradoxical qual- the transmission of weight-bearing forces. Functionally, the talus ities of stability and pliability. They achieve these requirements serves as a link between the leg and the foot. through an interaction of interrelated joints, connective tissues, Ligamentous Structures and muscles. Certainly, this part of the lower extremity is subject Although many ligaments and joint capsules are associated with the to a multiplicity of traumatic and postural disorders, leading to foot and the ankle, some are more important to localize, p\u00c2","366\t |\t Chiropractic Technique Dorsal Dorsal talonavicular cuneonavicular ligament ligaments Deltoid ligament Dorsal tarsometatarsal ligaments Spring ligament Navicular tuberosity Long plantar Plantar calcaneocuboid (plantar calcaneonavicular) ligament ligament (short plantar ligament) Plantar calcaneonavicular ligament Long plantar ligament Sustentaculum tali Figure 6-206\u00e2\u2022\u2026 Ligaments on the medial aspect of the left ankle. Groove for flexor Lateral tubercle hallucis longus of calcaneus Medial tubercle of calcaneus Figure 6-208\u00e2\u2022\u2026 Tuber calcanei (inferior aspect) Ligaments on the plantar aspect of the left foot. Deltoid Posterior second, third, and fourth metatarsals. As such, it serves primarily ligament tibiofibular as an inverter and adductor, or supinator, of the foot. The flexor Interosseous ligament hallucis longus and flexor digitorum longus muscles also have talocalcaneal tendons that pass under the medial malleolus, with each inserting Transverse on the distal phalanx of each toe, thereby creating flexion of the ligament tibiofibular toes. Anteriorly are the extensor digitorum longus, tibialis ante- ligament rior, and extensor hallucis longus muscles. The extensor digitorum longus attaches to the dorsal surfaces of each of the distal phalan- Calcaneofibular ges, primarily extending the four toes, but also serving to dorsi- ligament flex, evert, and abduct the foot. The extensor hallucis longus is the primary extensor of the big toe. The tendon of the tibialis anterior Figure 6-207\u00e2\u2022\u2026 Ligaments on the posterior aspect of the right ankle. passes over the ankle joint and across the medial side of the dor- sum of the foot, and inserts into the medial and plantar surface the anterior and posterior talofibular ligaments, and the calca- of the medial cuneiform bone and the base of the first metatarsal. neofibular ligament. The plantar calcaneonavicular (spring) liga- It\u00c2\u20acfunctions as the primary dorsiflexor of the ankle, but because ment attaches from the sustentaculum tali to the navicular (Figure of its insertion, it also inverts and adducts the foot. On the lateral 6-208). The function of this ligament is to keep the medial aspect aspect is the peroneus muscle group. The tendons of the peroneus of the forefoot and hindfoot in apposition and, in so doing, help longus and brevis pass under the lateral malleolus and cross the to maintain the arched configuration of the foot. cuboid to insert into the medial cuneiform and base of the first Musculature metatarsal. The chief action, then, of both peronei muscles is to Similar to the way the muscles of the wrist are located in the arm, evert the foot. The peroneus tertius is continuous, with the ori- the muscles of the ankle are located in the calf. Posteriorly, the gin of the extensor digitorum longus muscle; its tendon diverges large calf muscle group (gastrocnemius and soleus) attaches from laterally to insert into the dorsal surface of the base of the fifth the femoral condyles, proximal fibula, and tibia to the calcaneus, metatarsal bone. It works with the extensor digitorum longus to providing plantar flexion of the ankle. The tendon of the tibi- dorsiflex, evert, and abduct the foot. alis posterior passes under the medial malleolus to attach to the plantar surfaces of the navicular; cuneiforms; the cuboid; and the The ankle musculature can be divided into positional groups and divided according to the actions they perform (Table 6-19). The gastrocnemius, soleus, and plantaris muscles lie posteriorly and are responsible for plantar flexion of the foot and ankle. The extensor hallucis longus, extensor digitorum longus, peroneus tertius, and tibialis anterior muscles lie anteriorly and serve pri- marily to dorsiflex the foot and extend the toes. The peroneus longus and brevis muscles are situated laterally and pronate and evert the foot. The tibialis posterior, flexor digitorum longus,","Chapter 6\u00e2\u2022\u2026 Extraspinal Techniques\t |\t 367 TABLE 6-19\t A\u0007 ctions of the Muscles of the Foot and Ankle Action Muscles Longitudinal Metatarsal break midtarsal Ankle plantar flexion Gastrocnemius, soleus, and joint axis Ankle dorsiflexion plantaris Oblique Ankle inversion Extensor digitorum longus, midtarsal (adduction) tibialis anterior, peroneus joint axis tertius, and extensor Ankle eversion hallucis longus 57\ufffd 62\ufffd (abduction) 9\ufffd Tibialis posterior and tibialis Toe flexion anterior Toe extension Extensor digitorum longus, peroneus longus and Figure 6-209\u00e2\u2022\u2026 Dorsiflexion and plantar flexion in the foot and ankle brevis, and peroneus tertius occur around an oblique axis, and eversion and inversion occur around the longitudinal axis. (Modified from Wadsworth CT: Manual examina- Flexor digitorum longus and tion and treatment of the spine and extremities, Baltimore, 1988, Williams & flexor hallucis longus Wilkins.) Extensor digitorum longus and extensor hallucis longus and flexor hallucis longus muscles are medial and function to TABLE 6-20\t \u0007Arthrokinematic and invert the foot and flex the toes. The intrinsic muscles of the Osteokinematic Movements of foot lie in layers and generally perform the actions indicated by the Ankle and Foot Joints the muscle names. Osteokinematic Degrees Arthrokinematic Biomechanics Movements Movements The functional biomechanics of the foot and ankle must include Ankle dorsiflexion 20 Roll and glide the ability to bear weight and allow flexible locomotion. The ankle Ankle plantar 50 Roll and glide joint is a uniplanar hinge joint, with talus motion occurring primar- ily in the sagittal plane about a transverse axis. The lateral side of the flexion 5 Roll and glide transverse axis is skewed posteriorly from the frontal plane (Figure Subtalar inversion 5 Roll and glide 6-209). The primary movement at the ankle mortise is dorsiflexion Subtalar eversion 10 Roll and glide (20 to 30 degrees) and plantar flexion (30 to 50 degrees) (Table Forefoot abduction 10 Roll and glide 6-20). Through the normal gait pattern, however, only 10 degrees Forefoot abduction of dorsiflexion and 20 degrees of plantar flexion are required.24 bony structure necessary for stability at the heel-strike stage of The subtalar joint formed between the talus and calcaneus is gait. Pronation, on the other hand, allows for the axes of motion also a hingelike joint. The axis of movement passes through all to become aligned, which allows for increased mobility and three cardinal planes of movement, thereby allowing movement decreased stability. The ligaments that run on the plantar surface to some extent in all three planes. Movement of this joint, then, between these tarsal bones are an essential component for absorb- includes the complex movement of supination and pronation of ing stress and maintaining the longitudinal arch. Table 6-21 iden- the calcaneus under the talus. Supination is a combination of tifies the close-packed and loose-packed positions for the ankle inversion, adduction, and plantar flexion, whereas pronation is and toe joints. a combination of eversion, abduction, and dorsiflexion (Figure 6-210). The subtalar joint has the important function of absorb- The individual tarsal joints, metatarsal-tarsal joints, meta- ing shock at heel strike and rotating the lower extremity in the tarsophalangeal joints, and interphalangeal joints enhance transverse plane during the stance phase of gait. the foot\u2019s stability or flexibility. They must provide a base for the stance phase, as well as the necessary hinges for flexion The transverse or midtarsal joint is composed of the talo- and extension during toe-off. Ligaments and tendons further navicular and calcaneal cuboid articulations. The amount of enhance stability and flexibility by maintaining arches in the movement occurring at these joints, which function in unison, foot (Figure 6-211). depends on whether the foot is in pronation or supination. The supinated position creates a divergence of the axes of movement, which decreases the amount of movement, setting up a rigid","368\t |\t Chiropractic Technique Pronation A B Pronation Supination Supination Figure 6-210\u00e2\u2022\u2026 Pronation and supination movements in free swing action (open kinetic chain) (A) and with weight-bearing (closed kinetic chain) (B). TABLE 6-21\t \u0007Close-Packed and Loose-Packed of the leg and foot change through the different components. (Rest) Positions for the Ankle and Pronation of the subtalar joint occurs initially at heel strike while Foot Joints the tibia internally rotates. This is followed by supination of the subtalar joint and external rotation of the tibia through mid- Joint Close-Packed Loose-Packed stance and propulsive stages, as well as through the swing phase Position Position of gait. This creates a shifting area of weight-bearing across the foot, starting from the posterolateral aspect of the calcaneus and Tibiotalar Full dorsiflexion 10 degrees of curving over to the first metatarsophalangeal joint. Abnormal plantar flexion supination or pronation of the subtalar joint will result in altered articulation midway gait patterns, as well as weight-bearing stresses on the plantar between full surface of the foot. Toes Full extension inversion and eversion Evaluation Flexion With the concentrated stress that occurs to the foot and ankle dur- ing bipedal static and dynamic postures, these areas are susceptible During the gait cycle, two main phases are described. The to many injuries. Commonly, ankle injuries have an acute trau- first occurs when the foot is on the ground and is called the matic onset, whereas the foot is more likely to develop chronic and stance phase, and the second occurs when the foot is not contact- insidious onset disorders from stress overload. Pain and paresthe- ing the ground and is called the swing phase (Figure 6-212). The sias arising from the lower lumbar or first sacral NRs should not stance phase is further divided into a contact component, mid- be overlooked (Figure 6-213). Most foot and ankle pain, however, stance component, and a propulsive component. Movements arises from local disease or pathomechanic processes. Anterior tibialis Posterior tibialis The most common traumatic injury to this area is the inver- sion sprain of the ankle, causing a separation to the lateral com- Plantar ligaments partment with damage to the anterior talofibular ligament and Plantar aponeurosis possibly to the calcaneofibular ligament. Rarely does inversion occur alone, because usually plantar flexion of the ankle, as well as Figure 6-211\u00e2\u2022\u2026 The longitudinal arch of the right foot formed by the external rotation of the leg, also occur. tibialis anterior and posterior. An eversion sprain involving trauma to the medial aspect of the ankle and affecting the deltoid ligament usually occurs when the foot is fixed in an excessive amount of pronation and the individ- ual turns forcefully toward the opposite foot. The stress is applied first to the anterior tibiofibular ligament. Shin splints refer to a generalized, deep aching or, sometimes, sharp pain along the tibia. It is considered an overuse or abuse syndrome occurring commonly because of running or jumping on a hard surface. This activity causes the talus to be driven upward into the mortise, forcing the tibia and fibula to separate. Stress to the interosseous membrane results and may cause a periostitis.","Chapter 6\u00e2\u2022\u2026 Extraspinal Techniques\t |\t 369 60% 40% Stance phase of gait cycle Swing phase of gait cycle Normal Heel Foot Heel Toe strike flat off off Heel Foot Heel Supination strike flat off Toe off Pronation Heel Foot Heel Toe strike flat off off Figure 6-212\u00e2\u2022\u2026 Gait pattern demonstrating that 60% of the gait is the stance phase, and 40% is the swing phase. Also shown is the pattern of weight- bearing on the plantar surface of the foot normally and in pronation and supination. Furthermore, activity of the anterior tibialis may result in fluid Identify tone, texture, and tenderness changes through soft tis- becoming entrapped within the fascial covering, creating a com- sue palpation of the medial and lateral ligaments, Achilles tendon, partment syndrome. and plantar fascia, as well as the musculature that controls move- ment of the foot and ankle. Additionally, palpate the posterior Plantar fasciitis results as a strain to the plantar fascia on the tibial artery and dorsalis pedis artery. sole of the foot. This may be a result of standing on hard sur- faces, quick acceleration or deceleration, repeated shocks, stand- Evaluate accessory joint movements for the foot and ankle ing on ladders, or long periods of pronation. A calcaneal heel spur articulations to determine the presence of joint dysfunction may eventually occur as the fasciitis continues or worsens. The (Table 6-22). Assess long-axis distraction of the tibiotalar articu- fascia will pull the periosteum off the calcaneus, creating a painful lation or ankle mortise joint with the patient supine, the knee periostitis, and bone will be laid down at the site of stress. flexed to approximately 90 degrees, and the hip flexed and abducted. Sit on the table between the patient\u2019s legs and face Hallux valgus is a lateral deviation of the big toe, usually with a caudal. Place web contacts over the dome of the talus and supe- concomitant metatarsal varum. Improperly fitting footwear, as well as rior aspect of the calcaneus, applying a distraction force through an unstable and pronated foot, has been blamed for this condition. both hands (Figure 6-214). The evaluation of the foot and ankle begins with observation Evaluate A-P and P-A glide of the ankle mortise joint with during static posture, as well as gait for symmetry, arches, toe the patient supine and the hip and knee both slightly flexed so deformities, and soft tissue swelling. Inspect the plantar surface of that the calcaneus rests on the table. Stand at the side of the table the foot for signs of weight-bearing asymmetry in the form of cal- and place a web contact of your cephalic hand over the anterior lous formation. Identify osseous symmetry and pain production aspect of the distal tibia while placing a web contact with your through static palpation of the distal tibia and fibula (malleoli), caudal hand over the anterior aspect of the dome of the talus. dome of the talus, navicular, cuboid, calcaneus, cuneiforms, meta- With both hands, grasp the respective structures and maintain the tarsals, and phalanges.","370\t |\t Chiropractic Technique \t\t6-214 \t Figure 6-214\u00e2\u2022\u2026 Patterns of referred pain to and from the ankle. (Modified from Magee DJ: Orthopedic physical assessment, ed 5, St Louis, 2008, Saunders.) Figure 6-213\u00e2\u2022\u2026 The low back, hip, and knee can refer pain to the ankle and foot area. TABLE 6-22\t \u0007Accessory Joint Movements of \t Figure 6-215\u00e2\u2022\u2026 Assessment of anterior-to- the Foot and Ankle Joints posterior and posterior-to-anterior glide of the Joint Movement \t\t6-215 right tibiotalar joint. Tibiotalar joint Long-axis distraction joint in its neutral position. Apply an A-P and P-A translational A-P glide force through both hands, working in opposite directions, looking Subtalar joint P-A glide for a springing joint play movement (Figure 6-215). M-L tilt (inversion) Tarsals (cuboid, navicular, L-M tilt (eversion) Assess M-L and L-M glide of the tibiotalar articulation with and cuneiforms) A-P glide the patient supine. Stand at the foot of the table, facing cephalad. P-A glide Grasp the dome of the talus with the fingers of both hands, using Intermetatarsal joints M-L tilt (inversion) the thumbs to grasp under the plantar surface of the foot. Then Metatarsophalangeal and L-M tilt (eversion) stress the talus in an M-L and L-M direction, feeling for a spring- A-P glide ing joint play movement (Figure 6-216). interphalangeal joints P-A glide A-P glide Evaluate subtalar joint glide with the patient lying in the prone P-A glide position and the knee flexed to approximately 60 degrees. Stand Long-axis distraction at the foot of the table, facing cephalad, with the plantar surface A-P glide of the patient\u2019s toes resting against your abdomen. Then grasp the P-A glide calcaneus with palmar contacts while interlacing your fingers in a M-L glide and tilt \u201cpraying-hands\u201d position. Use both hands to create A-P and P-A L-M glide and tilt glide, as well as M-L and L-M glide movements (Figure 6-217). Internal rotation External rotation Perform A-P and P-A glide of the navicular, cuboid, and cuneiforms by grasping the specific tarsal bone while stabilizing the proximal tarsal A-P, Anterior-to-posterior; L-M, lateral-to-medial; M-L, medial-to-lateral; P-A, posterior- and creating an A-P and P-A glide movement (Figure 6-218). to-anterior. Perform A-P and P-A shear of the intermetatarsals by grasping adjacent metatarsals with each hand and creating an A-P and P-A shear (Figure 6-219).","Chapter 6\u00e2\u2022\u2026 Extraspinal Techniques\t |\t 371 A B \t\t6-216 \t Figure 6-216\u00e2\u2022\u2026 Assessment of medial-to-lateral (inversion) (A) and lateral-to-medial (eversion) (B) glide of the left tibiotalar joint. Evaluate the metatarsophalangeal and interphalangeal \t\t6-217 \t Figure 6-217\u00e2\u2022\u2026 Assessment of anterior-to-posterior, joints for A-P and P-A glide, M-L and L-M glide, axial rota- posterior-to-anterior, medial-to-lateral, and lateral-to- tion, and long-axis distraction by grasping the metatarsals medial glide of the right subtalar joint. with one hand for stabilization and placing the specific pha- lanx between the index and middle fingers of the other hand IND: Loss of long-axis distraction joint play movement of the (Figure 6-220). tibiotalar joint. Adjustive Procedures PP: The patient is supine on the table, with the pelvic s\u00c2","372\t |\t Chiropractic Technique \t\t6-218 \t Figure 6-218\u00e2\u2022\u2026 Assessment of anterior-to-posterior BOX 6-14\t Ankle and Foot Adjustive Techniques and posterior-to-anterior glide of the left cuboid (same procedure used for the navicular and cuneiforms). Tibiotalar Supine: Bimanual reinforced interphalangeal grasp\/anterior talus \t\t6-219 \t Figure 6-219\u00e2\u2022\u2026 Assessment of anterior-to-posterior metatarsals. and posterior-to-anterior shear between the left pull; long-axis distraction (Figure 6-221) Reinforced webs\/anterior talus push anterior-to-posterior \t\t6-220 \t Figure 6-220\u00e2\u2022\u2026 Assessment of long-axis distraction, internal and external rotation, and anterior-to-poste- glide (Figure 6-222) rior, posterior-to-anterior, medial-to-lateral, and lateral-to-medial glide of the Reinforced middle interphalangeal\/talus pull; lateral- left metatarsophalangeal joints (same procedure for the interphalangeal joints). to-medial glide (eversion) or medial-to-lateral glide (inversion) with long-axis distraction (Figure 6-223) Web\/talus, mid-hypothenar (knife-edge)\/calcaneus; long-axis distraction with either inversion or eversion (Figure 6-224) Tibiotalar Prone: Reinforced webs\/talus push; posterior-to-anterior glide (Figure 6-225) Subtalar Prone: Reinforced web\/calcaneus; long-axis distraction (Figure 6-226) Interlaced bimanual grasp\/calcaneus; lateral-to-medial glide; medial-to-lateral glide; anterior-to-posterior glide; posterior-to-anterior glide (Figure 6-227) Tarsometatarsal Prone: Hypothenar\/cuboid with forefoot distraction; plantar-to- dorsal glide (Figure 6-228) Hypothenar\/navicular (cuneiforms) with forefoot distraction; plantar-to-dorsal glide (Figure 6-229) Reinforced thumbs\/cuneiform (cuboid, navicular) with forefoot distraction; plantar-to-dorsal glide (Figure 6-230) Tarsometatarsal Supine: Reinforced hypothenar\/navicular (cuboid, cuneiforms); anterior-to-posterior glide (Figure 6-231) Reinforced middle interphalangeal\/cuneiform (navicular, cuboid) pull; anterior-to-posterior glide (Figure 6-232) Intertarsal Supine: Bimanual webs\/tarsals; long-axis distraction (Figure 6-233) Intermetatarsal Supine: Bimanual thenar\/metatarsal grasp shear; anterior-to-posterior and posterior-to-anterior glide (Figure 6-234) Metatarsophalangeal Supine Thumb metatarsal\/thumb phalanx shear; plantar-to-dorsal glide (Figure 6-235) Thumb index grasp\/phalanx; long-axis distraction (Figure 6-236) First Metatarsophalangeal Supine: Web metatarsal\/finger grasp phalanx; medial-to-lateral glide with pendular distraction (Figure 6-237) Interphalangeal Supine: Thumb index grasp\/phalanx; long-axis distraction; internal or external rotation; anterior-to-posterior or posterior-to-anterior glide; lateral-to-medial or medial- to-lateral glide (Figure 6-238)","Chapter 6\u00e2\u2022\u2026 Extraspinal Techniques\t |\t 373 PP: The patient is supine on the table, with the heel just off the end of the table. DP: Stand at the foot end of the table, facing cephalad. SCP: Dome of the talus. CP: With your outside hand, establish a web contact over the dome of the talus, grasping the foot with your thumb and fingers. IH: With your other hand, either reinforce the contact hand or grasp the distal tibia for stabilization. VEC: A-P. P: Apply an A-P translational thrust to the talus. Reinforced Middle Interphalangeal\/Talus Pull; Lateral- to-Medial Glide (Eversion) or Medial to Lateral Glide (Inversion) with Long Axis Distraction (Figure 6-223) 6-22\t\t 1 Figure 6-221\u00e2\u2022\u2026 Adjustment for long-axis distraction of the left tibiotalar joint. P: Maintain the ankle in dorsiflexion and apply a long-axis dis- A traction with both hands. To induce subtalar long-axis distrac- tion, move the knife-edge or web contact of your IH to the posterosuperior aspect of the calcaneus. Reinforced Webs\/Anterior Talus Push; Anterior-to-Posterior Glide (Figure 6-222) IND: Loss of A-P glide tibiotalar joint, and anterior misalignment of the talus. B Figure 6-222\u00e2\u2022\u2026 Adjustment for A-P glide of the \t\t6-223A, B \t Figure 6-223\u00e2\u2022\u2026 Adjustment for lateral-to- left tibiotalar joint. medial (A) and medial-to-lateral (B) glide of the 6-22\t\t 2 right tibiotalar joint.","374\t |\t Chiropractic Technique IND: Loss of medial or lateral glide at the tibiotalar articulation, \t\t6-225 \t Figure 6-225\u00e2\u2022\u2026 Adjustment for posterior-to- medial or lateral misalignment of the talus. anterior glide of the left tibiotalar joint. PP: The patient is supine, with the leg straight and the foot off Prone: the end of the table. Reinforced Webs\/Talus Push; Posterior-to-Anterior Glide DP: Stand at the foot end of the table, facing cephalad. (Figure 6-225) SCP: Dome of the talus. IND: Loss of P-A glide movement, posterior misalignment of the CP: To produce eversion, use your inside hand to establish a mid- talus. dle finger distal interphalangeal contact over the dome of the PP: The patient is prone, positioned with the distal tibia at the talus, drawing tissue and articular slack medially. To produce inversion, use your outside hand to apply the middle finger edge of the table. contact over the dome of the talus, drawing tissue and medial DP: Stand at the foot end of the table at the side of the table, slack laterally. IH: With your other hand, grasp the posterior aspect of the facing the side of involvement. calcaneus. SCP: Posterior aspect of the talus. VEC: L-M or M-L. CP: With your caudal hand, establish a web contact over the P: Use both hands to distract in the long axis and give a thrust, drawing the dome of the talus in an L-M or M-L posterior aspect of the talus. direction. IH: With your cephalic hand, grasp the distal tibia for Web\/Talus, Mid-Hypothenar (Knife-Edge)\/Calcaneus; Long- Axis Distraction with Either Inversion or Eversion (Figure stabilization. 6-224) VEC: P-A. IND: Loss of long-axis distraction joint play movement of the P: With your contact hand, apply a thrust, creating P-A glide of tibiotalar joint. PP: The patient is supine on the table, with the pelvic \u00c2s","Chapter 6\u00e2\u2022\u2026 Extraspinal Techniques\t |\t 375 Figure 6-226\u00e2\u2022\u2026 Adjustment for distraction of the left subtalar joint. DP: Stand at the foot end of the table, facing cephalad, so that IND: Loss of subtalar glide movements (P-A, A-P, L-M, M-L), the plantar aspect of the patient\u2019s foot can rest against your abdomen. misalignment of the calcaneus (anterior, posterior, medial, or lateral). SCP: Calcaneus. PP: The patient lies prone, with the knee flexed to approximately CP: With both hands, grasp the calcaneus, interlacing the fingers 45 degrees. in a \u201cpraying-hands\u201d position. VEC: A-P, P-A, L-M or M-L. P: While stabilizing the patient\u2019s foot against your abdomen, the calcaneus can be moved medially, laterally, anteriorly, or posteriorly. Tarsometatarsal Joint Prone: Hypothenar\/Cuboid with Forefoot Distraction; Plantar-to- Dorsal Glide (Figure 6-228) IND: Loss of plantar-to-dorsal movement of the cuboid, inferior misaligned cuboid. PP: The patient is prone, with the knee bent to 90 degrees. DP: Stand between the patient\u2019s legs, facing the affected side at its medial aspect. SCP: Plantar aspect of the cuboid. CP: Use your cephalic hand to apply a pisiform\/hypothenar c\u00c2","376\t |\t Chiropractic Technique 6-23\t\t 0 Figure 6-230\u00e2\u2022\u2026 Adjustment for plantar-to-dorsal glide of the right first cuneiform. 6-22\t\t 9 Figure 6-229\u00e2\u2022\u2026 Adjustment for plantar-to-dorsal glide of the right navicular. VEC: Plantar-to-dorsal. IND: Loss of plantar-to-dorsal accessory joint movement of the P: Use your IH to accentuate the longitudinal arch against the cuneiforms, plantar misalignment of the cuneiforms. pressure applied to the plantar surface of the cuboid. Then give PP: The patient is prone, with the knee flexed to approximately a thrust through the contact hand in a plantar-to-dorsal direc- 45 degrees. tion on the cuboid. Hypothenar\/Navicular (Cuneiforms) with Forefoot Dist\u00c2","Chapter 6\u00e2\u2022\u2026 Extraspinal Techniques\t |\t 377 \t\t6-231 \t Figure 6-231\u00e2\u2022\u2026 Adjustment for dorsal-to-plantar glide of the tarsals (left navicular shown). CP: Use either hand to establish a pisiform contact over the dorsal \t\t6-232 \t Figure 6-232\u00e2\u2022\u2026 Adjustment for dorsal-to-plantar aspect of the involved tarsal bone. glide of the tarsals (right cuneiform shown). IH: With your other hand, reinforce the contact. PP: The patient is supine, with the leg externally rotated and VEC: Dorsal-to-plantar. abducted off the table. P: Deliver a very quick dorsal-to-plantar impulse or recoil-type DP: Stand on the affected side, facing caudal, with the inside foot thrust. A mechanical drop section can be used to enhance this on the table so that the lateral aspect of the patient\u2019s affected procedure. foot can rest on the doctor\u2019s thigh. Reinforced Middle Interphalangeal\/Cuneiform (Navicular, Cuboid) Pull; Anterior-to-Posterior Glide (Figure 6-232) SCP: Medial aspect of the navicular. IND: Loss of dorsal-to-plantar accessory joint movement, dorsal misalignment of a tarsal bone. \t\t6-233 \t Figure 6-233\u00e2\u2022\u2026 Distraction between the navicular, PP: The patient is supine, with the affected leg straight. foot. first cuneiform, and first metatarsal joints of the left DP: Stand at the foot of the table, facing cephalad. SCP: Dorsal aspect of a tarsal bone (cuboid, navicular, or cuneiform). CP: Use either hand to apply a middle finger distal interphalan- geal contact over the dorsal aspect of the affected tarsal. IH: With your other hand, reinforce the contact, wrapping both hands around the plantar aspect of the foot with the thumbs just distal to the point of contact. VEC: Dorsal-to-plantar. P: Use both hands to apply a dorsal-to-plantar pressure, while the thumbs apply an opposite plantar-to-dorsal stress. Then apply a quick dorsal-to-plantar thrust through the contact hand. Intertarsal Joint Supine: Bimanual Web\/Tarsals; Long-Axis Distraction (Figure 6-233) IND: Metatarsal varum, hypomobility of the medial tarsal articulations.","378\t |\t Chiropractic Technique 6-23\t\t 4 Figure 6-234\u00e2\u2022\u2026 Adjustment for anterior-to-posterior 6-23\t\t 5 Figure 6-235\u00e2\u2022\u2026 Adjustment for plantar-to-dorsal metatarsals. and posterior-to-anterior glide between the right glide of the right metatarsophalangeal joints. CP: With your inside hand, establish a web contact over the IND: Loss of plantar-to-dorsal accessory joint movement of a medial aspect of the navicular. metatarsal, plantar misalignment of a metatarsal. IH: Use your outside hand to apply a web contact over the medial PP: The patient is supine, with the leg straight and resting on the aspect of the proximal metatarsal. table. VEC: Distraction. DP: Stand at the foot of the table, facing cephalad. P: Using your thigh as a fulcrum, thrust both hands away from SCP: Plantar aspect of a metatarsal bone. CP: Use your outside hand to apply a thumb contact over the each other, effectively separating the navicular from the first cuneiform and the first cuneiform from the proximal plantar aspect of the affected metatarsal. metatarsal. IH: With your inside hand, establish a thumb contact over Intermetatarsal Joint the dorsal aspect of the phalanx just distal to the metatarsal Supine: contact. Bimanual Thenar\/Metatarsal Grasp Shear; Anterior-to- VEC: Plantar-to-dorsal. P: Use both thumbs to create a simultaneous shear, emphasizing Posterior and Posterior-to-Anterior Glide (Figure 6-234) the plantar-to-dorsal component on the metatarsal. IND: Restricted intermetatarsal glide movements. Thumb Index Grasp\/Phalanx; Long-Axis Distraction (Figure PP: The patient is supine, with the affected leg in slight flexion. 6-236) DP: Stand at the foot of the table, facing cephalad. IND: Loss of long axis accessory joint movement in the metatar- SCP: Metatarsal bone. sophalangeal or interphalangeal joints. CP: Establish a thumb-thenar contact on the palmar aspect of a PP: The patient is supine, with the affected foot extending off the end of the table. metatarsal bone, and with your fingers, hold the same metatar- DP: Stand at the foot of the table, facing cephalad. sal shaft on the dorsal surface of your hand. SCP: Individual phalanges. IH: Make the same contacts on the adjacent metatarsal. CP: Use either hand and loosely curl the index finger, applying its VEC: A-P or P-A. radial aspect against the plantar surface of the metatarsopha- P: Use both hands to create an A-P and P-A shear between the langeal joint. With the thumb, then grasp the phalanges from two metatarsals. above (dorsal aspect) and distal to the index contact on the Metatarsophalangeal Joint plantar surface. Supine: IH: With the other hand, grasp the foot to stabilize it. Thumb Metatarsal\/Thumb Phalanx Shear; Plantar-to-Dorsal VEC: Long-axis distraction. Glide (Figure 6-235) P: With the thumb, draw the phalanges over the index contact, and apply a dorsal-to-plantar distractive thrust.","Chapter 6\u00e2\u2022\u2026 Extraspinal Techniques\t |\t 379 \t\t6-236 \t Figure 6-236\u00e2\u2022\u2026 Adjustment for long-axis distraction DP: Stand at the foot of the table, facing cephalad. of the right metatarsophalangeal joints (same proce- SCP: Proximal phalanx of the great toe. dure for the interphalangeal joints). CP: With your outside hand, grasp the proximal phalanx between First Metatarsophalangeal Joint your index and middle finger. Supine: IH: Using your inside hand, apply a web contact over the medial Web Metatarsal\/Finger Grasp Phalanx; Medial-to-Lateral aspect of the metatarsophalangeal joint. Glide with Pendular Distraction (Figure 6-237) VEC: M-L. IND: Hallux valgus, bunions, loss of M-L movement of the first P: With the contact hand, elevate the foot, using gravity to create metatarsophalangeal joint. long-axis distraction at the metatarsophalangeal joint. Induce PP: The patient is supine, with the affected foot off the end of side-to-side rocking with the contact hand to mobilize the joint initially. A very shallow M-L thrust can then be applied the table. by the IH. Interphalangeal Joint Supine: Thumb Index Grasp\/Phalanx; Long-Axis Distraction; Internal or External Rotation; Anterior-to-Posterior or Posterior-to-Anterior Glide; Lateral-to-Medial or Medial-to- Lateral Glide (Figure 6-238). IND: Loss of accessory joint movement in the toe joints, mis- alignment of the toes joints. PP: The patient is supine. DP: Stand and face the patient. \t\t6-238 \t Figure 6-238\u00e2\u2022\u2026 Adjustment for internal and external rotation and anterior-to-posterior, poste- rior-to-anterior, lateral-to-medial, and medial-to-lateral glide of the right \t Figure 6-237\u00e2\u2022\u2026 Adjustment for medial-to-lateral metatarsophalangeal joints (same procedure for the interphalangeal \t\t6-237 glide of the right first metatarsophalangeal joint. joints).","380\t |\t Chiropractic Technique SCP: Distal component of the affected joint. P: Apply an impulse thrust to the affected metatarsophalangeal or CP: Grasp the distal member of the joint to be adjusted with interphalangeal joint, using A-P and P-A glide, L-M and M-L glide, and internal and external rotation. either hand. The use of manipulative or adjustive techniques with IH: With the other hand, grasp the proximal member of the joint peripheral joint problems is a valuable aspect in chiropractic being adjusted. practice, requiring no more or no less skill than techniques for VEC: A-P and P-A glide, L-M and M-L glide, and internal and the spine. external rotation.","Nonthrust Procedures: Chapter Mobilization, Traction, and 7 Soft\u00c2\u20acTissue Techniques OUTLINE 381 McKENZIE METHOD\t\t 387 Effects of Soft Tissue 393 381 Treatment Principles\t\t 388 Manipulation\t\t 394 JOINT MOBILIZATION\t 382 Three Syndromes: Postural, 408 Definition\t\t 382 Dysfunctional, and 389 Specific Techniques\t\t 410 Primary Goal\t\t 383 Derangement\t\t 391 Ischemic Compression\t\t 413 Various Types\t\t 392 Body Wall Reflex Techniques\t 417 Selected Examples\t 384 CRANIAL MANIPULATION\t 392 Logan Basic Technique\t\t 418 384 Sagittal Suture Spread\t\t 392 Spondylotherapy\t\t MANUAL TRACTION- 386 Cranial Universal\t\t 393 CONCLUSIONS\t\t\t DISTRACTION\t\t Parietal Lift\t\t\t Definition\t\t Specific Procedures\t SOFT TISSUE MANIPULATION\t W hereas most chiropractic adjustive techniques impart Nonthrust procedures are also viable options in circumstances a thrust, many manual therapy procedures are designed in which the doctor is unable to produce a thrusting force that to affect physiologic processes without using a thrust. is capable of producing joint cavitation. If the doctor\u2019s size, The principal procedures that do not incorporate a thrust include strength, or ability to develop the needed speed and amplitude joint mobilization, traction, and soft tissue manipulation (STM). is inadequate to produce the necessary force, some other type of This chapter presents a description and overview of the practical technique application may provide an effective alternative. This is application of many of the common nonthrust procedures applied suitable only in the circumstance in which both thrust and non- in manual therapy and chiropractic. thrust procedures are assumed to have the same physical effects. All manual therapies are not equivalent simply because a wide The chiropractic profession did not develop most of the tech- variety of methods exist.5 Most of the procedures described in niques and procedures discussed in this chapter. Therefore, they this chapter were developed empirically. Typically they are asso- should not be considered unique to the chiropractic profession. ciated with a particular innovator or profession, but invariably Moreover, a small percentage of chiropractic professionals do development, refinement, and modification by subsequent inno- not use them because of the exclusiveness of thrust techniques. vators has led to an environment of multiple definitions, descrip- However, they are important forms of manual therapy that can be tions, and variations of the same procedure. The intention of this used alone or in combination with thrust procedures. Procedures chapter is not to present a comprehensive discussion of the varia- characterized by a high-velocity thrust (adjustment) may indeed tions and nuances of each procedure, but to offer a fair represen- have effects that are different than and, in certain clinical situa- tation of techniques and an overview of each method presented. tions, superior to nonthrust procedures.1,2 Ideally, the descriptions of the procedures contained within this chapter will broaden your awareness of nonthrust manual pro- Nevertheless, both procedures share common physical attri- cedures and stimulate further critical evaluation of those proce- butes and overlapping potential positive clinical effects. Grieve3 dures that pique your interest. contends that all mobilizations and manipulations are actually soft tissue techniques, because it is in the soft tissue that the lesions JOINT MOBILIZATION treated and the effects produced are found. DEFINITION Chiropractors commonly encounter circumstances in which Joint mobilization may be defined as a passive therapeutic move- thrust manipulation is contraindicated or the primary neuromus- ment up to but not exceeding the anatomic end range of joint culoskeletal (NMS) disorder is not the product of joint dysfunc- movement. A nonthrust maneuver is not commonly applied tion or a pathologic condition. In such circumstances, it benefits beyond a joint\u2019s elastic barrier. Movement beyond the elastic bar- both the doctor and the patient if the chiropractor is skilled in rier takes the joint into the paraphysiologic joint space and is alternative nonthrust manual procedures. Indeed, various and typically associated with an audible pop or click. Therefore mobi- numerous forms of manual therapy exist within the profession lization is less commonly associated with an audible crack than of chiropractic.4 Examples of circumstances in which nonthrust manipulation. Grieve3 considers spinal mobilization a more procedures might be more appropriate include the treatment of the older adults or patients with osteoporotic or extremely acute 381 conditions, treatment of patients in the later stages of pregnancy, or treatment of patients with a diagnosis of myofascial pain syndrome (trigger point).","382\t |\t Chiropractic Technique gentle, persuasive pressure performed within the available acces- BOX 7-1\t A\u0007 mplitude Grades for Oscillatory sory range or at the end of the accessory range. However, mobi- lization can be applied over a wide range and can thus involve a Technique series of movements (stages or grades). Mobilization is a coaxing, repetitive, rhythmic movement of a joint that can be resisted by Grade I A small-amplitude movement near the starting the patient. Inherent within a nonthrust manipulation is a patient Grade II position of the range feedback mechanism. Because the motion is relatively slow, con- A larger-amplitude movement that carries well trolled, and gentle, the patient can report the effect of the tech- Grade III into the range, occupying any part of the range nique during the application. Grade IV that is free of stiffness or muscle spasm A large-amplitude movement that moves into PRIMARY GOAL stiffness or muscle spasm A small-amplitude movement that stretches The primary goal of mobilization is to restore optimal range of into stiffness or muscle spasm motion (ROM), quality of movement, and comfort to the joint being addressed. Indirect benefit is thought to accrue because of BOX 7-2\t G\u0007 eneralized Graded Oscillatory improved function within each part of the kinetic chain in need of treatment. For example, compensatory mechanical stress on Mobilization Procedure adjacent structures may be reduced when a previously painful or restricted part of the chain is returned to normal function. Such 1. Take the joint to tension (engage barrier or point of return to comfortable, maximal ROM usually serves as a passive pain). This involves firm pressure until resistance is felt. treatment end point.6 Mobilization can be performed in a physi- However, it is important to avoid using heavy forces that ologic direction (rotation, flexion, extension, or lateral flexion) might create reactive muscle spasm. or in a nonphysiologic direction (e.g., longitudinal traction or posterior-to-anterior [P-A] gliding). Furthermore, various types 2. Hold gently against the barrier until a release of of mobilization can be used to restore segmental motion and resistance occurs (3 to 10 seconds). This will be perhaps reduce pain in the spine and extremities. Graded oscil- perceived as a \u201cmelting\u201d or softening of resistance. lation, progressive stretch, and continuous stretch mobilization Alternatively, repetitively and rhythmically mobilize until form the basis for most types of mobilization techniques. a release of resistance occurs. VARIOUS TYPES 3. Continue mobilizing until motion is normal (average is 3 to 10 mobilizations). Graded oscillation technique is a form of mobilization whereby alternate pressure (on and off ) is delivered at different parts of 4. Stay just short of reproduction of the symptoms, barely the available range.7 The amplitude of the oscillation may also engaging the point of pain and backing away. vary according to the purpose of the technique. Oscillatory technique is graded on a 1-to-4 scale based on the amplitude of 5. If the amplitude is too small, the procedure will be the motion and part of the range being reached (Box 7-1). The less effective; if the amplitude is too great (going vibratory nature of the graded oscillation technique is thought too far into the painful area), the symptoms will be to activate sensory mechanoreceptors that may help reduce pain aggravated. and improve proprioceptive function. Box 7-2 lists general- ized procedural steps for the application of graded oscillatory periarticular soft tissues about a spinal joint by means of collagen mobilization. fiber realignment and viscosity change allows for improved joint mobility. Progressive stretch mobilization involves a series of successive short-amplitude, spring-type pressures or a series of short- Mobilization can be performed at general regions or at spe- amplitude stretch movements.8 The pressure or stretch is imparted cific joint levels. The difference between these procedures rests at progressive increments of the range. Progressive stretch is graded in the localization of forces. To produce a specific mobilization, on a 1-to-4 scale, as is graded oscillation. The major indication for a particular segment must be placed in its most favorable posi- the use of progressive stretch mobilization is mechanical or soft tion for movement, and contacts must be placed on or close to tissue restriction or both. the segment being mobilized. A general or regional mobiliza- tion incorporates the use of longer levers or contacts placed at Continuous stretch is a sustained, gradually increased stretch points distal to the area being mobilized. In addition, the arc or pressure without interruption. Maintaining a stretch or pres- of movement for a generalized or regional mobilization will be sure throughout the mobilization procedure is recommended greater than the arc of motion used for the specific or segmental when immediate tissue feedback is desired. Adaptively shortened mobilization. periarticular soft tissue structures are most likely to be affected using continuous stretch technique. Improving extensibility of the In addition, special attention should be given to the traction component of mobilization. Where anatomic relationships allow","Chapter 7\u00e2\u2022\u2026 Nonthrust Procedures: Mobilization, Traction, and Soft\u00c2\u20acTissue Techniques\t |\t 383 traction to accompany mobilization, traction should be used as Figure 7-1\u00e2\u2022\u2026 Oscillatory cervical lateral flexion to produce left lateral an integral part of the treatment program. In many cases of pain- flexion mobilization of the cervical spine. induced failure of a mobilization technique, that is, when angular or even translational force vectors produce increased pain, pure trac- Figure 7-2\u00e2\u2022\u2026 Oscillatory atlas lateral glide developing a left-to-right tion techniques may still be useful. This fact reinforces the concept translational lateral glide movement of the atlantoaxial articulation that traction is one of the least invasive mobilization methods.9 (C1-C2). articular processes of a cervical segment, the transverse processes SELECTED EXAMPLES of a thoracic segment, or the mammillary processes of a lumbar segment. The thumbs may be on the same side of the patient or The following is a representative sample of spinal and extrem- can cross the spine. The clinician produces a P-A oscillatory move- ity mobilization procedures. These procedures have been selected ment over the vertebra. because they represent a variety of methods, not because they Progressive Stretch Lumbar Rotation (Figure 7-5) demonstrate superior effectiveness as compared with other mobi- The patient lies in a prone position over an elevated table or lization procedures. Dutchman roll. The clinician stands in a square stance at the Oscillatory Cervical Lateral Flexion (Figure 7-1) side of the table opposite the area to be mobilized. The clinician\u2019s The patient lies in the supine position, with the head and neck supported on the headrest and by the clinician\u2019s hands. The clinician sits or stands at the head end of the table. To produce left lateral flexion mobilization of the cervical spine, the clinician\u2019s right hand comfortably grasps the patient\u2019s chin while the forearm rests on the side of the head. The other hand supports the patient\u2019s occiput. Both hands support the patient\u2019s head and produce a repetitive, rhythmic left lateral flexion movement around the z-axis. An oscillatory movement is produced as the hands move reciprocally, and all excursions have equal value. Oscillatory Atlas Lateral Glide (Figure 7-2) The patient lies in the side-posture position with both knees bent to maintain pelvic stability, the upper arm resting along the side of the body and the hand grasping the thigh, and the head placed in a neutral position on an elevated headrest. The clinician sits or stands, facing the patient, and contacts the lateral aspect of the atlas transverse process with both thumbs, one on top of the other. A lateral-to-medial oscillatory move- ment is produced, developing a translational lateral glide movement. Progressive Stretch Thoracic Extension (Figure 7-3) The patient lies in the prone position with the hands interlaced behind the neck and the elbows together (Figure 7-3, A). The \u00c2c","384\t |\t Chiropractic Technique AA B Figure 7-4\u00e2\u2022\u2026 Oscillatory posterior-to-anterior (P-A) glide applied to the L3 vertebra. The patient lies in the prone position. The clinician stands on the side of the table, facing cephalically, in a lunge position (fencer stance). The clinician establishes bilateral thumb contacts over the articular processes of a lumbar segment. The thumbs may be on the same side of the patient or may cross the spine (A). A bilateral contact can also be established (B). A P-A oscillatory movement is produced over the vertebra. B Continuous Stretch Rotation (Figure 7-6) Figure 7-3\u00e2\u2022\u2026 Progressive stretch thoracic extension. A, Prone. B, Sitting. The patient lies in a prone position over an elevated table or Dutchman roll. The clinician stands at the side of the table, caudal hand grasps the anterior superior iliac spine while the facing cephalically, in a lunge position (fencer stance). The cli- cephalic hand establishes a broad contact over the lower rib nician establishes a thumb contact against the lateral aspect of cage on the side to be mobilized. The clinician raises and low- a spinous process with the caudal hand. The cephalic hand is ers the pelvis against the resistance provided by the cephalic placed over the lateral aspect of the pelvis. A firm, continu- hand, producing a rhythmic rocking lumbar rotation of small ous pressure to the patient\u2019s tolerance is applied against the L5 amplitude. spinous process while the pelvis is stabilized. Continuous pres- sure is held for 8 to 12 seconds and repeated up to three times. MANUAL TRACTION-DISTRACTION DEFINITION The term traction refers to the process of pulling one body in rela- tionship to another, which results in separation of the two bod- ies. Traction is passive translational movement of a joint, which","Chapter 7\u00e2\u2022\u2026 Nonthrust Procedures: Mobilization, Traction, and Soft\u00c2\u20acTissue Techniques\t |\t 385 Figure 7-5\u00e2\u2022\u2026 Progressive stretch lumbar rotation to mobilize the right Figure 7-6\u00e2\u2022\u2026 Continuous stretch rotation of L4, producing a left rota- side of the lumbar spine. The patient lies in a prone position over an tional mobilization of L4 over L5. The patient lies in a prone position over elevated table or Dutchman roll. The clinician stands in a square stance an elevated table or Dutchman roll. The clinician stands at the side of the at the side of the table opposite the area to be mobilized. The clinician\u2019s table, facing cephalically, in a lunge position (fencer stance). The clini- caudal hand grasps the anterior superior iliac spine while the cephalic cian establishes a thumb contact against the lateral aspect of the pelvis. A hand establishes a broad contact over the lower rib cage on the side to be firm, continuous pressure to the patient\u2019s tolerance is applied against the mobilized. The clinician raises and lowers the pelvis against the resistance L5 spinous process while the pelvis is stabilized. Continuous pressure is provided by the cephalic hand, producing a rhythmic lumbar rotation of held for 8 to 12 seconds and repeated up to three times. small amplitude. occurs at right angles to the plane of the joint, resulting in separa- BOX 7-3\t Treatment Aims of Manual Traction tion of the joint surface. Kaltenborn10 graded manual traction by the three effects it produces. With the first effect, there is no 1.\t Relief of pain and reduction of muscle spasm appreciable joint separation because only enough traction force 2.\t Restoration of normal tissue-fluid exchange, soft tissue is applied to nullify the compressive forces acting on the joint. The compressive forces are the result of muscle tension, cohesive pliability and extensibility, and normal joint relationship forces between articular surfaces, and atmospheric pressure. The and mobility second effect produces a tightening in the tissue surrounding the 3.\t Correction of muscle weakness or imbalance joint that is described as \u201ctaking up the slack.\u201d The third grade of 4.\t Stabilization of unstable segments traction requires more traction force to produce a stretching effect 5.\t Restoration of adequate control of movement into the tissues crossing the joint. The principal aim of treatment 6.\t Relief from chronic postural or occupational stress is restoration of normal painless ROM (Box 7-3). 7.\t Functional rehabilitation of the patient Traction produces measurable separation of vertebral bod- BOX 7-4\t Effects of Traction ies and centripetal forces exerted by the tension applied to sur- rounding soft tissues. However, traction has other effects as well. Simple mobilization of joints with reversible stiffness Grieve11 identifies some other effects that are the result of both Modification of the abnormal patterns of afferent impulses sustained and rhythmic traction (Box 7-4). from joint mechanoreceptors Manual traction is not a unique and separate form of treat- Relief of pain by inhibitory effects on afferent neuron ment but is simply one form of passive mobilization.12 Traction can be varied in many ways; almost any form of passive handling impulses subserving pain may be used, with some form of oscillation or as a static hold. Reduction of muscle spasm Therefore, a longitudinal movement may be performed as an oscil- Stretching of muscle and connective tissue latory mobilization, as a slow rhythmic stretch, or as a static trac- Improvement of tissue-fluid exchange in muscle and tion. Traction may be manual or mechanical, static or rhythmic, or fast or slow; the force applied may be strong or gentle, and it connective tissue may be applied symmetrically or asymmetrically. These variations Likely improvement of arterial, venous, and lymphatic flow must be explored to determine which combination is most suit- Physiologic benefit to the patient of rhythmic movement able for the patient\u2019s needs or the clinician\u2019s abilities. The effects Lessening of compressive effects of traction are not necessarily localized, but may be made more specific by careful positioning.","386\t |\t Chiropractic Technique For traction to achieve maximal success in a minimal amount to be distracted (e.g., to distract the L5\u2013S1 segment, contact is of time, the patient must be positioned accurately, a minimal on the L5 spinous process). The contact hand is slightly cupped, effective force must be used, and each patient\u2019s treatment must be creating an indentation between the thenar and hypothenar emi- based on his or her signs and symptoms rather than the diagno- nence to receive the prominence of the spinous process without sis. The potential theoretic effects of traction on the spine include placing undue pressure and causing subsequent discomfort to stretching of the muscles and ligaments, improving glide of the the patient.16 The patient is encouraged to relax, and the cli- dural root sleeves, freeing fixation of articular facets, changing nician depresses the handle at the foot of the table. If there is hydrostatic pressure in the discs and repositioning nuclear no handle, the clinician depresses the foot of the table (pelvic fragments, and improving the blood supply to the spine and its section) by hand. The handle is an improvement over placing surrounding structures.13 the hand on the caudal section of the table because it provides increased leverage and a better stance position for the clinician SPECIFIC PROCEDURES (Figure 7-7). Manual Lumbar Flexion-Distraction (Cox Method) The pelvic section is then depressed until the clinician\u2019s hand Flexion-distraction is a mechanically assisted form of joint mobili- detects that the musculature has reached a point of tautness and all zation or distraction, blending osteopathic and chiropractic prin- tissue and joint play have been removed from the area under treat- ciples into one technique. Flexion-distraction has been advanced ment. This point is maintained, and an additional 2 to 3 inches in the chiropractic profession largely by the work of chiropractor of table depression is achieved manually. The caudal section is James Cox. Much of Cox\u2019s initial work in developing his tech- then allowed to return to neutral, followed by another downward nique of flexion-distraction was based on the work of the osteo- movement to the previous point over a 20-second period. This path J.V. McManis. Moreover, the design of the early Cox table process creates a \u201cpumping action\u201d and is repeated three times, was a direct emulation of the McManis table of the early 1900s. with a break of a few seconds between each 20-second session This manual table provided an advantage to both the patient and (Box 7-6). the clinician, allowing a multiple-plane approach to distraction, including flexion-extension, lateral flexion, and rotation. The A patient with a protruding disc may sense mild pain on trac- McManis table incorporated many of the features that appear on tion, whereas a prolapsed disc does not usually produce such a sen- contemporary tables, including split headpieces, multiple sections sation. Too much traction during the session should be avoided adjustable for patient comfort, and positioning for various adjus- because it may produce further annular injury and impairment. tive maneuvers.14 In the case of disc involvement, the disc and motion segment are potentially sensitized to pain and mechanical stimuli, and the A number of lumbar disorders have been presented as condi- patient is probably sensitive and sore at the point of the injury. tions suitable for treatment with lumbar flexion-distraction. They Therefore, it is better to undertreat the patient than to overtreat, include lumbar disc protrusion, spondylolisthesis, facet syndrome, and caution is encouraged in the application of the technique. subluxation, and scoliotic curves of a nonsurgical nature.15 The Furthermore, if the patient does not tolerate the flexion-distrac- theoretic benefits that have been associated with this form of spi- tion movement or if the pain is peripheralized, the process should nal manipulation are presented in Box 7-5. not continue. Further traction should concentrate on relieving the pain before the therapeutic distraction begins in earnest. The Cox method uses a process of analysis that incorporates Any intolerance should be viewed with caution and, although physical examination, orthopedic and neurologic testing, and this does not become a clear contraindication for the treatment, imaging as indicated to establish the presence of a disc lesion, it certainly should be treated with respect and restraint. In this facet syndrome, or any other condition affecting the low back. instance, more is not better but, in fact, may make the patient\u2019s Cox distraction therapy typically consists of three 20-second condition worse. flexion-distraction sessions. Once the patient is properly posi- tioned on the table and the tolerance of the patient to flexion is determined, the sessions can begin. The hand is placed over the spinous process of the superior vertebra of the motion segment BOX 7-5\t \u0007Theoretic Benefits of Flexion-Distraction Figure 7-7\u00e2\u2022\u2026 Cox flexion distraction for the L4 disc (L4\u2013L5 segment) with a contact established over L4 spinous process as the caudal section is Technique depressed, producing distraction. Increasing IVD height Removal of pressure on the disc Centering of the nucleus of the disc, thus relieving disc pressure Restoration of normal motion to the spine Improvement of posture IVD, Intervertebral disc.","Chapter 7\u00e2\u2022\u2026 Nonthrust Procedures: Mobilization, Traction, and Soft\u00c2\u20acTissue Techniques\t |\t 387 BOX 7-6\t E\u0007 ssential Steps of Flexion-Distraction Figure 7-8\u00e2\u2022\u2026 Leader lumbar distraction for the L4\u2013L5 segment. Motorized pelvic section allows both hands to be used for contact. Treatment muscles). Contacts taken under the base of the occiput (see Figure 1. The patient is assisted into a prone position, with the 7-9, B) will allow the neck to flex slightly to provide more distrac- ASIS positioned at the base of the thoracic section. tive separation and stretch to the posterior structures (facets and The low back is then tested for tolerance to manual paraspinal muscles). A towel may be substituted for hand contacts distraction. When tolerance has been tested and (see Figure 7-9, C). distraction is found to be tolerable to the patient, the Motorized Cervical Traction ankle straps can be applied, increasing the traction force A motorized traction table, such as the Leader table, can be used to in the area of the proposed treatment. assist in the production of cervical traction (Figure 7-10). Traction to the cervical spine is usually applied in the prone position while 2. Depression of the caudal section of the table is the pelvic section of the table produces continuous passive motion performed until tautness of the spinal musculature is felt in the long axis of the spine. The clinician can apply a stabiliz- by the clinician. ing pressure at the base of the occiput or anywhere in the cervical spine to produce a counterpressure against the distractive force 3. Contact is made and maintained on the spinous produced by the table\u2019s moving pelvic piece (Box 7-7). process of the vertebra immediately above the disc involvement. McKENZIE METHOD 4. Contact on the spinous process of the vertebra is to be The McKenzie method is most commonly associated with the maintained with one hand while the other contacts the promotion and application of lumbar extension exercises for handle or the foot of the table. the treatment of low back pain (LBP). Consequently, it is often viewed incorrectly as only a treatment method. The McKenzie 5. Traction is maintained by pressing on the caudal section method is both an evaluation and treatment approach to the man- of the table. Patient comfort should be maintained. agement of painful spinal conditions. It is based on a structured The subsequent pumping of the caudal section creates and focused assessment of the effects of repeated movements and a milking action of the disc and, according to Cox,15 sustained postures on a patient\u2019s symptoms and spinal biomechan- speeds the recovery process. ics. The information gained about the patient\u2019s symptomatic and mechanical responses to loading allows the clinician to determine 6. The process outlined should be repeated to the patient\u2019s which specific movements, positions, and activities to either pur- tolerance. The clinician may palpate a release at the sue or avoid in the treatment plan. This information is specific to noted vertebral level. a particular patient at a specific point in time and provides repro- ducible objective and subjective criteria on which to base clinical 7. One more distraction session (the third) should be decisions. It has been shown to reliably differentiate discogenic performed to patient tolerance for approximately from nondiscogenic pain, and a competent from incompetent 20 seconds. annulus.17 In comparison with magnetic resonance imaging, it demonstrates superior ability in distinguishing painful from non- 8. Following treatment, the caudal section of the table is painful discs.17 returned to the neutral position and secured, and the ankle straps are released. ASIS, Anterior-superior iliac spine. Motorized Lumbar Distraction (Leader Method) A motorized traction table, such as the Leader table, can be used to assist in the production of lumbar traction (Figure 7-8). Traction to the lumbar spine is applied in the prone position while the pel- vic section of the table produces continuous passive motion in the long axis of the spine. The clinician can apply a stabilizing pres- sure, using both hands over the spinous process of the segment to be distracted to produce a counterpressure against the distractive force produced by the table. Manual Cervical Traction Cervical traction can be applied manually or with mechanical assistance. Manual cervical traction is generally accomplished with the patient in the supine position. The clinician sits or stands at the head end of the table and establishes contacts with the fin- gers of both hands on the posterior aspect of the cervical spine. Contacts taken over the C5\u2013C6 segment (Figure 7-9, A) will allow the neck to extend slightly to provide more distractive separation and stretch to the anterior structures (the disc and longus coli"]