PRINCIPLES OF MANUAL MEDICINE THIRD EDITION BY PHILIP E. GREENMAN

Upper Extremity Chapter 18 Upper Extremity Technique 407 Sternoclavicular Joint 3. The patient is asked to actively \"shrug the shoul­ ders\" by bringing the shoulder tip to the ear bilater­ Diagnosis ally (Fig. 18.2). Test for Restricted Abduction 4. The operator's palpating fingers follow the move­ 1. Patient supine on table with arms resting easily at ment at the medial end of the clavicle. the side. 5. The normal finding is equal movement of the medial 2. Operator stands at side or head of table with paired end of both clavicles in a caudad direction. fingers over the superior aspect of the medial end of the clavicle (Fig. 18. 1). 6. A positive finding is the failure of one clavicle to move caudad when compared to the opposite. It ap­ pears to be held in the original starting position. Note: This test can also be done with patient sitting. Figure 18.1. Figure 18.2.

408 Principles of Manual Medicine 3. The operator abducts the extended upper extremity to the resistant barrier (Fig. 18.4) and sweeps it Upper Extremity across the patient's torso in the direction of the op­ posite knee while constant caudad pressure is Sternoclavicular Joint maintained by the thenar eminence on the medial end of the clavicle (Fig. 18.5). Mobilization Without Impulse (articulatory treatment) Diagnosis: Restricted Abduction 4. Several repetitions are done, increasing the abduc­ tion movement of the patient's extended arm. (A 1. Patient sits on the examining table or stool. high-velocity thrust by the thenar eminence may be 2. Operator stands behind patient with the thenar emi­ used.) nence of one hand over the superior aspect of the 5. Retest. medial end of the dysfunctional clavicle, the other hand grasps the patient's forearm (Fig. 18.3). Figure 18.4. Figure 18.3. Figure 18.5.

Upper Extremity Chapter 18 Upper Extremity Technique 409 Sternoclavicular Joint 4. Operator internally rotates the dysfunctional upper extremity and carries it into extension off the edge Muscle Energy Technique of the table to the resistant barrier while monitoring Supine with the opposite hand at the sternoclavicular re­ Diagnosis: Restricted Abduction gion (Fig. 18.7). 1. Patient supine on table with the dysfunctional upper 5. Patient performs a 3- to 5-second muscle contrac­ extremity at the edge of the table. tion to lift the arm toward the ceiling against opera­ tor resistance for three to five repetitions. 2. Operator stands on the side of dysfunction facing cephalad. 6. Following each relaxation, the operator increases the extension of the upper extremity to a new resist­ 3. Operator places one hand over the medial end of ant barrier and patient again repeats the effort of the dysfunctional clavicle while the other grasps the lifting the arm toward the ceiling. patient's forearm just above the wrist (Fig. 18.6). 7. Retest. Note: This procedure also increases internal (ante­ rior) rotation at the sternoclavicular joint. Figure 18.6. Figure 18.7.

410 Principles of Manual Medicine 3. With the elbow at 90 degrees, the upper extremity is externally rotated and abducted to approximately Upper Extremity 90 degrees with additional abduction until the resis­ tant barrier is engaged (Fig. 18.9). Sternoclavicular Joint 4. Patient performs muscle contraction to adduct the Muscle Energy Technique upper extremity three to five times for 3 to 5 sec­ Sitting onds against resistance offered at the elbow by the Diagnosis: restricted abduction operator. 1. Patient sitting on table or stool. 5. After relaxation, operator engages new barrier. 2. Operator standing behind patient with the thenar 6. Retest. eminence of one hand in contact with the superior aspect of the medial end of the dysfunctional clavi­ Note: This procedure also enhances the external cle and the other hand controlling the dysfunctional (posterior) rotation at the sternoclavicular joint. upper extremity at the elbow (Fig. 18.8). Figure 18.8. Figure 18.9.

Upper Extremity Chapter 18 Upper Extremity Technique 411 Sternoclavicular Joint 4. Operator evaluates movement of the medial end of each clavicle (Fig. 18. 11). Diagnosis Test for Restricted Horizontal Flexion 5. The normal finding is for each clavicle to move sym­ metrically in a posterior direction as the lateral end 1. Patient supine on table. of the clavicle moves anteriorly. 2. Operator stands at side or head of table with fingers 6. A positive finding is for one clavicle not to move in a symmetrically placed on the anterior aspect of the posterior direction during the reaching effort. medial end of each clavicle (Fig. 18. 10). 3. Patient extends the upper extremities in front of the Note: This test can also be done with the patient body by reaching toward the ceiling. sitting. Figure 18.10. Figure 18.11.

412 Principles of Manual Medicine 3. Operator takes the upper extremity into horizontal extension (Fig. 18.13) and sweeps it forward in hori­ Upper Extremity zontal flexion (Fig. 18.14) with increasing arcs of movement, while the thenar eminence of the oppo­ Sternoclavicular Joint site hand maintains a posterior compressive force on the medial end of the dysfunctional clavicle. (A Mobilization without impulse (articulatory) treatment high-velocity thrust by the thenar eminence may be Diagnosis: Restricted Horizontal Flexion substituted.) 1. Patient sitting on table. 4. Retest. 2. Operator standing behind with one hand on the an­ terior aspect of the medial end of the dysfunctional clavicle and the lateral hand grasping the forearm (Fig. 18. 12). Figure 18.13. Figure 18.12. Figure 18. 14.

Upper Extremity Chapter 18 Upper Extremity Technique 413 Sternoclavicular Joint 4. Patient's hand grasps back of operator's neck with an extended arm. Muscle Energy Technique Supine 5. Patient engages the horizontal flexion barrier by Diagnosis: Restricted Horizontal Flexion standing more erect and lifting the dysfunctional scapula (Fig. 18. 16). 1. Patient supine on table. 2. Operator stands on side of table opposite the dys­ 6. Patient pulls down upon the operator's neck with 3 to 5 second muscle effort for three to five repeti­ functional sternoclavicular joint. tions while operator maintains posterior compres­ 3. Operator places cephalic hand over the medial end sion on the anterior aspect of the medial end of the dysfunctional clavicle. of the dysfunctional clavicle and the caudad hand grasps the patient's shoulder girdle over the poste­ 7. Operator engages new barrier after each of pa­ rior aspect of the scapula (Fig. 18. 15). tient's muscle contraction. 8. Retest. Figure 18.15. Figure 18.16.

414 Principles of Manual Medicine Figure 18.17. Upper Extremity Sternoclavicular Joint Mobilization without impulse (articulatory) Technique Diagnosis: Restricted Horizontal Flexion 1. Patient supine, operator stands on opposite side of dysfunction. 2. Operator places caudad forearm on table between chest and humerus. 3. Patient's opposite hand grasps wrist of dysfunc­ tional extremity. A pull places traction on the clavi­ cle. 4. Operator's cephalic hand applies pressure on me­ dial end of dysfunctional clavicle (Fig. 18. 17). 5. Patient pulls on wrist distracting the clavicle while operator springs the medial end of the clavicle pos­ teriorly. 6. Retest.

ACROMIOCLAVICULAR JOINT Chapter 78 Upper Extremity Technique 415 The acromioclavicular joint contributes only a small 3. Operator introduces adduction and external rotation amount of motion to the shoulder region, but its con­ of the forearm monitoring a gapping movement at tribution to total upper extremity abduction is critical. the acromioclavicular joint (Fig. 18.19). The primary movements of this articulation are ab­ duction and internal and external rotations. The joint 4. Absence of the gapping movement is evidence of restriction of adduction movement. is angled laterally at approximately 30 degrees from 5. Comparison is made with the opposite side. before backward. The joint largely depends on liga­ ments for its integrity and frequently separates during 6. Operator introduces abduction movement while trauma. Productive change at this joint is common. monitoring at the joint for movement (Fig. 18.20). Clinical experience has shown that loss of acromio­ clavicular joint function is highly significant, particu­ 7. Comparison is made with the opposite side. larly the loss of abduction. This is important to re­ member during motion testing of the shoulder girdle. Dysfunction of this joint is one of the most frequently overlooked in the upper extremity. Upper Extremity Acromioclavicular Joint Diagnosis: Test for Restricted Abduction and Add'Jction 1. Patient sitting with operator standing behind. 2. Operator's medial hand palpates the superior as­ pect of the acromioclavicular joint and the lateral hand controls the patient's proximal forearm (Fig. 18.18). Figure 18.19. Figure 18.18. Figure 18.20.

416 Principles of Manual Medicine Figure 18.21. Upper Extremity Acromioclavicular Joint Muscle Energy Technique Sitting Diagnosis: Restricted Abduction 1. Patient sitting on table or stool with operator stand­ ing behind. 2. Operator maintains compressive force on lateral end of the clavicle, medial to the acromioclavicular joint. 3. Operator's lateral hand takes patient's upper ex­ tremity to horizontal flexion of 30 degrees and abducts to the barrier (Fig. 18.21). 4. Patient pulls elbow to the side against resistance of­ fered by the operator for 3 to 5 seconds and three to five repetitions. 5. Operator engages new abduction barrier after each muscle effort. 6. Retest.

Upper Extremity Chapter 78 Upper Extremity Technique 417 Acromioclavicular Joint 3. Operator's lateral hand moves the upper extremity into horizontal flexion to 30 degrees and abduction Diagnosis: Test for Restricted Internal and External to the first barrier (Fig. 18.22). Rotation 4. Operator introduces internal rotation (Fig. 18.23) 1. Patient sitting on table or stool with operator stand­ and external rotation (Fig. 18.24) while monitoring ing behind. mobility of the acromioclavicular joint. 2. Operator's medial hand palpates the superior as­ 5. Comparison is made with the opposite side. pect of the acromioclavicular joint. Figure 18.23. Figure 18.22. Figure 18.24.

418 Principles of Manual Medicine 4. External rotational barrier is engaged with the oper­ ator's lateral hand grasping the patient's wrist and Upper Extremity places forearm to patient's forearm (Fig. 18.25). Acromioclavicular Joint 5. Operator engages internal rotation barrier by threading lateral forearm under patient's elbow and Muscle Energy Technique grasping distal forearm (Fig. 18.26). Diagnosis: Restricted Internal or External Rotation 6. Patient provides muscle contraction for 3 to 5 sec­ 1. Patient sitting on table or stool with operator stand­ onds and three to five repetitions against resistance ing behind. of either internal or external rotation. 2. Operator's medial hand stabilizes the lateral aspect 7. Operator engages new barrier after each muscle of the clavicle and monitors the acromioclavicular contraction. joint. 8. Retest. 3. Operator takes upper extremity to 30 degrees of horizontal flexion and abduction to 90 degrees. Figure 18.25. Figure 18.26.

GLENOHUMERAL JOINT Chapter 18 Upper Extremity Technique 419 The glenohumeral joint has one of the widest ranges extension, internal rotation, and external rotation. of movement of any joint within the body. The depth Adduction moves the humerus toward the body and of the glenoid is increased by the cartilaginous gle­ in front of the chest, and abduction moves the arm noidal labrum. For this joint to perform its normal away from the body with full range extending so that function it is dependent upon the ability of the the elbow can touch the ear. All of these motions scapula to move on the thoracic cage with the glenoid should be tested and compared with the opposite side. being elevated for upper extremity abduction. For this The primary movement loss in the glenohumeral joint reason, the muscular attachments to the scapula must involves the functions of external rotation and abduc­ perform their normal actions. Tightness and shorten­ tion. The humeral head must move from cephalad to ing of the levator scapulae and the latissimus dorsi caudad on the glenoid during abduction. Loss of this muscles are notoriously found in a dysfunctional up­ ability to track from superior to inferior during ab­ per extremity, particularly the impingement syn­ duction results in major restriction at the gleno­ drome of the rotator cuff. The articular capsule is nor­ humeral joint. mally quite lax and loose, particularly inferiorly, providing for a wide range of movement. Joint in­ Because the vast majority of dysfunctions within tegrity is maintained by the intimate attachment of the the glenohumeral joint are muscular in origin, mus­ rotator cuff muscles (supraspinatus, infraspinatus, ter­ cle energy diagnostic and therapeutic techniques are res minor, and subscapularis) to the articular capsule. most effective. The principles of diagnosis and treat­ ment are (a) to evaluate range of motion in all of the The extensive movements of this joint are de­ motion directions described above, (b) to evaluate scribed in relation to the vertical and horizontal the strength of each of the muscle groups, (c) to planes. In the vertical or neutral plane, the humerus is treat restricted range of movement by postisometric at the side of the body. Movement then occurs in flex­ relaxation technique at the restrictive barrier, and ion, extension, internal rotation, and external rota­ (d) if weakness is identified, to treat by means of a se­ ries of concentric isotonic contractions. Each motion tion. In the horizontal plane, with the humerus at 90 should be compared with that available on the oppo­ site side. degrees to the trunk, it is also possible to have flexion,

420 Principles of Manual Medicine web of the hand over the acromioclavicular joint, and the thumb posterior and inferior over the spine Glenohumeral Joint of the scapula. Muscle Energy Procedure 6. Operator's lateral hand controls patient's elbow and forearm. 1. Patient sits on table or stool with operator standing behind. 7. Operator introduces the following motions and treats accordingly: 2. Range of motion is tested in all, directions by engag­ ing the restrictive barrier. Comparison is made with • Neutral flexion (Fig. 18.27) the opposite side. • Neutral extension (Fig. 18.28) 3. If motion is restricted, operator engages resistant barrier. Patient performs three to five repetitions of a • Neutral external rotation (Fig. 18.29) 3 to 5 second isometric contraction against operator resistance. • Neutral internal rotation, stage 1 (Fig. 18.30) 4. The operator performs strength testing by having • Neutral internal rotation, stage 2 (Fig. 18.31) the patient contract the muscle in the direction of operator resistance. Comparison is made with the • Adduction (Fig. 18.32) opposite side. If one muscle group is weak, the pa­ tient performs a series of three to five concentric • Abduction (Fig. 18.33) isotonic contractions through the total range of movement against progressively increasing resis­ • Horizontal flexion (Fig. 18.34) tance by the operator. • Horizontal extension (Fig. 18.35) 5. Operator's medial hand stabilizes the shoulder gir­ • Horizontal internal rotation (Fig. 18.36) dle with the fingers on the coracoid process, the • Horizontal external rotation (Fig. 18.37) 8. Retest. Figure 18.27. Figure 18.28.

Chapter 18 Upper Extremity Technique 421 Figure 18.29. Figure 18.30. Figure 18.32. Figure 18.3 1. Figure 18.33.

422 Principles of Manual Medicine Figure 18.34. Figure 18.36. Figure 18.35. Figure 18.37.

Glenohumeral Joint Chapter 18 Upper Extremity Technique 423 Glenoidal Labrum (Green's) Technique 3. Operator next grasps patient's humeral neck with thumbs on the greater tuberosity, the index and This technique enhances movement of the humeral middle fingers on the attachment of the rotator cuff, head within the glenoid and glenoid labrum and is use­ and the ring and little fingers surrounding the proxi­ ful as the initial treatment in a patient with adhesive cap­ mal shaft, controlling the humeral shaft against the sulitis (frozen shoulder). thenar eminences (Fig. 18.40). 1. Patient prone with the involved arm off the edge of 4. Operator applies movement through the humeral the table and operator sitting at side facing dysfunc­ head in an anterior-posterior, cephalic--caudal, and tional shoulder (Fig. 18.38). medial and lateral traction-distraction directions. 2. Operator grasps distal humerus in both hands and 5. Operator induces circular and figure-eight motions, applies caudad and anterior traction with internal enhancing range in all directions. and external rotation two to three times (Fig. 18.39). 6. Operator emphasizes increase in caudal translatory movement of the humeral head on the glenoid. 7. Retest. Figure 18.39. Figure 18.38. Figure 18.40.

424 Principles of Manual Medicine 4. Step 1: Operator gently flexes (Fig. 18.41) and ex­ tends arm (Fig. 18.42) in the sagittal plane with the Glenohumeral Joint elbow flexed. Repetitions are made within limits of pain provocation. Spencer Seven-Step Technique 5. Step 2: Operator flexes patient's arm in the sagittal The principle is a sequential, direct action, mobilization plane with elbow extended in a rhythmic swinging without impulse (articulatory) technique against motion movement, increasing range so that patient's arm resistance. covers the ear (Fig. 18.43). 1. Patient in lateral recumbent position with affected 6. Step 3: Operator circumducts patient's abducted shoulder uppermost, head supported, and knees humerus with the elbow flexed. Clockwise and flexed. counterclockwise concentric circles with gradual in­ crease in range are made within limits of pain (Fig. 2. Operator stands facing patient. 18.44). 3. Operator's proximal hand stabilizes the shoulder gir­ dle including the clavicle and scapula. Figure 18.4 1. Figure 18.43. Figure 18.42. Figure 18.44.

7. Step 4: Operator circumducts patient's humerus Chapter 18 Upper Extremity Technique 425 with elbow extended in clockwise and counterclock­ wise circles, increasing range as permitted by pain 9. Step 6: Operator places patient's hand behind the (Fig. 18.45). rib cage and gently springs elbow forward and in­ ferior, increasing internal rotation of the humerus 8. Step 5: Operator abducts patient's arm with elbow (Fig. 18.47). flexed with gradual increases of range of abduction against the stabilized shoulder girdle (Fig. 18.46). 10. Step 7: Operator grasps patient's proximal humerus with both hands and applies lateral and caudad traction in a pumping fashion (Fig. 18.48). 11. Retest. Figure 18.45. Figure 18.47. Figure 18.46. Figure 18.48.

426 Principles of Manual Medicine 4. Operator's hands introduce translatory movement medially (Fig. 18.49) and laterally (Fig. 18.50) ELBOW REGION through the arc from flexion to extension testing for resistance. There are three joints at the elbow region: the humeroulnar joint, the humeroradial joint, and the 5. Comparison made with the opposite side. proximal radioulnar joint. The primary movements are flexion and extension, pronation and supination, 6. A direct action mobilization without impulse, pro­ and a small amount of abduction-adduction. All gressively carried through to mobilization with im­ joints participate in elbow function. Flexion-exten­ pulse, has operator engage either the adduction or sion is the primary movement at the humeroulnar abduction barrier while extended (Fig. 18.51). Mobi­ joint, and pronation-supination is a combined lization without impulse repetitions are made humeroradial and proximal radioulnar joint move­ against resistant barrier with final mobilization with ment. Abduction-adduction movement is primarily a impulse performed. joint play movement at the humeroulnar joint, and, when dysfunctional, reduces the flexion-extension 7. Retest. range. The elbow region has a number of related pain syndromes that are frequently described as \"tennis el­ Note: Adduction restriction is more common than bow.\" Many of these patients present with pain on the abduction. lateral aspect of the elbow, radiating into the forearm, which is aggravated by activity. Dysfunction of the ra­ dial head involving the proximal radioulnar and humeroradial joints is a frequent finding. Radial head dysfunction is the most common somatic dysfunction within the elbow region. Elbow Region Diagnosis: Restricted Abduction-Adduction (humeroulnar joint) 1. Patient sitting on table with operator standing in front. 2. Operator's two hands circumferentially grasp proxi­ mal radioulnar region. 3. Operator supports patient's hand and wrist between medial side of elbow and trunk. Figure 18.50. Figure 18.49. Figure 18.51.

Elbow Region Chapter 18 Upper Extremity Technique 427 Muscle Energy Technique 5. Operator progressively engages elbow extension Restricted Elbow Extension barrier after each muscle contraction (Fig. 18.53). 1. Patient sitting on table with operator standing in 6. Retest. front. 7. An alternate technique has patient perform a se­ 2. Operator's medial hand grasps patient's distal ries of isotonic contractions of the triceps muscle supinated forearm with lateral hand stabilizing the through full flexion-to-extension arc. elbow. 8. Operator fully flexes the elbow, stabilizing elbow 3. Patient's elbow extension barrier is engaged (Fig. with lateral hand, grasping distal forearm to pro­ 18.52). vide resistance to isotonic contraction (Fig. 18.54). 4. Patient performs a series of three to five muscle 9. Patient performs three to five repetitions with pro­ contractions for 3 to 5 seconds against operator's gressively increasing resistance by the operator's resistance. medial hand until full elbow extension is achieved (Fig. 18.55). 10. Retest. Figure 18.52. Figure 18.54. Figure 18.53. Figure 18.55.

428 Principles of Manual Medicine 3. Operator introduces supination (Fig. 18.57) and pronation (Fig. 18.58) testing for restriction. Elbow Region 4. Comparison is made with the opposite side. Muscle Energy Technique Restricted Pronation and Supination 5. Treatment of restricted supination has operator's lat­ eral hand stabilizing the flexed elbow and monitor­ 1. Patient sitting on table with operator standing in ing the radial head while medial hand supinates front. forearm to resistant barrier (Fig. 18.59). 2. Operator's medial hand stabilizes patient elbow 6. Patient performs three to five muscle contractions flexed to 90 degrees. Lateral hand grasps distal for 3 to 5 seconds against resistance offered by op­ forearm, wrist, and hand with patient's thumb point­ erator's medial hand. ing vertically (Fig. 18.56). Figure 18.56. Figure 18.58. Figure 18.57. Figure 18.59.

7. Operator engages new supination barrier after each Chapter 78 Upper Extremity Technique 429 patient effort. Elbow Region 8. Treatment of restricted pronation has operator's two hands in same location but engaging pronation bar­ Diagnosis of Radial Head Dysfunction rier (Fig. 18.60). Test 1: Palpation for Asymmetry 9. Patient performs three to five muscle contractions 1. Patient sitting on table, elbows flexed to 90 degrees, for 3 to 5 seconds against operator resistance. forearm supinated and supported in lap. 10. Operator engages new pronation barrier after each 2. Operator stands in front and palpates the radial muscle contraction. head posteriorly with the index fingers and the soft tissues anteriorly with the thumbs (Fig. 18.61). 11. Retest. 3. Operator assesses the symmetric relationship of Note: Restricted pronation and supination of the the radial head to the capitulum of the humerus. forearm combines motion of the humeroradial, prox­ imal radioulnar, and distal radioulnar articulations. 4. In addition to asymmetry, the dysfunctional side is Supination is the most common restriction. usually tender with tension of the periarticular tis­ sues. Figure 18.60. Figure 18.6 1.

430 Principles of Manual Medicine 3. Operator's medial hand grasping distal radius and ulna introduces supination (Fig. 18.62) and prona­ Elbow Region tion (Fig. 18.63). Diagnosis of Radial Head Dysfunction 4. Comparison is made with the opposite side. In dys­ Test 2: Motion of the Radial Head function, asymmetry is identified in the motion be­ tween the radial head and the capitulum. 1. Patient sitting on table with elbow flexed to 90 de­ grees. 2. Operator stands in front with lateral hand palpating the radial head at the humeroradial articulation with the index finger posteriorly and the thumb anteriorly. Figure 18.62. Figure 18.63.

Elbow Region Chapter 18 Upper Extremity Technique 431 Diagnosis of Radial Head Dysfunction 3. Operator's medial hand grasps distal forearm and Test 3: Motion Test introduces supination to the barrier (Fig. 18.66). 1. Patient sits on table with forearms supin.ated. 4. Patient pronates the hand against operator resis­ 2. Patient flexes and brings elbows to front of chest tance for 3 to 5 seconds for three to five repetitions. with medial margins of forearm and hand approxi­ 5. Operator engages new supination barrier after each mated (Fig. 18.64). patient effort. 3. Patient attempts to extend elbows while maintaining 6. With last patient muscle effort, an attempt is made forearms together (Fig. 18.65). to flex the elbow against resistance in addition to pronation. 4. Pronation of the forearm during elbow extension identifies radial head dysfunction. 7. Retest. Elbow Region Muscle Energy Technique Diagnosis Position: Radial Head Posterior Motion Restriction: Supination 1. Patient sitting on table with elbow flexed to 90 de­ grees. 2. Operator stands in front with lateral hand support­ ing the proximal forearm and index finger over the posterior aspect of the radial head. Figure 18.65. Figure 18.64. Figure 18.66.

432 Principles of Manual Medicine 3. Operator controls patient's distal forearm, hand, and wrist between elbow and chest wall. Elbow Region 4. Operator engages barrier of extension, supination, Mobilization with Impulse Technique and slight adduction (Fig. 18.68). Diagnosis Position: Radial Head Posterior 5. Operator performs mobilization with impulse thrust Motion Restriction: Supination in a lateral and anterior direction. 1. Patient sitting on the table. 6. Retest. 2. Operator stands in front grasping proximal forearm with index finger of lateral hand overlying posterior aspect of radial head (Fig. 18.67). Figure 18.67. Figure 18.68.

Elbow Region Chapter 78 Upper Extremity Technique 433 Mobilization with Impulse Technique 3. Operator pronates and flexes patient's forearm Diagnosis while thumb holds radial head posteriorly (Fig. Position: Radial Head Anterior 18.70). Motion Restriction: Pronation 4. When barrier is engaged, an increasing elbow flex­ 1. Patient standing or sitting on table. ion mobilization with impulse thrust is performed. 2. Operator stands in front with medial hand grasping 5. Retest. proximal forearm and thumb of lateral hand over the anterior aspect of the radial head (Fig. 18.69). Figure 18.69. Figure 18.70.

434 Principles of Manual Medicine WRIST AND HAND REGION Wrist and Hand Region Like the elbow, the wrist is not a single articulation but Diagnosis a combination of many. They include the radiocarpal joint with the distal radius articulating with the carpal 1. Patient sitting on table with operator standing in scaphoid and lunate, the distal radioulnar joint, the front. ulnar-meniscal-triquetral, the intercarpal joint, the carpometacarpal joints, and the proximal and distal 2. Patient's arms at the side with elbows flexed to 90 interphalangeal joints. Movements at the wrist region degrees. include dorsiflexion, palmar flexion, adduction (ul­ nar deviation) , abduction (radial deviation) , and 3. Operator introduces palmar flexion (Fig. 18.71), dor­ pronation and supination. Pronation and supination siflexion (Fig. 18.72), ulnar deviation pronated (Fig. occur primarily at the distal radioulnar joint and are 18.73), radial deviation pronated (Fig. 18.74), radial related to similar pronation-supination movement at deviation supinated (Fig. 18.75), and ulnar deviation the elbow region. supinated (Fig. 18.76) testing for restricted range of movement. 4. Muscle strength testing can be performed in the same directions. Figure 18.7 1. Figure 18.72.

Chapter 78 Upper Extremity Technique 435 Figure 18.73. Figure 18.75. Figure 18.74. Figure 18.76.

436 Principles of Manual Medicine 4. Patient performs 3 to 5 second muscle contractions against operator resistance for three to five repeti­ Wrist and Hand Region tions. Muscle Energy Technique 5. Operator engages new barrier after each patient ef­ fort. 1. Patient sitting on table with operator standing in front. 6. Retest. 2. Operator's proximal hand stabilizes patient's distal forearm while distal hand engages resistant barrier of wrist and hand motion. 3. Operator engages resistant barriers in palmar flex­ ion (Fig. 18.77), dorsiflexion (Fig. 18.78), pronated radial deviation (Fig. 18.79), pronated ulnar devia­ tion (Fig. 18.80), supinated radial deviation (Fig. 18.81), and supinated ulnar deviation (Fig. 18.82). Figure 18.78. Figure 18.77. Figure 18.79.

Chapter 18 Upper Extremity Technique 437 Figure 18.80. Figure 18.8 1. Figure 18.82.

438 Principles of Manual Medicine pect of the scaphoid and lunate (Fig. 18.83) and in­ dex fingers grasping volar aspect of the scaphoid Wrist and Hand Region and lunate (Fig. 18.84). Mobilization with Impulse Technique 3. Operator engages dorsiflexion barrier and applies mobilization with impulse thrust by taking patient's 1. Patient sitting on table with operator standing in wrist toward the floor (Fig. 18.85). front. 2. Operator's two hands grasps patient's hand and wrist with operator's thumbs contacting dorsal as- Figure 18.84. Figure 18.83. Figure 18.85.