__Manipulative_Therapy__Musculoskeletal_Medicine

Manipulative Therapy • in the movement of a joint, the point at which ways. Everything that has been said about soft- the barrier is reached tissue lesions applies to active scars. • whether the barrier is normal or pathological. The soft tissues surround the muscular and articular structures everywhere, and need to move A small area of skin can be examined by stretching in harmony with them. The same principle also it between the fingertips (the interdigital folds are applies to the internal organs. For this reason, an example) – a larger area is examined between dysfunctions that are closely associated with the the thumbs and the palms of the hands – always function of joints and muscles can be diagnosed in taking up the slack until the point where the barrier the soft tissue. It is the mobility and elasticity of the is engaged, and always comparing one side with the soft tissues that enable them to move, and there is other (see Figure 6.56). a harmonious interplay between these and movement. This mobility has been little studied, but 4.3.2 Subcutaneous tissue if it is disturbed, the neuromusculoskeletal system and fasciae cannot function normally. To examine – and also treat – subcutaneous con- 4.3.3 Trigger points nective tissue, including that in scar tissue and shortened muscles, the practitioner should create Palpation is the means of diagnosing the most char- a fold (see Figure 6.57) and stretch (not squeeze) acteristic change, the myofascial trigger point (TrP). it until the barrier is reached. If it is not possible Various terms for this exist in the literature; it is to create a fold, slight pressure alone is enough to known, for example, under the names myogelosis, arrive at this barrier. fibrositis, or local hypertonus. Here we shall apply the definition and terminology given by Travell & In examining fasciae, the most useful character- istic to look for is their mobility against the under- Figure 4.1 • Flat palpation of TrPs. (A) Taut muscle bundle lying layer, that is mobility of the subcutaneous (detected by palpation). (B) Local twitch response. layer against the muscle and especially of the mus- cle against the bone. This mobility is examined as follows: • The muscles of the back in the cranial or caudal direction, with the patient prone. • The gluteal muscles in the cranial direction. • The muscles around the thorax in the dorsoventral direction. • The muscles of the neck around the longitudinal axis of the neck. • The muscles of the limbs around their longitudinal axis (pp. 232–234). The scalp also behaves in the same way as a fascia relative to the skull. Resistance (pathological barrier) is often discov- ered at periosteal pain points when trying to shift the subperiosteal tissue in various directions, and an easing of the pain is achieved when mobility is restored. This applies particularly at the attach- ments of tendons and ligaments. Bones that are linked not by joints but by con- nective tissue also move relative to one another. Examples are the metacarpal and metatarsal bones, and the fibula relative to the tibia. Testing of their mobility relative to each other often reveals path- ological barriers, which are treated in analogous 94

Diagnosis of dysfunctions of the locomotor system Chapter 4 Simons (1999), who describe the TrP as a hyperir- inhibition, ‘spray and stretch’ or simple pressure, ritative spot in skeletal muscle, which is associated the problem usually disappears instantly, showing it with a hypersensitive palpable nodule in a taut band. to be a functional, reversible disturbance. A twitch reaction can be elicited by snapping palpa- tion which can be registered by electromyography. Recent studies show that the hardening derives At the same time the patient feels characteristic from the part of the muscle fiber that is stretched, pain, which is accompanied by signs from the auto- and that the nodule of contracted muscle is the nomic nervous system (see Figures 4.1 and 4.2). actual myogelosis. These changes have also been demonstrated histologically (Windisch et al 2001), A muscle bundle in which there are TrPs con- findings which indicate that there are also TrPs that tains some muscle fibers that are in a state of con- are chronic and irreversible. These respond little traction, alongside others that are uncontracted to the reflex methods mentioned above, requiring (relaxed). If we succeed in relaxing the contracted instead aggressive therapy such as needling (see fibers, using post-isometric relaxation, reciprocal Chapter 6, p. 248). Figure 4.2 • Examination of myofascial TrPs. (A) Flat snapping palpation. (B) Palpation using pincer grip. 95

Manipulative Therapy Myofascial TrPs can also be studied objectively Pain points can also be found in the region of by means of electromyography (EMG) using the vertebral and limb joints wherever these are monopolar needle electrodes. This method has suc- accessible to palpation. At the spinal column this is cessfully been used (Hong & Yu 1998; Hubbard particularly so in the cervical region. They are also & Berkoff 1993; Simons 2003) to show that what found at the sternocostal joints and at the temporo- they were observing were end-plate potentials origi- mandibular joint. nating in TrPs. Table 4.2 lists the most important periosteal Two kinds of TrP can be distinguished: active and points and their clinical significance. latent. Active TrPs are those that give rise to pain, especially referred pain. Latent TrPs do not give rise 4.3.5 Radicular syndromes to spontaneous pain, but are painful on palpation and participate, often decisively, in chain-reaction As already stressed, radiating pain alone (even mere patterns. paresthesia) are not sufficient for the diagnosis of a radicular syndrome. Conclusive evidence of radicu- Myofascial TrPs are not the only pain points lar syndrome is provided by neurological deficit, that can be palpated; points of tenderness can also the main signs being: be found at the periosteum, in joint capsules, at • hypesthesia attachment points of tendons and ligaments, and • localized hypotonia and/or atrophy within muscles in the absence of any area of hard- • muscle weakness ness. Since the hardened area forms part of the def- • decreased tendon and periosteal reflexes inition of a ‘TrP’ the term cannot strictly be applied • increased idiomuscular excitability. in this case and instead it is best to use the term ‘tender point’ (TeP). These can also be the point of Unless these signs are present we may suspect root origin of referred pain. If the TeP is the attachment lesion, but this requires further proof. of a tendon, this is usually closely associated with the TrP of the corresponding muscle, the actual There are certain signs, however, which strongly cause of the pain at the tendon attachment. suggest radicular syndrome, without being positive proof. These are if the pain and paresthesia radiate Characteristic muscular pain points are also down to the fingers (or toes), especially if objec- present in system-wide disease, as for instance in tive examination also finds increased resistance to fibromyalgia syndrome, but a particular feature of stretching at the interdigital fold, and difficulty in these is that there are no areas of hardness. There the mobility relative to each other of the metacar- is also no twitch response, and these pain points do pals (metatarsals) in the corresponding segment. If not respond to reflex relaxation. the straight-leg raising test produces a finding below 45°, this also raises suspicion. Another sign is when Table 4.1 lists some muscle TrPs that are impor- the patient reports that control of the limb feels tant for their diagnostic implications. different from usual. 4.3.4 Periosteal pain points The individual radicular syndromes are dealt with in Section 7.8.2. There is disagreement as to the Numerous pain points on the periosteum are also dermatomes, and some individual variation has to be found in most cases of dysfunctions of the locomo- expected. The scheme we observe, particularly for tor system. The appearance and resolution of these the trunk, is that of Hansen & Schliack (1962) (see pain points – as well as their treatment – play an Figure 4.3A–C and E); for the lower limbs, that of important role in the course of the dysfunction. Keegan (1944) (see Figure 4.3D). In radicular syn- dromes and herpes zoster, the authors work on the Many periosteal pain points are sites of attach- basis of Head zones (referred pain) findings. There ment of tendons or ligaments closely associated is very credible evidence to support the existence of with TrPs in the muscles, and have the effect of the cervicothoracic and the lumbosacral hiatus; this producing increased tension there. This is called term describes the fact that segments C5–T1 are enthesopathy. On examination, mobility testing of only found on the upper limbs and segments L2–S2 the subperiosteal tissue against the underlying bone only on the lower limbs. This means that on the reveals characteristic resistance in one or more trunk, segment C4 is followed immediately by T2, directions on the affected side as compared with the healthy side. 96

Diagnosis of dysfunctions of the locomotor system Chapter 4 Table 4.1 Muscular trigger points Muscle Clinical significance Soleus Pain at the Achilles tendon Quadriceps femoris Lesion in L4 segment; pain at the upper edge of the patella; ‘pseudo hip and/or knee pain’ Tensor fasciae latae Pain at the hip and at the superior border of the patella Thigh adductors Lesion in the hip joint; TrP in pelvic region Iliacus Lesion in S1 segment; coccyx; pseudovisceral pain Piriformis Lesion in L5 segment; ‘hip pain’ Ischiocrural muscles Lesion in segments L5, S1 (straight-leg raising test positive); pain at the ischial tuberosity and head of the fibula Levator ani Pain at the coccyx Coccygeus Low back pain; many chain reactions due to pelvic floor dysfunction Erector spinae Back pain in the corresponding segment Psoas major Pseudovisceral pain; restricted rotation of trunk Quadratus lumborum Acute lumbago; restricted rotation of trunk Rectus abdominis Tenderness at xiphoid process and pubic symphysis; pseudovisceral pain Pectoralis major Pain at chest wall; pseudocardiac pain Pectoralis minor Tender coracoid process, sternocostal joints, and superior thoracic aperture Diaphragm Chest pain; cervical syndrome Transverse (middle) part of Cervicobrachial and radicular syndromes trapezius Subscapularis Pain in the shoulder; in the arm; at the lesser tubercle; pseudocardiac pain Supraspinatus, infraspinatus Pain in the shoulder; in the arm; at the greater tubercle Supinator, biceps brachii, Radial (lateral) epicondylopathy forearm extensors Triceps brachii Pain in the axilla; epicondylopathy Finger flexors Ulnar (medial) epicondylopathy Descending (superior) part of Neck pain; headache and shoulder pain trapezius Levator scapulae Shoulder pain; headache; neck pain Scalene muscles Pain at Erb’s (supraclavicular) point; at the superior thoracic aperture Craniocervical extensors Upper cervical syndrome Sternocleidomastoid All cervical syndromes Masticatory muscles Earache; upper cervical syndrome 97

Manipulative Therapy Table 4.2 Clinically important periosteal points Periosteal point Clinical significance Head of metatarsals Metatarsalgia in the case of splay foot; also in the case of tarso-metatarsal restriction Calcaneal spur TrP of deep plantar flexors Head of fibula TrP in biceps femoris, tibialis posterior; restriction of fibular head; forward-drawn posture Pes anserinus (tendinous expansions of TrP in the hip adductors; osteoarthritis of hip joint muscles at medial border of tuberosity of tibia) Insertion of collateral ligament Lesion of a meniscus in the knee Superior border of patella TrP in quadriceps femoris and tensor fasciae latae Ischial tuberosity TrP in the ischiocrural muscles Posterior superior iliac spine (PSIS) Frequent but not specific Lateral border of the pubic symphysis TrP in the hip adductors; hip Superior border of the pubic symphysis TrP in the rectus abdominis; forward-drawn posture Coccyx TrP in the levator ani, tension in the gluteus maximus Iliac crest TrP in the gluteus medius and quadratus lumborum Pain at spinous process Hypermobility with TrP in the erector spinae muscles Spinous process T4—T6 Weakest region of erector spinae with TrP Spinous process of C2 Lesion in segments C2—C4; TrP in levator scapulae Xiphoid process TrP in rectus abdominis Ribs in the medioclavicular line TrP in pectoralis minor Ribs in the axillary line TrP in the serratus anterior Sternoclavicular joint TrP in the scalene muscles and superior parts of the pectoralis muscles Sternum just below 1st rib Sternocostal joint of 1st rib Angle of ribs TrP in subscapularis; restriction of ribs Sternal end of clavicle TrP in sternocleidomastoid Pain at Erb’s point TrP in scalene muscles; radicular syndromes Transverse processes of atlas TrP in sternocleidomastoid Posterior margin of foramen magnum Restriction of retroflexion at C0/C1; headache; migraine Nuchal line Referred pain from the short craniocervical extensors, insertion of splenii capitis muscles Condylar process of mandible TrP in masticatory muscles Hyoid TrP in digastric and mylohyoid muscles Styloid process of radius Lesion of the radioulnar joint Radial (lateral) epicondyle TrP in biceps, supinator, extensor muscles of the fingers Ulnar (medial) epicondyle TrP in flexor muscles of the fingers Attachment of deltoid TrP in deltoid; frozen shoulder 98

Diagnosis of dysfunctions of the locomotor system Chapter 4 Figure 4.3 • The dermatomes. (A) Ventral aspect. (B) Dorsal aspect. (C) Lateral aspect of the trunk (after Hansen & Schliack 1962). (D) Lateral aspect of the lower limb (after Keegan 1944). (E) The perineum (after Hansen & Schliack 1962). 99

Manipulative Therapy patient. The muscle contraction is then described as concentric, isometric, or eccentric. If testing is not performed isometrically, the movement against resistance can be performed isotonically (i.e. main- taining the same force) or isokinetically (i.e. at con- stant speed). The object of testing is to examine not only the force produced by the muscle but also the provocation of pain, and coordination. Figure 4.3 • (Continued). 4.4.3 Passive mobility and L2 by S2. These dermatome charts regularly First and most obviously, the testing of passive show a ‘step’ on the trunk, approximately on the movement examines joint function. Very consid- axillary line, which marks the boundary of the area erable changes in joint function may be found, supplied by the dorsal ramus and ventral ramus of however, as a result of muscle tension. Findings the spinal nerve, and which is usually clearly observ- fall into three categories: normal mobility, move- able in herpes zoster (see Figure 4.3). ment restriction, and hypermobility; this relates both to functional movement and to joint play (see 4.3.6 Conclusion Chapter 2). There are many functional and reflex changes that The following changes should be looked for dur- correspond to nociceptive stimulation of the skin, sub- ing examination: cutaneous tissues, and muscles, at the periosteum and the points of attachment of tendons and ligaments. • Restriction of the movement of a joint as These changes can be diagnosed clinically and can also compared with the contralateral joint or the be registered instrumentally, by means of thermogra- neighboring spinal segment. phy, measurement of electrical resistance, and EMG. These present a means of precise diagnosis by straight- • Increased resistance during movement, forward methods, so enabling targeted treatment. particularly during the examination of joint play. 4.4 Mobility testing • Resistance to springing in the end-of-range This section will deal with general principles only. The position (i.e. at the barrier). Note whether this regular procedure should be to examine active and resistance is physiological or pathological, or passive mobility and movement against resistance. whether it is found during functional movement or on testing of joint play. 4.4.1 Active mobility Figar & Krausová (1975) were able to measure the resistance to springing using a resistance transducer. This was done in a restricted cervical segment before treatment, during manipulation, and after treatment (see Figure 4.4). Active movement includes muscle activity and joint mobility in the absence of any influence on the part of the examiner. This corresponds to voluntary movement. 4.4.2 Movement against Figure 4.4 • Measurement of force during the examination resistance of side-bending of the cervical spine: increased resistance in the restricted segment (left); resistance during manipulation The force applied by the examiner may be less of the restricted segment (center); equal resistance after than, equal to, or greater than that used by the manipulation (right). The peak preceding each curve is the gauge of 400 g (after Figar & Krausová 1975). 100

Diagnosis of dysfunctions of the locomotor system Chapter 4 The spinal column 4.5 Examination of the pelvis It is important when examining the spinal column Examination of the pelvis is usually preceded by to discover which of two neighboring segments is screening assessment of the lower limbs, in particu- restricted. The question as to which of the paired lar since problems there can be the cause of pelvic joints is restricted is less important because the obliquity. determining factor is the direction in which the treatment is applied. 4.5.1 Screening examination The lumbar spine Inspection It helps to picture the joints as positioned with the Points to observe are: articular facets fully covering each other in retroflex- • deviation to one side ion, but as being in their end position in anteflexion. • unilateral prominence • height of the buttocks If anteflexion of a spinal joint is restricted, the • irregularities of the rhomboid of Michaelis, spine deviates to the restricted side in anteflexion. If retroflexion is restricted, then also the spine devi- which is formed by the dimples above the ates to the restricted side during retroflexion (see PSISs, the spinous process of L5, and the Figure 4.5). However, the deviation to one side that uppermost point of the intergluteal cleft. is observed is frequently the result of antalgic pos- Deviation of the upper end of the intergluteal cleft ture in order to relieve reflex pain, for example in to one side is the result of asymmetrical positioning radicular syndromes. of the inferior end of the sacrum and coccyx. The cervical and thoracic spine Palpation In the cervical and thoracic spine, it is (in theory) Palpation begins at the iliac crest, which the examiner possible to discover on which side the restricted can find by sliding the edge of his forefinger down- joint is by examining side-bending first in retroflex- ward from the patient’s ribs. The reason this is impor- ion and then in anteflexion. tant is that the iliac crest is often considerably higher than might be expected from the localization of the If side-bending is more restricted in retroflex- contours of the buttocks (often it is even just below ion, then the joint on the side to which the patient the costal arch). A spirit level can be used to confirm is bending is affected; if side-bending is more the horizontal position of the pelvis (see Figure 4.6). restricted on the opposite side, then it is the joint on the opposite side that is restricted. Figure 4.5 • Schematic drawing of side-bending of two Figure 4.6 • Comparison of the level of the iliac crests lumbar vertebrae. using a spirit level. 101

Manipulative Therapy If the pelvis deviates to one side, this creates A check can be made at the same time by placing the impression that it is higher on the side toward each of the patient’s feet separately onto a balance which it deviates. This is because the examiner can scale, and placing a heel insert under the shorter leg easily contact the top of the iliac crest on the side to equalize the length. This produces one of three to which the pelvis deviates, whereas on the other possible results: side the superior border of the iliac crest is hid- den under the costal arch and has to be searched 1. The difference remains the same. for. Working in a medioparavertebral direction, the examiner can then locate the PSISs. 2. The difference is equalized. The most reliable way to perform the palpation 3. The difference increases. of the PSIS is from laterally and below, since this corresponds to the shape of the spines. The same The patient should be asked each time whether it is approach is suited to the palpation of the anterior more comfortable with the heel insert, or whether iliac spines. it feels awkward. If the patient finds at the very least that the (unaccustomed!) heel insert does not If both the anterior and posterior iliac spines are feel awkward, the effect is seen to be favorable. at the same level on both sides, the pelvis is hori- Equalization of length can then be recommended, zontal in the neutral position. A point worth men- unless of course the patient has one flat foot. An tioning here is that the rise in obesity has made X-ray check (with patient standing) is recom- palpation more difficult in many cases, and this is mended to confirm the difference in leg length. especially true when palpating the posterior iliac spines. 4.5.3 Pelvic distortion Deviation of the pelvis to one side can be the This is a curious phenomenon which must be result of a difference in leg length; in this case the distinguished from pelvic obliquity. The dorsal pelvis deviates to the higher side. More frequently inspection usually shows the pelvis to deviate to the it is the result of (usually minor) scolioses, the pel- right, with the appearance of being slightly rotated vis being horizontal. In the case of true pelvic obliq- to the left. uity the iliac crest and anterior and posterior iliac spines are lower on one side. Palpation of the iliac crests may show their height to be symmetrical laterally, but as the exam- 4.5.2 Pelvic obliquity iner’s palpating fingers (the edge of the forefingers) advance medially and approach the PSISs, they do Measurement of leg length is more difficult than not meet: one of the iliac spines (usually the right) might be thought, because the head and neck of lies higher than the other. This can be confirmed by the femur are not externally evident. Pelvic obliq- direct palpation of the PSIS (from below). uity is therefore the most reliable clinical sign of difference in leg length, unless there is a measur- The finding for the anterior iliac spines is the able difference in the length of the lower leg. How- converse: here the right anterior superior iliac ever, this may be compensated by the length of the spine (ASIS) is usually lower than the left. The thigh. two ilia seem to be twisted relative to each other. There is always a discrepancy when the position of Where there is a difference in leg length the the ASIS, PSIS, and the iliac crests are compared. pelvis is generally seen to deviate to the higher side However, the difference at the anterior or posterior if the patient stands with weight equally distrib- iliac spines, and at the iliac crests, can vary, so that uted on both legs. The shoulder is typically seen to it is not always easy to distinguish pelvic distortion be lower on the side where the pelvis is higher. The from pelvic obliquity, especially if both changes are findings can be tested clinically by placing a block simultaneously present. In such cases it is advisable or heel insert under the shorter leg. When this is to begin by treating the pelvic distortion and then done the pelvis becomes horizontal and no longer to repeat the process of measurement. deviates to one side, and the shoulders level out. However, this effect only takes place if any sig- Another feature of pelvic distortion is the over- nificant movement restrictions have already been take phenomenon. On anteflexion the PSIS that resolved. is lower (usually the left) momentarily ‘overtakes’ the right. After 10–20 seconds the finding reverts to what it was before. Cramer’s (1965) analysis of the 102

Diagnosis of dysfunctions of the locomotor system Chapter 4 mechanism involved (see Figure 3.12) appears best Testing for ‘overtake’ to match our understanding of what is happening. This also leads us to expect findings such as exter- Testing for the overtake phenomenon, as described nal rotation of the leg on the side of the ilium that above in connection with pelvic distortion, is more is tilted so as to be lower posteriorly. difficult to assess in patients with a degree of adi- posity. The changes observed in overtake, unlike The aspect that now seems to us to be more sig- those in pelvic distortion, are not transitory, but nificant is that of muscular dysfunctions which are remain during anteflexion. Bear in mind that it associated with pelvic distortion and accompanied is not possible to retain hold of the posterior iliac by asymmetrical muscle function. Pelvic distortion spine, since it disappears under the skin during is always secondary, and the cause is usually located anteflexion; it does not present the same surface in in the atlanto-occipital and atlantoaxial joints (see anteflexion, and of course, if the restriction is bilat- Chapter 2); the findings at the muscles are incon- eral the test fails completely to reveal it. sistent. 4.5.4 Pelvic tilt The spine sign test A third condition can be distinguished in addi- The ‘spine sign’ is a more successful test to use with tion to pelvic obliquity and pelvic distortion; this non-adipose patients, following the method devised is pelvic tilt. To examine for this it is necessary to by Dejung (2003) (see Figure 4.7). The examiner palpate the anterior and posterior superior iliac sits behind the standing patient, placing one thumb spines. The line between them is normally horizon- on the posterior inferior iliac spine and the other on tal. In patients with a drooping belly the pelvis is the spinous process of L5. The patient is then told usually tilted forward, and in patients with tension to bend the knee and lower the hip on the side being of the gluteal and ischiocrural muscles it is tilted backward. 4.5.5 Restriction of the sacroiliac joint There is still a frequent tendency to overestimate Figure 4.7 • The ‘spine sign.’ the importance of restriction of the sacroiliac joint. One reason for this is the fact that there are no muscles between the sacrum and ilium, yet despite this, restrictions here were a relatively fre- quent finding, and this led to the assumption that this was a ‘pure’ joint restriction, with no involve- ment of muscle spasm or TrPs. However, this view has proved untenable, because it is often possible to release ‘indirect’ restrictions in the case of TrPs in the biceps femoris (head of the fibula), pelvic floor, piriformis muscle, and elsewhere, after which it is usually found that restrictions of the sacroiliac joint are also resolved. Such chain reactions indi- cate that most restrictions of the sacroiliac joint are secondary. There is also a practical problem: diagnosis usu- ally relies on palpation of the mobility of bony structures, which often lie under a considerable layer of fat and connective tissue. This reduces the reliability of comparative examination. 103

Manipulative Therapy Figure 4.8 • Springing test of the ilium against the sacrum Figure 4.9 • Springing test of the ilium against the sacrum with the patient supine, one leg flexed. with the patient in the side-lying position. examined. The normal finding is that the distance The patient is side-lying with the uppermost leg between the examiner’s two thumbs increases: the bent, knee resting on the treatment table. The thumb on the iliac spine moves caudad and later- examiner’s caudad arm should be placed so that his ally while the thumb on the spinous process of L5 forearm lies gently on the region of the ASIS and remains still. If there is restriction, the distance does iliac crest, and is angled to point ventrally, medi- not increase and the examiner can feel the laterally ally, and cranially. Gliding pressure with a springing directed pressure of the spinous process of L5. movement is then exerted on the ala of the ilium in the same direction. This has the effect of producing Springing test with patient supine a dorsal gapping (distraction) of the sacroiliac joint. The thumb of the examiner’s other hand senses the The remaining examination methods are all ‘spring- springing motion between the PSIS and sacrum. ing’ tests. The springing test with the patient supine (see Figure 4.8) is much used. The examiner Springing test with patient prone stands by the table and grasps the patient’s contral- ateral leg (which is bent, while the other remains The superior portion of the sacroiliac joint is exam- extended) and adducts her leg until the pelvis ined with the patient lying prone. The practitioner begins to follow. This engages the barrier and sets takes hold of the patient’s ASIS from the ventral up the position from which the test is performed. side by curling the fingers of one hand around With the hand that is guiding the patient’s knee, it, then lifts it slightly on taking up the slack, and the examiner exerts pressure in the longitudinal shakes it upward with a springing movement. axis of the thigh in the direction of the PSIS, to The thumb of his other hand is meanwhile used take up the slack. The examiner then exerts spring- to palpate the sacrum, to sense whether it moves ing pressure. The springing is palpated with the together with the ASIS. It will only do so if the hand under the posterior iliac spine. Adduction (to joint is restricted (see Figure 4.10). the barrier) is usually measurably restricted on the affected side. This is a useful test to use as a screen- The inferior portion of the sacroiliac joint is exam- ing examination and is simple to perform. ined by applying pressure with a springing movement to the inferior apex of the sacrum with the patient Springing test with patient in the prone. Mobilization techniques, which are described side-lying position in Chapter 6, can also be used for examination. Test technique according to Rosina This test produces a springing response of gapping The ‘traditional’ tests described so far all involve (distraction) of the joint, so that the technique is some degree of unreliability in view of the great also suitable for use in therapy (see Figure 4.9). number of obese patients. Lewit & Rosina (1999) 104

Diagnosis of dysfunctions of the locomotor system Chapter 4 Figure 4.10 • Springing test with the patient prone, to side to which the head is turned. Only very slight examine the superior part of the sacroiliac joint. pressure from above is required in this test. The layer of fat on the iliac crest does not influence the has developed a technique that is also reliable when result (Lewit & Rosina 1999). The effect is absent examining such patients. if there is restriction of the sacroiliac joint. Lewit & Rosina (1999) observed that, when The mechanism involved in this test is unknown. the subject’s head is turned, the ASIS is displaced Although the difference in height of the two iliac caudally on the side toward which the head turns. crests is very noticeable, no difference in their Following this observation we found that the oppo- position can be demonstrated radiologically. The site happens at the posterior iliac spines; in other effect must therefore be due to a shifting of soft words, that pelvic distortion occurs. On the side to tissues, producing a palpatory illusion (see Figure which the head turns, the posterior border of the 4.11). iliac crest also rises at the same time as the poste- rior iliac spine. On anteflexion with head turned, it is even pos- sible to observe a transitory overtake phenomenon For this test the patient is standing. The exam- on the side that lies lower. There is no movement if iner places the edges of the forefingers of both the sacroiliac joint is restricted. (No explanation for hands on the iliac crests, approaching them from this has been found.) the lateral aspect of the iliac crests in a medial direction just above the PSIS. The patient is then Pain points asked to rotate her head to the side. There may be pain points at the upper margin of After a few seconds’ latency, in a normal subject the sacroiliac joint, at the lower end of the joint, the examiner finds that the forefinger rises on the and also, more rarely, in the iliacus muscle, at the attachment point of the adductors at the symphysis (slightly positive Patrick’s sign) and above the pos- terior iliac spine, although these findings need not be present. The position of the pelvis is usually normal in cases of restriction of the sacroiliac joint. The relevant factor is simply the movement restriction, the sign of which is the poor springing of the joint. Figure 4.11 • Palpatory illusion. (A) The ischia and ischial tuberosities are seen to be symmetrical, but to palpation they seem extremely asymmetrical. (B) The bones of the pelvis are unchanged; what has changed is the position of the examiner’s thumbs. 105

Manipulative Therapy 4.5.6 Shear dysfunction 4.5.7 Outflare and inflare (Greenman) (upslip and downslip) Greenman and Tait (1986) described an apparently isolated change in the position of the ASISs, which When there is tenderness at the superior border caused a distortion of the triangle formed by these of the pubic symphysis and tenderness to pressure iliac spines and the navel (see Figure 7.3). Our at the ischial tuberosities, the usual finding on pal- experience shows this change to be clinically impor- pation is that the medial end of the pubic bone is tant, and it is discussed in more detail in Chapter higher on the side that is painful, and that the ischial 7 (see Section 7.1.8). One iliac spine (usually the tuberosity is lower on the side where the gluteus right) is usually found to be flatter and its distance maximus is tense. Clinically we have found these from the navel to be greater (‘outflare’) than the to be signs of a syndrome associated with tension other (usually the left), which is more prominent (TrPs) of the rectus abdominis muscles, forward- and closer to the navel (‘inflare’). At the same time, drawn posture, tension of the erector spinae and palpation shows tonus in the lower part of the neck extensors, gluteal muscles, and biceps femoris. abdomen on the flattened side to be (relatively) decreased, as compared with the other side. The sacroiliac joints do not themselves play any significant role in our experience. Curiously, In this case the finding is certainly not a palpa- the position of the symphysis and ischial tuberosi- tory illusion, because the tissue layer over the ante- ties appears to be symmetrical when the patient is rior iliac spine is very thin, and the asymmetrical standing. Still more remarkably, after treatment positioning is clearly visible in slim patients. In the palpatory finding had normalized but the X-ray adipose patients it is necessary to palpate it, since showed no evidence of change even though palpa- otherwise a clinically important lesion would be tion had found changes of up to 2 cm at the ischial missed; one that is easy to treat. tuberosities. The clinical significance (i.e. the effect of treat- To try to find an explanation for this, X-rays ment) was for a long time a mystery, but we have were taken showing the examiner’s thumbs as they recently been able to establish (Lewit & Olšanská, palpated before and after treatment. The result was 2005) that this change is always associated with an clear: what had changed was not the position of the asymmetrical internal rotation of the hip joint. This bones, but that of the examiner’s palpating thumbs rotation is restricted on the side of the inflare and (see Figure 4.11). In this way we were able to instantly becomes normal following treatment. obtain evidence to document a ‘palpatory illusion.’ 4.5.8 The pelvic floor and It must be remembered that bones are often coccygeus muscle overlain by a layer of soft tissues, including muscles, and this may sometimes be considerable. If painful Examination of the pelvis also includes palpation of disorders produce a change in tension in these tis- the pelvic floor, the coccygeus muscle. sues, that must exert an effect on the position of the fingers palpating the site. In the particular case In 1989, Silverstolpe described a syndrome described here, this would be taking place at the which he called ‘pelvic dysfunction.’ He performed attachment of the rectus abdominis on the pubic the examination by exerting pressure next to the symphysis and that of the biceps femoris at the coccyx, in the direction of the sacrotuberous liga- ischial tuberosity. ment, and this had the effect of provoking intense pain. The types of pain reported by the patients The general principle to be drawn is that if there usually varied considerably and included visceral is asymmetry of tension in the soft tissues, a devia- pain. In these patients he found extremely pain- tion in the position of the underlying bone (e.g. ful TrPs in the region of the thoracolumbar erector spinous processes) can generally be palpated; these spinae muscles, and snapping palpation of the prone are then found to be ‘repositioned’ once tension has patient produced dorsiflexion of the lumbar spine been balanced. The same effect can be observed if and pelvis. By maintaining the (painful) pressure in cotton wool or foam rubber of varying thickness is the direction of the sacrotuberous ligament he was wrapped around the corners of a matchbox and the able to resolve most of the symptoms these patients object is then palpated with eyes closed: the shape were experiencing (see Figure 4.12). of the matchbox is felt to be distorted. 106

Diagnosis of dysfunctions of the locomotor system Chapter 4 misleading; only pain experienced at the tip of the coccyx is diagnostically useful. Patients often report pain at the coccyx when what they are experiencing is in fact referred pain from other pelvic structures, in which case pain points will also be found laterally (pelvic floor, lower sacroiliac joint, etc.). In addition, a HAZ is often found in the sac- ral region, resembling a cushion of fat. There are often concomitant findings in the straight-leg rais- ing test and Patrick’s test and a TrP in the iliacus muscle. In the history, the patient may report pain on sitting. 4.5.10 Ligament pain Figure 4.12 • Palpation of the coccygeus muscle from a A condition known as ‘ligament pain’ (Barbor 1964, paracoccygeal position in the direction of the sacrotuberous Hackett 1956) tends to be found where there is ligament. sustained static load; this may be associated with sacroiliac restriction, especially if there is hypermo- If this palpation provokes pain, the examiner will bility. It particularly involves the iliolumbar and the sense distinct resistance; if the pressure is main- sacroiliac ligaments. tained, the resistance resolves. What this palpation has found is a TrP in the coccygeus muscle, the pel- The key to diagnosis is the ability to provoke vic floor. The great significance of this finding is that pain, and the following technique is used. The the pelvic floor forms part of the deep stabilization patient lies supine on the table with one leg bent system which gives rise to effects in the form of at the hip and knee. The examiner should stand chain reactions in the entire locomotor system. This beside the table. He grasps the patient’s bent leg at explains the importance of finding this TrP. the knee and adducts the thigh, at the same time exerting pressure along the axis of the thigh to take up the slack (see Figure 4.13). 4.5.9 The painful coccyx A coccyx that is tender to pressure should never be Figure 4.13 • Testing of ligament pain. ignored, because it is a considerably more frequent contributory cause of low-back pain than coccygo- dynia. Palpation of the coccyx should therefore be carried out when diagnosing low-back pain. Palpation of a painful coccyx can be more diffi- cult than might be expected. The problem here is one of myotendinosis (insertion tendopathy) result- ing from tension of the gluteus maximus and a TrP in the levator ani, which can be palpated quite eas- ily via the rectum. A tender coccyx is always ventrally curved. The pain point is typically on the ventral surface of the tip of the coccyx, so it is necessary to feel around for the ventrally curved coccyx, which pro- duces resistance from the tense gluteus maximus. Mere touch is enough to provoke pain. Any strong pressure here is always painful and therefore 107

Manipulative Therapy At about 90° of hip flexion, the maintenance of not only identify movement restriction, but also local adduction tests primarily the iliolumbar ligament, hypermobility, which is seen as a sharp lordotic bend and the patient will feel pain in the groin. At a hip on retroflexion, often in the inferior-most part of flexion of 60–70° it is mainly the sacroiliac ligaments the lumbar spine or at the thoracolumbar junction. that are tested. This time, as the examiner maintains If retroflexion is painful and inhibited without actual the adduction, the pain radiates down the leg in the restriction, this may be a sign of TrPs in the rectus S1 segment. It is important to ensure before testing abdominis muscle with tenderness to pressure at the the ligaments that there is no sacroiliac joint or lum- pubic symphysis, or pain at the spinous processes. bosacral restriction. The localization of the provoked pain is the main criterion for diagnosis. Side-bending Closer examination will show that in these When examining side-bending, the examiner needs patients adduction is restricted on the painful side. to ensure that the patient’s movement does not It is easy to measure this by looking at the distance deviate in the forward or backward direction. He between the adducted knee and the table. This should then compare on both sides how far down degree of increased resistance cannot be due to liga- the leg the patient’s arm extends when side-bending ments alone. The fact that it is often resolved using with arms and fingers extended. (Do the fingertips post-isometric relaxation (PIR) suggests a muscu- reach as far as a point above, or – more frequently – lar cause. The authors quoted above treat ligament beyond the knee?) As the patient bends, the exam- pain with injections of hypertonic solutions at the iner notes whether the spinal column arches over in attachments of the ligaments, and we have also an even curve, or with a sharp bend at some point, treated this type of pain by means of straightfor- or whether it remains stiff. ward needling. This we follow with PIR and recip- rocal inhibition (RI), both of which are suitable A further aspect to look for is rotation synkine- methods for use in self-treatment. sis, in which the pelvis rotates in the opposite direc- tion to the side-bending as soon as the side-bending If movement restriction is found on testing of the movement reaches the thoracolumbar junction. iliolumbar or sacroiliac ligaments, this is due to This movement is evidently determined by the muscle tension, which can be treated by PIR and RI. rotation of the lumbar spine during side-bending. Anteflexion 4.6 Examination of the When examining anteflexion with the knees held lumbar spine straight, the examiner should test how close to the floor the patient’s fingertips reach with knees fully 4.6.1 Screening examination of extended, and at the same time note the arch of active movement the lumbar spine and the position of the pelvis; it is important to distinguish whether anteflexion Retroflexion happens mainly at the pelvis with minimal lumbar kyphosis, or whether the main action is flexion of Examination of the lumbar spine can properly the lumbar spine with shortened ischiocrural mus- be said to have begun with that of the pelvis. The cles. Certain kinds of flattening of the bend during examination starts with the patient standing, ideally anteflexion are common and can be normal vari- in retroflexion, and the examiner should not only ations. These occur at the thoracolumbar junction assess the overall range of motion but also observe and at the lumbosacral junction. whether the movement extends into the lumbosacral segment. In normal cases this is easily seen, because The examiner compares the prominence of the dorsiflexion is greatest in the lumbosacral segment, transverse processes as well as that of the erector while the excursion in other directions of movement spinae muscles that are stretched over them. This is greatest in the L4/L5 segment. The examiner can provides a sign of rotation as found in scoliosis, or possible deviation to one side such as happens in radicular syndromes. When measuring the distance between the reach of the fingertips and the floor it is important to note 108

Diagnosis of dysfunctions of the locomotor system Chapter 4 not only an increased fingertip–floor distance but disks), so that it is important to avoid testing the also a negative measurement. If the patient is able spinous processes at the same time. The thenar and to place the flat of her hand on the floor, this is a hypothenar eminences of one hand are placed on sign of hypermobility. the transverse processes, ‘bridging’ over the spinous process. The examiner exerts very slight pressure The patient’s body proportions should be noted, with the extended arm to take up the slack, fol- looking at the length of the trunk, legs, and arms. lowed by ‘springing’ pressure (see Figure 4.14). Anteflexion can be painful, even when there is no Another method is to place the tips of the sec- restriction. One reason is the ‘painful arc’ described ond and third fingers of one hand on the transverse by Cyriax (1978): during anteflexion, often shortly processes from the caudal direction, then using the after beginning to bend forward, the patient feels ulnar (medial) edge of the other hand to take up considerable pain. An evasive movement of the the contact, then taking up the slack and applying spinal column can often be seen, as if the patient the springing pressure (see Figure 4.15). is working around some obstacle, after which the action continues quite normally. On straighten- The springing test is not totally specific to a ing again the pain reappears and there is an evasive particular segment. If there is joint restriction, reaction at the same point. This sign indicates disk increased resistance (an absence of springing) is felt herniation. It is also possible for the patient to carry after the slack has been taken up, and the patient out the anteflexion movement normally but experi- may also experience pain. However, if the patient ence the pain on straightening. This indicates joint feels pain when springing of the segment is normal, restriction in retroflexion. this is a sign of disk pain. If the fingertip–floor distance is increased, move- If the springing test produces pain in the lumbar ment restriction of the lumbar spine is not the only spine and joint restriction is either absent or has possible cause, since this finding may also be linked been resolved, this indicates a disk lesion. to a positive straight-leg raising test. Therefore, if an increased fingertip–floor distance is found, the exam- iner should also test anteflexion in the sitting posi- tion with knees bent. If anteflexion is also restricted in sitting, and mobility of the hip joints is normal, this localizes the disturbance to the lumbar spine. Before testing the mobility of the individual motion segments of the lumbar spine it is advisable to examine muscles with TrPs that are characteris- tic for disturbances in particular motion segments (see Table 4.1). 4.6.2 Examination of individual motion segments Palpation The examination can begin with palpation. The fingertips are used to provoke pain at the spinous processes. Although the spinous process lies in the midline, careful palpation will show that it is only truly tender to pressure on one side. Springing test Following palpation, the springing test is applied. Figure 4.14 • Springing test, using the thenar and This examines resistance and also provokes pain in hypothenar eminences and with the arm extended. the deeper-lying structures (mainly the joints and 109

Manipulative Therapy Figure 4.15 • Springing test, using the tips of the second and third fingers. (A) Position of the fingertips. (B) Position of the fingertips, illustrated using a skeleton (schematic drawing). (C) The arm applying the springing pressure exerts this using the medial (ulnar) edge of the hand placed on top of the fingertips. Palpation of mobility In a normal case this is sensed as a slight dor- sal shifting of the lower of the two vertebrae Carefully directed palpation of mobility serves to against the upper one that is fixed. This move- localize a hypomobile or hypermobile motion seg- ment is not felt if there is restriction, as long as the ment more precisely. Retroflexion Restricted retroflexion can be localized as follows Figure 4.16 • Examining retroflexion of individual lumbar to the segment affected: the patient is in the side- segments by means of springing pressure. lying position on the treatment table, with hips and knees flexed at an angle of about 100°. The exam- iner stands facing the patient, and begins by fixing the upper vertebra of the segment to be examined. This is done by placing one finger of each hand, one on top of the other, on the spinous process. Using his thighs he should then exert pressure against the patient’s bent knees in the dorsal direction, toward the fingers that are holding the vertebra fixed (see Figure 4.16). Having taken up the slack, he applies springing pressure to the knees, taking up the impulse at his fingers. 110

Diagnosis of dysfunctions of the locomotor system Chapter 4 Figure 4.18 • Examining anteflexion of individual lumbar segments by means of palpation. Figure 4.17 • Examining retroflexion of individual lumbar flexed to the abdomen and positioned so to lie close segments by means of palpation. to the edge of the treatment table. examination is not being done forcefully. It has The examiner stands facing the patient and fixes been shown radiologically that this is in fact a slight, her thoracic region by placing one elbow on it from localized dorsiflexion, not a shift. above. With his thighs, he exerts a push against the patient’s knees so as to produce kyphosis of the It is extremely important when carrying out this lumbar spine and take up the slack. With the other technique that the application of very slight pressure to hand, which is resting on the patient’s buttocks, he the patient’s knees to take up the slack by the fingers now applies a springing pressure designed to create should be done in absolute synchrony. The examiner further kyphosis. At the same time, the fingers of can achieve this by straightening his trunk, which forces the hand fixing the upper thoracic spine palpate the his thighs forward to deliver the push to the patient’s mobility, sensing the separation of the spinous proc- knees at the same time as bringing his arms backward. esses of two neighboring vertebrae, or sensing the This technique is one of the very few that can localize resistance if there is restriction (see Figure 4.18). the restriction to one single segment. In 35 patients examined at random independently by two examiners It is important for the practical success of this familiar with that technique there was full agreement technique to ensure that the hand fixing the spinal in 30 cases and only 5 disagreements (see Figure 4.16). column from above is used to take up the pressure delivered by the examiner’s other hand and thighs. Retroflexion can also be examined with the patient in the side-lying position. The examiner If the patient is very tall and the examiner small, should grasp the patient’s lower legs above the this will make it impossible to reach the spinous ankles and push them away from the neutral posi- processes of the lower lumbar spine with the same tion in a dorsal direction, so flexing the lumbar hand while it continues to fix the patient’s shoulder spine dorsally. The fingers of the other hand palpate region. In that case it will be necessary to use the between the spinous processes as these approach fingers of the hand on the patient’s buttocks both one another. Resistance is felt if there is restriction to palpate and to deliver the pressure. (see Figure 4.17). It is important for the success of this technique to keep the patient’s ankles on the Side-bending treatment table, and not to lift them, when exert- ing the push in the dorsal direction. The patient adopts the side-lying position for this examination. Her underneath leg should be bent at Anteflexion right angles both at the hip and at the knee, so that her lower legs lie parallel to the line of her trunk, Anteflexion of the lumbar spine is examined with knees protruding slightly over the edge of the table. the patient in the side-lying position, with knees The examiner stands facing the patient, and grasps the underneath leg just above the ankle. 111

Manipulative Therapy underneath leg, like a lever operating from a point of support resting against his thigh, using this to side-bend the lumbar spine (see Figure 4.19). The thumb of the other hand, which is on the spinous process of the upper vertebra in the seg- ment being examined, is used to palpate movement (or resistance). 4.7 Examination of the thoracic spine 4.7.1 Screening examination of active movement Figure 4.19 • Examining side-bending of the lumbar spine Examination begins with active movement. The by means of palpation. patient should sit astride the end of the treatment table and bend backwards and then forwards, easing As he does so, her other leg becomes more flexed, out the body as she does so; she should then bend so that her foot is now behind the thigh of the to each side, and rotate to each side with a slightly underneath leg. With the thumb of the other hand, kyphotic posture. This enables the examiner to the examiner fixes the upper vertebra of the seg- note the angle between her shoulder girdle and the ment being examined, from above. The examiner table, and to see clearly any irregularities in the line should now raise the lower part of the patient’s of the spinous processes. A springing test is performed using the same technique as that described for the lumbar spine, with the patient lying prone (see Figures 4.14 and 4.15). The spinous processes are palpated; this is best done with the patient seated in a kyphotic position (see Figure 4.20). Figure 4.20 • (A) Palpation of the spinous processes, patient sitting in a kyphotic posture. (B) Schematic drawing using a skeleton. 112

Diagnosis of dysfunctions of the locomotor system Chapter 4 Mobility of the individual segments can be observed from the side with the patient prone, by means of deep inhalation and exhalation as described by Tesarová (1969). It is helpful if the patient is asked to inhale first into the abdomen and then into the chest. This enables the exam- iner to observe the rise and fall of the back and also the fan-like movement of the spinous processes as they expand and separate during inhalation and draw together during exhalation. If this movement is absent anywhere, this indicates joint restriction. This test cannot be applied in a case of pronounced clavicular breathing (in which the thorax is lifted during inhalation), because the chest wall is not being expanded. 4.7.2 Palpation of mobility For the specific palpation of mobility the examiner Figure 4.21 • Examining retroflexion of individual segments should stand to one side behind the patient. The of the thoracic spine by means of palpation. patient sits on the table with arms clasped behind the back of her neck. Retroflexion The patient’s elbows should be angled forward, and the examiner grasps them from below with one hand. With his other hand he should palpate with one finger between two spinous processes (see Figure 4.21). Then he should bring the patient’s thorax into retroflexion until the barrier is engaged, following this with a springing pressure. In those locations where the spinous proc- esses do not move toward each other, the exam- iner will simultaneously sense resistance if there is joint restriction. It is important in this technique to guide the patient’s trunk in such a way that the apex of the retroflexion occurs at the position of his palpating hand. This can be done if the patient is made to lean against the examiner’s body and the two move in concert. 4.7.3 Anteflexion Figure 4.22 • Examining anteflexion of individual segments of the thoracic spine by means of palpation. To examine anteflexion, practitioner and patient adopt the same position as for retroflexion; this between the spinous processes with the fingers time, however, the practitioner grasps the patient’s of the other hand to sense the increase in ten- elbows from above. He should anteflex the patient’s sion during the springing pressure. No springing is trunk in kyphosis to take up the slack, and apply felt if joint restriction is present. The hand which a springing pressure (see Figure 4.22), palpating 113

Manipulative Therapy anteflexes the patient’s trunk also feels increased resistance, which makes the diagnosis easier. Again, in this examination it is important to move the patient’s trunk in such a way that the point of maximum kyphosis is the site of palpation by the examiner’s other hand. 4.7.4 Side-bending To examine side-bending the practitioner stands Figure 4.24 • Palpation of the thoracic spine in side- behind the patient, who is sitting. The practitioner bending with the patient sitting, in broad-shouldered should place one hand dorsally around the patient’s patients. ribs at the level of the segment being examined, the thumb palpating between the spinous processes If the patient has a very broad back (and the of the segment from laterally. He places his other examiner has a very small hand), the following hand at approximately shoulder height (according technique is more appropriate: the examiner should to the level of the segment being examined) on the stand at the patient’s side, grasp her farther elbow, other side, side-bending the patient’s upper body to which is raised, and draw that elbow toward him. engage the barrier (see Figure 4.23). He uses the thumb of the other hand, from a lat- eral direction, to fix the spinous process of the With his palpating hand the practitioner stabi- lower vertebra in the segment being examined (see lizes the patient’s thorax while the thumb palpates Figure 4.24). the resistance to the springing pressure delivered by his other hand. Resistance is greater if there is joint restriction. For this technique it is important for the fin- gers on the ribs to create a fulcrum as they sup- port the patient’s trunk. At this point it seems as if the thumb will not be able to reach the spinous processes, but during the side-bending the thoracic spine rotates, which brings the spinous processes into contact with the palpating thumb. 4.7.5 Rotation Figure 4.23 • Examining side-bending of individual For this examination the patient should sit astride segments of the thoracic spine by means of palpation. the end of the treatment table, with her back toward the examiner, and actively turn her trunk from one side to the other. The examiner compares the extent of rotation and notes any asymmetry. On palpation (sometimes even on inspection) with the patient in slight kyphosis it is often found that the spinous processes in the region of the tho- racolumbar junction do not move evenly to each side. In the past this was interpreted as a sign of restriction; however, this was disproved by Singer & 114

Diagnosis of dysfunctions of the locomotor system Chapter 4 Giles (1990) in a computerized tomography (CT) rib that had been lower ‘overtakes’ the other. This study during rotation. Further, clinically it was then indicates joint restriction on the side that was ‘over- found that the rotation restriction to one side is taken.’ muscular in origin; it is produced by TrPs in the tho- racolumbar erector spinae, psoas major, and quad- The most useful method of examining the upper ratus lumborum muscles, especially those on the and middle ribs is the palpation of resistance dur- contralateral side to the rotation restriction. The ing retroflexion as described by Kubis (1970). The treatment we give to our patients, therefore, con- patient is sitting. For this examination she should sists almost entirely in relaxation of these contralat- adopt the same position as was used to examine eral muscles. Because of the way that these muscles retroflexion of the thoracic spine, except that this are linked, to relax just one of them is enough to time she should raise only the elbow on the side of normalize rotation (see Chapter 6). the rib to be examined. This she raises to the maxi- mum, placing her hand on the back of her head. The 4.8 Examination of the ribs examiner stands on the other side, grasps the elbow from in front, and uses it to bend the patient’s trunk 4.8.1 Screening examination backwards. The pads of the fingers of his other hand take up contact with the angle of the rib under The examination continues with the thorax, includ- examination and offer resistance (see Figure 4.25). ing the ribs. Just as the spinous processes are pal- pated for tenderness when examining the thoracic The examiner applies pressure in a dorsal direc- spine, so it is the angle of the rib that is palpated tion to the raised elbow, toward the fingertips of when examining the ribs for pain points (Tilscher & the other hand, to take up the slack, followed by Oblak 1974). The angle of the ribs is the most prom- inent part dorsally, situated laterally to the erec- Figure 4.25 • Palpation of resistance at the upper ribs tor spinae muscles. It is accessed by abducting the during retroflexion, by the method according to Kubis scapula, which can be done by pressing the patient’s (1970). elbow against the thoracic cage on the same side. Pain points at the angle of the rib must be dif- ferentiated from a frequently-found TrP in the mid- dle part of the trapezius, which tenses like a tendon medially to its attachment to the scapula when this is fully adducted, and is also tender to pressure. There is a pain point at the sternocostal joint that generally corresponds to pain points at the angle of the rib. (This is the point of attachment of the pectoralis minor muscle.) The respiratory excursion of the ribs is exam- ined by comparing rib movement on both sides dur- ing inhalation and exhalation, with the patient lying down. This movement should be assessed visually and by palpation of the area between the ribs. The patient should be asked to inhale and exhale deeply. When the excursion of the ribs is at its maximum it is easiest to assess whether the inhalation (or exha- lation) stops sooner on the affected side than on the healthy side. When the patient is supine, an overtake phe- nomenon is often observed in the region of the upper ribs. One rib is found to be slightly lower than its opposite number; during inhalation, the 115

Manipulative Therapy springing pressure to test whether the springing of Palpation of mobility is carried out by the fol- the joint at the end of range is normal. lowing method. The patient is sitting. The exam- iner begins by drawing the patient toward him and It is important to support the patient’s body, and placing the lateral edge of one forefinger on her to guide the elbow in such a way that movement clavicle, laterally to the neck, to create a fulcrum. occurs only in the sagittal plane and that there is no The patient’s neck is rotated contralaterally and rotation of the patient’s trunk. then inclined forward until resistance is felt (see Figure 4.26). If there is restriction of the first rib, When examining in the region of ribs 2–5 it is this diagonal anteflexion will be markedly restricted necessary to palpate through the shoulder blade, as compared with the normal side. but this does not affect the quality of the palpation. There is a close link between restrictions of the first Putting pressure on the lower arch of the tho- rib and dysfunctions of the cervicothoracic junction. rax (mainly the 10th rib) between two fingers from inside and outside is diagnostic for a ‘slipping rib’. 4.8.2 Examination of the first rib 4.9 Examination of the cervical spine The first rib occupies a special position, and dys- function causes pain at the upper border of the 4.9.1 Screening examination shoulder and just below the clavicle, toward the sternal manubrium, where the first rib articulates This begins with inspection, concentrating in par- with the sternum. ticular on head posture and symmetry, followed by palpation of the soft tissues and TrPs. The assess- Restriction of the first rib is common. The sim- ment of active movement looks at anteflexion, ret- plest method of testing for this is to apply springing roflexion, side-bending (inclining the ear toward pressure from above, which is done as follows: the the shoulder), and rotation to both sides. Examina- examiner should stand behind the patient, place the tion against (isometric) resistance is also important radial (lateral) edge of one forefinger on the first rib in order to diagnose any muscular lesion, especially from above and apply slight pressure to take up the following an accident. slack. This is followed by springing pressure, and the examiner can then sense whether there is any Palpation is done with the patient supine, her springing at the first rib. head beyond the end of the treatment table, slightly raised and supported against the examiner’s thighs (see Figure 4.27). In this position all the muscles are relaxed and the examiner can palpate not only Figure 4.26 • Examination of restriction of the first rib. Figure 4.27 • Palpation of the structures of the cervical spine, patient supine with the head raised. 116

Diagnosis of dysfunctions of the locomotor system Chapter 4 the spinous processes but also the transverse and holding the upper thoracic spine fixed from behind, articular processes. and noting the tension. The supine position with head raised is necessary The most common cause of restriction here is in order to palpate the short craniocervical exten- shortened neck muscles. If pain is felt at the start sors, posterior arch of the atlas, and posterior bor- of anteflexion, this may indicate restriction of the der of the foramen magnum, where important pain atlanto-occipital and atlantoaxial joints; meningeal points are found. The pain points at the nuchal line or radicular pain is typically felt during the course are secondary. of anteflexion, and pain felt at the barrier, after a period of latency, is most probably ligament pain In order to palpate the site of important pain (see Section 7.6.1, Anteflexion headache, p. 332). points on the lateral aspect of the spinous process of C2, the examiner should incline the patient’s head to Side-bending the opposite side. As he does so, it rotates toward his fingers, which he uses to palpate from a lateral posi- In order to test side-bending, the examiner should tion. The patient can be either sitting or lying down. fix the shoulder from the side toward which the side-bending is performed and ease the patient’s Palpation of the transverse process of the atlas is ear down toward her shoulder, comparing mobility better carried out with the patient sitting, palpat- in both directions. ing from laterally and below, between the mastoid processes and the ascending ramus of the mandible. Rotation This transverse process is more prominent laterally than those of the other cervical vertebrae. Following This test is the most important for diagnosis. this, the examiner should palpate TrPs in the two sternocleidomastoid muscles, between his thumb Examination with patient sitting and forefinger. The patient should be sitting erect. The examiner Accurate localization of the spinous process of fixes her shoulder from in front, on the side away C7 can sometimes be important for precise orien- from that to which the patient’s head is to be tation, since the examiner has to ensure that the turned, using his elbow to do so. As he turns her process found is that of C7 which is not always the head, the examiner should note how close it is pos- vertebra prominens. This is best done during retro- sible to bring the chin to the shoulder on either side flexion, placing a finger on each of two neighboring (see Figure 4.28A). Care must be taken to rotate spinous processes at the cervicothoracic junction. the head accurately about a vertical axis. During retroflexion the spinous process of C6 moves deeper, while that of C7 remains in the same place. An alternative method is to perform this test with hands crossed. To turn the patient’s head 4.9.2 Examination of passive to the left, the examiner applies lateral pressure mobility with the right hand to her chin, while his left hand guides the occiput to the right. The examiner The assessment of passive mobility begins with a should fix the patient’s right shoulder, using his screening examination of the whole of the cervical forearm from behind (see Figure 4.28B). spine. The patient is sitting and the examiner must fix (immobilize) the cervicothoracic junction so that any resistance, or indeed tenderness, can be detected. Retroflexion and anteflexion With the head in maximum anteflexion Retroflexion is examined as follows: the examiner should stand beside the patient and ease her head To test rotation in maximum anteflexion the exam- backward, testing springing of the cervicothoracic iner stands behind the patient, who is sitting. With junction. one hand on the occiput he should ease her head into maximum anteflexion, while using the fingers To test passive anteflexion the examiner should of the other hand to fix her chin. guide the patient’s chin toward the chest while 117

Manipulative Therapy Figure 4.28 • Examination of rotation of the entire cervical spine. (A) Shoulder fixed by the examiner’s elbow, from in front. (B) Shoulder fixed using the forearm from behind, hands crossed. In this position, rotation takes place almost entirely In retroflexion between the atlas and axis. It is particularly important in this case to ensure that the rotation takes place In retroflexion the atlanto-occipital and atlantoaxial about the longitudinal axis of the cervical spine; the joints are locked and the examination looks at the cervical spine will now be almost horizontal. This can region below C2/C3. The farther backward the cer- only be achieved by ensuring that the main movement vical spine is inclined, the more the rotation takes is that of the occiput from one side to the other, while place in the lower and cervicothoracic sections. the chin is held fixed as described (only the minutest Here, too, care has to be taken to ensure that rota- amount of movement should be permitted). tion occurs about the longitudinal axis of the cervi- cal spine. Because the examiner sees only the patient’s occiput, he only sees the movement there, and so The crossed-hand hold shown in Figure 4.28B is tends to move the chin. A warning must be given: helpful here. One hand simultaneously moves the when carrying out rotation in maximum anteflexion chin to one side and raises it. Again, the chin should it is a serious mistake to exceed an angle of 45° in move only minimally, and it is mainly the occiput either direction. that is moved. Care should be taken not to permit any lateroflexion. With maximum forward nutation of the head Having completed these investigations, which are designed essentially as a screening examination, To test rotation with the patient’s chin drawn to its we proceed to the examination of the individual maximum extent towards the neck (forward nuta- motion segments. tion), the examiner stands behind the patient and eases her chin toward her neck, rotating her head as 4.9.3 Examination of the far as it will go to one side and then the other and motion segments at the same time applying slight traction. Accord- ing to Jirout (1979b), rotation takes place almost Side-bending exclusively in the C2/C3 motion segment. This can be performed with the patient sitting or Again it is important to ensure that rotation lying down. For each segment, the examiner inclines takes place about the correct axis, and this is done the patient’s head to the side with one hand while by moving mainly the occiput, and permitting the the other creates a fulcrum at the lower vertebra of minimum of movement at the chin. 118

Diagnosis of dysfunctions of the locomotor system Chapter 4 Figure 4.29 • Examination of side-bending of individual motion segments of the cervical spine with the patient supine (A) between the atlas and axis; (B) between the vertebrae from C3 to C7. the segment under examination; the examiner uses With patient sitting the edge of his forefinger to do this and the cervical spine is inclined over this fulcrum. With the hand For side-bending at the cervicothoracic junction, the that moves the patient’s head, the examiner then patient must be sitting as erect as possible. Using applies very slight pressure to take up the slack. the ulnar (medial) fingers of one hand in the region Springing pressure is given to test springing at the of the zygomatic bone, the examiner should bend end of range (resistance) as well as range of move- the patient’s head backward and to the side, at ment. The findings are compared with the other the same time rotating it in the opposite direction side and with neighboring segments. to that of the side-bending. While performing this rotation, the examiner uses the thenar eminence of With patient supine the other hand to contact and fix the spinous proc- ess of the upper vertebra of the pair in the segment For the examination in the supine position the being examined. With the thumb of the other hand, patient’s head extends beyond the end of the he applies springing pressure from the side to the table and is cradled in the examiner’s hand, spinous process of the lower vertebra of that seg- slightly raised and rotated gently toward the ment and senses the resistance (see Figure 4.30). contralateral side. When examining C1/C2, the cervical spine up to C2 should remain as far as With patient in the side-lying position possible in the neutral position, with only the head nutated to one side: to be precise, the head The examination is somewhat easier to perform is rotated about an axis at the level of the root of with the patient in the side-lying position. The the nose (see Figure 4.29A). examiner should stand facing the patient, with his forearm under her head, his elbow supported For the lower segments the index which forms on the table, and his hand cradling the patient’s the fulcrum is lowered to the examined segment occiput. The examiner should now push the sup- and the head side bent accordingly to take up the porting elbow forward on the table, so that his hand slack and to sense resistance against springing in end automatically produces a side-bending movement position (see Figure 4.29B). 119

Manipulative Therapy Figure 4.30 • Examination of side-bending of the cervicothoracic junction with the patient seated: (A) as seen from the rear; (B) as seen from in front. of the patient’s head combined with rotation to The examiner will find it easier to perform this the opposite side. This is done until the barrier is test with his knee supported on the treatment engaged, when he applies springing pressure in the table. same direction. The thumb of his other hand mean- while fixes the spinous process of the lower verte- Rotation bra of the pair (see Figure 4.31). Figure 4.31 • Examination of side-bending of the The patient is sitting, and the examiner stands cervicothoracic junction with the patient side-lying. behind her. He fixes the vertebral arch of the lower vertebra of the segment, from one articular proc- ess to the other, between the thumb and forefinger of one hand. With his other hand, he should rotate the patient’s head to the side (usually guiding it by the chin) until he senses resistance at the thumb or forefinger of the hand fixing the vertebral arch. He can then deliver slight springing pressure (see Figure 4.32). The examination begins by fixing the axis and establishing the range of movement between atlas and axis; it then proceeds with C2/C3, and on down to C5/C6. The range of movement increases step- wise. If there is a restriction in a segment, this step increase is absent on one or both sides. This method can be used to register the movement found, which was successfully done by Berger (1990) by means of cervicomotography (see Figure 4.33). The following points are important in order to perform this technique accurately: 120

Diagnosis of dysfunctions of the locomotor system Chapter 4 Figure 4.32 • Examination of rotation of individual motion segments of the cervical spine. Figure 4.34 • Examination of rotation of the cervicothoracic junction. Figure 4.33 • Step diagram produced using forehead rests in the crook of his elbow. With the cervicomotography according to Berger (1990). 1, little finger of the same hand, he should then span Movement restriction between C1/C2 and C2/C3 (arrows), the arch of the upper vertebra of the segment being and hypermobility between C3/C4. 2, After mobilization, examined. The thumb of his other hand fixes the restriction between C2/C3 and hypermobility between C3/ spinous process of the lower vertebra from the con- tralateral side (see Figure 4.34). Next the examiner C4. 3, Normal finding after further treatment. should turn the patient’s head to take up the slack, and exert gentle springing pressure. • The vertebra that is fixed during the investigation must be held exactly in the neutral position. Shifting techniques • Only the minimum of force should be used to These techniques are used to examine joint play in fix the vertebra, because as soon as the finger the cervical spine in the ventrodorsal and laterola- that is fixing (palpating) the vertebra reaches teral directions. the articular process, a reflex response by the patient causes it to stop, which has the effect of The patient should be sitting erect. The exam- determining the range of motion. iner stands at the side and takes hold of the Another useful place to examine rotation is at patient’s head between his forearm and upper arm. The little finger of the same hand spans the verte- the cervicothoracic junction. The examiner stands bral arch of the upper vertebra of the segment to be behind the patient, who is sitting erect on a low tested. From this point, two methods are possible: chair. The examiner takes hold of the patient’s head between his forearm and upper arm, so that her 1. The examiner shifts the patient’s head backwards until the barrier is engaged, and then applies springing pressure. In this case he 121

Manipulative Therapy Figure 4.35 • Examination of dorsal shifting (springing) Figure 4.36 • Examination of dorsal shifting (springing) at in the motion segments of the cervical spine with the the cervicothoracic junction. exception of C1/C2 but including the occiput–atlas. should fix the lower vertebra of the segment the patient’s trapezius muscle. The lower vertebra at the vertebral arch by holding it between of the segment is fixed with the finger or the thumb thumb and forefinger. of the other hand (see Figure 4.36). 2. The examiner side-shifts the patient’s head The backward pressure applied to the shoulder and that part of the cervical spine down as muscles has the effect of delivering a dorsal push to far as the upper vertebra of the segment, the spinal column while fixation of the lower verte- holding the lower vertebra of the pair fixed bra of the segment localizes it. using either his thumb, working toward him, or his forefinger, away from him. Each time, 4.9.4 Testing of mobility on engaging the barrier he applies gentle between occiput and atlas springing pressure (see Figure 4.35). Anteflexion This technique can be used to examine the segments from C2/C3 down to C5/C6 backward and to the The patient is supine. The examiner should place side. It can also be used successfully, in the backward his hand, palm uppermost and completely relaxed, direction only, to test the occiput–atlas segment. In on the treatment table, allowing the patient’s this case slight anteflexion of the head is advisable. occiput to rest in the palm. He should rest his The fixing hand grasps around the arch of the axis, thumb and forefinger on the superior, posterior bor- but shifting is only possible between the atlas and the der of the transverse process of the atlas to fix the occipital condyles, not between the atlas and axis. vertebra from the cranial direction. The other hand is placed on the patient’s forehead and she is asked From C6 to T3, the shifting technique can be to look down toward the chin to engage the barrier used successfully in the backward direction for diag- (see Figure 4.37). nosis. The patient is sitting erect on a low chair. The examiner takes hold of the patient’s head between In this position, springing pressure is applied. his forearm and upper arm, so that her forehead This is done using the fingers on the transverse rests in the crook of his elbow. With the ipsilateral hand, he applies pressure in the dorsal direction to 122

Diagnosis of dysfunctions of the locomotor system Chapter 4 Figure 4.37 • Examination of anteflexion between the occiput and atlas. processes of the atlas, as the fingers release their Figure 4.38 • Examination of passive side-bending hold, so that the examiner can verify how effective between the occiput and atlas. fixation of the atlas is. At that moment, anteflexion should increase. This test is carried out once with the patient’s head rotated to the right, and once to the left. Side-bending Rotation The patient lies supine, head beyond the edge of The patient is sitting erect. The examiner should the table. The examiner should take hold of the stand behind the patient, place one hand on the patient’s head and rotate it so as to lock the atlas/ patient’s cheek and, with this hand, rotate the axis segment, then very gently carry out side- bending between the occiput and atlas sufficiently to engage the barrier, and apply springing pressure (see Figure 4.38). With older patients, head rota- tion need not exceed 50–60°. Retroflexion The patient lies supine, head well beyond the edge Figure 4.39 • Examination of passive retroflexion between of the table. The examiner should take hold of the occiput and atlas. the patient’s head by the chin and at the occiput, well up toward the top of the skull, then raise the head a little and rotate it so as to lock the rest of the cervical spine. In this position, the examiner should incline the head backward sufficiently to engage the barrier, and apply springing pressure (see Figure 4.39). The hand on the occiput needs to be placed high enough up the skull so that it does not obstruct retroflexion (this also applies during the mobilization). 123

Manipulative Therapy patient’s head to one side. It is stabilized against re-establishment of joint play are fundamental to the body of the examiner. Care should be taken to therapy. The technique used to examine joint play ensure that the head rotates about a vertical axis. is identical to that used for joint mobilization per- Using the very minimum of force, the examiner formed for the purpose of therapy; it is therefore should take up the slack and gently apply spring- described in Chapter 6, in connection with therapy. ing pressure, again with the absolute minimum of force. Springing is sensed with a fingertip of the 4.10.1 The shoulder other hand, placed on the transverse process of the atlas. If there is joint restriction, no springing is felt, Active movement either at the chin or at the transverse process of the atlas. Active movement can be further classified into the categories of abduction, adduction, internal rota- 4.10 Examination of the tion, anteflexion, and retroflexion. limb joints The most commonly found disturbance, and also Dysfunctions of the locomotor system affect the the most painful, is that of abduction. Pain is felt limbs as much as they do the spinal column, and on movement within a circumscribed range, which both are so closely linked that it is always hard to can be overcome (the ‘painful arc’): the patient decide the location of the primary or more serious feels pain during abduction at a particular angle of disturbance. As a result, the diagnosis and treat- less than 90°, but if it is possible to pass this point, ment of these disturbances are an important part of abduction continues quite normally to the full everyday practice. extent. The cause of this lies in the fact that the head of the humerus and rotator cuff slip under the Examination always begins with inspection, fol- acromioclavicular ligament during abduction. This lowed by active movement, then passive movement is enabled by the subdeltoid bursa. If there is a dis- and movement against resistance, so as to differen- turbance of the subdeltoid bursa or in the rotator tiate between a disturbance of the joint and one of cuff, this initially results in a transitory constraint; the muscle. Weakness in a muscle need not be the however, if the change is more advanced it leads to result of paresis; it may be caused by pain. a painful, absolute, isolated barrier to abduction. When examining passive movement, a distinc- This is the interpretation given by Cyriax (1977) tion has to be made between functional movement and is the basis of ‘impingement syndrome,’ and is and joint play. In disturbances of functional move- widely accepted. Examination of patients with this ment, we distinguish between a situation in which clinical picture, that is impaired abduction but nor- movement is affected within the joint itself, and mal rotation with the arms in abduction, regularly one in which it is affected by an external obstruc- presents lack of joint play as shown in Figure 4.42. tion (such as a disturbance of the subdeltoid bursa After mobilization – restoring joint play – abduction at the shoulder joint). In this case, mobility of the is regularly restored (see Figure 6.13). joint is restricted only in the direction in which the obstruction operates; for example abduction of The explanation lies in the biomechanics of the the shoulder if there is a disturbance in the region glenohumeral joint as given by Latarjet (Testut of the subdeltoid bursa. In the other case, all the 1928). On page 592 we read: ‘If the distal part of movements of the joint are affected; not to the the humerus is lifted, its proximal part or its head same degree in every direction, but nevertheless slips down in the fossa glenoidalis; on the other a clear proportional relationship can be observed. hand, if the same extremity moves upward in the This has been termed a ‘capsular pattern’ by Cyriax glenoid cavity then the humerus which was previ- (1977). Every joint has its own characteristic cap- ously raised returns to its position of rest in adduc- sular pattern, and it is this pattern that determines tion’ (see Figure 4.42). the diagnostic significance. ‘Whatever the role of tears in the rotator cuff Movement restriction of the joint itself usually and/or changes in the bursa subdeltoacromialis, also involves restriction of joint play. Therefore once joint play is restored, that is the normal bio- this should always be examined; joint play and the mechanics of the glenohumeral joint, the patient can abduct (lift his arm) normally and without pain.’ 124

Diagnosis of dysfunctions of the locomotor system Chapter 4 Figure 4.40 • Provoked pain, tested by means of isometric tension, of the muscle attachments: (A) against isometric abduction, of the supraspinatus; (B) against isometric external rotation, of the infraspinatus; and (C) against isometric anteversion, of the long biceps tendon. The most commonly found painful changes of Figure 4.68) or from the side at the inferior angle muscle attachments in the region of the rotator cuff of the scapula. can be investigated by isometric contraction against resistance in the starting position. External rotation Pain produced by the tension of abduction with It is important when examining external rotation the arm fully adducted (see Figure 4.40A) indicates to ensure that the patient’s upper arm remains a lesion of the supraspinatus. Pain produced by the adducted and the elbow flexed at 90°. External tension of external rotation (see Figure 4.40B) indi- rotation is usually examined on both sides at once cates a disturbance of the infraspinatus. (see Figure 4.41). The long biceps tendon can be palpated directly, but if the patient reports pain when this is done, it originates from the attachments at the crest of the greater or the lesser tubercle. A more reliable method is to provoke the pain by anteversion of the supinated arm, bent at the elbow, against resist- ance (see Figure 4.40C). The subscapularis, the most important internal rotator muscle, has to be palpated deep inside the axilla. Passive movement If passive mobility is impaired at the shoulder Figure 4.41 • Examination of external rotation with the joint itself (the scapulohumeral or glenohumeral arms in adduction and elbows flexed at right angles. joint), the characteristic capsular pattern observed is, according to Sachse (1995), the following: first and most commonly, abduction is restricted, fol- lowed by external rotation and then internal rotation. The starting position is with the arm adducted and elbow ventrally directed. The shoul- der blade must be fixed, either from above (see 125

Manipulative Therapy Internal rotation The acromioclavicular joint Internal rotation is usually also examined on both Two more joints frequently cause shoulder pain: the sides at once, by drawing the patient’s thumbs acromioclavicular and the sternoclavicular. Distur- upward behind her back and comparing the two bance of the former is very frequent, although its sides. When this examination is performed, adduc- involvement is seldom recognized; however diag- tion produces a degree of retroflexion. nosis is not difficult: adduction of the arm in front of the thorax causes the patient to feel pain and Abduction is restricted in comparison with the normal side. This is done by passively moving the elbow of the In this case there is a characteristic disturbance of affected side toward the opposite shoulder. Direct joint play: with the upper arm abducted at a right palpation of the joint itself is also painful. angle, the examiner applies slight pressure to the head of the humerus from above to engage the The sternoclavicular joint barrier, followed by springing pressure (see Figure 4.42). If there is a true capsular pattern and the Dysfunction of the sternoclavicular joint is a patient is still able to abduct her arm to approxi- much less common condition. The patient experi- mately 90°, joint play is normal, indicating that the ences pain when moving the shoulder blades and frozen shoulder is not due to dysfunctional joint on movements involving greater excursion of the restriction but to reactive capsulitis. shoulders; on palpation the joint is tender to pres- sure. The following points should be noted, how- If abduction alone is restricted, there is gener- ever: tenderness of the medial end of the clavicle is ally also a disturbance of joint play. In this case the also found in cases of myotendinosis of the sterno- head of the humerus cannot glide down from the cleidomastoid. Also, laterally below the clavicle is narrow, upper part of the glenoid cavity as it needs the joint between the first rib and the manubrium to in abduction. It is important when performing of the sternum, and this is tender to pressure in this test to ensure that the pressure is applied at the cases of restriction of the first rib. correct point: on the head of the humerus, which is lateral to the apex of the deltoid (see Figure 4.42). The expression ‘periarthritis humeroscapularis’ or ‘shoulder periarthritis’ is still much used, but is meaningless and unhelpful as a description of frozen shoulder. Specific diagnosis of the disturbance is required. 4.10.2 The elbow Figure 4.42 • Examination of joint play in the shoulder joint Disturbances of the elbow joint produce restriction by springing pressure applied from above to the head of the in flexion and extension, with flexion being more humerus, with the arm abducted at 90°. markedly affected in accordance with the capsular pattern. The joint play here is a sideways (radial or ulnar) springing of the forearm, especially of the ulna relative to the upper arm. The elbow is also the location of the radioulnar joint, and it is here that pronation and supination take place. The most frequently found clinical condition is pain at the epicondyles. There is tenderness on palpation involving application of pressure. If the 126

Diagnosis of dysfunctions of the locomotor system Chapter 4 radial epicondyle is affected, pain is produced by ulna relative to the radius. Radial abduction is shaking hands or lifting a chair with the arm pro- accompanied by a synkinetic pronation of the fore- nated. Lifting with the arm supinated is painful if it arm when the hand is kept in the same plane. Simi- is the ulnar (medial) epicondyle. larly, on ulnar abduction there is a corresponding slight supination. The radius also moves proximally 4.10.3 The wrist relative to the ulna during radial abduction, and dis- tally during ulnar abduction. Lateral movements in The wrist joint is complex, consisting of the radius the wrist are therefore dependent on the mobility and ulna, the carpal bones, and their articulations of the radius relative to the ulna. This is the main with the metacarpals. cause of certain frequently occurring painful condi- tions, such as pain at the radial styloid process or, In order to localize findings anatomically it less frequently, at the ulnar styloid process, teno- is useful to know that the skin fold on the dorsal synovitis and persistent pain following fracture of aspect of the wrist in dorsiflexion corresponds to the radius. the radiocarpal joint, and that the fold on the pal- mar aspect in palmarflexion corresponds to the car- The cause of restricted abduction of the wrist in a pometacarpal joints. radial (lateral) or ulnar (medial) direction is most frequently found in the radioulnar joints, most The general appearance of the wrist joint (artic- importantly at the elbow. ulatio radiocarpalis) is at first sight rather like an egg that is free to move around in every plane in The metacarpophalangeal joints are in fact ball the shallow joint socket of the radius. Its functional and socket joints, which permit movement in movements, in combination with the midcarpal joint every plane, but the absence of rotator muscles (articulatio mediocarpalis), are in fact limited to dor- means that only flexion, extension, and laterola- sal extension and palmar flexion and radial and ulnar teral movements are actively possible. The only abduction. Rotation is entirely possible in terms of exception is the saddle joint between the tra- joint play, but as regards functional movement the pezium and first metacarpal. This joint permits muscles to perform active rotation are lacking. movement in all three planes, whereas the first metacarpophalangeal joint only permits flexion The wrist joint and midcarpal joint each have a and extension. distinct role to play in dorsal extension and palmar flexion. Palmar flexion takes place mainly in the The interphalangeal joints are hinge joints, wrist joint, the proximal row of the carpal bones which permit only flexion and extension. Joint gliding in a dorsal direction relative to the radius. play in the finger joints is dealt with in Section Dorsal extension takes place mainly in the midcar- 6.2.1. pal joint, the distal row of the carpal bones gliding in a palmar direction relative to the proximal row. 4.10.4 The hip In ulnar abduction, the proximal row glides radi- Although the hip is a limb joint, clinically it is part ally (laterally) relative to the radius. of the pelvis, borne out by the fact that frequently the first symptom in lesions of the hip joint is low- In ulnar abduction, the proximal row glides radi- back pain. ally (laterally) relative to the radius. In disorders of the hip joint, the hip – and Radial abduction involves the most compli- therefore also the knee – is in flexion; it is also in cated mechanism. The proximal end of the first external rotation, which often has the effect of metacarpal draws closer to the radius, and as it increasing the lumbar lordosis. This makes it pos- does so the lateral end of the scaphoid tips in the sible to distinguish hip pain from acute lumbago at palmar direction. The trapezium and trapezoid first glance. The distinction is still clearer in retro- glide in the palmar direction, rather as they do in flexion. dorsal extension. This explains why it is possible to perform radial abduction at the same time as dorsal extension, but not simultaneously with pal- mar flexion. In dorsal extension, ulnar abduction is prevented. A further factor affecting ulnar abduction and, still more, radial abduction, is the mobility of the 127

Manipulative Therapy Figure 4.43 • Patrick’s sign (‘frog-leg’ position). Figure 4.44 • Examination of internal rotation of the hip joint with the patient supine, hip and knee flexed at 90°. The most constant sign to be looked for is Patrick’s sign (see Figure 4.43), and it is with this 4.10.5 The knee that the examination proper begins. The leg to be tested is flexed at hip and knee (‘frog-leg’ posi- The inspection of the knee should note: tion). The test is positive if abduction of that leg is • valgus or varus alignment restricted. • genu recurvatum (back-knee) • deterioration of fine structural features as in The capsular pattern in dysfunction is first and most markedly restriction of internal rotation. osteoarthritis This is tested with the patient supine, with the • the height of the hollows of the knees. knee and hip flexed (see Figure 4.44) or with the patient lying prone with the hip straight (examin- Again, asymmetry here can cause pelvic obliquity. ing both sides at the same time). This is followed The knee, like the elbow, consists of two joints: by an examination of extension (with the patient prone), of maximum flexion (patient supine), and it is made up of the true knee joint, between the finally external rotation. In addition, active abduc- femur and the tibia, and the joint between the tibia tion of the leg with the patient in the side-lying and fibula (the tibiofibular joint). The movements position is painful. The range of motion may be that take place at the knee joint are flexion, exten- normal at first, but springing in the end position sion, and, when the knee is flexed, rotation. is painful. There is considerable joint play, partly because The most important pain points are at the fem- the joint surfaces are incongruous, and partly on oral head in the groin, the greater trochanter, and account of the articulation with the patella. The the attachment of the adductors on the pes anseri- joint play consists of gliding in the ventrodorsal nus of the tibia, which the patient experiences as direction with the knee flexed, distraction, laterola- pain in the knee. The articular head and socket teral shifting, and springing with the knee extended; being largely congruous, the only joint play is also of craniocaudal and laterolateral shifting of the distraction. patella. 128

Diagnosis of dysfunctions of the locomotor system Chapter 4 The joint pattern of the knee means that the normal locomotion the heel strikes the ground first; first and most common restriction is that of flexion. the foot then uncurls, mainly along its lateral bor- This must therefore be examined first, by bring- der, into pronation and pushes off with the aid of ing the heel toward the buttock as far as it will go. the toes. If the patient concentrates on the lateral It will be necessary to guide the patient’s heel so border and tries to sense this during walking, this is as to deviate slightly medially or laterally, to avoid often enough to restore the function of the foot. obstruction of the approach caused by the substan- tial belly of the calf and ischiocrural muscles. Rota- The function of the toes in pushing off often tion between the upper and lower leg can also be suffers restriction. This insufficiency of the toe examined when the patient’s knees are flexed. flexors is closely associated with splay foot. Véle’s test (personal communication) examines this. If the The most important pain points are at the patient, standing barefoot, transfers her weight for- medial collateral ligament, in the hollow of the ward without going on tiptoe, this automatically (as knee, at the superior border of the patella, and at a reflex response) produces flexion of the toes, evi- the attachment of the patellar ligament (house- dently as a defensive action to prevent falling. This maid’s knee). reflex is frequently absent, especially when there is weakness of the short flexors of the foot in the case The tibiofibular joint participates in the rotation of splay foot or S1 radicular syndrome. Therefore, of the lower leg on the thigh. Passive movement in the case of splay foot, this synkinesis needs to be can most accurately be examined by comparing the practiced. The patient is asked to rock rhythmically internal and external rotation of the feet with the to and fro. patient prone and the knees flexed. The joint play consists of dorsomedial and ventrolateral rotation Hallux valgus is commonly found, representing of the fibular head, and is best examined with the a deviation of the great toe toward the lateral side patient supine and with knees flexed. of the foot as a result of wearing constricting shoes, and involving a weakness of the abductor hallucis. Restriction of the head of the fibula is clini- This muscle also supports the longitudinal arch of cally very significant. The fibular head is the point the foot, so that the patient has to learn (labori- of insertion of the biceps femoris, and restriction of ously!) how to exercise the muscle. Shoes are a fac- the fibular head is regularly associated with a TrP in tor not only in hallux valgus, but also in causing the this muscle. This disturbs the fixation of the pelvis, deficient function of the toes and so also for splay affecting the abdominal and gluteal muscles and so foot. overall posture (forward-drawn posture). The best method of screening all the joints of 4.10.6 The foot the foot is to test rotation about its longitudinal axis. The patient is supine, the examined leg flexed Some aspects have already been dealt with when with the heel resting on the table. The examiner discussing the inspection. Assessment of flat foot can grasps the foot with one hand at the first metatar- be carried out most accurately and with equivalence sal head and the other at the fifth, and rotates it on both sides by inserting the tip of the finger under around the longitudinal axis, which passes through the longitudinal arch from medially, pushing the fin- the talar head. If there is dysfunction in any of the gertip inward, and comparing findings. The finger foot joints, this rotation is impaired: either the foot meets resistance sooner on the side that is flattened. deviates from the axis before the end of the rota- If asymmetry is found, this is often the cause of pel- tion, or increased resistance is found if the axis of vic obliquity. The patient should be asked to stand rotation is maintained. supported on the lateral edges of the foot; both iliac crests then become horizontally level. The ankle joint (articulatio talocruralis) is a hinge joint which allows only the movements of Besides establishing the shape of the foot, a func- dorsiflexion and plantarflexion. As a result of its tional diagnosis is needed. For this, the examiner joint pattern, the prime, most common restric- must observe the arch of the foot from medially, tion of this joint is dorsiflexion. This is generally during walking. The point that needs to be checked examined with the patient’s knees flexed, because, is whether the arch of the foot is maintained or with the knee extended, a short gastrocnemius yields during the action of walking, irrespective muscle hinders dorsiflexion. Joint play consists of of the degree of arching or flatness of the foot. In ventrodorsal shifting of the tibia and fibula against the talus, and distraction. It is important to realize 129

Manipulative Therapy that, when there is dysfunction of this joint, this is TrPs can be found in the temporal region in the clearly shown by the joint play, while the range of temporalis muscle, through the cheeks or from the functional movement often remains normal. mouth in the masseter muscle, behind the mandib- ular angle in the medial pterygoid muscle and, most The joints of the foot include the subtalar (talo- frequently, in the lateral pterygoid in the mouth calcaneal) and talocalcaneonavicular joints between above the wisdom teeth; this TrP is most intensely the talus, the calcaneus and the navicular bone, painful. Tension in the floor of the mouth, caused the transverse tarsal (Chopart’s) joint, and the tar- by TrPs in the digastric and mylohyoid muscles, is sometatarsal (Lisfranc’s) joints between the tarsals also important. These are best diagnosed by palpa- and metatarsals. They enable active pronation and tion of resistance at the thyroid cartilage or at the supination combined with eversion and inversion. hyoid, which is more difficult to perform. The ten- Joint play in particular should be examined, and sion on one side is often so considerable that lateral this is used for mobilization (see Section 6.2.2). deviation of the thyroid cartilage is seen toward the side of the tension, as well as distortion of the floor Examination of the toe joints is done in the same of the mouth. The characteristic muscular imbal- way as that of the finger joints. Although there is ance is shortening of the masticatory muscles, with no articulation between the heads of the metatar- weakening of the muscles that govern the opening sals, in the foot their free mobility one against the of the mouth. The main causes are a faulty bite, other is especially important. This mobility is often ill-fitting dentures, or trauma, or they may be func- disturbed in painful splay foot and in radicular syn- tional and brought about by stress and grinding of dromes. The problem is due to a soft-tissue lesion the teeth (bruxism). Functional chain reactions are between the metatarsals. frequent, especially in the craniocervical region. 4.11 Examination of the 4.12 Examination of temporomandibular joint disturbances of balance The temporomandibular joint forms a functional As has already been made clear (see Section 2.5), unit together with the masticatory muscles and the spinal column plays a significant part in main- muscles of the floor of the mouth, and it is of great taining or disturbing balance; and it is therefore importance, as can be seen from the term ‘mandib- important to have straightforward methods of clini- ulocranial syndrome.’ In fact, the mandibulocranial cal examination to assess dysfunctions of the spinal syndrome can cause symptoms that are difficult to column in cases of disturbed balance. distinguish from craniocervical syndrome, includ- ing headache and even vertigo. When the main Hautant’s test seems the most suitable for this symptom is pain in the face, differential diagnosis purpose. The patient is seated comfortably in a is important to exclude trigeminal neuralgia. Pain in chair which supports her back, with eyes closed the region of the ear, and dysphagia, sometimes also and both arms stretched forward. The examiner tinnitus, are also typical symptoms. stands facing her, with his thumbs pointing at the patient’s fingertips (see Figure 4.45). This enables An important diagnostic indication is tenderness him to detect whether the patient’s arms devi- to pressure of the capitulum in front of the tragus, ate (not owing to rotation of the trunk) and then on palpation from the direction of the external assess the role played by the cervical spine. The auditory meatus. This may intensify on opening and test is repeated with different positions of the head closing of the mouth. TrPs in the masticatory mus- relative to the trunk and enables the examiner to cles are another important sign. recognize ‘pathogenic’ and also relief positions, by judging whether the deviation appears, increases, The functional movements of this joint are the or disappears. Between each test, when the patient opening and closing of the mouth, shifting the man- changes the position of her head, the examiner dible from anterior to posterior and also laterally. must hold her hands in neutral position to prevent Dysfunction causes restriction of mouth opening. deviation due to synkinesis of the arms. When test- It is normally possible to insert the width of three ing each head position, the examiner should wait finger knuckles between the upper and lower inci- sors. Joint play consists of distraction and side-to- side movement. 130

Diagnosis of dysfunctions of the locomotor system Chapter 4 Figure 4.45 • Hautant’s test to assess lateral deviation of the patient’s outstretched arms. for about 5–10 seconds to see whether deviation Figure 4.46 • Trace registering lateral deviation using sets in or is spontaneously corrected. Berger’s recording apparatus: In the sections marked ‘g’ the patient’s head is in the neutral position, in section ‘r’ it is This test has great advantages: being seated with rotated to the right and in section ‘l’ it is rotated to the left. the back supported, the patient feels safe even if In that bottom section, the line on the left (marked ‘3’) can dizziness occurs, and any deviation that is found be seen to deviate toward the right. After treatment, the line is not caused by nervousness, as is often the case on the right (marked ‘4’) shows no deviation. in Romberg’s test or Unterberger’s stepping test. The second advantage is that with the patient’s deviation can be registered for various head posi- back leaning against a chair, the back is fixed and tions (see Figure 4.46). The test can be performed only side deviation of the arms is possible. There before and after treatment for comparison. is no swaying to and fro as in disturbance of the labyrinth. If the patient is asked to turn her head For the test using two scales, the patient is when in the sitting position, this best enables the asked to stand with legs extended and to distribute examiner to assess the role of the cervical spine. her body weight equally on both, since otherwise it The reaction produced is so characteristic that it is natural to place more weight on the stance leg. is possible to speak of a ‘cervical pattern’ (see Sec- What is tested is therefore the patient’s ability to tion 7.6.2). This examination is therefore indicated estimate accurately the symmetrical distribution of whenever the patient complains of disturbances body weight on the legs. of balance and also when the test standing on two scales produces a difference of more than 4 kg. It is of course essential to make a distinction between the position of the head relative to the Berger (1990) has constructed a simple tech- trunk and the position in space of the head and nique to register this deviation: the patient is sit- trunk together, that is to diagnose positional ver- ting with eyes closed; in one outstretched hand she tigo. To do so we must change the position of the holds a ballpoint pen and moves it from right to left patient’s head and trunk simultaneously (e.g. sitting and back for about 1 cm each time on paper that up and lying down are done with the patient’s head is moving forward at a constant speed. In this way in a neutral or rotated position; turning to one side or the other supine is done by turning the head and 131

Manipulative Therapy the rest of the body simultaneously). The positional based almost exclusively on clinical examination, since vertigo produced in this way is true labyrinthine the alternative, electromyography, is so cumbersome rotatory vertigo. Although it lasts only a few sec- and time-consuming that it is seldom practicable. onds, it is usually very intense, as can be seen from the patient’s reaction. The patient tends to close Clinical kinesiological examination her eyes, so that it is not usually possible to see the nystagmus, which lasts only very briefly. In addition to neurological screening, the examina- tion should include: To determine the role of the vertebral artery in • muscle strength (muscle tests) vertigo, the patient is examined in positions assumed • shortened muscles to restrict blood flow in the artery on the contralat- • hypermobility eral side to the rotation. De Kleyn’s test is suitable • overall tonus, mobility, and elasticity of the soft for this. The patient is supine, with her head beyond the end of the treatment table. Rotation is examined tissues including the fasciae in retroflexion. The examiner needs to wait to see • posture, standing and sitting whether the patient begins to experience vertigo; if • sensitivity, especially in the regions of the hands her eyes are open, nystagmus will be seen. This test is particularly conclusive if there is no restriction in and feet the position being tested, and all the symptoms can • simple movements therefore be attributed to the disturbance of blood • gait, including tests of walking in unaccustomed flow. If concomitant restriction is found, this should be treated and the test then repeated. If the result posture such as on tiptoe or on the heels, or of the test is again positive, the cause must lie with with arms raised or hanging down. the vertebral artery. In the neurological examination the signs of special interest are those characteristic of minimal brain In some instances de Kleyn’s test may provoke damage, such as marked asymmetry, especially of positional vertigo. If this is observed the examiner the face and the limbs, restlessness, clumsiness, agi- should recognize the fact and follow either of two tation, and also minor deficits such as slight paresis, options, the first being to repeat the test at short hypesthesia, and paresthesia. intervals. In positional vertigo, adaptation soon occurs so that no vertigo is provoked. No such adap- Evaluation of muscle function tation takes place if there is insufficiency of the ver- tebral artery. The other option is to maintain the test The muscle test was originally introduced to exam- position and wait. Positional vertigo never lasts more ine paresis of individual muscles or of muscle groups than a few seconds, whereas the patient’s condition in such diseases as poliomyelitis. It essentially exam- gets worse if there is insufficiency of the vertebral ines muscle strength during a simple coordinated artery; this situation involves some degree of risk. movement. This enables the strength of one specific muscle or muscle group to be assessed. Standard Differential diagnosis of vertigo can be considerably conditions must be maintained, so that results are refined by using manual techniques. comparable. Results are graded as follows: • 0: No muscle activity. 4.13 Examination of muscle • 1: Muscle twitch without motor effect. function • 2: M uscle contraction enabling movement 4.13.1 General principles without resistance, therefore in the horizontal plane. One fundamental difficulty of examination is • 3: Movement against gravity. undoubtedly the lack of established definitions as to • 4: Movement against moderate resistance. what is to be considered normal. Diagnosis has to be • 5: Movement against maximum resistance. Our patients are for the most part seeking treat- ment for painful conditions, and none of them apart from those with radicular syndromes are suffering from true paresis; consequently the values 132

Diagnosis of dysfunctions of the locomotor system Chapter 4 we find range between grades 4 and 5, and only the a distinction is made in line with the work of Janda abdominal muscles and deep neck flexors occasion- between those muscles with a tendency to weak- ally exhibit weakening to grade 3. As a result, the ness and laxity and those with a tendency to hyper- degree of distinction that can be made using grades activity and shortening. 4 and 5 is not fine enough to be useful for the assessment of our patients. 4.13.2 Examination of muscles with a tendency to Without going into details, the examiner must weakness bear in mind the following principles when per- forming the muscle test: The gluteus maximus • The position of the patient must be constant. Before performing the classic muscle test we begin by examining active retroflexion (hyperextension) • Resistance must remain constant throughout the of the hip, with the patient prone in order to iden- movement. tify the patient’s accustomed stereotype (move- ment pattern; see Figure 4.47). Electromyography • The direction and speed of movement should has established that, far from simply being a func- remain as constant as possible. tion of the gluteus maximus alone, retroflexion of the hip is carried out by the coordinated action • The movement must above all be isotonic. of the ischiocrural muscles (knee flexors), glu- teus maximus, and erector spinae. The major role • Isometric resistance can also assess the degree is performed by the ischiocrural muscles, rather of force in the muscle but does not assess coordination. Some modification of the muscle function test therefore are helpful for our patients, who do not suffer from paresis. The most important techniques are described below. In the sections dealing with muscular stereotypes (see Sections 2.9 and 4.15), Figure 4.47 • Examination of the gluteus maximus by palpation of the gluteus maximus, the ischiocrural, and erector spinae muscles (A) with the lower limb extended; (B) with the knee flexed; and (C) with the lower limb in external rotation. 133

Manipulative Therapy than the gluteus maximus. The action begins with the very beginning of the movement. The same contraction of the ischiocrural and gluteus max- applies in upright gait. On the other hand, when the imus muscles, followed by the erector spinae on person is getting up from a chair or climbing steps, the contralateral and finally the ipsilateral side. It is the gluteus maximus contracts immediately. therefore advisable to palpate the gluteus maximus and ischiocrural muscles with one hand, and the The gluteus medius erectores spinae of both sides with the fingers of the other. In the frequent cases of an inhibited glu- The gluteus medius is examined with the patient teus maximus, contraction is found to be retarded, in the side-lying position, her underneath leg flexed so that it is passed over and the contraction of the slightly. She should be asked to raise the upper- ischiocrural muscles is immediately followed by an most leg laterally (i.e. upward from the table), exaggerated contraction of the ipsilateral erector completely spontaneously. The examiner should spinae. In the most severely disturbed movement make no intervention at this stage, but instead patterns muscular contraction may start at the observe whether she makes a true abduction (see superior part of the trapezius. Figure 4.48A), or a combined movement, involving flexing of the hip and external rotation of the leg The muscle test proper is performed with the (see Figure 4.48B). Only the first is genuine abduc- patient prone, face down and knee flexed. Resist- tion, employing the true abductor muscles (gluteus ance to the extension of the hip is applied above medius and minimus) at the same time as contract- the knee (see Figure 4.47B). ing the tensor fasciae latae. The second reveals incoordination, in which there is substitution by If we wish to facilitate the gluteus maximus, the the tensor fasciae latae. It is therefore advisable to best approach is to examine retroflexion of the hip palpate both the gluteus medius and the tensor fas- with the leg in external rotation (see Figure 4.47C). ciae latae during the examination. In incoordination there is also premature contraction of the quadra- If the patient’s leg, in extension, is allowed to tus lumborum, producing side-bending of the trunk hang down beyond the edge of the treatment table rather than hip abduction. so that the extension of the hip begins from that position, the examiner will see that the gluteus maximus does not contract until the leg is horizon- tal, whereas the ischiocrural muscles are active from Figure 4.48 • Examination of hip abduction by contraction of the gluteus medius with the patient in the side-lying position. (A) Pure abduction correctly carried out. (B) False abduction (incoordination) by substitution by the hip flexors, particularly by the tensor fasciae latae. (C) The ‘classic’ test for the abductors. 134

Diagnosis of dysfunctions of the locomotor system Chapter 4 The classic test is performed by applying resist- The transversus abdominis ance against the lower third of the thigh from later- ally and above, at the same time fixing the pelvis in The transversus abdominis cannot be tested by such a way as to prevent substitution by the quad- means of a particular movement; the examiner sim- ratus lumborum (see Figure 4.48C). Meanwhile, ply has to observe whether the patient’s flanks are with the thumb and forefinger of the other hand, drawn inward during sitting up or rotation of the the examiner should palpate the gluteus medius trunk. If the patient’s flanks bulge outward, this is and tensor fasciae latae. a reliable sign of insufficiency. Another indication of insufficiency is seen when the patient’s abdomen The rectus abdominis bulges on lifting an object from a position of ante- flexion. The classic test is performed with the patient The inferior (ascending) part of the supine, knees flexed, and arms clasped behind the trapezius back of her neck. The examiner fixes the patient’s lower limbs and pelvis. She is then asked to sit up, For this muscle test the patient should be prone, beginning by lifting her head, then her thorax, ‘curl- face down, and with the arm on the tested side ing up’ in the process. stretched forward. With one hand, the examiner grasps the outstretched arm, and with the other he For our purposes it is better if the patient should grasp the inferior angle of the scapula, tell- sits up unaided with arms stretched forward (see ing the patient to pull her arm and shoulder down Figure 4.49). This can only be done if the abdominal in the caudal direction (see Figure 4.50). muscles are sufficiently strong. Very strong patients will even be able to sit up with arms clasped behind For our purposes, the best way to diagnose the back of the neck. Although bending the knees incoordination is simply inspection. The patient inhibits the hip flexors to some degree, sitting up is face down, with her arm against her body. She is always the result of coordinated action together is then asked to draw one shoulder down in the with the hip flexors. To examine the abdominal caudal direction (i.e. in line with the muscle fib- muscles alone, excluding the hip flexors, the exam- ers). If the trapezius is weak, the inferior scapular iner should place his hands under and behind the angle moves medially like a hook and protrudes patient’s heels, telling her to press down onto his under the skin, as it does in winged scapula (scap- hands with her heels. Then she is asked to lift her ula alata). This movement, which is normally head and her thorax in succession. The moment forceful, can in this case be prevented easily by the patient starts using the hip flexors, the pres- the thumb and forefinger of the examiner’s hand. sure of her heels on the examiner’s hands ceases. The patient should be able to move the scapula The stronger the abdominal muscles, the higher the in a caudal (and slightly medial) direction against patient can lift her head and trunk without relaxing resistance. the pressure of her heels. Figure 4.49 • Examination of the rectus abdominis (see also Figure 6.139A). 135

Manipulative Therapy arms rather than putting the weight on her knees, and her shoulder blades should be abducted. She can flex her elbows slightly as she does this (see Figure 4.51). She must then maintain this posi- tion while the examiner waits and observes. If the muscle is weak, then after a period of latency the medial border of the scapula lifts, leading to the appearance of slight winged scapula. The deep flexors of the neck Figure 4.50 • Examination of the inferior part of the The patient is supine and is told to lift her head in trapezius. an arching movement, drawing her chin toward the jugular fossa. The examiner fixes the patient’s chest The serratus anterior from above with one hand while the other, on her forehead, applies resistance (see Figure 4.52). If This muscle is tested with the patient on all fours. there is weakness of the deep neck flexors, a ventral She should distribute her weight forward onto her shift of the head (incoordination) is seen, due to predominance of the sternocleidomastoid muscles. There is a useful ‘quantitative’ test that can be applied: the patient is asked to raise her head as if reading (without lifting the thorax). If strength is normal, this position can be maintained for half a minute or even longer, but if the muscles are weak, the patient’s head sinks back down onto the treat- ment table after a few seconds. To test the sternocleidomastoid muscles, the examiner should apply resistance to the ventral lift- ing of the head. 4.13.3 Examination of muscles with a tendency to shortening Figure 4.51 • Examination of the serratus anterior with the Evaluation of those muscles that tend to hyper- patient positioned on all fours. activity and shortening – the ‘predominantly Figure 4.52 • Examination of the deep neck flexors. (A) Head raised in an arc: good muscle function. (B) Head raised vertically: insufficiency; predominance of the sternocleidomastoid muscles. 136

Diagnosis of dysfunctions of the locomotor system Chapter 4 Figure 4.53 • Test for shortening of the soleus. (A) Normal muscle stretch. (B) Raising of the heel from the floor on adopting a squatting position: this indicates shortening. postural muscles’ identified by Janda (see Table 2.1, knee flexed, and this can be shown quite simply by p. 28) – is essentially a matter of observing how far comparing dorsiflexion with the knee extended and a muscle can be stretched without the use of force; flexed (see Figure 4.54). For this reason the mobil- as this is done in the same way as if taking up the ity of the ankle joint should never be tested with slack in PIR, only those muscles for which the tech- the knees extended. The foot must be guided pre- niques differ are dealt with here. cisely at the lateral border while applying traction at the heel. The soleus The ischiocrural muscles If this muscle is shortened, dorsiflexion of the ankle joint is restricted. This can be tested by asking the The ischiocrural muscles are tested in the same patient to squat down without raising her heel from way as in the straight-leg raising test. The patient the floor. If she has to lift her heels from the floor, is supine. The leg that is not being examined should then it is primarily the soleus that is shortened (see be fixed on the table from above, and the other Figure 4.53). leg flexed at the hip, with the knee extended. The ischiocrural muscles are considered shortened if the If, as often happens, it is only the gastrocnemius extended leg cannot be flexed at the hip to an angle that is shortened, dorsiflexion of the ankle joint is of 90°. All the patient feels in this case is tension in restricted with the knee extended but not with the Figure 4.54 • Examination of muscle stretch of the gastocnemius by dorsiflexing the foot (A) with the leg extended and (B) with the knee bent. A marked difference in dorsiflexion indicates that the gastrocnemius is shortened. 137

Manipulative Therapy the hollow of the knee and in the thigh, but (unlike some disturbances can be identified straight away in radicular syndrome) no real pain. by simple inspection: if the iliopsoas is shortened, the knee of the leg being tested will be raised. If Shortening of these muscles is the most frequent the rectus femoris is shortened, the lower leg will reason why a clinically healthy subject cannot touch not hang vertically; instead there will be an obtuse the floor when bending forward with the arms and angle between the lower leg and thigh. If the tensor legs straight. This is most clearly evident when fasciae latae is shortened, the thigh will be slightly observed from the side: on anteflexion, considera- abducted and the patella will deviate slightly out- ble kyphosis of the lumbar spine is seen, but ventral ward. inclination of the pelvis is inadequate. To evaluate the individual muscles, the exam- The hip flexors iner should reinforce fixation of the flexed knee (the one not being examined) from above with one These comprise the iliopsoas, the rectus femoris, hand. With the other hand, the examiner then: and the tensor fasciae latae. They are examined in the position for Mennell’s test. The patient is • exerts pressure from above on the knee of the supine with the buttocks at the end of the table, leg being tested in order to assess shortening of and draws one knee toward her chest, close enough the iliopsoas to flatten lumbar lordosis (see Figure 4.55). The other leg (the one to be tested) is allowed to hang • applies pressure to the lower leg to flex the down over the edge of the table. In this position knee: the knee of the leg being tested rises prematurely, even with knee flexion greater than 90° Figure 4.55 • Examination of the hip flexors. (A) The examiner notes whether the thigh is raised above the horizontal, and/or whether the lower leg is extended forward, or the thigh and patella deviate to the side. (B) By pressure from above, the examiner brings out the shortening of the iliopsoas; by pressure from the side, the examiner brings out the shortening of the tensor fasciae latae. (C) Flexion of the knee produces the avoidance reaction of hip flexion if the rectus femoris is short. 138

Diagnosis of dysfunctions of the locomotor system Chapter 4 Figure 4.56 • Examining for shortness of the lumbar erector spinae muscles. (A) Drawing the forehead to the knees. (B) The patient fixes her pelvis with her hands. Restricted anteflexion in the lumbar spine due to short spinal erectors can now be easily diagnosed. • applies lateral pressure to the slightly abducted knee. Premature resistance is felt and the tension can be seen in the iliotibial tract, as if in a groove on the lateral aspect of the thigh. The lumbar erector spinae Examination for a shortened lumbar erector spinae is Figure 4.57 • Examination of the quadratus lumborum. carried out with the patient sitting, the knees flexed and the trunk in anteflexion. The patient’s hands side-lying is more accurate; the patient should raise should rest behind her body, palms uppermost and her upper body, supported on her elbow and fore- the back of her hands flat on the treatment table arm, so as to produce side-bending of the lumbar (see Figure 4.56A). She is asked to draw her fore- spine. The lower part of her trunk should remain head to her knees. This cannot be done if the erec- on the table (see Figure 4.57); if necessary the tor spinae muscles are shortened. However, other examiner should fix the patient’s pelvis from above factors are also capable of preventing this: for exam- to prevent her from raising her trunk too far. If the ple it is impossible if the patient’s trunk is long and quadratus lumborum is shortened, side-bending is her thighs short. Conversely, however, if the patient reduced. has a short trunk and long thighs, it is possible to perform the movement even if the muscles of the The muscles of the nuchal region back are shortened. A modified version of the test is therefore more reliable: the patient, seated, fixes her pelvis by placing her hands on the iliac crests, and humps her spine to create lumbar kyphosis. If the lumbar part of the erector spinae is shortened, lum- bar lordosis remains unaltered (see Figure 4.56B). The quadratus lumborum The technique used to test for shortening of the superior (descending) part of the trapezius, pecto- Shortening of the quadratus lumborum can be iden- rales, and levator scapulae muscles is identical to tified on side-bending, but scoliosis or a difference that used in PIR treatment to take up the slack, and in leg length can give a false impression of shorten- is described in the section dealing with this (see ing of this muscle. Examination with the patient Section 6.8). 139

Manipulative Therapy of hypermobility in pathogenesis has already been described (see Section 2.10); here we shall focus on diagnosis. The guidelines in this respect have been set out by Sachse (1969), and enable the examiner to make the distinction between normal mobility, hypomo- bility, and hypermobility, all within the range of the normal. It is nevertheless important to bear in mind the great variability between individuals, and also between age groups. What may be considered hypermobile in an adult male may be perfectly normal in a female or a child. With this proviso in mind, it will be helpful in what follows to present the results not in the form of a continuous scale of measurements, but of three levels of mobility, A, B and C: • A: hypomobile to normal • B: slightly hypermobile • C: marked hypermobility. I also compare Sachse’s criteria with the data given by Kapandji (1974) and describe the technique. 4.14.1 The spinal column Figure 4.58 • Overload of the upper fixators of the The overall mobility of the spinal column on the shoulder girdle and superiorly convex ‘Gothic’ shoulders. basis of X-ray examination is 145° for anteflex- ion, 135° for retroflexion, 75° for side-bending, On inspection, shortening of the pectoralis is and 90–95° for rotation to each side, as found by shown by increased thoracic kyphosis, shorten- Kapandji (1974). Clinically, each of these move- ing of the superior part of the muscle is shown by ments is measured separately. forward-drawn shoulders, and hypertonus of the superior part of the trapezius is revealed by the One sign of hypermobility of the lumbar spine upwardly convex ‘Gothic’ shape of the shoulders which is of particular clinical importance is this: (see Figure 4.58). hyperlordosis is seen when the patient is standing, and changes to hyperkyphosis when the patient For rapid screening assessment, the muscles adopts a relaxed sitting position. of the nuchal region are examined as follows. The patient should draw her chin to her chest (with The lumbar spine mouth closed). If the muscles are short, the patient will be unable to do this, and a gap remains, which Retroflexion the examiner can measure in terms of fingers’ breadth. Short nuchal muscles are the most fre- The average range of retroflexion is 35° according quent cause of inability to bring the chin down on to Kapandji (1974). Clinical examination may show to the chest. the maximum angle of retroflexion to be either lumbosacral or thoracolumbar. According to Sachse 4.14 Examination of (1969) the test is carried out with the patient hypermobility prone so as to exclude synkineses of the pelvis. The patient’s hands should be placed underneath her as Not only weakness and tautness, but hypermobility, support, flat on the table, and positioned so that her too, is mainly muscular in origin. The significance fingertips are immediately under her shoulders (see Figure 4.59A). The examiner should fix her pelvis 140

Diagnosis of dysfunctions of the locomotor system Chapter 4 Figure 4.59 • (A) Testing the range of retroflexion of the trunk. (B) Evaluation: A, hypomobile to normal; B, slight hypermobility; C, marked hypermobility. from above. The patient is asked to direct her gaze at the floor and to lift her upper body by the pres- sure of her arms, raising it as far as her lumbar spine will allow without involving any movement of the pelvis. The degree of movement can be read indi- rectly by looking at the internal angle of the elbow. Range A is up to 60°, range B up to 90°, and range C in excess of 90° (see Figure 4.59B). Anteflexion The average range of anteflexion is 60° according to Figure 4.60 • Testing the range of anteflexion of the Kapandji (1974). When this is tested by having the trunk. Evaluation: A, hypomobile; B, slight hypermobility; patient bend to touch the floor, hip flexion is also C, marked hypermobility. tested, and if done with legs extended, this also tests the muscle stretch of the ischiocrural muscles (see Figure 4.60). Range A covers a finger–floor dis- tance through to 0 cm. Greater flexibility, through to the point where the patient is able to touch the floor with her knuckles, is classed as range B. Range C covers anything beyond this. The patient is sometimes even able to place the chest against the thighs. This examination has the disadvantage that it tests not only the kyphosis of the lumbar spine but also muscle stretch of the ischiocrural muscles. The following test can focus much more specifically on anteflexion of the trunk: for this the patient is in the sitting position and is asked to bend and try to touch her knees with her forehead. In this test, range A describes anteflexion that does not go beyond a forehead–knee distance of 10 cm, range B covers anteflexion to the point where the patient 141

Manipulative Therapy can touch the knees with her forehead, and in range Rotation C the patient can put her forehead between her knees. The range of lumbar rotation is given by Kapandji (1974) as 5°, which is not capable of being clinically Side-bending tested. The lumbar spine allows side-bending of approxi- The thoracic spine mately 20° to each side; in the test devised by Sachse (1969) the patient stands with legs closely Rotation together and flexes to the side. The plumb line from the fold of the contralateral axilla reaches no The figure given by Kapandji (1974) for trunk rota- further than the intergluteal cleft in range A. In B tion is 35° to each side. The patient sits astride the it reaches beyond this point as far as the middle of end of the treatment table and fixes her shoulder the buttock of the side toward which the patient is girdle with her hands, which are clasped behind the side-bending, while in C it reaches beyond the lat- nape of her neck. She is asked to turn to the right eral aspect of the buttock (see Figure 4.61). When and left in succession, while the examiner ensures testing anteflexion and side-bending the examiner that the pelvis remains fixed. Up to 50° to each side must take into account the mobility of the hips and, is defined as range A, from 50–70° as range B, and in particular, the body proportions of the patient: beyond 70° as range C (see Figure 4.62). there may be ‘false’ hypermobility due to a long trunk and short legs. In anteflexion this impression We now know that rotation of the trunk pro- can also be given if the patient has long arms. duces simultaneous side-bending of the spinal col- umn in a coupled movement, in which the lumbar spine also participates (see Section 3.4.1). Anteflexion, retroflexion, and side-bending Testing of anteflexion, retroflexion, and side-bending of the trunk also involve the thoracic spine. The exam- ination of these movements (with the patient in the standing position) has already been described above as tests for the assessment of the lumbar spine. Kapandji (1974) gives the range of movement for the thoracic spine as 45° in anteflexion, 25° in retroflexion, and 20° to each side in side-bending. If the examiner wishes to measure anteflexion and retroflexion of the thoracic spine clinically, this Figure 4.61 • Testing the range of side-bending of the Figure 4.62 • Testing the range of trunk rotation. trunk. Evaluation: A, hypomobile to normal; B, slight Evaluation: A, hypomobile to normal; B, slight hypermobility; hypermobility; C, marked hypermobility. C, marked hypermobility. 142

Diagnosis of dysfunctions of the locomotor system Chapter 4 Figure 4.63 • Testing the range of rotation of the head. Evaluation: A, hypomobile to normal; B, slight hypermobility; C, marked hypermobility. should be done with the patient sitting, asking her Figure 4.64 • Testing the dorsal extension of the to hump her back and straighten up. metacarpophalangeal joints. Evaluation: A, hypomobile to normal; B, slight hypermobility; C, marked hypermobility. The cervical spine following test is based on this fact. The patient is Rotation asked to bend her elbows and place her forearms and hands firmly together in front of her. She In the cervical spine, rotation can be measured should then extend her arms as much as she can clinically. According to Kapandji (1974), this move- without separating her elbows (see Figure 4.65). If ment is 50° to each side. When tested with the the internal angle at the elbows remains less than patient’s head in perfectly erect posture (see Figure 110°, this is assessed as range A, an angle of 110– 4.63), the degree of movement is assessed as range 135° is range B, and beyond this is range C. A when it is up to 70° to each side, B from 70–90°, and C when it is over 90°. When examined in this The shoulder way the rotation also involves the upper thoracic spine. If the head is held slightly bent forward, this For this test the patient is asked to bring the hori- synkinesis can be eliminated. zontally raised upper arm towards the shoulder of the opposite side. Range A mobility enables the 4.14.2 The joints of the patient to bring the elbow to the midline at most, upper limb range B from there to a point half way between the midline and the contralateral shoulder, and The figures used in this section are those given by range C beyond this. In extreme cases the elbow Sachse (1969). may even reach the contralateral shoulder (see Figure 4.66). The metacarpophalangeal joints Another test examines the patient’s ability to In passive dorsal extension (in which the inter- make both hands meet diagonally behind the back. phalangeal joints may be bent), an average range of The test is performed on both sides, and relates to movement of up to 45° is assessed as A, between the side of the hand approaching from below. The 45° and 60° as B, and measurements beyond this as result is recorded as range A if the fingers do not C (see Figure 4.64). touch or if the fingertips just come into contact, as range B if the patient’s fingers overlap, and as C if The elbow the fingers can be placed in the palm (see Figure 4.67). There must be no hyperlordosis of the spinal At the elbow joint, there is often a correlation column. between valgus alignment and hypermobility. The The best way to test the mobility of the gleno- humeral joint specifically is by means of passive abduction. If the examiner fixes the shoulder blade 143