principles of manual therapy (a manual therapy approach to musculoskeletal dysfunction)

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Principles of Manual Therapy



Disclaimer

Every effort was made to ensure that the information provided in

this literature review is accurate and meets contemporary practice

standards. However, the patient is unique with respect to their needsand desires. Manual therapy is a specialized subject requiring a great

deal of practice and sound clinical judgment. The reader is suggested

caution at every level, based on the individual needs of the patient,

taking into consideration all possible contraindications before treatment.

The author and/or the production associates are not responsible for

any untoward consequences that may result from the execution/

application of clinical information provided in this literature review.

The reader/clinician is required to assume full responsibility by

utilizing his/her clinical experience combined with sound clinical

judgment prior to the execution of treatment procedures.



Principles of

Manual Therapy A Manual Therapy Approach to

Musculoskeletal Dysfunction

Deepak SebastianBPT PGDR MHS, PT MTC DPT PhD

Physical Therapist and Clinical InstructorAlternative Rehab.

Institute of Manual Physical Therapy

Michigan, USA

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Principles of Manual Therapy

© 2005, Deepak Sebastian

All rights reserved. No part of this publication should be reproduced, stored in a retrieval system,

or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or

otherwise, without the prior written permission of the author and the publisher.

This book has been published on good faith that the material provided by author is original.

Every effort is made to ensure accuracy of material, but the publisher, printer and author will not

be held responsible for any inadvertent error(s). In case of any dispute, all legal matters to besettled under Delhi jurisdiction only.

First Edition: 2005

ISBN 81-8061-504-9

Typeset at JPBMP typesetting unit

Printed at Gopsons Paper Ltd, Noida



To My parents

Dr S Snehalatha and Mr R Sebastian, the Almighty,

and my profession

Prof Mary Chidambaram,my first impression of a

physiotherapist

All my teachers in India and theUnited States



Acknowledgements

Behind every endeavor stand able and enthusiastic minds and sources of inspiration. I wishto thank Prof. Mary Chidambaram, Formerly Chief Physiotherapist, College of Physiotherapy,Chennai, for her dynamism as a clinician and teacher, which was indeed a great sourceof inspiration and her constant emphasis on the character of a clinician. I express gratitudeto Prof. IS Shanmugam MBBS, Dorth, DPhys Med, Retd Director Govt Institute of Rehabilitation Medicine, KK Nagar, Chennai for giving me an opportunity in this professionand for his guidance and encouragement. My deepest gratitude to Prof. PVA MohandasMB, D (Orth), MS, Mch (Orth), Professor of Orthopedic Surgery, MIOT, Chennai, for giving

me an exposure to a new work culture, for his dynamic mentorship and his emphasis towardsinnovation. His ideology is followed and shared to this day. My heartfelt thanks to myteachers Dr George Ibrahim, PT, DO, Consultant, St Joseph Mercy Health System, Ann Arbor,Michigan and Dr Stanley V Paris, PhD, PT, Professor of Manipulative Therapy and President,University of St Augustine for Health Sciences, St Augustine, Florida, my very sources of motivation to specialize in manual therapy. I wish to thank Helen Smith, MSA, PT, SystemsManager, Department of Physical Therapy, St Joseph Mercy Health System, Ann Arbor,Michigan for her friendship and support through the early days of my career in the UnitedStates and Dr Peter Loubert, PhD, PT, ATC, Professor of Physical Therapy, Central MichiganUniversity, Mount Pleasant, Michigan, for his valuable academic advice over the last decade.My immense gratitude to Dr MG Mokashi, PhD, PT, formerly head, Department of Physical

Therapy, All India Institute of Physical Medicine and Rehabilitation, Mumbai, my first exposureto controlled research and critical enquiry.Much is owed to my colleagues Raghu Chovvath, PT, OCS, (Dr PT) Ramesh Malladi,

PT (Dr PT) and Toby Manimalethu, PT, at Alternative Rehab Inc, Livonia, Michigan, fortheir dedication and zealous enthusiasm despite their hectic work and family responsibilities.Their clinical and technical support has indeed made this book a possibility.

I wish to recognize and thank Nazir VM Ahmed, PT, MSc, Consultant, Henry Ford HealthSystem, Detroit, Michigan, a friend and colleague, who dedicates most of his valuable timecaring for patients who to him stand as his biggest priority.

Words cannot express the moral support that I received from my friends Salil Raje, BSc,MBA, MS, Kshitija Raje, PT, MSc, MS, GCS, Suvarna Aphale, PT, Sanjay Kulkarni, MD, PhD,

Amit Mehta, PT (MBA), Smitha Mehta, PT, Sachin Desai, PT, MSc and Swapna Desai, PhD,whose genuine love and affection saw me through some very hard phases of my life asI was writing this book.

Lastly, but truly firstly, my parents, Dr S Snehalatha, MD, Professor of Pathology andformerly Vice Principal/Acting Dean, Madras Medical College and Mr R Sugumar Sebastian,retired Abrasive Consultant and Technical Director, who set an example and constantlyinstilled in me the value of education and the importance of persistent hard work. They,to this day, motivate me to move on.



Preface

Manual therapy is a form of hands on treatment approach, which has evolved over timefrom an orthodox approach to a clinical science. Of all the clinical specialties, especially inIndia, hands on treatment are provided most by physical therapists. For the most parttreatments of this sort are palliative and also for functional enhancement. However, manualtherapy today has evolved into a clinical science, more intricate with regards to examinationand treatment and most importantly an effective diagnostic tool. Rapidly developing inEurope, Australia and North America, institutions now have clinical residencies in manualtherapy.

In India, physical therapists practise manual therapy in various forms. Some clinicianshave the opportunity to travel abroad for training, which they share with the community by way of continuing education courses and conference presentations. Besides these fortunatefew, other clinicians practise their philosophy by information gleamed from textbooks written by foreign authors. These textbooks often carry terminology that is difficult to understandand treatment strategies that may differ from a cultural perspective. The bigger handicap being, besides the availability of these textbooks being relatively remote, they are indeedexpensive. A textbook for every clinician or student may not be a realistic expectation.

Hence, the goal of this endeavor is to address these deficits. First, to standardize theinstruction of manual therapy with a standard text and offer structure to treatment concepts.Then to make possible the availability of an inexpensive book to every physical therapist

and student to be used as a day-to-day reference manual, both for self-improvement, andthe welfare of the patient. This book contains conceptual aspects and treatment techniques.They are categorized by regions of the body and carry a fairly extensive number of clinicalphotographs.

The target population are physical therapists and physical therapy students. This book,however, serves as a reference for any practitioner involved in the management of musculoskeletal dysfunction. There are now several hundreds of physical therapy collegesin India and very many practising physical therapists. Most colleges are now headed towardspostgraduate education in physical therapy and this book, well taken, may be the needof the hour.

I sincerely hope and pray God that this endeavor offers physical therapists in India,more structure with regards to their manual therapeutic approaches.

The cover depicts four hands, two pairs working as a team, as no endeavor is completedalone. The signs are actually finger alphabets denoting the alphabets H, E, A and L andthe entire logo signifies ‘hands on healing’. The depiction on the lower part of the signsare a concave and convex surface, a vertebra, and the sacrum.

Deepak Sebastian



Section 1: General Aspects

1. Introduction .............................................................................................................................. 3

2. Evolution of the Practice of Manual Therapy ............................................................... 5

3. Manipulation: Definition and Types ............................................................................. 11

4. Understanding Mechanical Dysfunction ....................................................................... 14

5. Principles of Management of Mechanical Dysfunction ............................................ 19

6. Palpation ................................................................................................................................. 23

7. Principles of Diagnosis ....................................................................................................... 28

Section 2: Regional Application (Spinal Manipulation)

Introduction ............................................................................................................................ 44

8. Cervical Spine ....................................................................................................................... 45

9. Thoracic Spine ....................................................................................................................... 70

10. Lumbar Spine ........................................................................................................................ 8011. Pelvic Complex...................................................................................................................... 88

Section 3: Regional Application (Extremity Manipulation)

Introduction .......................................................................................................................... 112

12. Ankle and Foot ................................................................................................................... 115

13. Knee ....................................................................................................................................... 133

14. Hip .......................................................................................................................................... 145

15. Shoulder ................................................................................................................................ 155

16. Elbow ..................................................................................................................................... 175

17. Wrist and Hand .................................................................................................................. 186

Index ........................................................................................................................................ 205

Contents



Section 1General Aspects

1. Introduction

2. Evolution of the Practice of Manual Therapy

3. Manipulation: Definition and Types

4. Understanding Mechanical Dysfunction

5. Principles of Management of Mechanical Dysfunction

6. Palpation

7. Principles of Diagnosis



Manual therapy is a skilled, specific hands onapproach used by clinicians including physicaltherapists to diagnose and treat soft tissueand joint structures for the purpose of

decreasing pain, improving joint range andalignment, improving contractile and noncon-tractile tissue repair, improving extensibilityand stability and facilitating function. Assistedtherapeutic exercise and passive movementmost definitely encompass the practice of manual therapy, but manual therapy todayhas evolved as a science with a greater degreeof specificity and broader area of application.Most importantly in the diagnosis of musculo-skeletal dysfunction which are usually not

visualized by complex imaging procedures.Management of musculoskeletal dysfunc-

tion is often symptom based. The pain is oftentreated as opposed to the cause of the pain.1

The reasons are often times due to ignoranceof the intricacy of the cause or time cons-traints. If the cause is detected, the chronicityof the problem is minimized and the needfor complicated procedures, includingsurgery, in many instances is avoided.

The musculoskeletal system is a system of

chains and links united in function andenveloped by fascia. No part of the bodyfunctions independently. In which case noinjury, that is cumulative in nature, occurssecondary to a single entity. The reverse istrue as when injury occurs secondary to anoutside force or trauma (falls, motor vehicle

1 I ntroduction

accidents) recovery, especially normalfunctional recovery, does not occur due torestoration of functional integrity in a singleentity. A whole chain or functional chain is

usually involved and its integrity is essentialfor normal function. This functional chainconsists of the osseous component (bone and joint), the soft tissue component (muscle,fascia and ligaments) and the neural compo-nent (central and peripheral). Infrequently,the autonomic component may be of relevanceto the physical therapist. The detection of aberrant function of this functional chain asa whole and correlating it to the existingpathology is the essence of the art and science

of manual therapy.3

Hence, manual therapy as is traditionallyviewed as a technique-based treatment modeis in reality, a diagnostic tool. The diagnosisis made by sensitive feel and astute clinicalobservation of the functional chain, both thatrequire a great deal of practice.2 Thetreatment ‘technique’ is often the smallestcomponent of the management strategy andtruly the diagnosis, or detection of thedysfunction is where a lot of the mental

energy is exercised.The health care arena is now headed

towards what is known as evidence-basedpractice. This implication is felt significantly by the profession of physical therapy,especially physical therapist’s practicingmanual therapy. Quantification4 of favorable



4 Principles of Manual Therapy

outcomes or hard facts denoting efficacy of treatment procedures is often times stressedupon. It is indeed unfortunate if there is amonetary implication to this. It may be

healthy though if it is the result of a turf warsecondary to insecurity of a certain professionof an imminent encroachment. Whatever bethe case, the clinician must understand thatthere are many parameters that cannot bequantified that can offer effective outcomesconsistently. It should however be nowhereclose to being justified as quackery.

In manual therapy the gray zone isreproducibility. Since most diagnosticprocedures are by ‘feel’, two or more

examiners are expected to feel the samefinding which is to be statistically significant.This is called inter-rater reliability.5 Theefficacy of treatment procedures is undoubtedfrom an empirical perspective, however,inter-rater reliability has not been found to be good overall. One should know thatreproducibility within the same examiner has been found to be fair to good. Research wouldterm this intra-rater reliability. This is indeeda consolation, however, the clinician should

also know that a similar dilemma exists inother health professions that incorporatepalpatory examination in their respectivepractices. The point to be made is, clinicians,especially manual therapists, should constan-tly strive to structure and improve consistencyin their philosophy. Extensive practice witha sound background of bio and pathomec-hanics combined with meaningful research,should always be stressed upon.

This literature review combines traditionalosteopathy with traditional physical therapyto establish what is known as a somaticdiagnosis. As much as structure would governfunction, the harmonious movement interplay

of this structure that is influenced byneuromuscular integrity, would also governfunction. Be there any aberrance in this unitya dysfunction would henceforth result. Hence,

the clinician should remember that manualtherapy is a science of not just technique butalso a science of somatic diagnosis.

Just like any other treatment philosophy,manual therapy is not a cure at all. It has to be combined with other philosophies asappropriate. When addressing every singlecomponent of the neuromusculoskeletal appa-ratus all appropriate tests and most impor-tantly all standard precautions and contrain-dications should be considered to avoid unfavorable

outcomes.This literature review hence intends to

enlighten the physical therapy clinician, notonly the techniques of application, but alsothe conceptual basis of why such techniquesare incorporated with an emphasis ondetection or diagnosis of the dysfunction. Italso intends to reinforce the fact ever so oftento“treat the cause not the symptom.”

REFERENCES

1. Paris SV. Manual Therapy: Treat Function NotPain. In Michel TH. Pain. Churchill Livingston,1985.

2. Sahrmann SA. Diagnosis by the physicaltherapist – a prerequisite for treatment. PhysTher. 1988;68 (11):1703-6.

3. Greenman PE. Principles of Manual Medicine.Baltimore: Williams and Wilkins, 1996.

4. Van Dillen LR, Sahrmann SA, Norton BJ,Caldwell CA, Fleming DA, McDonnel MK,Woolsey NB. Reliability of physical exami-nation items used for classification of patients

with low back pain. Phys Ther. 1998; 78 (9): 979-88.

5. Gonella C, Paris SV, Kutner M. Reliability inevaluating passive intervertebral motion. PhysTher 1982;62(4):436-44.



Evolution of the Practice of Manual Therapy 5

BEGINNING

The earliest records of medical practice dates back to 600 BC, with Ayurveda being consi-dered the mother of all practice forms.

Acharya Susrutha (600 BC) (Figure 2.1) isconsidered the father of surgery andinterestingly may also be considered aproponent of manual medicine. His bookcalled Susrutha Samhitha has explainedtreatment with the hands about 5000 yearsago, over 100 years prior to Hippocrates. Hehas described points on the body wherecontractile and non-contractile structuresmeet and has named them as ‘marma points’.He describes detecting them using finger

units (anguli) and treating them withpressure. He has mentioned 107 such points.

Figure 2.1: Susrutha— Father of surgery

2Evolution of the Practice

of Manual Therapy

The ‘ hands on‘ approach of healing dates back to the old testament but the so-calledmodern manual medicine had its birth with Hippocrates (460-355 BC) (Figure 2.2). He was

probably the first to describe restrictions inthe joints. Hippocrates was a physician of great skill and recognized as the father of medicine. Interestingly, he is known to havederived many of his concepts from Ayurveda.He has described a number of manipulationtechniques, including traction. He has alsodescribed the use of steam heat prior tomanual therapy procedures which is a conceptthat is still being followed. His famoussuccessor Galen (131-202 AD) also preached

the use of manual medicine and has describedmanual therapy procedures for the extremitiesand the cervical vertebrae.

Figure 2.2: Hippocrates —Father of medicine




MIDDLE AGES AND RENAISSANCE

In the middle ages, a written summary of medicine that survived as an authoritativetext until the 17th century, was the work done by an Arabian physician Abu’ Ali ibn Sina (980-1037 AD). It included manual medicine techni-ques advocated by Hippocrates. Chang ChungKing, referred to as the Chinese Hippocratesalso advocated treating patients with manualmedicine during the middle ages.

The renaissance (new learning) in medicine began with Andreus Versalius, who in 1543described the detailed anatomy of the human body. He also outlined the anatomy of the

intervertebral disc, and differentiated theannulus and the nucleus. A little more than30 years hence , Ambrose Pare,a famous surgeonto four successive French kings did much toraise the standard of orthopedic surgery andalso used a considerable amount of manipu-lation. The use of spinal traction, as well asmedieval Turkish manipulation during trac-tion were recorded in the leading textbooksof the renaissance. Ambrose Pare wrote,“When a vertebra dislocates posteriorly and

protrudes, the patient should be tied downprone with ropes under the arm pits, waistand thighs. He should then be pulled andstretched as much as possible from up and below, but not violently”. This concept is still being followed as lumbar traction fordiscogenic pain.

BEGINNING OF CONTEMPORARY

MANUAL MEDICINE

John Hunter (1728-1793) in his teachings

emphasized the value of moving joints afterinjury in order to prevent stiffness andadhesions. He recommended the need forstretching, to break down adhesions that areend products of inflammation. A concept thatis the basis for mobilization practiced byphysical therapists. However, in the 17th and

18th centuries, the treatment by manualmeans lost favor in the medical profession but manual treatments were being practicedoutside of the medical community by who

were known as “Bone Setters.”

BONE SETTING

A practice called “bone setting”2 flourishedin Britain in the 17th and 18th centuries. Itwas based on the belief that little bones wereout of place and the click that followed mani-pulation was that of little bones going backin place. Bone setting is practiced in India tothis day in places like Puthur for more seriousconditions sometimes with good results andoften times with unfavorable consequences.Bone setting, as in India, was not favored bythe medical community in Britain, however,in 1867, Sir James Paget (1814-1899) lecturedon “Cases That Bone-Setters Cure.” Hisadvice was “…..Learn then, to imitate whatis good and avoid what is bad in the practiceof bone setters….too long a rest is, I believe, by far the most frequent cause of delayedrecovery after injury of joints and not only

to injured joints but to those that are keptat rest because parts near them have beeninjured”.1 Again, a concept being followed tothis day by physical therapists. Bone-setterswere dying out only in the middle of the 20thcentury when physical therapy andosteopathy assumed its place.

OSTEOPATHY

The roots of manipulative therapy in theUnited States began with Andrew Taylor Still

(1828-1917), who founded osteopathic medi-cine in 1874 (Figure 2.3). He was a physicianfrom Kansas city and was an eccentric, non-conformist. He pursued his beliefs with inten-sity and devoted himself to the philosophyof medicine and the study of man as a totalunit. Perhaps the loss of his three children




to a meningitis epidemic in 1864 intensifiedhis pursuits as he felt that the status of medicine was inadequate.

In his study Still observed that when jointsrestricted in motion due to mechanicallocking, were normalized, certain diseaseconditions improved. He made much of bloodand nerve ‘flow’ and wrote that suchrestrictions can diminish arterial supply,which by nature was intended to supply andnourish every nerve, ligament, muscle, skin, bone and the artery itself. He also wrote thatto successfully solve the problem of diseaseor deformity of any kind, obstructions to anartery or vein must be corrected, the resultotherwise being manifestations of disease.Thus was enunciated as what was to beknown in osteopathy The Law of the Artery.

The osteopathic concept has been brieflystated as:8

1. The body is a unit.2. Structure and function are reciprocally

interrelated; and3. The body possesses self regulatory

mechanisms for rational therapies basedon an understanding of body unity, self regulatory mechanisms and the inter-relation of structure and function.

Osteopathy continued to grow but alsoembraced the advances made by medicine,as it was not a stand alone cure-all. Hence,it was losing some of its appeal. In the United

States, few osteopaths manipulate while amajority of them practice traditional medicine(which is not the case in Europe). A lot of what they have left behind are being practicedin Physical therapy clinics, but, of course, forneuromusculoskeletal dysfunction only andnot for disease, that osteopathy originallyclaimed to cure. It is inferred that Still, duringhis period of research had adopted many of his techniques from that of bone setters in

India, a fact that might lead us to believe thatmanual therapy was practiced in India long before, however with no strong scientific basis.

CHIROPRACTIC

The founder of the chiropractic (from theGreek words cheir, meaning hand and praxis,meaning done by hand) profession was DanielDavid Palmer, a grocer and a practicingmagnetic healer. He asserted his philosophy

in 1895. Although proponents of chiropracticattribute the discovery to Palmer, he himself admits in his writings that it was learnt froma medical practitioner.

The theoretical basis of chiropracticdefined by chiropractors Janse, House andWells is as follows:1. That a vertebra may become subluxed.2. That this subluxation tends to impinge

other structures (nerves, blood vessels andlymphatics passing through the interver-

tebral foramen).3. That, as a result of impingement, the

function of the corresponding segment of the spinal cord and its connecting spinaland autonomic nerves is interfered withand the function of the nerve impulseimpaired.

Figure 2.3: AT Still —Founder of osteopathy




4. That as a result thereof, the innervationto certain parts of the organism isabnormally altered and such parts becomefunctionally or organically diseased or

predisposed to disease.5. That adjustment of a subluxed vertebra

removes the impingement of the structurepassing through the intervertebral fora-men, thereby restoring to diseased partstheir normal innervation and rehabilitatingthem functionally and organically.This philosophy in chiropractic came to be

known as the Law of the Nerve.1 Chiropractorswho follow the above traditional philosophyare known as “straights” and are losing

appeal. Most chiropractors today are knownas “mixers” who mix traditional chiropracticand physical therapy rehabilitation techniqueslike electro and exercise therapy.

Both osteopathy and chiropractic aresimilar in their philosophies in two aspects,they advocate the release of an obstructionor an impingement and their assessment is based on positional faults of anatomicstructures.

MANIPULATION BY PHYSICIANS ANDPHYSICAL THERAPISTS

Two physicians who instructed physicaltherapists in the art of manipulation wereEdgar and James Cyriax,5 and James and JohnMennel,4 father and son.

In 1907, James Mennel associated himself with the Chartered Society of Physiotherapy,and instructed joint and soft tissue mani-pulation techniques. He encouraged his

medical colleagues to send patients to physicaltherapists by prescription. He may have beenthe first to use the term “manual therapy”to avoid the confusing array of terms suchas articulation, mobilization, leading to mani-pulation. Manual Therapy was the title of his book in which he exclusively addressed topicsof massage, passive, assisted and resisted

movement, and joint manipulation. His son John Mennel published his book Joint Pain,in 1960, and described that the principle causefor joint pain and pathology was the synovial

joint and not the intervertebral disc. He mayalso have been the first to use the term “jointplay” to describe the quality of motionwithin a joint. He, like his father, instructedtechniques principally to physical therapists.

Another famous name who workedclosely with physical therapy was EdgarCyriax, who wrote extensively on manualtherapeutic methods. In 1917, he publisheda paper Manual Treatment of the CervicalSympathetics, in which he outlined the techni-

que of palpating the cervical sympatheticganglions and treating them by transversefriction in order to stimulate their function.His son James Cyriax did much to promotemanipulation among physical therapists. Hepublished the Textbook of Orthopedic Medicinein two volumes which has become a classicand is valuable to this day for its clarity indifferentiating between soft tissues onexamination. He also popularized the term“end feel” to draw attention to the sense of resistance that can be felt in all joints at theend of the range and he attempted todistinguish between normal and abnormal.1,8

He strongly emphasized on evaluation andidentification of the problem rather thantreatment which is the best piece of instructionfor any manual therapist. He trained physicaltherapists and advocated that they, more thanthe physician, were the appropriate clinicians,to perform manipulation.

The 1930s saw the birth of arthro-kinematics. Movement had been traditionallydescribed as spatial relationships of thelimbs and trunk to the axis of the body.1

Hence, joint movement was described asflexion, extension, etc.1 In 1927, Walmsley3

began using a new terminology called‘arthrokinematics’ which was later accepted




by Gray’s anatomy, where he describedmovements taking place within the joint suchas roll, glide and spin. Freddy Kaltenborn,a physical therapist saw the significance of

the concept of arthrokinematics and appliedit to joint manipulation some years later, thusdeveloping a whole new approach tomanipulation distinctive to physical therapy.In 1955, Steindler,7 in his work Kinesiology of the Human Body under Normal and PathologicConditions, summarized earlier research andadded a great deal of additional arthrokine-matic knowledge. Kaltenborn6 was the firstto link manipulation to this new concept of

arthrokinematics and in 1961 he publishedExtremity Joint Manipulation.In 1963, Stanley V Paris, then on the faculty

of the New Zealand School of Physiotherapy,published the Theory and Technique of Specific Spinal Manipulation in the New Zealand Medical Journal. He wrote “degeneration willcommence in any joint in which there is lossof movement and while this is happeningother joints above and below will sufferinjury, degeneration and pain.” He called the

restriction as a ‘dysfunction’ and advocated,treating the restriction which is the cause,rather than pain which is the symptom of thepersisting dysfunction. His philosophy washence aimed at treating movement faults andhad a functional emphasis. He then wrote a book The Spinal Lesion.1,8

In 1964 Maitland of Australia publishedVertebral Manipulation, in which he refined theart of oscillatory manipulation and used ittreat reproducible signs. His approach was

to identify either an active or a passive move-ment that was painful, to oscillate that jointand test again. If it hurt less, he continuedwith the oscillations; if there was no change,he tried a different oscillatory technique thathe had observed would be the next most likelyto succeed.1,8

On October 26, 1966, a meeting by fourphysical therapists—Maitland, Grieve,Kaltenborn and Paris change the face of manual physical therapy. These dedicated

forerunners were exemplary visionaries whodecided to formalize high standards of manual physical therapy. They, as a matterof fact were thinking at a global level. Theresult was the prestigious InternationalFederation of Orthopedic Manual Therapy(IFOMT) which was founded in Montreal,Canada, during the meeting of the WorldConfederation of Physical Therapy, under thechairmanship of Paris. Erhard from theUnited States was elected-president.

In the late 1970s McKenzie began topopularize the concept where he describedspinal extension for the treatment of low backpain. He described that the posterior bulgingof the disc was much aggravated by flexiondue to hydrodynamics of the disc which wascompressed anteriorly by the vertebral bodies. He felt that the extension hencecompressed the posterior elements, whichminimized the risk of the disc moving furtherposterior towards pain sensitive structures.

His methods have gained worldwide accep-tance and his school conducts trainingprograms all over the world.

In 1991, the American Academy of Orthopedic Manual Physical Therapy(AAOMPT) was founded with Farrel as thefirst president. The academy was lateraccepted for membership in IFOMT. TheAAOMPT decided that manual therapy wasa hands on subject and that theoreticalknowledge should essentially be combinedwith formal hands on training. It realized theneed for residency based training and henceestablished residency standards for manualtherapy training in the United States.

The practice of manipulation by physicaltherapy is quite eclectic or a mixture of philosophies. Most clinicians examine bothpositional and movement faults and use




mechanical, isometric, oscillatory, direct andindirect techniques. Hence the focus of thisliterature review will be to combine allphilosophies taking the most appropriate from

each to be able to provide the best of availablecare. This literature review has been writtenwith a base formed by three existingphilosophies, namely Paris, Kaltenborn andOsteopathy.

REFERENCES

1. Paris SV. A history of manipulative therapythrough the ages and up to the currentcontroversy in the United States. Journal of Manual and Manipulative Therapy 2000;8

(2):66-67.

2. Hood W. On so called “bone setting”, it’s natureand results. Lancet 1871;1:336-8, 372-4, 441-3.

3. Walmsley. T. Articular mechanism of diartrosis. J Bone J Surg 1927;10:40-5.

4. Mennel J. Rationale for joint manipulation.Physical Therapy 1970;50(2):181-86.

5. Cyriax J. The pros and cons of manipulation.Lancet 1964;1:571-73

6. Kaltenborn F. Mobilization of the extremity joints: Examination and basic techniques. 3rded. Oslo, Norway: Olaf Noris Bokhandel A/S,1980.

7. Steindler A. Kinesiology of the human bodyunder normal and pathological conditions.Thomas, Springfield, IL: 1955.

8. Paris SV, Loubert PV. Foundations of ClinicalOrthopedics. St. Augustinel, FL: Institute Press,

Division of Patris Inc., 1990.



Manipulation: Definition and Types 11

3Manipulation: Defini tion

and Types

Apparently there are so many discrepanciesin terminology, more because individualphilosophies try to be different or original,however, from a practical standpoint they

may be similar. So this book aims to simplifythe types for easier understanding, especiallyfor the novice practitioner. ‘Manual Therapy’indeed is a broad term and comprises termssuch as articulation, mobilization and manipu-lation. Some of the manual therapy gurushave a preference to one more than the other.For example, Kaltenborn uses the term mobili-zation while Paris uses the word manipulationin his courses. Some describe manipulationonly for high velocity thrust techniques that

results in a ‘pop’ or a ‘crack’, whilemobilization is a term used for non thrusttechniques. The reason why manipulation isa term often avoided is because of theapprehension of the medical communitytowards chiropractors and the possibleadverse effects of a manipulation (as it wasconsidered a forceful movement), especiallyon the spine. Thus physical therapists usedless controversial terms such as mobilization.But how often have we heard the term soft

tissue manipulation for massage, which isalmost never very forceful or manipulationunder anaesthesia done by physicians, whichis not always a high velocity thrust type of a procedure. So, manipulation by definitionis— A skilled passive movement to a joint.1 Paris,SV (1979).

The passive movement thus executed may be of different types, it may be a sustainedstretch or range of motion or an oscillationor a high velocity procedure. It may be over

the joint or on a soft tissue. So for purposeof simplification since all skilled passivemovements are considered manipulations, itcan be broadly classified as Non-Thrust (whichcomprises mobilization and articulation) andThrust (which comprises high velocity pro-cedures).

Whether the type of manipulation is thrustor non-thrust, the area where it is applied isof importance. It can be applied to a veryspecific area like an individual vertebra or a

specific soft tissue, or a general area likeseveral vertebrae or a wider area of softtissue. Hence, the next differentiation to makeis between a general (regional) and a specific(localized) manipulation (Table 3.1).

MANIPULATION

The skilled passive movement to a joint.

Thrust

When a sudden, high velocity short amplitudemotion is delivered at the restricted physio-logical limit of a joint’s range of motion.

Non-thrust

When a joint or soft tissue is taken within orto the limit of the available active or passive




range (within physiological limits), andstretched or oscillated. Neuromuscular thera-

pies also comprise non-thrust manipulation.

Graded Oscillation

Graded oscillation is a form of cyclic loadingwhereby alternative pressure, on and off, isdelivered at different parts of the availablerange. Graded oscillation techniques have been widely promoted by Maitland and hedescribes four grades.

Grade 1: Small amplitude movement perfor–med at the beginning of the range.

Grade 2: Large amplitude movement perfor–med within the range but not reaching thelimit of range.

Grade 3: Large amplitude movement perfor–med up to the limit of the range.

Grade 4: Small amplitude movement perfor–med at the limit of the range.

Progressive Loading/Stretch

Progressive loading mobilization involves asuccessive series of short amplitude, springtype pressures. The pressure is imparted atprogressive increments of the range and isdefined on a 1-4 scale as in a gradedoscillation. Progressive loading is utilized formechanical, joint and soft tissue restrictions.

Sustained Loading/Stretch

Sustained loading is continuous, uninter-

rupted pressure or force which may remainthe same in intensity, increase or decreasedepending on the patient reaction. Theviscoelastic properties of adaptivelyshortened soft tissues can be influenced bythe use of sustained loading. Sustainedloading mobilization, however, may or maynot be sufficient to mobilize a joint thatpossesses an intra-articular restriction.

Soft Tissue Mobilization

The manual manipulation of soft tissues donefor producing effects on the nervous, mus-cular, lymph and circulatory systems.Massage, rolfing are examples. The charac-teristics influenced are tone or tension statusand extensibility or the ability to elongate.

Myofascial Release

It is a form of soft tissue therapy, which is based on neuroreflexive responses that reduce

tissue tension. The key is location of the bestpoint of entry into the musculoskeletal system,application of the most suitable type of stressto induce inhibition and sensitivity inpalpation to react properly to tissue response.The result is a relaxation of tissue tension anddecrease in myofascial tightness, leading to

Table 3.1: Classification of manipulation

Manipulation

Thrust (General or Specific) Non-thrust

High velocity Mobilization/Articulation comprising• Graded oscillations• Progressive or sustained stretch or loading• Soft tissue mobilization/Myofascial

release and• Neuromuscular therapies

PNF MET SCS



Manipulation: Definition and Types 13

improved tissue extensibility and reductionof pain.

Neuromuscular Therapies

Proprioceptive Neuromuscular Facilitation (PNF):Developed by Herman Kabat MD, andMargarett Knott PT, it is a method of promoting the response of the neuromuscularmechanism through stimulation of proprio-ceptors. It describes that all movements inthe body occur in diagonal patterns and theapplication of manual stimulus specific indirection, timing and resistance helps to elicitthe desired neuromuscular response.

Muscle Energy Technique (MET): Developed byFred Mitchell Sr, DO (Doctor of Osteopathy),it is a form of manipulative treatment wherean active muscle contraction (usuallyisometric) is used to induce movement in a bony element by virtue of its insertion, andsubsequently mobilize joint restrictions. Thekey is to localize the contraction to the desiredarea. While avulsion fractures occur bydisplacement of bony elements due to violentcontractions of the inserting tendon, a similar

concept may be applied beneficially to move bony elements by moderate contractions of the tendon.

Strain Counterstrain (SCS): Developed byLawrence Jones DO. The underlying basisis that, the activity that causes a muscle to

strain places it in a contracted position.According to Irvin Korr’s muscle spindletheory, the gamma motor neurone activityto the spindle of the shortened muscle is

increased and remains contracted. Hence,there is a distinctly palpable tender area inthe contracted muscle.

By the passive placement of the strainedmuscle in a shortened or contracted positionfor 90 seconds (which can be further confir-med by a marked decrease in local muscletenderness) the aberrant gamma motoractivity in the muscle spindle is decreasedrestoring the muscle to its normal length anddecreasing pain.

This simplified classification may help thenovice practitioner to be able to interpret theexisting discrepancies in classification, whenhe or she pursues further reading. Thetreatment techniques described in this bookis a combination of the components of thisclassification. However, the neuromusculartherapies are not elaborated on as they are beyond the scope of this book and the readeris suggested alternative reading.2

REFERENCES

1. Paris SV. Mobilization of the spine. Phys Ther.1979;59(8):988-95.

2. Nyberg R, Basmajian JV. Rational ManualTherapies. Baltimore: Williams and Wilkins,1993.




4 Understanding Mechanical Dysfunction

The novice clinician, should understand the basic terminology that underlie movement.Often, the word ‘restriction’ is used, and may be described as one of the main causes for

a dysfunction, but where this restrictionoccurs is understood better if the basicterminology is understood.

Movement, as we know, is primarilydescribed as spatial relationships of the limbsto the axis of the body and are termed asflexion, extension, abduction, etc (Figure 4.1).These are called ‘osteokinematic’ movementsand these are gross movements of the limbs.A restriction of these movements can bevisually observed and measured with a gonio-

meter. However, as these movements occuroutside of the joint, simultaneous movementoccurs within the joint as well. The best analogywould be a moving door. As the door movesto open or close the hinges by which the door

is fixed also moves. If the hinge is restricted,then the movement of the door is restrictedas well. The door can be compared to the limbsor the long bones of the body and the hinge

can be compared to the joints. Hence, as thelimbs move there should be relative movement‘within’ the joint as well. This movement thatoccurs within the joint surface is called bonemovement or ‘arthrokinematic’ movement.Arthrokinematic movement cannot bevisualized. They have to be passively elicitedand are small in range, hence making theirexamination difficult.2,4

In manual therapy, when the term ‘jointrestriction leading to a dysfunction’ is used,

it is a restriction in the arthrokinematicmotion that is being referred to. The skill indetecting a restriction in arthrokinematicmotion is a strong essential basis for diag-nosing a dysfunction (Figure 4.1). Gross range

Figure 4.1: (1) Frontal plane, (2) Sagittal plane, (3) Horizontal plane, (4) Osteokinematic (flexion),(5) Osteokinematic (abduction), (6) Osteokinematic (rotation), (7) Arthrokinematic (posterior glide),

(8) Arthrokinematic (inferior glide), (9) Arthrokinematic (inferior or posterior glide)



Understanding Mechanical Dysfunction 15

of motion is described in degrees of movement, whereas arthrokinematic move-ment is not described so for each joint, andwould be difficult to measure as well.

Hence a manual therapist will make anassessment of arthrokinematic restriction bythe following means:1. The amount of restriction of the gross

range of motion.2. Detecting an asymmetry by comparing

arthrokinematic movement with the othernormal joint.

3. Detecting an asymmetry or faulty positionof bony landmarks during motion.A more detailed description of detecting

an arthrokinematic restriction or asymmetry,is covered in the Chapter 7, ‘Principles of Diagnosis’. However, the reader shouldunderstand that whether the goal is to dia-gnose a dysfunction, or treat a dysfunction,the concept of movement ‘within’ the jointor arthrokinematic motion should beunderstood.

A consult or a referral to a physical therapyclinician is a patient whose symptoms arecommonly pain, some type of restriction

causing a change in mobility, or weakness.They usually have a diagnosis or a diagnosisis made in the physical therapy clinic. Assumethe referral is a cricketer with shoulder pain,the onset being after a bout of bowlingpractice. A medical cause is ruled out and youmake a diagnosis of a supraspinatusimpingement tendonitis. You begin to addressthe pain with appropriate electrotherapymodalities and exercise therapy, includingmobilization to restore gross range of motion.He is an active cricketer and a bowler andhe does obtain relief of symptoms, resumesplaying cricket and the pain recurs. We henceshould question ourselves twice as follows:a. The cause for the pain…..bowling, but is

that the real cause?

b. The diagnosis…..supraspinatus tendonitis, but is that an appropriate physical therapydiagnosis?Consider two common objective findings

in your day to day examination. Jointrestriction and muscle weakness. This is to bring about a conceptual idea and simple asthey may sound, the implication may besignificant. They will be dealt with morespecific detail in subsequent chapters.

JOINT RESTRICTION

A gross motion occurs by the ball of the jointeffectively gliding over the socket (Figure 4.2).The supporting cartilage is minimally stressedas the ball moves over the entire area of thesocket and the forces of loading are evenlydistributed. Consider a restricted situation.The arc of movement of the ball over thesocket decreases. Hence, the forces of loadingare not distributed over a wider area butrather are focused on a smaller area. This mayresult in greater local stress resulting incartilage wear, osteoarthritis, irritation of thesurrounding soft tissue and pain.3

Figure 4.2: Consider a ball and socket joint. (1)Socket, (2) Cartilage, (3) Glide, (4) Gross motion

Now consider a clinical situation. Theshoulder, being a ball and socket joint can bean example. During abduction the head of thehumerus glides inferiorly and externallyrotates on the glenoid. When this occurs thespace between the greater tuberosity and theacromion is adequate and the supraspinatus




tendon is not impinged. If a restriction prevailsthen the inferior glide of the humeral headdecreases and the greater tuberosity maypinch the tendon against the acromion as it

rides up on forceful abduction. If the thoracicsegments are restricted in flexion it candisturb the mechanics of the trapezius andthe rhomboids which in turn attach to thescapula. A resulting protracted scapula orrounded shoulders may disturb the scapulo-humeral rhythm, bringing the acromion closerto the greater tuberosity (Figure 4.3) andcause an impingement of the tendon. Routinelocal injections or medication may providesymptomatic relief but to obtain a more

functional outcome the inferior glide of thehumeral head has to be restored, backward bending of the thoracic segments has to beachieved, efficiency of the trapezius,rhomboids and shoulder rotators has to berestored, then the cause for the problem isaddressed. Your physical therapy diagnosiswill be a flexed rotated sidebent thoracicsegment, or a decreased inferior and posteriorglide of the humeral head. This results in asupraspinatus tendonitis. Range of motion

may be restored by forceful mobilizationmaneuvers but, may occur at the risk of

Figure 4.3: (1) Flexed thoracic segments, (2) Protractedscapula, (3) Supraspinatus, (4) Acromion, (5) Greatertuberosity

overstretching the ligaments or associatedsoft tissue structures.

MUSCLE WEAKNESS

There is undoubtedly no dispute that normalmusculature move and attenuate or absorbshock in a joint, on loading. In many instancesthe reason why strengthening exercises areprescribed for pain is to support the joint andattenuate shock. Consider a weight-bearing joint supported by weak musculature. Chronicoveruse or loading can result in excessivestress on the cartilage, ligament and other softtissue structures including the muscle, due todecreased shock absorption resulting in wearand tear and subsequently pain.

Now consider a clinical situation. Thegluteus medius runs from the gluteal surfaceof the ilium to the greater trochanter of the femur and functions to abduct the hipand stabilize the pelvis during one leggedstance. It is well-known that weakness of thegluteus medius results in what is called a‘Trendelenburg Sign’. (The following scenariocan occur even if a classical Trendelenburg

sign is not present but just a mild weaknessof the gluteus medius.) As the patient continuesto weight bear on a hip supported by a weakgluteus medius the sacroiliac joints can bestrained due to the pelvic asymmetry onweight bearing. A restriction of the sacrumresults as the mechanics is affected resultingin a sacral dysfunction. The piriformis musclecan be involved by virtue of its attachmentto the sacrum, and, as it runs very close tothe posterior aspect of the hip joint can cause

pain in the hip area and may be mistaken fora hip pathology. The bursa can becomeirritated due to faulty mechanics resulting ina bursitis. The sciatic nerve that runs closeto the sacroiliac joint and sometimes throughthe piriformis can be irritated resulting in aradiculopathy and can be mistaken for a discpathology (Figure 4.4).



Understanding Mechanical Dysfunction 17

Hence, when the physical therapist islooking at a so-called diagnosis like hip pain, bursitis, sacroiliac pain, sciatic pain or radi-culopathy, the cause for the problem may bea sacral dysfunction (restricted torsion) orweakness of the gluteus medius and hencewould be the appropriate physical therapydiagnosis.

The list goes on but the conceptual thoughtis that the physical therapy clinician mustunderstand that faulty skeletal alignment andmechanics, including soft tissue imbalances

that result in joint and soft tissue injury, canresult in common pathologies like sprains,strains, bursitis, tendonitis, radiculopathy etc.These are known as mechanical dysfunctionsand not diseases. If the pain is arising froma medical cause say a malignancy, a vascularcompromise or an infection, then they are notmechanical dysfunctions.

Thus mechanical dysfunctions manifest aseither increases or decreases of motionusually due to restriction, faulty mechanics

and weakness, and present as aberrantmotion. This aberrant motion continues tostress the pain sensitive supporting structuresresulting in pain. Treatment should hencefocus on the cause for the abnormal movementand not just medications or therapeuticmodalities for pain caused by the abnormalmovement.1

The cause for a certain symptom, say sciaticpain, may be different. It may be mechanicalas in a restricted sacroiliac joint, or medical,

like a tumor in the pelvic area compressingthe sciatic nerve, but the symptoms may bethe same as they can both produce sciatic pain.Hence, it is important for the physical therapyclinician to combine traditional knowledge inaddition to a thorough understanding of functional anatomy and relevant mechanicsto be able to accurately differentially diagnosea mechanical dysfunction as opposed to amedical cause. The need, obviously, is to notdiagnose the medical cause but to know thatthe symptom is not of a mechanical origin andthence execute an appropriate referral.

Appropriate therapeutic modalitiesincluding pain medication still have their placeprovided the cause is addressed. As a matterof fact they very well address the sorenessthat accompanies manual treatments besides

Figure 4.4: (1) Gluteus medius, (2) Piriformis, (3)Sacrum, (4) Ilium, (5) Sciatic nerve, (6) Sacroiliac joint,(7) Shift in center of gravity




their actual physiological effects. Hence, theiruse as an adjunct or in conjunction should becontinually encouraged

REFERENCES1. Paris SV. The Spinal Lesion. New Zealand

Medical Journal 1963;62:371.

2. Walmsley T. Articular mechanism of diartrosis. J Bone J Surg 1927;10 :40-5.

3. Kaltenborn F. Mobilization of the extremity joints: Examination and basic techniques. 3rd ed.Oslo, Norway: Olaf Noris Bokhandel A/S, 1980.

4. Steindler A. Kinesiology of the human bodyunder normal and pathological conditions.Thomas, Springfield, IL:1955.



Principles of Management of Mechanical Dysfunction 19

5Principles of Management of Mechanical Dysfunction

ALIGNMENT

It is obvious that there is an inseparableinterdependence between structure andfunction. Structural integrity brings about

harmonious motion with minimal stress onthe supporting structures. Movement can still be achieved with abnormal structure, but only by increasing stress on supporting structuresresulting in further pain and dysfunction. Inother words, normalcy of ‘alignment’ is thekey for normal musculoskeletal function. Asa manual therapy clinician it is the skill indetection of a specific cause for faultyalignment that is of importance.

Consider this example quoted by Dr. S.V.Paris, in his teachings.4 The ‘atlas’ or the firstcervical vertebra always follows the occiputor the head in all movements. The joints of the atlas may sustain an injury for variousreasons, say a sudden jerky movement of thehead as in a whiplash injury or a hit on thehead, etc. This may favor holding the regionin a certain direction due to muscle guardingand displacement. Assume the direction of guarding is in right rotation of the atlas. If untreated it may remain stuck in rightrotation due to formation of adhesions fromthe serofibrinous exudate of the joint injuryand adaptive shortening of the soft tissues.Since the occiput and the atlas work together,a right rotation of the atlas may favor a rightrotation of the head (occiput). The patientobviously would prefer to turn the head and

face level and hence a compensatory leftrotation should occur elsewhere to compen-sate. This left rotation occurs at a lower levelin the mid cervical region. The joint orienta-

tion of the mid cervical region however issuch that the left rotation occurs with leftsidebending which unlevels the eyes. To levelthe eyes a compensatory right sidebendingoccurs in the mid thoracic region. The resultis a structural scoliosis of a minimal degreeand the resultant faulty mechanics may stressthe supporting soft tissues resulting in head,neck, radicular and thoracic pain (Figure 5.1).

Symptomatic treatment may temporarilyrelieve pain but resumption of activity may

continue to stress the supporting structuresas the cause for the dysfunction remainsuntreated. The cause obviously is the atlasstuck in right rotation. This is the so-calledspecific cause for the faulty alignment.Conceptually this segment specific alignmentrather than gross alignment forms the basisfor the diagnosis of a mechanical dysfunction.2

STRENGTH/STABILITY/LENGTH

(Relevant to Alignment)

In the previous chapter under the subtitlemuscle strength, the relevance of musclestrength to mechanical dysfunction wasdiscussed. In this chapter, however, therelevance of muscle strength to alignment will be discussed. Although same, conceptually,it is just a matter of specificity.




‘Alignment’ continues to for the basis for

management of mechanical dysfunction. Non-dysfunctional states are achieved as long asnormal alignment is maintained. As theskeletal system is a functional unit the riskof stress on the alignment can occur withvarying intensities of function. The key tomaintaining non-dysfunctional alignment is by adequate supporting musculature.Consider the previous example of the gluteusmedius and its effect on alignment of thesacrum. Assuming that the sacral dysfunction

was identified as being rotated and sidebent(torsion). Following correction of thedysfunction using an appropriate manualtherapeutic technique neutral alignment can be achieved, but failure to strengthen thecorresponding gluteus medius can cause a

recurrence of the sacral dysfunction as thepelvis continues to dip due to weakness.1

The cycle can be vice versa. We have seenthat a weak muscle can cause faulty alignment,

and likewise, in turn, faulty alignment canrender the corresponding muscle weak. Inthis example we saw a weak gluteus mediuscausing a sacral dysfunction. Assume that thepatient had a slip and fall with a direct hiton the sacrum (which is very common incolder countries due to icy conditions) thenthe impact of the fall can cause a sacraldysfunction which can restrict the sacroiliac joint on the corresponding side and cause achange in the normal pelvic mechanics. When

the original range is decreased the corres-ponding muscle does not function in its fullrange or capacity and over a period of timecan weaken. This further adds to thedysfunction and the vicious cycle continues.Hence it is important to know the exacthistory and duration of the problem to makean effective mechanical diagnosis.

Muscle tightness or the length of excursionis of equal importance as muscle strengthwith relevance to a mechanical dysfunction.

All muscles have a certain length which helpsto achieve optimal function. Activity that isin conflict with the length of a muscle cancause injury. How often we have heard of hamstring strains in individuals who do notstretch adequately prior to activity. Remem- ber that all muscles with a few exceptionshave insertions into the bony skeleton by wayof which they move the joints. They not onlymove a joint but also help to support the bones. Hence, if the length is inadequate thenthe possibility of stressing the alignmentexists.1

Consider a tent which has a pole in thecenter held by two ropes on either sides.Assume the lengths of the ropes are the samethen the pole is in neutral alignment.

Figure 5.1: To maintain head and eyes level,(1) Right rotation of atlas causes (2) Left rotation andsidebending of mid-cervical spine, (3) Right rotationof thoracic spine, (4) Pelvis level



Principles of Management of Mechanical Dysfunction 21

However, if one rope is shorter in length thenthe alignment of the pole is altered. A similaranalogy can be applied to the body with thespine as the pole and the spinal musculature

as the ropes. The importance however, is thespecificity as one should consider that eachvertebra has muscle attachments on eithersides. Consider the levator scapulae as anexample. It attaches into the transverseprocesses of the first four cervical vertebraeon either sides. If one side is tighter than theother it can pull a specific segment into side- bending and rotation to the same side andif it persists it can cause a restriction in thatposition causing faulty alignment. Hence, even

if the dysfunction is detected at a later dateand corrected using a manual technique, thecorresponding levator scapulae should bestretched to minimize recurrence of thedysfunction3 (Figure 5.2).

Figure 5.2: Posterior view. (1) Pole (spinal

column), (2) Ropes (l. scapulae), (3) Scapula

CARE DURING FUNCTION

In the principles on management we haveseen two important aspects, alignment andsoft tissue integrity. Once this is addressed,the most important component emerges and

that is function. A dysfunction starts with aparticular function and can be viewedregionally. Consider the neck and a computerprofessional. Constant viewing of the

computer in a forward head position can causethe posterior neck muscles to fatigue as theyhave to work harder to support the headwhich is in their perspective a little furtheraway. If the strength in the musculature isadequate, then the fatigue component can beminimized. However, in weak situations,which is common, a prolonged forward headand rounded shoulders position can fatiguethe posterior neck muscles and the responseto fatigue is a contraction. As the contraction

progresses, it alters the length of the musclewhich by virtue of its attachment to thevertebra can cause a faulty alignment bypulling on it. If the faulty activity is continuedthe muscle continues to be stressed,contracted, and the dysfunction can persist.

Hence, in the management of musculo-skeletal dysfunction, all three componentsshould be addressed. Alignment, musclestrength/length, and care during function.When management in the clinic is completed

the patient must be instructed on homeexercises to maintain proper alignment andinstructed on proper function (proper bodymechanics, proper footwear etc) as appro-priate. Failing which the probability of arecurring dysfunction is high.

Chronic pain is term to denote pain thatpersists for an extended period of time.Routine treatments offer temporary relief butthe pain continues to recur. If the pain issecondary to a mechanical dysfunction it maypersist to a chronic state as long as thedysfunction persists. Hence, often times thereason why mechanical pain is renderedchronic is because the underlying causeremains undetected. Consider the example of the stuck atlas. The resulting dysfunction cancause significant headaches. The greater




occipital nerve and the auricular nerves supplythe superficial occipital and temporal areasrespectively. A restriction of the atlas and theaxis (C1 and C2) can irritate the sub-occipital

musculature which can subsequently irritatethese nerves and cause significant occipitaland temporal headaches. This patient may becontinually treated for headaches of aneurological or vascular origin withmedications etc, with no significant relief andthe pain may persist to a chronic state. The bigger implication is that an investigativeprocedure like an X-ray or a CT scan may beconsidered normal. The reason being thatthey may not reveal the restriction as there

is no disruption in the anatomy as in a softtissue tear or fracture. However, a skilledmanual exam of the C1 and C2 for mobility,position and palpatory tenderness mayindicate a dysfunction and the physicaltherapy clinician can relate the headaches toa ‘myogenic’ or muscular origin rather thanvascular or neurologic origin. Manualtreatment of the first and second cervicalvertebra and the sub-occipital musculaturemay minimize these headaches.

As a similar example, the lateral ligamentof the ankle is commonly strained, and inmany instances recurrent strains are seen,especially in athletes. Symptomatic treatmentlike local injections, or ultrasound may stillheal the ligament but recurrences can occurwith resumption of vigorous activity. Hence,the clinician should consider that the reasonwhy recurrent strains occur is due to faultyalignment of the subtalar joint and midtarsal joints or an internal rotation of the tibia or

the femoral neck. These are causes for thedysfunction which predisposes the foot to buckle into forced inversion and subsequentlystraining the lateral ligament. Appropriate

manual treatment to mobilize the involved joints and prescription of exercises to streng-then the evertors in addition to an orthotic,to maintain neutral alignment, will addressthe cause. If the cause is not addressed thenthe result is a ‘chronic’, recurrent ankle strain.

The point here is, a skilled mechanicaldiagnosis can often times help to detect anunderlying unidentified cause for a medicaldiagnosis. In the first example the medicaldiagnosis of a migraine headache, may in

actuality be muscular rather than vascular(and hence a myogenic headache).

The consequences may be frustrating if thecause is not identified, as the pain does notresolve and the patient may even beconsidered to be faking the pain. The paincontinues to persist, eventually to a chronicstate limiting the patient in his or herfunctional abilities. It may hence be concludedthat treating the cause may prevent chronicdysfunctional and painful states.

REFERENCES


2. Jull G, Bogduk N, Marsland A. The accuracy of manual diagnosis for zygoapophyseal jointpain syndromes. Med J Aust 1988;148: 233-36.

3. Travell JG, Simons DG, Simons LS. Myofascialpain and dysfunction: The trigger point manual.Baltimore: Williams and Wilkins, 1999.

4. Paris SV. S3 course notes. St. Augustine, FL:Institute press, 1988.



Palpation 23

6 Palpation

Palpation is probably the key tool that is usedfor examination procedures in manual therapy.The hand is an extremely sensitive toolconsidering the fact that 25 percent of the

pacinian corpuscles in the human body are inthe hand. A trained manual therapist may claimthat he or she feels something that is difficultto see or even feel. Do not doubt him or heruntil you have practiced hard enough, and thatword cannot be emphasized enough…hard.

Technology today has rendered a situationwhere clinicians rarely touch or palpate theirpatients. This may be a tragic situation andwe, as physical therapists, should considerour position favorable as we continue to feel

and touch our patients. A well read mind anda trained pair of hands can detect clinicalsituations that complex imaging proceduresdo not. It may be of benefit to alwaysremember that a compassionate and caringtouch, for reasons that cannot be describedor quantified, can also have a healing effect.2

As the famous words by Alan Stoddardwould describe—“By continuous practice and thinking hard throughthe fingers, in other words concentrating upon the

senses observed through the fingertips, it is possibleto develop that elusive quality of the manipulativeskill-tissue tension sense.”

PRINCIPLES

The first question, when we palpate toidentify musculoskeletal dysfunction what are

we looking for? The word to bear in mindisART. This is an osteopathic philosophy andis quoted by Philip Greenman DO,1 in hiswritings. They represent,

A—AsymmetryR—Restriction of mobilityT—Tissue texture abnormality

Asymmetry

It helps that most musculoskeletal landmarkscome in pairs. This helps to aid in making amechanical diagnosis. Asymmetry may not be synonymous to alignment, but rather wecan say that by detecting an asymmetry weconfirm faulty alignment. Unilateral hyper-trophy or wasting of muscles can be consi-dered an asymmetry. An elevated scapula onone side can be considered an asymmetry.Such changes can usually be visualized,however, a more intricate method of detecting asymmetry is one that cannot bevisualized but rather palpated. As anexample, often times pelvic asymmetries ariseand to detect them by palpation will be toplace both hands over the iliac crests to detecta difference in heights. This obviously is aneasier example, as most students in Indiaperform evaluations of this type on poliopatients. Still a good precursor for palpatoryskills. More intricate situations occur withpalpation of vertebral asymmetries. Knowingthe levels of the segments or knowledge of anatomy is a prerequisite. The bony landmark




that is easiest to palpate in a vertebra is thespinous process. They are the projections wesee (in a lean individual) or feel, in the centerof the back. By knowing the levels and how

many vertebra in each level the correctsegment can be identified. Similar methodsare adopted by knowing bony landmarks forextremity joints.

Restriction of Mobility

Restriction of mobility is the most commoncomponent of mechanical dysfunction. Theresulting dysfunction, that can occur becauseof restriction in a joint, is described in earlierchapters. Hence the ability to detect arestriction by palpation is mandatory in amanual therapy examination as it has to betreated. Technically restriction of mobility isalso an asymmetry if it occurs unilaterally.For example, each vertebra has two facet joints on either side. A restriction on one sidecan cause an asymmetry as to how thevertebral segment moves and cause faultyalignment. Hence, a restriction can cause anasymmetry that results in faulty alignment.

As described earlier, the arthrokinematiccomponent of motion is what is palpated, asgross range of motion can be visualized.Hence, a manual therapist will make anassessment of an arthrokinematic restriction by palpating the appropriate bony landmarkand inducing a passive motion. A relativelyeasier example will be the patella. Bypalpating the lateral borders of the patellaand inducing knee flexion, one can feel thepatella moving laterally. Similar methods are

adopted, however with increasing difficulty,to detect arthrokinematic motion in other joints.

Tissue Texture Abnormality

This aspect of palpation can be made elaborate but to simplify it to the essential aspect, theone finding in a soft tissue in conjunction with

a mechanical dysfunction is tenderness withsoft tissue hypertrophy. Tenderness in amuscle can lead to an assumption that themuscle is the source of the dysfunction. This

may be the case but not always. Every jointor motion segment has a correspondingmuscle that helps to effect movement.Dysfunctional states of the joint can causeadditional stress on the supporting soft tissueand result in muscle guarding. This can leadto an accumulation of metabolites in theinvolved muscle and result in local tender-ness, with hypertrophy due to guarding.

Tissue texture abnormality comprises yetanother component which is described in

Chapter 7 on Principles of Diagnosis. This isthe soft tissue pain elicited with contraction.A concept called ‘selective tissue tension’ willhelp to assess pain in the contractile elementsof the soft tissue component of a dysfunction.

PALPATION LAB

The bony skeleton is the framework of the body, hence identifying bony landmarks bypalpation can help provide a baseline for

identifying a dysfunction. They are describedin a descending order with an emphasis onthe more obvious and clinically relevantlandmarks.3

Base of Skull, Cervical and Thoracic Spine

External Occipital Protuberance and Nuchal Line

Found on the midline of the skull, posteriorly,at the level where the posterior neck musclesattach to the skull. The superior nuchal line

is palpated just below the external occipitalprotuberance and can be felt as a dip at the base of the skull.

Mastoid Process

The mastoid process is palpated just behindthe ear as bony prominences.



Palpation 25

Transverse Process of C1

This is palpated just below the mastoid,deep to the soft tissue, and is tender onpalpation.

Spinous Process of C2

With the neck in mild flexion, the bony rimof the base of the occiput is palpated. Thefirst bony prominence below it is the spinousprocess of C2 (as C1 does not have a spinousprocess).

Spinous Process of C7

At the level of the shoulders the prominent

spinous process which dips on neck extension.Also called the vertebra prominens.

Transverse Processes/Articular Pillars of C3 to C7

Approaching the neck laterally, the bonylandmarks immediately palpable beyond themuscle tissue are the articular pillars and thefacet joints of C3 to C7. Remember that themid cervical spine does not have prominenttransverse processes. The articular pillars are

in line with the mastoid process, and behindthe sternomastoid.

Angle of First Rib

This is palpated above the clavicle, just belowthe superficial contour of the upper fibres of trapezius.

Spinous Process of Third Thoracic Spine (T3)

This can be palpated approximately at the

level of the medial end of the spine of thescapula.

Spinous Process of Seventh Thoracic Spine (T7)

This can be palpated approximately at thelevel of the inferior angle of the scapula.

Shoulder

Spine of Scapula

This is palpated as an obvious bony

prominence in the upper part of the posteriorthoracic cage.

Inferior Angle of Scapula

On palpating the medial border of the spineof scapula and tracing downward andmedially to the tip of the inferior end, theangle can be palpated.

Acromion

By tracing laterally over the spine of scapula,the acromion can be palpated on the lateraland superior surface of the shoulder joint.

Greater Tuberosity of Humerus

This is palpated slightly below and anteriorto the lateral rim of the acromion.

Coracoid Process

This is palpated anterior and medial to theacromion and is a deeply placed bonylandmark.

Elbow

Olecranon

This is palpated as a bony projection on theposterior aspect of the elbow joint.

Radial Head

With the elbow flexed to 90 degrees, thelateral epicondyle is palpated. Just below thelateral epicondyle, the radial head is palpated.To confirm, the radial head can be feltmoving with pronation and supination of theforearm.




Wrist and Hand

Radial Styloid

This is palpated as a bony prominence on the

lateral side of the wrist.

Ulnar Styloid

This is palpated as a bony prominence on themedial side of the wrist.

Capitate

This is the standard landmark of the carpal bones and is palpated at the base of the thirdmetacarpal. There is a slight palpabledepression on the capitate.

Lunate

This is palpated immediately proximal andmedial to the capitate, next to the scaphoid.

Scaphoid

This is palpated as a depression just distal tothe radial styloid. It protrudes with ulnardeviation.

Trapezium This is palpated just distal to the scaphoid asan immediate elevation.

Triquetrium

This is palpated immediately distal to theulnar styloid. It protrudes on radialdeviation.

Pisiform

On the palmar surface of the hand, the ulnarstyloid is first palpated. If you move slightlydistally and medially, the first bonyprominence is the pisiform.

Hook of Hammate

Moving slightly medially and distally fromthe pisiform, the hook of the hammate is

palpated deeply (it is slightly more difficultto palpate).

Lumbar Spine, Pelvis, and Hip

Iliac Crest

At the level of the pelvis, lateral to theabdomen, the obvious bony prominences arethe iliac crests.

Anterior Superior Iliac Spine (ASIS)

The anterior most portion of the iliac crestis palpated as a prominence which are theanterior superior iliac spines.

Posterior Superior Iliac Spine (PSIS) The posterior most part of the iliac crests areseen as dimples and inferior aspect of thesedimples are palpated as the posterior superioriliac spines.

Ischial Tuberosity

This landmark is palpated just at the inferiorgluteal line and is very obvious, as we sit onit.

Spinous Process of L4 This is palpated in the midline, at the levelof the iliac crests.

Spinous Process of L5

The PSIS is first palpated, and moving 30degrees superiorly and medially, the spinousprocess of L5 is palpated. This is the leastprominent of the lumbar spinous processes.

Spinous Process of S2

This is palpated in the midline at the levelof the PSIS.

Base of the Sacrum

Just immediately medial to the PSIS, the baseof the sacrum is palpated. This is a difficultlandmark to palpate and requires practice.



Palpation 27

Inferior Lateral Angle of the Sacrum (ILA)

By placing the base of the palm on the buttockand pushing upwards, the coccyx can be felt.On palpating the coccyx, and moving slightlyupwards and laterally the sacrum just beginsto flare out. Just at the out flare, moving tothe superior surface, the ILA’s can bepalpated.

Pubic Tubercle

This can be palpated on either side of thegenital area, lateral to the midline. It is slightlyhigher in males and lower in females.

Greater Trochanter With the hip flexed to 90 degrees, the greatertrochanter can be palpated on the lateral sidesof the hip.

Knee

Lateral Condyle and Medial Condyle of Femur

The two obvious bony landmarks palpatedon the superior medial and lateral surfacesof the knee joint are the medial and lateral

condyles, respectively.

Head of Fibula

This can be palpated laterally and just belowthe lateral condyle of femur.

Lateral Tibial Condyle

This is palpated just medial to the head of fibula.

Medial Tibial Condyle

This is palpated inferior to the medial condyleof femur.

Ankle and Foot

Talus

This is palpated immediately anterior to theinferior and anterior surface of tibia.

Navicular

This is palpated as a bony prominenceimmediately anterior to the talus medially.

Medial Cueniform

This is palpated immediately anterior to thenavicular.

Cuboid

This is palpated immediately anterior to thecalcaneus laterally.

REFERENCES

1. Adams T, Steinmetz MA, Heisey SR, HolmesKR, Greenman PE. Physiological basis for skinproperties in palpatory physical diagnosis. JAm Osteopath Assoc. 1982;81(6):366-77.

2. Montagu A. Touching. The human significanceof the skin. New York: Columbia UniversityPress, 1971.

3. Hoppenfield S. Physical Examination of theSpine and Extremities. Norwalk, Connecticut:Appleton and Lange, 1988.




7 Principles of Diagnosis

The diagnosis of a musculoskeletal dysfunc-tion essentially applies the three parametersdescribed earlier, asymmetry, restriction of mobility, and tissue texture abnormality.1,3

How, when and where is essentially theapplication of principles.

The two important factors that the clini-cian needs to consider is that any musculoske-letal dysfunction has a structural componentand a movement component. Take the anklefor example. Assume the presentation is inequinus, the restriction of mobility hence, isdorsiflexion, as the foot is restricted inplantarflexion. Thus, when you assess thisstructure, without movement, the ankle is in

equinus and hence, would be the abnormalposition of the ankle. This is known as thestructural or positional fault. On moving thisankle, since it is restricted in plantarflexionpreventing dorsiflexion, it would be theabnormal movement of the ankle. This isknown as a movement fault. To review:

Positional Fault

Ankle restricted in equinus.

Movement FaultPrevents dorsiflexion as it is restricted or‘stuck’ in plantarflexion• The asymmetry here is the equinus foot

with regards to the other neutral, normalfoot.

• The restriction of mobility is dorsiflexion.

• The tissue texture abnormality would be thetight or painful gastrosoleus.This is a simplified example for purpose

of understanding the basic concept, as the

level of complexity increases. From what werecollect from the earlier chapters, this would be a gross motion and hence an example froman ‘osteokinematic’ standpoint. An exactlysimilar principle is applied from an arthro-kinematic perspective for a more intricatemanual diagnosis.

The regional application in most manualtherapy schools are categorized as the ‘spine’and the ‘extremities’ and is hence beingfollowed in this book. Their principles of

diagnosis vary as well, due to the variationin anatomy and joint mechanics. Hence theywill be described separately.

THE SPINE

Prior to discussing the principles, the clinicianmust understand where mobility occurs in thespine and subsequently the areas of probablerestriction. The spine, like any other synovial joint, is a functional unit for the fact that itis mobile and effects motion. The spine, aswe know, are blocks of skeletal structuresarranged over each other. Hence, they requirean articulation for mobility and stability.These articulations that hold the vertebraetogether and effect movement, are what areknown as ‘facet joints’. They are pairedstructures and lie laterally in each vertebral



Principles of Diagnosis 29

body. Each vertebral body has a pair of superior and inferior articulating facets. Theinferior articulating facets of one vertebra arti-culates with the superior articulating facets

of the vertebra below it to form a vertebralmotion segment. Vertebral movement isdescribed as the superior segment movingover an inferior segment and not vice versa.For example, L4 is described as moving overL5 and never L5 over L4. Hence when asegment is described as being restricted ormoving excessively, it is with relevance to thesegment below it. Three movements occur ina vertebral motion segment and duringfunction they invariably occur together. The

three movements are flexion (forward- bending), extension (backward-bending) androtation (with side-bending). Assume asshown below:

L4L5The circles denote the inferior articulating

surface of L4 and superior articulating surfaceof L5.

Forward-bending

During forward-bending, the superior facetson either sides of the vertebral segment slideequally forward over the inferior facets. Thisis termed as a flexed or ‘open’ position of thefacet (Figure 7.1).

Figure 7.1: Forward-bending

Backward-bending

During backward-bending, the superiorfacets on either side slide equally backwardover the inferior facets. This is termed as anextended or ‘closed’ position of the facet(Figure 7.2).

Figure 7.2: Backward-bending

Rotation and Side-bending

Rotation is one movement where the facetsdo not slide equally in the same direction, but rather opposite. For example, in rightrotation, the right facet slides backward andthe left facet slides forward. Hence, the rightfacet has ‘closed’ and the left facet has‘opened’. The exact opposite occurs during

left rotation. The same occurs with side bending (Figure 7.3).

Figure 7.3: Rotation and side-bending

Since rotation and side-bending do notoccur individually, they are called coupledmovements. However, depending on thecurvature of the spine, they occur either tothe same side or to opposite side. Three




situations can occur and they are termed as‘Fryettes rules’.1 These are as follows:1. If rotation and side-bending occur to the

opposite side they are called Type 1 or

neutral mechanics.2. If rotation and side-bending occur to the

same side they are termed as Type 2 ornon-neutral mechanics.

3. A third situation occurs when, in the threeplanes of motion, if movement is intro-duced in one plane, the movement in theother two planes is reduced. This is termedas Type 3 mechanics.Types 1 and 2 are seen in vertebral motion

dysfunctions and are specific to the regions

of the spine. As an example, the lumbar spinenormally exhibits neutral mechanics, howeverfaulty mechanics as in forward-bending andtwisting, or unilateral facet restriction cancause this to change, resulting in non-neutralmechanics and will require correction. Hence,knowledge of the type of mechanics in thedifferent regions of the spine is necessary.They are as follows:• Subcranial spine: Neutral• Mid-cervical spine: Non-neutral

• Thoracic spine• Upper thoracic: Non-neutral• Lower thoracic: Neutral

• Lumbar spine: Neutral• Sacrum: Neutral

As a whole the spine, from the cervicalto pelvic region strives to maintain neutralmechanics.

Type 3 mechanics is incorporated to loca-lize motion during manipulation techniques.

POSITIONAL FAULTS

Palpation

The bony landmarks that are palpable in avertebral body are the spinous processeswhich is one in number for each vertebra andis the posterior projection of the spine. Onobserving a skinny individual, the bony

projections in the middle of the back are thespinous processes. They are arranged in astraight line one above each other with equaldistances between them. They can be palpated

by pinching (gently) their lateral borders anddetermining their position (Figure 7.4).

Figure 7.4: Palpation in positional fault

Dysfunction

The position of the spinous process can deter-mine the faulty position of that individualsegment and is done by observinga. the distance between each spinous process

and

b. the position of the spinous process withrelevance to the one above and below itin their vertical arrangement

Figure 7.5: Forward bent




Observe the arrangement of the spinousprocess from Figure 7.5. There is equaldistance between L1 and L2 and subsequentlyL4 and L5. However, L3 has moved forward

and is closer to L2 with relevance to L4. Itcan be presumed that the L3 segment is ina forward bent position.

Figure 7.6: Backward bent

In the arrangement in Figure 7.6 thedistance between T12 and L1 is equal and soare the distances between L3, 4 and L4, 5.

However, L2 has moved backwards and iscloser to L3 with relevance to L1. It can bepresumed that L2 is in a backward bentposition.

Figure 7.7: Right and left rotation

In Figure 7.7, T12, L2, L3 and L5 are ina straight line, however, L1 has movedslightly left and L4 has moved slightly right.This could mean that the segments are rotated

but the direction of rotation is important tounderstand.

On observing the segment from Figure7.8, note that the spinous process is placedposteriorly. Since the vertebra is a circularstructure, rotation to one side will move thespinous process to the other side. So, if thespinous process has moved left, technicallythe segment has rotated right and vice versa.Hence, in Figure 7.8, since the spinous processof L1 has moved left, it has rotated right with

relevance to T12 and L2. Similarly, since thespinous process of L4 has moved right withrelevance to L3 and L5, it has rotated to theleft. Hence, in this arrangement, L1 is in rightrotation and L4 is in left rotation (Figure 7.8).

Figure 7.8: Anterior and posterior rotation

The validity of a positional diagnosisshould be questioned because anatomicalanomalies of the spinous process can bemisleading. This is due to the fact that the

spinous process of a vertebral segment can be abnormally deviated in a faulty position.

As an example, in Figure 7.9 the spinousprocess is shown to have deviated left dueto an anatomical anomaly, but the vertebralsegment is neutral. Since the position of thespinous process is anomalous, it cannot be




assumed that the segment is rotated to theright (Figure 7.9). Hence, the clinician shouldexercise caution and not make a diagnosis based on positional faults alone.

Figure 7.9: Anatomical anomaly

MOVEMENT FAULTS

Palpation

On observing the body of a vertebra the twolateral projections of the vertebral body arethe transverse processes. They are placedabout an inch lateral to the spinous processand their levels with relation to the spinous

process vary with the different levels of thevertebral column. They are discussed inSection 2. These are difficult structures topalpate and it is done by first locating thespinous process to determine the level andmoving slightly laterally by placing thethumbs on either sides of the spinous process(Figure 7.10).

Figure 7.10: Palpation in movement fault

Dysfunction

Determining the side of the prominence of thetransverse process is the key to establishinga diagnosis.

Vertebral dysfunctions do not alwaysoccur in isolation. It usually is a combinationof movements occurring as a combination inthe three planes. This is owing to (a) thenature of normal movement, and (b) theorientation of the facet joints.

Normal movements occur in patterns ordiagonals. It usually is a combination of movements in all three cardinal planes(flexion/extension, sidebending, androtation) and the key movement is rotation.The reason being that it is the rotation thatwill determine the prominence of thetransverse process.

For example, on placing the thumbs oneither side of the spinous process (which isover the transverse process), a greaterprominence on the left will indicate that thesegment is in left rotation, because a rotationof the vertebral segment will move thetransverse process posteriorly on the side of the rotation (Figure 7.11).

Figure 7.11: Determining posteriority oftransverse process

This prominence is termed as a posteriorityand is the key to making a diagnosis of spinalmovement dysfunction. It appears as a poste-rior projection on forward and backward-




bending owing to the layers of muscle thatit pushes outward, adding to the promi-nence.1,3

The movements of the vertebral column

occur in diagonal patterns and two possibi-lities can exist as far as dysfunctions areconcerned. They are as follows:a. Extension, rotation, sidebending (ERS) b. Flexion, rotation, sidebending (FRS)

ERS

On reviewing spinal joint motion we inferredthat during flexion the facets slide equallyforward and the exact opposite duringextension. Let us consider two segments—L4 and L5. Assume the left facet of L4 isrestricted, or stuck in extension. In the neutralposition, the transverse processes are neutraland hence will appear neutral (Figure 7.12).L4L5

Figure 7.12: ERS

In backward-bending, the left facet isalready stuck in extension and hence willappear posterior. The right facet also movesposteriorly as it is not stuck and is movingfreely. Since both are posterior they willtechnically appear neutral in backward- bending (Figure 7.13).

Figure 7.13: ERS: Backward-bending

However, in forward-bending, since theright facet is moving freely it slides forward but since the left facet is stuck in extensionit remains where it is (in extension). This will

appear as a prominence of the L4 transverseprocess on the left (Figure 7.14). Hence, yourdiagnosis will be an ERS left of L4, as thesegment is stuck in extension and the rotationand sidebending to the left go with it.

Figure 7.14: ERS: Forward bending

Remember, the ‘side’ of your diagnosis is alwaysthe side of the ‘posteriority.’

FRS

Assume that the left L4 facet is stuck in flexion.In neutral they invariably appear neutral(Figure 7.15).

L4L5

Figure 7.15: FRS

During forward-bending, the left facet is

already stuck in flexion and hence has slideforward. The right facet is freely moving andwill also slide forward. On palpation of thetransverse processes in forward-bendingthere will be no evidence of a posteriorityas both facets have slide forward and areneutral (Figure 7.16).




Figure 7.16: FRS: Forward-bending

However, during backward-bending theright facet moves freely and hence slide backward. The left facet, however is stuckin flexion. Hence, it stays in that position of flexion and does not slide backward. Here,since the right facet has slide backward thetransverse process on that side appears

posterior but the left does not as it is inflexion.

The restriction is on the left as it is theleft facet that is stuck in flexion, but theposteriority is on the right as the freelymoving right facet has slide backward. Hence,the diagnosis will be FRS right of L4 as thediagnosis is always by the side of the posteriority and not by the side of therestriction (Figure 7.17).

Figure 7.17: FRS: Backward-bending

CLINICAL IMPLICATION

Abnormal alignment / mechanics, be it an ERSor an FRS can produce clinical scenarios wesee in our day to day practice (Figures 7.18and 7.19). The dysfunction that was discussedearlier of the L4 segment is depicted in Figure7.20. Note that L4 is restricted in extension

and would hence be an ERS. If movementcontinues to occur in this abnormal positionit can significantly shear the disc (which ispart of the motion segment) and may resultin a disc pathology. The size or the patencyof the foramen is altered and as the nerveexits through the foramen it can be pinched,resulting in a radiculopathy. The facet, dueto abnormal weight-bearing stresses of faultyalignment can be susceptible to cartilage andfacet capsule shearing (Figure 7.20). Theeffusion that occurs due to this can be pouredinto the foramen, increasing nerve rootsymptoms. Hence, by freeing the facetrestriction and correcting the alignment, thepatency of the foramen is restored, the

Figure 7.18: Picture depicts an FRS right

Figure 7.19: Picture depicts an ERS left




shearing of the disc is reduced and the facet joints are rendered less susceptible to loadingstresses. This can significantly minimizesymptoms.

Figure 7.20: (1) Disc shearing, (2) Facetshearing, (3) Foraminal encroachment

The large muscle groups that effect

movement in this motion segment can bestressed due to faulty mechanics. Hence,correcting vertebral alignment can reduce theworkload of these large spinal and pelvicmuscles, which can later be effectivelystabilized to maintain alignment.

Mechanical traction may temporarily openthe foramen. Facet injections may temporarilyrelieve facet and nerve root pain so do otheraspects of management including medication.They most definitely have their place as acute

pain has to be addressed by these means, butin combination, if the mechanics and align-ment are addressed, it may address the causeof the dysfunction.

To summarize, the above scenario, the:

Positional fault: Deviation of spinous processand transverse process.

Movement fault: L4 not sliding forward or backward (FRS, ERS).

Asymmetry: Posteriority of transverse pro-cesses or faulty position of spinous process.

Restriction of mobility: L4 stuck in flexion orextension and sidebending/rotation.

Tissue texture abnormality: Local tendernessover the transverse processes and dys-

functional states of large and local smallsupporting musculature.

EXTREMITIES

From a manual therapy and a physical therapyperspective, the functional outcome is the bigger concern. Joint classification based onmorphology is indeed of importance to us,however, it is important to know, what typeof (bone) movement occurs in each joint?2

MacConaill’s classification of joints reflectsthis theory. He describes joint surfaces aseither ovoid or sellar (Figure 7.21).

Figure 7.21: Type of joint surfaces

Ovoid

This can be either convex or concave in alldirections and are similar to a piece of eggshell in that their surfaces are of a continuallychanging angular value.

Sellar (Saddle)

These are inversely curved with convex andconcave surfaces situated at right angles toeach other.

MACCONNAIL’S CLASSIFICATION OF

JOINTS1. Unmodified ovoid (ball and socket),

triaxial, e.g. hip and shoulder.2. Modified ovoid (ellipsoid), biaxial, e.g.

MCP joints.3. Unmodified sellar (saddle), biaxial, e.g.

CMC joints.




4. Modified sellar (hinge) uniaxial, e.g. inter-phalangeal joints.It would be of importance to know that

in most joint positions, the articular surfaces

are not fully congruent. This may be becausethe convex partner may be more curved thanthe concave partner.

It has been described earlier that themanual therapist is more concerned aboutarthrokinematic movement rather thanosteokinematic movement. In manual therapy jargon, arthrokinematic movements aretermed as joint movements. Bone movementsare what we traditional learn in our intro-ductory anatomy occurring in the three car-

dinal planes as flexion/extension, abduction/adduction and internal/external rotation.

However, bone movements are ones thatcause movement to occur within the joint andare as follows:1. Rotation.2. Translation.

The principal difference between the twomovements is that rotation is under voluntarycontrol and translation is not.

RotationAll active movements are essentially rotations because they occur around an axis. Hence,the normal movements of flexion, extensionetc occurring in the three cardinal planes areessentially rotations. It is important to knowthat normal function occurs in rotatory anddiagonal patterns, if one could recollectpatterned motion described in PNF texts. Thisis probably due to the spiral and diagonalorientation of the musculature. Coinciden-

tally, it is interesting to note that as much asosteokinematic movement occurs in rotatorydiagonals, arthrokinematic movements occurin the same fashion. For example, during kneeextension there is an anterior glide and anexternal rotation of tibia.

Roll-gliding

All bone rotations produce a combination of roll and gliding. Rolling occurs when newpoints of equal distances in one surface comesinto contact with new points of equaldistances in another surface (Figure 7.22).

Figure 7.22: Rolling

Gliding occurs when one point on a jointsurface contacts new and different points inanother joint surface (Figure 7.23).

Figure 7.23: Gliding

Gliding and rolling occur together in all bone movements. Gliding with rolling canonly occur on flat or curved/congruentsurfaces. There are no entirely flat or curved/congruent surfaces and hence pure gliding

Figure 7.24: Gliding and rolling on concave surface




does not occur in the human body. Thedirection of gliding depends on whether aconvex or concave surface is moving. Whena concave surface moves, joint gliding is in

the same direction, e.g. knee (Figure 7.24).When a convex surface moves, joint gliding

is in the opposite direction, e.g. shoulder(Figure 7.25).

Figure 7.25: Gliding and rolling on convex surface

This is known as the Kaltenborn concave-covex rule and is an universal principle appliedduring joint mobilization.2

Translation

Translation is a bone movement that is notunder voluntary control, however, they areessential for free painless motion. Bone trans-lation produce isolated traction, compressionor gliding joint play movements. These aredescribed by Kaltenborn as Translatory joint play (TJP) movements.

Traction

Traction is a TJP movement that results inseparation of joint surfaces.

Compression

Compression is a TJP movement that resultsin approximation of joint surfaces.

Gliding

Gliding is a TJP movement that results in asliding movement of joint surfaces. They arepossible in small proportions over short

distances. A traction movement usuallyprecedes a gliding movement for ease andsafety of performance.

To summarize, the gross motions of our

limbs in normal conditions are a result of rotations and translations that occur withinthe joint. The TJP movements normalize theroll-gliding that is essential for active move-ment. During dysfunction this mechanism islost due to restriction of TJP movements. Thisaffects the normal mechanics (roll-gliding) of the joint and abnormally loads the contractileand non-contractile elements of the joints,resulting in pathology. Hence, from a manualtherapy diagnosis perspective, it is the TJP

movements that needs to be restored, torestore normal roll-glide. For description thisis termed as voluntary gliding.

For each movement occurring in theextremity joints there occurs a combination,of voluntary gliding movements. Considerthis example.7

Wrist extension: The gross motion of wristextension is the osteokinematic motion. Thearthrokinematic motion is as follows:7

• The distal row of carpal bones glides

dorsal and the proximal row volar.• At 60 degrees the hammate, capitate,

trapezoid and scaphoid are close packedand hence radial deviation occurs.

• The rigid mass moves as a whole on thetriquetrum and lunate.

• The triquetrum and lunate move volar onthe radius.

• Pisiform moves caudal.• Radius moves cephalad.• Common extensors are contracting.

When a blow is received on the extendedhand the force is taken via the 3rd metacarpalto the lunate, scaphoid and thence to theradius and the common extensor organ.

Consider a clinical situation. Assume atennis player or a typist that does periodicextension of the wrist either repetitively over




time or against a resistance as in tennis. If the above mentioned mechanics is intact withgood muscle strength, the forces are evenlydistributed and the risk of injury is lesser.

If the mechanics is altered for various reasons,say a restriction of superior glide of radiusor dorsal glide of the distal row of carpal bones (or for that matter weakness of thewrist extensors). This can affect the normalexcursion of the wrist extensors and thestresses on the muscle may be higher as itis subjected to more loading to compensatefor the altered mechanics. The stresses may be felt greatest at the tendon insertion resul-ting in a tennis elbow or lateral epicondylitis.

Symptomatic treatments are essential, nodoubt, as in local ultrasound or injections ora rest cuff, but if the alignment and mechanics(voluntary gliding) including strength, is notaddressed, the problem can recur withresumption of activities. Similarly, ligamentstrains, nerve entrapments and tendoninjuries can occur due to altered mechanics.

A manual therapy diagnosis will assess therestriction of (voluntary gliding) movementsthat comprise the mechanics, that lead to a

pathology. Every joint in the human body hasa similar clinical implication. This example ismerely to bring to light what the focus of amanual therapy diagnosis is.

The evaluation of this altered (voluntarygliding) movement requires thorough know-ledge of each (voluntary gliding) movementthat occurs with each joint of the human bodyduring normal motion. They are describedin subsequent chapters in the sectionMechanics. They are evaluated passively byfeel and movement and to make an accuratefinding requires a great deal of practice. Thenovice clinician may compare findings withthe opposite normal joint to arrive at a senseof what he or she is looking for. The oneaspect that makes the whole process lesscomplicated is that the evaluation method

comprises the treatment technique as well.For example, in the above scenario, whiletesting for a superior glide of the radius, thesame procedure (with some modification) is

the treatment technique as well, to restorethat motion.

A restriction in joint play in a joint/motionsegment can cause the bony elements to moveto a new position. For example, a scapularestricted in downward rotation may havea scapular spine more horizontal incomparison with the scapula on the otherside. This asymmetry can be picked up byskilled observation and palpation. Itcomprises the asymmetry component of the

dysfunction triad.The asymmetry and restricted joint play,

together interfere with the normal mechanicsof the joint. When they occur continually inthe presence of the dysfunction, they renderthe pain sensitive supporting structuresvulnerable. When irritated, these vulnerablestructures present as conventional diagnosiswe see in our day-to-day practice such as bursitis, tendonitis, etc. The pain sensitive/vulnerable supporting structures of a joint

motion segment are:1. Muscle and tendon2. Capsule3. Bursa4. Ligament5. Nerve

Muscle and Tendon

It is hypothesized that just as a muscle can be rendered tight due to disuse or injury a joint can, as well. When this occurs inside the

joint, it is detected by clinical examination asa restriction in voluntary gliding movements.A restricted position from neutral can changethe position of the bony elements of the jointand result in an asymmetry. With theknowledge of bony landmarks around a joint,this asymmetry can be detected in comparison




with the other normal joint. This positionaldiagnosis in correlation with the movementrestriction (voluntary gliding) can strengthenthe diagnosis of a mechanical dysfunction.

Taking this concept one step further, thediagnosis of mechanical dysfunction, uniqueto this philosophy, is that it is made withrelevance to the dysfunction leading to thepathology rather than a routine motionrestriction.

For example, the traditional physicaltherapy clinician will evaluate a certainmotion restriction and upon sensing it willapply a technique to restore that motion foran overall increase in motion and thence

function. As an example, consider a patientwho has had, say, ankle surgery and wasimmobilized for a certain period of time,resulting in joint restriction. The physicaltherapy clinician will incorporate treatmenttechniques to restore this restricted osteokine-matic mobility. A more informed clinician,especially one that is trained in manualtherapy, will approach it a step further andwork at an arthrokinematic level to restoremotion. However, remember that all

orthopedic dysfunctions in the clinic are notpostsurgical or postimmobilization situations.For example, the mechanical neuromusculo-skeletal pathologies that are described as in,say, a tibialis posterior tendonitis or Iliotibial band friction or pain are not post-surgicalsituations or postimmobility situations. Theymay present with functional osteokinematicmobility, but they still present with restrictionat an arthrokinematic level. That restriction,hence, is very unique to the dysfunction inquestion. Identifying the restriction (by bothabnormal position and movement) thanpredisposes to the dysfunction is what asomatic diagnosis is all about, rather thanidentifying overall motion dysfunction. If onehappens to read texts or literature onextremity joint mobilization or manipulation,

an angular or osteokinematic motion is described and all the arthrokinematic componentsnecessary to restore that motion is described,in addition to the type of joint (ball and

socket, hinge, concave over convex etc) andtheir mechanical rules. Although this know-ledge is required to restore the motion, thedirection of restriction of motion mostrelevant to the pathology being treated isimportant and an absolute necessity. Thephilosophy on which this textbook is writtenaims to address this component. A bicipitaltendonitis will be described with relevanceto identifying and diagnosing an internallyrotated humerus. A tibialis posterior tendo-

nitis will be described with relevance to thediagnosis of an everted calcaneus or aninternally rotated navicular.

In addition, the overall functional mobilityand their relevant artrokinematics will also be addressed like other philosophies. This isstill a valuable tool to address overallrestriction that is seen in a postimmobilitysituation. Hence, treatment of mechanicaldysfunction in the extremity joints will bedescribed as two categories:

1. Treatment for specific somatic dys-function.

2. Treatment for overall improvement of range of motion.

SELECTIVE TISSUE TENSION TESTING

(STT)

Muscles work together in a synergy toproduce a movement. As in the ‘tennis elbow’scenario, the movement of wrist extension is

the result of a group of muscles workingtogether. Routine manual muscle testing of wrist extension may hence, not be reliable ineliciting pain in a selective musculotendinousunit. Hence STT is used. A concept originated by Cyriax,4 helps localize the contractile softtissue involved in the dysfunction.




Wrist extension in the above scenario mayelicit pain, but localizing extension to themiddle finger may selectively test the ECRB,confirming the diagnosis. Hence, to maintain

normal alignment/mechanics, knowledge of STT may help address selected structures tolocalize the dysfunction. Although this is avaluable tool for a mechanical diagnosis,another component that might be included,is detection of the presence of tender points.This will encompass the tissue textureabnormality component of the ART triad.Most mechanical dysfunctions indicatehyperactivity of the soft tissue componentsof the lesion which might be the pathology

itself and may present as tender points.Knowledge of the presence of tender pointsmay aid the clinician to arrive at the resultingpathology and pain and when elicited, may be a psychologically enhancing for the patientthat the clinician has an idea as to where thepain or discomfort lies.

Several theories exist as to why such apersistent soft tissue lesion can occursecondary to overuse. The three mostcommon theories are as follows.

1. Prolonged and excessive contraction aswould occur with overuse may inducefatigue in a muscle. The muscle contractsin response to fatigue and persists tocreate a local soft tissue dysfunction withlocalized tender point called ‘triggerpoints’.5 This may also entrap adjacentnerve tissue.

2. Excessive and faulty muscle contractioncan cause injury to the myofibrils of themuscle bulk, which may heal withscarring. This scarring can inhibit normalphysiological contraction and deprive thearea of nutrition and encourage chemicalaccumulation causing pain. In additionpossible nerve endings in the healed scarmay also be pain sensitive.

3. Faulty activity can influence the muscle atan intrafusal level creating constantaberrant gamma motor activity, whichrenders the soft tissue dysfunctional.6

Soft tissue irritability can aid in thediagnosis as it is obvious as palpable tenderpoints. These tender points are seen inmuscles, musculotendinous and tenoperio-steal junctions. Breaking down the scar ortransverse friction compression of triggerpoints are suggested forms of manual therapyin addition to restoring normal arthrokine-matics. This is effective both for the spine andthe extremity joints and hence is describedin Sections 2 and 3. The neuromuscular com-ponent suggests further reading.

CAPSULE

This structure envelopes the joint and protectsit. It contains synovial fluid and lubricates the joint allowing the bones to glide smootWyagainst each other. Tightness of the capsuleis seen as a primary cause, however, faultymechanics in the joint can also render thecapsule tight causing specific patterns of

tightness. This can decrease the ability of the joint surfaces to glide smoothly, resulting indysfunction

BURSA

These are pouches of fluid that help preventfriction between two moving surfaces. In thepresence of a mechanical dysfunction (asym-metry or restricted voluntary gliding), theintervening bursa can be vulnerable to stress.Repetitive motion causing prolonged and

excessive pressure on the bursa can irritatethe bursa, resulting in bursitis.

LIGAMENT

In the presence of a mechanical dysfunction(asymmetry or restricted voluntary gliding),




the supporting ligament can be subjected toincreased tensile stress. Repetitive motioncausing prolonged and excessive tensile stresson the ligament can stretch the ligament,

resulting in ligament pathology.

NERVE

The nerve, like any other mechanical structureis a mobile unit. They have to change inlength to adapt for movement and hence havea gliding capacity. When the gliding is inter-rupted the nerve is vulnerable to dysfunction.This occurs secondary to occlusion of vascularchannel within the nerve, resulting in

ischaemic pain.The structures through which a nerve

glides have a profound influence inmaintaining normal gliding. These structuresinclude muscle, ligaments, fibrous bands andfascia, and are called interfaces. Gross motionof the nerve is called ‘neurodynamics’ andneurodynamic tests help to assess thenormalcy ofnerve gliding. Examples areSlump, SLR etc. However, due to faultymechanics, if one of the interfaces through

which nerve glides is irritated, it can interruptthe ability of the nerve to glide through them.This can result in a nerve irritation. Thisspecific motion of the nerve through a specificinterface is called a ‘neurokinematic’ motionand when restricted, is referred to as a‘neurokinematic’ restriction. This term has been coined by the somatic model approachto mechanical dysfunction.

In manual therapy jargon, neurodynamicswould be analogous osteokinematics (grossmovement), whereas ‘neurokinematics’ would be analogous to arthrokinematics (specificmotion). Treatment hence addresses the res-tricting interfaces first, before gross nervegliding is addressed.

Hypothetical Somatic Concept of Nerve

Dysfunction

Osteokinematic Neurodynamics(gross flexion, (gross nerve motion SLR,extension, etc) Slump, etc)

Arthrokinematics Neurokinematics(specific joint glides) (nerve gliding in specific

interfaces)

Mobilizing arthro- Mobilizing neurokinematickinematic restriction restriction restoresrestores osteokinematic neurodynamic motion/motion gliding

The principles of diagnosis in extremity joint dysfunction will hence follow the above

philosophy which comprises the ARTprotocol. In the scenario described earlier, theconclusive findings from an arthrokinematicstandpoint will be:

Positional fault: Radial head stuck or restrictedinferiorly, or superiorly, or a restriction of the carpal bones.

Movement fault: Superior glide of radial heador dorsal glide of distal carpals producingwrist extension.

Asymmetry: The restricted position of theradial head inferiorly or superiorly.

Restriction of mobility: The radial head notmoving superiorly or inferiorly (decreasedsuperior/inferior glide) or the distal carpal bones not moving superiorly (decreaseddorsal glide).

Tissue texture abnormality: The tenderness overthe lateral epicondyle and radial head, and

pain on STT of ECRB.To summarize, the diagnosis of musculo-skeletal dysfunction comprises all aspectsfrom various disciplines in health care. Thephilosophy described here is indeed unique but other components be it neurological,




vascular, radiological findings, special tests,etc, should also be considered. The manualtherapy component of diagnosis is intricateand is often times missed out. It also yields

favorable results, hence the astute clinicianshould be eclectic in his/her approach toevaluation and diagnosis.

REFERENCES

1. Bourdillon JF. Spinal Manipulation. Oxford,Boston: Butterworth-Heinemann, 1992.

2. Kaltenborn F. Mobilization of the extremity joints: Examination and basic techniques. 3rd edn.Oslo, Norway: Olaf Noris Bokhandel A/S, 1980.


4. Cyriax J. Textbook of Orthopedic Medicine, Vols1 and 2. London: Cassel and Company, 1944.

5. Travell JG, Simons DG, Simons LS. Myofascialpain and dysfunction: The trigger point manual.Baltimore: Williams and Wilkins, 1999.

6. Korr IM. The collected papers of Irvin M. Korr.Indianapolis: American Academy of Osteopathy,1993.

7. Patla CE, Paris SV. EI: Extremity Manipulation andEvaluationm Course Notes. Institute press: St.Augustine, 1996.



Section 2Regional Application

(Spinal Manipulation)

Introduction

8. Cervical Spine

9. Thoracic Spine

10. Lumbar Spine

11. Pelvic Complex




INTRODUCTION

Every joint in the human body has a purposeworth understanding. They serve as links tothe complex skeletal structures and the purposeof these intervening links is to effectmovement. When we observe gross move-ments of the body, the careful organization andresulting grace is much owed to the neuralinfluence of the central and peripheral nervoussystem. However, assuming that the neuralcontrol is intact, the normalcy of the intricatemechanics of the individual joint componentsis an absolute necessity for normal movement.

From a biomechanical perspective, move-ments in the extremity joints have been well

researched and their functional basis has beenwell described. This advancement withregards to the extremity joints may beattributed to various reasons. For one, thegross motion produced in an extremity jointis brought about by fewer articulations whichare better visualized on imaging proceduresor for that matter palpable. Consider shoulderflexion and the articulations that bring aboutthe movement. If, in your exam you haveelicited a limitation in shoulder flexion, what

structures would you suspect to narrow downyour focus. Now consider a limitation inlumbar flexion. Where does your logicalthinking zero in?

The more the specificity, the moreelaborate the examination and subsequenttreatment. When we observe an experiencedclinician examining an extremity joint, he orshe will carefully observe alignment, testrange of motion actively and passively andstress the supporting structures. A more

astute clinician may also examine joint playor arthrokinematic motion, perform specialtests and look for movement deviations of the joint in question. The spine, on thecontrary, may be tested for gross range of motion, rarely for strength, special tests orprovocative maneuvers for pain, and grossalignment with no specific detail. The serious

implication here is that the articulations of the spine are synovial articulations, nodifferent from the joints of the extremitieswith greater specificity in mechanics,

distinctly unique with every region.A bigger focus of this portion of the book

is to enlighten clinicians to set the samestandards of examination and treatment forthe spine as applied to the extremities. Adetail understanding of the mechanics foreach region (cervical, thoracic, lumbar andpelvic) is absolutely essential to diagnosemechanical spinal dysfunction.

Prior to discussing regional principles of the spine it is important for the clinician to

know the contraindications to manipulationof the spine. It should essentially be the firstthing that comes to mind before anytreatment procedure is initiated. The majorcontraindications are listed, however as mostmanual therapy guru’s would advise—

“when in doubt, don’t”

The clinician is hence advised to exercisesound clinical judgment prior to initiatingtreatment. The list is as follows, but notlimited to:

• Vertebral artery insufficiency• Ligament insufficiency, especially alar and

transverse• Rheumatoid arthritis, especially the sub-

cranial spine• Down’s synrome, especially the subcranial

spine• Connective tissue disorders• Recent fractures• Disc pathologies• Osteoporosis

• Malignancy or tumours• Spondylolysis, spondylolisthesis• Instability• Bladder, bowel incontinence• Pregnancy, bone disease• Surgical and congenital spinal fusion• Congenital spinal anomalies• Systemic disease



8The cervical spine functions to support andposition the head in space for purposes of function and proprioception. This demandsmobility and hence the stability in this area

is relatively lesser compared to the otherareas of the spine. This apparently increasestheir vulnerability to dysfunction. The ana-tomy and mechanics of the cervical area isunique and hence a clear understanding of how this area functions is an importantprecursor to evaluation and treatment.

RELEVANT ANATOMY1

The cervical spine consists of seven vertebralsegments. The first cervical vertebra or C1

is called the ‘atlas’ and the second cervicalvertebra or C2 is called the ‘axis’. The atlasarticulates with the occiput above to form theatlanto-occipital joint, and the altas articulateswith the axis below, to form the atlanto-axial joint. The occiput, atlas and axis together withtheir articulations are termed the ‘uppercervical’ or ‘sub-cranial spine.’ The areaformed by C3 through C7 is called the ‘mid-cervical spine’. The segments of the mid-cervical region differ from those of the sub-cranial region in structure and mechanics.3

MID-CERVICAL SPINE

Osseous Anatomy

A typical mid-cervical vertebra (Figure 8.1)consists of a body, two transverse processes/

Cervical Spine

articular pillars and a bifid (two projections)spinous process. On either side of the bodyare two openings called the foramen trans-versaria through which the vertebral arterypasses. The transverse process has twoprojections called the anterior and posteriortubercles. A shallow depression between thetwo tubercles is known as a nerve root gutter,through which the spinal nerve passes.Between the posterior tubercle and thespinous process are the articulating facets.

These articulations are the zygoapophysealor facet joints and are oriented in a 45 degreeangle (Figure 8.2). All manual therapy proce-dures incorporated, are to effect movementin these joints.

The superior surface of the cervicalvertebral bodies have bony processes that

Figure 8.1: Typical mid-cervical spine vertebra.(1) Nerve root gutter, (2) Foramen transversarium,(3) Vertebral body, (4) Facet joint, (5) Spinal canal,(6) Bifid spinous process




project upwards from the posterolateral rims.The inferior aspect, in conjunction is beveledso as to seat itself between the bony rims.They do so and form the lateral interbodyarticulations or the uncinate/unciform joints.1

They are also known as the joints of VonLushka, who first described them. Althoughthere is some controversy, these are notconsidered synovial joints. The unciform joints prevent excessive lateral bending andlateral translation to protect the cord and thevertebral artery from a laterally directedviolence.

Ligamentous Anatomy

The ligamentous apparatus of the cervical areafunction as checkreins and add to the overallstability of the cervical spine. The moreimportant ligaments are described withrespect to their location and function.

Anterior Longitudinal Ligament (ALL) and Atlanto Occipital Membrane

The ALL is attached to the vertebral bodiesand intervertebral discs at the level of C3 andall of the segments below it until the

periosteum of the sacrum. Superiorly, itattaches to the body of the atlas and the axisand continues upward towards the occiputand is known as the atlanto-occipital membrane. This ligament functions as a checkreinfor excessive extension.

Posterior Longitudinal Ligament (PLL) and Tectorial Membrane

The PLL runs from C2 all the way into thesacrum and on to the coccyx. It is continuedupward as the tectorial membrane which bypasses the atlas and inserts into the occiput.It serves as a restraint for any posterior pro-trusion of the disc and is most advantageousin the cervical area, as it is the widest in thisregion. This ligament checks excessive flexion.

Ligamentum Nuchae and Supraspinous Ligament

The ligamentum nuchae extends from the

spinous processes of C7 and T1 and attachesinto the external occipital protruberance. Theanterior placement of the head to the neckcauses a flexion moment on the head and thisis checked by the ligamentum nuchae. Thesupraspinous and interspinous ligaments blend with the nuchal ligament.

Ligamentum Flavum

The ligamentum flavum is an importantligament in the cervical spine. It attaches to

the inner rim of the vertebral arch and extendsto the lamina of the vertebral below. By thisposition, it forms one of the posterior boun-daries of the spinal canal. The ligamentumflavum extends from C2 to all of the caudalsegments. Above C2 it is replaced by theposterior atlanto-axial and atlanto-occipitalmembrane. This ligament checks flexion,however on extension it shortens by way of its elastic predisposition. Extension does notcause infolding of the ligament into the spinal

canal when there is normal disc height.However, in situations where there is a lossof disc height due to degenerative changes,extension of the cervical spine can cause aninfolding of the ligament into the spinal canalcausing spinal canal stenosis and myelopathy.

Figure 8.2: 45 degree orientation of facet joint



Cervical Spine 47

The ligamentum flavum also contributesto the formation of the anterior wall of thefacet joint capsule. It has an important functionof sliding the facet capsule in and out of the

facet joint during movements of the spine.This mechanism is often lost duringdysfunctional states of the ligamentum flavumas which occurs during a laminectomy dueto a posterior denervation, causing a facetcapsule impingement.

Hence, to summarize, in dysfunctionalstates the ligamentum flavum by way of itsattachment to the posterior wall of the spinalcanal can cause spinal canal stenosis byinfolding and by way of its attachment to the

facet capsule can cause a foraminal stenosis,due to impingement.

Muscular Anatomy

The muscles of the cervical area are catego-rized by side, anterior and posterior and bylocation, superficial and deep. The posteriorgroup is as follows:

Superficial1. Trapezius

2. Levator Scapulae3. Spleneii

Deep1. Sub-occipital muscles2. Multi-fidus

The anterior group is as follows:

Superficial1. Sternomastoid2. Scaleneii

Deep1. Longus coli2. Longus cervicis

The cervical muscles effect movement butadditionally it should understood that thesemuscles have a dense array of muscle spindlesand they also function as proprioceptors. The

cervical spine muscles are also required toperform unique and highly coordinatedfunctions because of the reflex connections between the sensory organs of the head and

motor neuron pools related to the cervicalspine.

Their relevance to manual therapists isobvious as discussed in the principles of management that these muscles are analogousto ropes holding the pole of a tent. Theirability to stabilize alignment should be takenadvantage of. In addition the length orexcursion needs to be considered as alteredlengths of muscles due to tightness or injuryor hyperactivity of muscle spindles may stress

on vertebral alignment by virtue of theirattachment to them.

The most important factor to be consideredis that these muscles, on contraction not onlyeffect movement, but also exert a compressiveforce on the cervical spine. Dysfunctionalstates of these muscles can increase thesecompressive forces further predisposing tomechanical dysfunction within the complex.From a manual therapy perspective twofactors should be remembered with relevance

to musculature. Their strength has to bemaintained as they help stabilize and maintainalignment and absorb the shock of routineactivity. Secondly, their length has to bemaintained so as to prevent further compres-sive forces on the spinal alignment andpredisposition of faulty alignment due to theirtraction effect on the skeletal insertion.7

The muscles are classified by Vladmir Jandaas postural and phasic muscles. It is an acceptedunderstanding that postural muscles tightenor contract in length and phasic musclesweaken during dysfunctional states. This maynot be a hard and fast rule but the case for themost part. In addition due to their dense arrayof muscle spindles they can be easily involvedduring injury and on the other hand effectively




influenced beneficially. Hence appropriateexercise prescription following manual therapynot only produces effective outcomes but alsounique to the way physical therapists manage

mechanical spinal dysfunction.The anatomy of the above muscles can be

gleamed from any standard text but the majorpostural and phasic muscles are worthknowing for appropriate management.

Postural

• Upper trapezius• Levator scapulae• Sternomastoid• All posterior cervical retractors

Phasic

• All anterior cervical musculature exceptsternomastoid.

• Mid and lower trapeziusRemember that postural muscles can

weaken as well and so do phasic musclestighten. Their primary tendency is such asmentioned above and hence, the managementshould be appropriate as in first lengtheninga postural muscle before strengthening and

vice versa for a phasic muscle.

SUB-CRANIAL SPINE

The sub-cranial spine is unique with regard toits mechanics as it works to support the occiputor the skull. The mechanics is complicated andprobably more than the other regions of thespine. The basic musculoskeletal, ligamentousand vascular anatomy is worth understandingfor accuracy in evaluation.3

Osseous Anatomy

Atlas

The atlas is termed so from the character inGreek mythology Atlas who apparentlysupported the earth over his upper back. Theatlas in the cervical spine works likewise as

it supports the occiput over it. Its uniquestructural characteristic is that it does not havea spinous process. It however, has twoprominent transverse processes laterally. It

has two superior articulating facets thatarticulate with the occipital condyles to formthe atlanto-occipital joint. The central openingis the spinal canal that lodges the spinal cord.On the anterior aspect of the inner rim of thespinal canal lies an articulating facet for thedens of the axis (Figure 8.3).

Figure 8.3: Atlas. (1) Anterior tubercle, (2) Facet joint,

(3) Foramen transversarium, (4) Spinal canal,(5) Posterior tubercle, (6) Groove for dens

Axis

The axis is termed so as it allows a significantamount of rotation occurring in the cervicalarea. It has a prominent spinous process andhence on palpation, inferior to the occiput,the first palpable spinous process is that of the axis (as the atlas does not have one). Onthe anterior aspect of the axis is a bonyprominence that projects superiorly. This bony prominence is called the odontoidprocess, or the ‘dens’. The dens articulateswith the facet on the anterior inner rim of

the spinal canal of the axis to form the atlantoaxial joint (Figure 8.4). (Along with the facet joints of the atlas and axis).

Ligamentous Anatomy

The sub-cranial area has several ligamentsand the important ones are described owing



Cervical Spine 49

to their strong relevance to manual therapyprocedures. It was mentioned earlier that thecervical spine has sacrificed a certain amountof stability owing to the mobility demandsin this area. The principal structures that offerstability to this area, especially the sub-cranialarea, are the ligamentous structures.Primarily, they stabilize the skeletal structuresand then prevent the skeletal structures fromcompromising the neural elements of the brain and the spinal cord. Their anatomy,function and tests for integrity are of extremeimportance to the manual therapist as theconsequences of improperly plannedtreatments may be disastrous.

Alar Ligaments

The alar ligaments attach laterally to each sideof the dens, run upward and laterally andattach to the occiput. They principally limitflexion of the occiput and also side-bending

and rotation. Their most important functionis that they serve to make the occiput, atlasand axis to function as one unit. Laxity ordegeneration of this ligament can severelylimit this function and render this areaunstable increasing the vulnerability of theneural structures.

The dens is a structure vulnerable tofractures and in such situations the alarligaments, by virtue of their attachments tothe dens can cause an upward pull as they

are attached to the occiput on the other end.Manual therapy procedures especially tractioncan cause the fractured dens to be pulledupwards into the foramen magnum andpossibly compress the medulla (Figure 8.5).

Figure 8.5: (A) Alar ligament and consequence ofinjury. (1) Occiput, (2) Alar ligament, (3) Dens, (4)

Atlas, (5) Axis. (B) Fractured dens pulled up by alarligament into foramen secondary to traction

In situations of laxity of the alar ligamentsdue to disease, degeneration and injury, anyform of manual or manipulative treatmentsto the sub-cranial spine can be gravely

dangerous and potentially life threatening.

Transverse Ligament

The transverse ligament attaches on eithersides of the inner rim of the spinal canal of the atlas and encircles and reinforces the dens.

Figure 8.4: Axis. (1) Dens, (2) Facet joint, (3)Spinal canal, (4) spinous process




By this position it offers a great deal of stability to the dens. It serves as a fence tothe spinal cord immediately posterior to itwithin the spinal canal and prevents the dens

from compromising the spinal cord (Figure8.6).

Figure 8.6: Transverse ligament. (1) Dens,(2) Transverse ligament, (3) Atlas, (4) Axis

When the integrity of this ligament is lostdue to disease or injury, the fence betweenthe dens and the spinal cord does not exist.The alar ligament may be the next line of defense however, not reliable. Any form of flexion, forward translation or rotation of thesub-cranial spine can bring the dens closer tothe spinal cord, resulting in a compromise

(Figure 8.7). Hence, in unstable situations of the transverse ligament, manual therapyprocedures of the sub-cranial spine, especiallythose involving flexion, forward translationor rotation can cause a serious spinal cordcompromise.

Vascular Anatomy

Vertebral Artery

The vertebral artery originates from the

subclavian and ascends upwards into the sixthcervical vertebra. It passes into the openingson the transverse processes known as theforamen transversaria. When it exits out of the altas, it turns inwards and horizontallyowing to the wide nature of the transverseprocesses of the atlas. It then runs upwardsinto the foramen magnum joins the vertebral

artery on the other side to form the basilarartery.

The brain requires blood supply to survive.The vertebral artery is one source of bloodsupply, and owing to its position in the

cervical spine, may be kinked. It can occurin the sub-cranial area if the occiput isextended and rotated to the same side. Theindividual may not have an adequate back-up from the carotids and proceed to havesigns and symptoms of cerbrovascularischemia.2

Manual therapy procedures to the sub-cranial spine involving excessive or violentextension or rotation can cause a compromiseof the vertebtal artery and there lies the risk

of a hemiparesis and possible death (Figure8.8).

Muscular Anatomy

Sub-occipital Triangle

The sub-occipital triangle is formed by thearrangement of the small muscles related to

Figure 8.7: Transverse ligament injury and con-sequence. (1) Apical ligament, (2) Dens, (3) Ruptured

transverse ligament, (4) Spinal cord

(1) Apical ligament, (2) dens, (3) Intact transverseligament, (4) Spinal cord



Cervical Spine 51

the occiput, atlas and the axis. In the mid-line are the rectus muscles:1. The rectus capitis posterior minor, and2. The rectus capitis posterior major

The rectus capitis posterior minor arisesfrom the posterior arch of the atlas and insertsinto the occiput. The rectus capitis posteriormajor arises from the spine of the axis andascends to the occiput. Lateral to the recti arethe obliquus muscles:1. The obliquus capitis superior, and2. The obliquus capitis inferior

The large inferior oblique muscle arisesfrom the spinous process of the axis and

adjacent lamina and attaches to the transverseprocess of the atlas. The superior obliquemuscle arises from the transverse process of the atlas and runs superiorly to attach to theocciput.

The two recti draw the head backwardsand so does the obliquus capitis superior. The

rectus capitis posterior and the obliquuscapitis inferior rotate the head to the sameside and the obliquus capitis superior to theopposite side (Figure 8.9).

Figure 8.9: Sub-occipital muscles. (1) Occipital area,(2) Rectus capitis posterior minor, (3) Obliquus

capitis superior, (4) Rectus capitis posterior major,(5) Obliquus capitis inferior

The posterior division of the secondcervical nerve emerges from the spinal canal between the posterior arch of the atlas andthe lamina of the axis, below the inferiorobliquus. It supplies a twig to this muscle andreceives a communicating filament from thefirst cervical nerve. It then divides into aninternal and external branch. The internal

branch, called the greater occipital nerveascends obliquely inwards between theobliquus inferior and the complexus. It piercesthe latter muscle and the trapezius near theirattachment to the cranium. It is now joined by a filament from the posterior division of the third cervical nerve, and ascending on the

Figure 8.8: Vertebral artery. (1) Horizontalorientation and risk of injury, (2) Sub-clavian




posterior part of the head with the occipitalartery, divides into two branches. Thissupplies the integument of the scalp as far asthe vertex, communicating with the lesser

occipital nerve. It gives off an auricular branchto the posterior part of the ear and a muscular branch to the complexus (Figure 8.10).

Figure 8.10: Inervation relevant to headaches.(1) G Occipital nerve, (2) L Occipital nerve, (3)Auriculotemporal nerve

The occipital nerve is of clinical significanceas it is the irritation of the occipital nerve thatresults in muscular headaches by virtue of their supply to the integument of the scalp.The pain typically occurs behind the head,vertex and temporal areas. The irritation of this nerve occurs secondary to a dysfunction

of the sub-occipital muscles, the occipito-atlanto-axial joint or both.4

COMBINED MECHANICS OF THE UPPER

AND MID-CERVICAL SPINE3

The movements possible at the mid-cervicalspine are forward-bending, backward-

bending, side-bending and rotation. At thesub-cranial spine ‘nodding’, as one wouldgesture a ‘yes’, occurs at the atlanto-occipital(OA) joint. It is important to remember that

nodding is different from forward-bendingas they occur at different levels of the cervicalspine. Rotation, as one would gesture a ‘no’occurs at the atlanto axial (AA) joint. Hencethe OA joints are often called the ‘yes’ jointsand the AA joints, the ‘no’ joints. Thefunctional importance is to have the headlooking straight and eyes level (except side- bending). The facet joints of the mid-cervicalspine are oriented at a 45 degree angle and

hence the movements occur as follows:• Forward-bending causes all of the facet joints to slide upward and forwardrelative to the facet joint below them.

• Backward-bending causes all of the facet joints to slide backward and downwardrelative to the facet joint below them.

• Rotation, say right rotation, will cause theright facet joints to slide downward and backward and the left facets to slideupward and forward.

The same occurs with side-bending as well.Due to the 45 degree orientation and rightside-bending will cause the right facets toslide down and back and the left facets toslide up and forward.

During forward-bending the head andface look down and the reverse occurs during backward-bending where the face looks up.

If the joints were flat, during rotation andside-bending, the face and head would look

straight over the shoulder as a perfect turnwould occur. When the joints are oriented ata 45 degree angle, side-bending and rotationwill technically cause the face to look downon the shoulder. So, how does the head andface look straight during side-bending androtation of the cervical spine?



Cervical Spine 53

The answer is as below:a. For every degree of side-bending at the

mid-cervical spine, a relative rotation inthe opposite direction occurs between the

atlas and the axis at the sub-cranial spineto keep the head and face looking straight.

b. For every degree of rotation at the mid-cervical spine, a relative side-bending inthe opposite direction occurs between theocciput and atlas in the sub-cranial spineto keep the head and face lookingstraight.3

The second important point to know isthat the atlas always follows the occiput exceptduring rotation. Hence, forward-bending will

cause the atlas to slide forward, backward- bending will cause the atlas to slide back-wards. Side-bending will cause the atlas toslide to the same direction as the side bend,however, rotation will cause the atlas to slidein the opposite side of the rotation. This isvery important to understand as it is anessential to diagnose a sub-cranial dys-function.

Hence, to summarize the combinedmechanics of the mid-cervical and sub-cranial

spine the following is the sequence that everymanual therapist should absolutely under-stand.3

Forward-bending

• The occiput rolls forward on the atlas• The atlas slides forward over the axis

following the occiput• The mid-cervical facet joints slide forward

and upward

• The uncinate joints translate forward• The vertebral canal narrows slightly

Backward-bending

• The occiput rolls backward on the atlas• The atlas slides backwards following the

occiput

• The mid-cervical facet joints slide backward and downward

• The uncinate joints translate backward• The vertebral canal narrows much more

than in forward-bending

Side-bending (e.g. right side-bending)

• The occiput rolls down and in on the rightover the atlas

• The atlas first slides right following theocciput

• The atlas then rotates left on the axis below to keep the face looking straight

• The mid-cervical facets on the right slidedown and back

• The mid-cervical facets on the left slideup and forward

• The uncinate joints on the right translate backward

• The uncinate joints on the left translateforward

Rotation (e.g. right rotation)

• The occipital condyle on the right rolls backand forward on the left

• The atlas first slides left, opposite to the

occiput• The occiput then side bends left over the

atlas to keep the face looking straight• The mid-cervical facets on the right slide

down and back• The mid-cervical facets on the left slide

up and forward• The uncinate joints on the right translate

backward• The uncinate joints on the left translate

forward

The reverse occurs with left side-bendingand rotation.

MECHANISM OF DYSFUNCTION

The first thing to consider in the managementof mechanical cervical dysfunction is posture.The cervical spine with its soft tissue




stabilizers work to support the head andposition/move the head for function. Aneutral and erect posture of the head andneck provide optimal balance, muscular

coordination and adaptation with minimalexpenditure of energy and minimal stress onthe supporting structures. If the posture isnot neutral and balanced, the weight is eitheranterior or posterior to the joint. The headand neck is then counter-balanced by passivetension in the soft tissues or increasedmuscular activity. The most common posturaldeviation of the cervical area is the forwardhead posture.

Components of the Forward Head Posture

The forward head posture is seen either asa habit, natural tendency, slouching orwearing bifocals (Figure 8.11). It is also seenin individuals who function looking down asin a desk job. The dynamics are as follows:

Figure 8.11: Forward head posture

To maintain the head in neutral a sub-

cranial backward-bending occurs. This cancause a shortening of the soft tissue structuresincluding the sub-occipital muscles. Restric–tion can occur in the OA and AA joints. Thegreater occipital nerve can be irritated causingoccipital and temporal headaches.

In the mid-cervical area, the facets are inforward-bending to compensate resulting ina loss of the normal cervical lordosis. Therestriction in the sub-cranial area can be

compensated by increased mobility in themid-cervical area, resulting in increased wearand tear and conventional ‘cervicalspondylosis’. The cervical musculature,especially the guide wires namely uppertrapezius, levator scapulae and sternomastoidcan contract and be altered in their lengthtension relationships. Their attachment to thecervical vertebra can alter alignment resultingin ERS and FRS dysfunctions. This can in turnaffect the facet joints and the capsule,

compromising the foramen and the spinalnerve resulting in radiculopathies)6 (seeChapter 7). The disc can be sheared pre-disposing to disc herniations and wear andtear. The muscle shortening can also cause acompressive effect on the joints and discsfurther leading to wear and tear. Contractionof the scalenes can compromise the thoracicoutlet and elevation of the first rib due toits distal attachment on the first rib. This cancompromise the costo clavicular space leading

to symptoms of a thoracic outlet syndrome.Due to the forward head position the jaw

is forced to open. To keep the mouth closedthe masseter and temporalis becomehyperactive, causing increased compressiveforces on the temporo mandibular joints(TMJ) leading to dysfunction.

The shoulder girdle protracts including thescapula which can cause an impingement of the supraspinatus tendon at the shoulder. Theinternal rotators including the pectoralisminor can tighten leading to symptoms of thethoracic outlet.

The abdominal wall can constrict due toa chronic forward head decreasing diaphrag-matic breathing and increases upperrespiratory breathing. This increases activity



Cervical Spine 55

of the scalenes which is an accessory muscleof breathing leading to symptoms of athoracic outlet syndrome.

The vicious cycle is obvious and the

clinician should remember that thesedysfunctions not only occur due to faultyposture, but also due to weakness of cervicalmuscles and overuse. Weakness and overusecan fatigue a muscle, which responds bycontracting or tightening and on persistencecan cause dysfunctions described above.

The function of the cervical musculatureto draw the head backwards also increasestheir vulnerability to dysfunction. Prolongedflexion of the head for extended periods of

time, as a surgeon or a writer would do forexample (looking down on the operating tableor the desk), can fatigue these muscles.8 Theimmediate response to excessive fatigue is acontraction, which can be continual inoccupational situations. This results indysfunctional states.

Trauma

The commonest cause for trauma andsubsequent irritation of the cervical area arewhiplash injuries. Often occurs secondary to being hit from behind by a moving vehicleor being violently pushed from behind. Theresultant momentum causes the head toviolently snap back into extension andsubsequently flexion. This results in traumaof the sub-occipital and cervical muscles andthe facet joints of the sub-cranial more thanthe mid-cervical complex.

The previous causes described were

secondary to faulty posture, fatigue andoveruse, however, whiplash injuries causeactual trauma to the cervical musculature,especially the sternomastoid, longus coli andcervicis as they are anteriorly placed andcontract heavily to prevent the head fromsnapping back.5 The facet joints of the sub-

cranial spine more than the mid-cervical spineare most involved. They hence, result in awider array of symptoms including intenseheadaches, making their management

relatively difficult.Owing to the strain of the facet capsule

and subsequent muscle guarding, the jointsof the sub-cranial complex can exhibit agreater deal of restriction and pain with moreintense headaches. The sub-occipital musclesare intimately related physiologically to theextrinsic and intrinsic ocular muscles and otherneck and trunk musculature. Hence, pain inthe region of the eye is a common feature.Proprioceptive impulses from them are

conveyed (over the first and second spinalnerves) to the upper cord and thence re-distributed to appropriate stations at thesegmental and supra-segmental levels. Thedirection of gaze, the visual axes andaccompanying head, neck and trunk posturingare produced and maintained by movementand fixations, among which these small sub-occipital muscles play a major role. Theprincipal interconnecting pathways betweenocular and neck musculature include the

medial longitudinal fasciculi and the reticularsubstance of the brain stem, both of whichreceive proprioceptive, exteroceptive andinteroceptive modalities essential for theintegration and regulation of externalorientation and internal homeostasis. These brainstem and cord functions guide and aregoverned by higher stations of neuralintegration, including the neuropsychiclevels. It is not surprising, therefore, thatdisturbances of equilibrium and autonomicfunctions, both subjective and objective occurin a traumatic situation since deep pain in theneck and head, together with evidence of cervical muscle spasm and head and neckalignment changes are prominent features inwhiplash injuries.11




It may be of value to add that thesesymptoms are not only seen in whiplashsituations, but also in prolonged and chronicoveruse/fatigue syndromes of the sub-cranial

spine. Their occurrence in whiplash injurieshowever, are relatively more common.7

EXAMINATION

Mid-cervical Spine

Mid-cervical examination is relatively straightforward as the facets slide only in twodirections, forward and backward. Thepossibility of a muscular restriction shouldfirst be ruled out to conclude that the

restriction is at the facet joint.

Active Movement

Forward-bending: The patient is asked to nodthe head and gently drop the neck downtowards the chest (Figure 8.12). Note for anyrestriction.

Figure 8.12: Forward-bending

Backward-bending: The patient is instructed to

look upward towards the ceiling withoutleaning the trunk backwards (Figure 8.13).Note for restriction. This movement is notoften tested and should be avoided in theelderly to avoid a possible vertebral arterycompromise.

Figure 8.13: Backward-bending

Side-bending: The patient is instructed to drop

the ear towards the shoulder with the facelooking straight (Figure 8.14). Note forrestriction. Now the shoulder on the oppositeside is raised as in a shrug and the elbow issupported by the examiner (Figure 8.15). Thiswill slacken the muscles on that side. Nowif the range of motion in side-bendingincreases then the restriction was probablymore muscular. If the range appearsrestricted despite slacking the musculature byshrugging, then the restriction is probably

more in the facet joints.

Figure 8.14: Side-bending

Rotation: The patient is instructed to turn thehead towards the side (Figure 8.16). The



Cervical Spine 57

Passive Movement

As mentioned earlier the facets in the mid-cervical area slide only in two directions. Upand forward and down and back. In otherwords, there is either an up slide or a downslide. The clinician should hence be able toexamine this movement occurring in every seg-ment of the mid-cervical spine (Figure 8.18).

Figure 8.18: Passive movement

TechniquePatient is lying supine. The clinician standswith the head of the patient resting on the

abdomen in slight flexion. The metacarpopha-langeal (MP) joint of the index finger contacton the transverse process/articular pillar of the vertebral segment being tested on bothsides. The other fingers mould around theneck on both sides. The thumbs rest on themandible. A downward pressure is exertedin a diagonal plane in the direction towardsthe opposite chest as the joints are oriented45 degrees. When this is done the neck is inthe position of side-bending and rotation on

the side tested. This will test downslide of the joint on that side. Note for restriction orend feel.

The MP joint of the index finger on theopposite side of the downslide exerts anupward pressure in a diagonal plane in thedirection of the opposite eye as the joint is

Figure 8.15: Shoulder of opposite site is raised

Figure 8.16: Rotation of head toward side

Figure 8.17: Shrugging the opposite shoulder

opposite shoulder is shrugged upwards anda change in range, if any, is noted to rule outa muscular restriction (Figure 8.17).




oriented 45 degrees. This will test upslide of the joint on that side. This is repeated for eachsegment from C3 through C7.

The reason for segmental testing versus

gross motion is absolutely important. Thereason being that even if one joint is restrictedthe other joints may move excessively andcompensate to complete the gross motion.This may give the clinician a wrong impres-sion that the motion is normal. In realityhowever there may be a segment that isrestricted and being compensated by thesegment above or below it which invariablyis rendered hypermobile and predisposed tofurther dysfunction.

The movement is tested both with theneck in flexion and extension. Caution should be exercised when the movement is testedin extension for possible vertebral arterycompromise and should be done withextreme caution in the elderly.

MID-CERVICAL SPINE SOMATICDIAGNOSIS

ERS

On reviewing the Chapter 7 on Principles of

Diagnosis, an ERS dysfunction is detected inflexion. The joint stuck in extension appearsposterior due to a prominent transverseprocess on that side during flexion (as it isstuck in extension and does not slideforward). With the only exception of thecervical spine the technique is slightlymodified for two reasons.1. The transverse processes are the articular

pillars and are not quite as prominent inthe cervical spine as the other regions of

the spine, making palpation difficult.2. It is difficult to position the head inextension and palpate the articular pillars/transverse processes in extension of theneck to diagnose an FRS dysfunction(although there appears a possibility of palpating the processes in flexion to detectan ERS dysfunction).

Hence the upslide, downslide techniqueis adopted.

Method

The technique is as described (Figure 8.18)above in the passive movement section andan ERS is tested with the neck in flexion.Assume the MP joints of both index fingersare palpating the transverse processes/articular pillars of C5. A downslide from rightto left is performed. If it appears restrictedthen the facet on the other side (left) is notsliding forward and upward to complete themotion. The reason being that it is stuck inextension. Conversely an upslide on the leftwill also appear restricted as it does not slideforward. However, a downslide on the leftwill appear free as it can slide backward . Itis therefore stuck in extension on the left andwould be an ERS Left of C5. A similar conceptis applied from C3 to C7 for both sides.

FRS

Method

The technique again is as described above but

this time with the neck in extension (Figure8.19). The patient should first be ruled outfor a vertebral artery compromise prior tothe exam.

Figure 8.19: Neck in extension



Cervical Spine 59

The tips of the middle/index fingerscontact the transverse processes/articularpillars of C5. A downslide is performed fromright to left. If it appears restricted the facet

on the right side is not sliding backward, asit is stuck in flexion. Simultaneously, upslideon the opposite (left) side will also berestricted. However, downslide on the leftside will appear free. It is therefore stuck inflexion on the right and hence would be anFRS left (not right) of C5. The reason being thatalthough the right facet is stuck in flexion,it is the left facet that appears posterior andthe diagnosis of the side is always by the sidethat is posterior. (Refer back to Chapter 7,

where in the case of an FRS it is not the sideof the restriction but the side of theposteriority). A similar concept is appliedfrom C3 to C7.

It is obvious that both sides be tested for both ERS and FRS dysfunctions. Theprinciples thus described are with regards tothe mid-cervical spine in isolation. However,the mid-cervical and sub-cranial spine workso closely to each other that dysfunctionsoccur as a combination due to the combined

mehanics. Examination of the sub-cranialspine should ideally be done first andidentification of combined dysfunctions withthe midcervical spine should follow.

SUB-CRANIAL SPINE

The sub-cranial spine, owing to its uniquemechanics, has a more intricate examinationprotocol with specific attention to localizefindings. The reason being that movementand symptoms may also arise from the mid-

cervical spine. The orientation of the facet joints in the sub-cranial spine are differentfrom those of the mid-cervical area, and arerelatively flatter. Hence examination is morestraightforward. The key is to lock the mid-cervical spine to localize movement. They will be dealt specifically.

The only exception is that the FRS and ERSconcepts do not apply in the sub-cranial joints(OA/AA). Their examination is more unique.The one other area where they do not apply

as well is the pelvic complex (sacrum andIlium).

Active Movement

Forward-bending

From what we inferred from the previouschapters, forward-bending and backward- bending occurs in the atlanto-occipital joint(OA). The movement is technically notforward-bending, but rather forward

‘nodding’, the ‘yes’ joints, as was described.Hence, the patient is asked to nod forwardas in saying ‘yes’. The landmark to beobserved is the chin in relation to the midline. If there is a deviation of the chin frommidline, an OA dysfunction should besuspected. The side of the deviation is theside of the dysfunction. For example, if thechin deviates to the right then the restrictionis probably at the right OA joint (Figure 8.20).

Figure 8.20: Forward nodding

Backward-bending

Similarly, the patient is asked to backward‘nod’ (not bend and look up to the ceiling).In a backward nod the chin deviation is




observed and the deviation is opposite to theside of the dysfunction. Hence, if the rightOA joint is restricted in backward-bending,the chin deviates to the left (Figure 8.21).

Figure 8.21: Backward nodding

Rotation

Rotation predominantly occurs in the atlantoaxial (AA) joint. Remember however thatrotation also occurs in the mid-cervical spine.The key is to localize this movement to theAA joints so that the rotation being testedis pure AA rotation. This is not accuratelypossible as an active movement, hence the

clinician must rely on the passive motion testto obtain information. It is described on page60 under Subcranial Spine Somatic Diagnosis.

Passive Movement Tests

Passive motion testing in the sub-cranial spineinvolves a greater risk of stressing thevulnerable structures as described earlier.Hence, these structures should be tested firstfor integrity before any other testingprocedures, or for that matter, treatment

procedures are done. The three structures to be tested first are the alar and transverseligaments, and the vertebral artery.

Alar Ligament

The patient is lying supine and the cliniciancradles the occiput with the hands on both

sides. The middle fingers of both hands areplaced on either side of the spinous process of C2 (which is the first palpable spinous processat the base of the occiput). The patient is

instructed to relax fully and informed that thehead is going to be side bent gently on eitherside for just a few degrees (Figure 8.22).

Figure 8.22: Alar ligament test in sitting position

On side-bending, the spinous process will be felt to deviate immediately to the oppositeside. So for example, if the head is side bentto the right the spinous process will be felt

to deviate to the left. If this does not occurthen one should suspect a laxity of the liga-ment or a fracture of the odontoid process,or both. Any sub-cranial treatment proce-dure, mainly traction is strictly contraindi-cated if a laxity of the alar ligament issuspected. The figure shows a sitting test forease of illustration, however, the lyingposition is preferred. When muscle guardingis excessive the clinician is advised to explainto the patient that he or she is going to gently

side bend the head to the side. Note that theside-bending should not be excessive.

The alar ligament is commonly stretchedor injured during whiplash injuries andinjuries to the cervical spine. Owing to itsattachment to the odontoid process, a fractureof the odontoid can allow the ligament to



Cervical Spine 61

cause a stretch on it leading to instability. Anyexcessive motion, especially side-bending canadd to the instability and can be life-threatening. A traction maneuver can possibly

dislodge the odontoid and cause it tocompress the neural structures in the foramenmagnum (see Figure 8.22). A compromise onalar ligament integrity is seen in disease statesespecially rheumatoid arthritis. It is also seenin an individual with Down’s syndrome.Other conditions that can affect alar ligamentstability are advanced stages of pregnancyand collagen disorders like Marfans syn-drome, Systemic Lupus Erythematosis, etc.These situations are strict contraindications

for manual therapy of the sub-cranial spine.

Transverse Ligament

The patient is sitting and is asked to performa forward-bending of the neck. The cliniciansupports the spinous process of C2. The otherhand can support the forehead or the chin(Figure 8.23).

A positive test can produce sharp pain thatis shock-like with tingling numbness in theextremities. Sometimes a ‘clunk’ can be heard

in situations of instability.

Figure 8.23: Forward bending of neck

The transverse ligament prevents the atlasfrom sliding forward during forward- bending. Hence, this ligament can be injured

during forced forward-bending. A laxity of this ligament can allow the atlas to slideforward bringing the odontoid process closeto the cord (see Figure 8.7). Hence on testing

it is not just pain that is produced but cordsigns as well such as tingling and numbnessin the extremities.

Manual therapy procedures especially sub-cranial forward-bending can seriously com-promise the cord if the transverse ligamentis lax and hence is strictly contraindicated.A patient with a compromise with the alarand transverse ligaments present with severemuscle guarding and hence sometimes thesetests cannot be performed and may also be

dangerous to do so. They present with aheavy head and difficulty holding their headup. They may also present with severeheadaches. All of the above warrantimmediate medical attention.

VERTEBRAL ARTERY

The patient is lying supine and the clinicianfaces the patient from the head side (Figure8.24). The clinician explains to the patient the

he or she is about to extend and rotate the neckto one side and hold it there for 15 to 20seconds. Ideally it is best not to suggest to thepatient as to what he or she may experience.

Figure 8.24: Neck rotation




The procedure is begun and ideally thehead is NOT brought over the edge of thetable. Either the head end of the treatmenttable can be tilted down or a pillow can be

arranged in the scapular area. The reason being that in case the patient tests positive,the head rest can be immediately brought toneutral or the pillow can be removed.

The clinician supports the head with bothhands and first extends the head fully backward. The patient is asked to keep theeyes widely open and the clinician monitorsfor signs. The head is then rotated to one sideand held in that position for 15 to 20 seconds.The clinician is advised to talk to the patient

and ask questions that require one wordanswers as in ‘yes’, ‘no’, etc. In the 15 to 20second period the clinician observes with fullattention and caution, the following:1. Dizziness2. Diplopia3. Dysarthria4. Dysphagia5. Drop attacks

If any of the above are suspected theclinician should immediately bring the head

back to neutral and elevate the leg withpillows to facilitate circulation to the head.Manual therapy, especially to the sub-cranialspine, is strictly contraindicated if the patienttests positive for vertebal artery insufficiency.

SUB-CRANIAL SPINE SOMATIC DIAGNOSIS

The occiput, for purpose of reference istermed C0, as the atlas and axis being C1 andC2 respectively. The dysfunctions in the sub-cranial spine are grouped as C0, C1 (OA) and

C1, C2 (AA) dysfunctions respectively. Thedysfunctions are termed according to thedirection of the restriction.

C0,C1 (OA Dysfunctions)

The movements possible at C0 and C1 areforward and backward nodding and side-

bending. The principles of diagnosis thenwould be to detect restriction of these move-ments specific to the direction of restriction.

C0, C1 Forward-bending RestrictionThe patient is lying supine and the clinicianfaces the patient from the head side. Theocciput is cradled in both palms with thefingers directed towards the occipitalprotruberance and mastoid. The thumbs gripthe temporal areas. The examiner gentlyglides the occipital condyles backward byapplying a downward pressure on the occiput(Figure 8.25). When this is done the occipitalcondyles roll backward and the atlas slidesforward. When either of these are restricteda restriction will be felt on performing thismaneuver. Note for restriction.

Figure 8.25: Forward bending restriction

With the face looking straight, both condy-les are being tested. However, to localize anddetect restriction on one side, the head is

rotated slightly and the same maneuver isapplied. For example, if the head is rotatedright and if a downward pressure is applied,then the right OA joint is being tested.

If a restriction is present the patienttypically feels pain and discomfort when themaneuver is applied. Also, when the



Cervical Spine 63

maneuver is localized to one side as in rotatingthe head to the right or left, the discomfortis usually felt locally on one side more thanthe other.

C0, C1 Backward-bending Restriction

The patient is lying supine and the clinicianfaces the patient from the head side (Figure8.26). The hold is similar as described inforward-bending restriction (see Figure 8.25).The only difference is that an upwardpressure is directed on the occiput. The side being tested is similar to testing forward- bending. When this maneuver is done, theoccipital condyles roll forward and the atlasslides backward. A restriction will be felt if this does not occur.

Figure 8.26: Backward-bending restriction

Testing backward-bending should bedone with caution for the risk of possiblevertebral artery compromise. The commonestrestriction seen however is forward-bending.If one recollects that in a forward head pos-ture the sub-cranial spine is stuck in backward- bending and hence forward-bending is oftenfelt to be restricted on testing.

One should always remember that whenthe term forward-bending restriction is used,it denotes that the forward-bending‘movement’ is restricted and that the segmentis stuck in backward-bending.

C0, C1 Side-bending Restriction

The position of the patient and clinician is asabove, except that the hold is such that themiddle fingers are palpating just anterior tothe transverse processes of C1. Upon recol-lection it was inferred that the atlas followsthe occiput with all movements exceptrotation. Hence, on side-bending, if notrestricted the atlas should be felt to slide tothe same side as the side-bending. It alsorotates to the opposite side, hence the trans-verse process is felt slightly anterior (Figure8.27).

Figure 8.27: Side-bending restriction

With the patient and clinician in theposition described above the head is side bentgently for a few degrees. The transverseprocess that is being palpated is felt as anincreased prominence on the side of the side- bending. For example, if the head is side bentleft, the transverse process on the left is feltas an increased prominence. If this is not feltthen it denotes a side-bending restriction of

OA on the left. The same theory applies onthe right.

C1, C2 (AA Dysfunctions)

The movements occurring at the atlanto-axial joint is exclusively rotation hence, that will be the only movement to be examined.




Rotation in the AA joint is howeveraccompanied by mid-cervical spine rotationand this has to be avoided during testing. Soto localize rotation at the AA joint the mid-

cervical spine should be locked. This isachieved by either side-bending or forward- bending the mid-cervical spine and then rota-ting the occiput. Side-bending is preferred asit is a more aggressive locking of the mid-cervical spine. Forward-bending is used if there is excessive restriction or guarding thatdoes not allow adequate side-bending.

Rotation Restriction

The patient is lying supine and the clinicianfaces the patient from the head side. Theclinician holds the occiput in flexion andgently side-bends the neck to the side, asallowed by available range. The neck is thenrotated to the opposite side (Figure 8.28). Thisexclusively tests the AA joint.

Figure 8.28: Rotation restriction

Determining the side being tested is of

importance when performing this test. As theneck is in flexion, the side being tested will be the side opposite to the side of therotation. For example, if the neck which isin flexion is side bent left and rotated right,it is the left AA joint that is being tested.

Hence, assume the neck that is in flexionis side bent left and rotated right. If arestriction is felt in the right rotationalmovement, it is concluded that the left AA

joint is restricted. The same principle isapplied with the neck in forward-bending.

Tissue Texture

Tissue texture abnormality in the sub-cranialand mid-cervical spine is usually felt as apalpable thickening which is often timestender. It can be felt on the spinous process,the lamina and the transverse process. Thefacet joints on either sides can be palpable

tender areas as well. Overall, one should feelfor palpable tender areas on the transverseprocess and the facet joints for clinicalsignificance to confirm the diagnosis andlocation. However, it is of greater significancewhen the tenderness is felt exclusively on thesite of the dysfunction.

TREATMENT

The progression for treatment is based on thefindings. If the dysfunction is identified exclu-sively at the sub-cranial or mid-cervical spinethen it should be addressed as appropriate.This is however relatively rare as dysfunc-tions are seen as a combination of both sub-cranial and mid-cervical. The progressionshould then be cephalo-caudal, in that the sub-cranial dysfunction be addressed first beforethe mid-cervical dysfunction is addressed.

Sub-cranial Spine

Treatment of the sub-cranial spine willincorporate techniques to free C0, C1 (OADysfunctions):1. Forward nodding restriction2. Backward nodding restriction3. Side-bending restriction



Cervical Spine 65

Soft Tissue Inhibition

The soft tissues, especially the muscle andmyofascia are strong supportive barriers forthe skeletal alignment. Hence, interventionof techniques to free joint restriction shouldalways be preceded by soft tissue inhibition.Traditional soft tissue mobilization andmassage may most definitely be effective, butfor specificity and time constraints inhibitiontechniques may be adopted (Figure 8.29).

Figure 8.29: Soft tissue inhibition

Inhibitive Distraction of the Sub-cranial Spine (sub-occipital release) (Figure 8.29)

The patient is lying supine and the clinicianfaces the head side of the patient. The clinicianplaces the index, middle, and ring fingers of each hand on either sides of the occipital rim, just distal to it.

The fingers first direct a gentle upwardcompression, and is then followed by a longaxis traction which is held for several secondsand released.

This is a powerful technique and is strictly

contraindicated in situations of ligamentinsufficiency especially the alar and transverseligaments.

Forward Nodding

The patient is lying supine and the clinician

faces the patient from the head side. Assumeforward nodding is restricted on the right.The middle finger of the clinicians’ left handis placed on the lamina of the atlas on the

right. The forehead of the patient is graspedwith the right hand. Sub-cranial nodding isinduced with the right hand while the leftmiddle finger blocks the atlas from sliding back due to the restriction (because ideallythe atlas should slide forward duringforward nodding, but since it is restricted onthe right it may slide backward as the occipitalcondyles roll backward) (Figure 8.30). Thiswill help free the atlas to slide forward freeingthe restriction.

Figure 8.30: Forward nodding

Backward Nodding

The patient and clinician position is the sameas above. The fingers of the clinicians’ handare placed on the external occipital protuberance on both sides. The patient is askedto push backwards with the head, against thefingers of the clinicians’ hand (Figure 8.31).

This contracts the rectus capitis posteriorminor and the obliquus capitis superior. Thesemuscles attach to the occiput and atlas andon contraction they pull the atlas backwards,which is stuck forward. This aids to free therestriction.




Figure 8.31: Backward nodding

Side-bending The patient and clinician is the same as inforward and backward nodding are as above.This is a difficult technique to performcorrectly and requires specificity and practice(Figure 8.32).

Figure 8.32: Side-bending of neck

Assume side-bending to the left isrestricted—Then the atlas does not slide to

the left. The technique should then press theatlas to the left. The technique is performedin the following steps:1. The transverse process of the atlas (C1)

on the right, is located.2. The head is then rotated to the left and

the base of the right second metacarpo-phalangeal (MP) joint (index finger) of the

clinician is placed on the right transverseprocess of the C1, that was located.

3. The left hand of the clinician holds thepatients jaw and the occiput is cradled on

the left forearm of the clinician.4. The clinician now moves to the right side

of the patient’s head and rests the headon the abdomen.

5. The left hand of the clinician that is cradlingthe occiput now gently side bends thehead to the left.

6. The right MP now exerts a LATERALpressure on the right transverse processof the patient to slide it towards the left.This will restore sliding of the atlas to the

left, restoring side-bending of the OA jointto the left.

C1, C2 (AA Dysfunctions)

Rotation Restriction

Assume right rotation is restricted and therestriction is at the left AA joint. Thetechnique is the same as for side-bendingrestriction. Hence, for a restriction in rightrotation, the head is side bent fully to the left

and slightly rotated right. As in side-bendingmanipulation, the opposite hand holds thechin and cradles the head in the forearm. Theabdomen of the clinician supports the headin position. The right MP joint contacts theright transverse process of CI. The right MPnow exerts a lateral and downward pressure onthe right transverse process of C1 to rotateit towards the right. This will restore rotationof the atlas to the right, restoring rotationof the AA joint to the right (Figure 8.33).

Remember to always assess and monitorfor signs of vascular compromise or instability.

Mid-cervical Spine

Treatment of the mid-cervical spine willincorporate techniques to free C3 to C7 (Mid-cervical dysfunctions):



Cervical Spine 67

1. ERS (Extension rotation side-bend restric-tion)

2. FRS (Flexion rotation side-bend restriction)

Soft Tissue Inhibition

Soft tissue inhibition for the mid-cervical spinecan be initiated using inhibitive distractionas described for the sub-cranial spine,followed by lateral stretch.

Figure 8.34: Soft tissue mobilization (method 1)

Method 1 (Figure 8.34): The patient is lyingsupine and the clinician stands on the sideof the patient’s head. If the clinician standson the left side of the patient, the right handholds the forehead to stabilize the head. The

left hand is placed on the cervical paravertebral

musculature. A lateral and anterior stretch isapplied and held for several seconds and relea-sed. The same is repeated on the oppositeside.

Method 2 (Figure 8.35): The patient is lyingsupine and the clinician faces the head sideof the patient. To inhibit the right side, theclinicians’ left hand is placed under the occiputof the patient. The right hand is placed overthe acromion on the right shoulder.

The occiput is laterally bent to the left

while a downward counter pressure isapplied over the right acromion. The headis then rotated slightly left to inhibit the rightlevator scapula and trapezius.

Technique to free an ERS restriction(Figure 8.36):Treatment for an ERS of the mid-cervical spineis in the same lines as diagnosis, with slightmodification.

Assuming the dysfunction is an ERS leftof C5.• So, the left facet of C5 is stuck in extension

and not sliding forward into flexion.• Patient is lying supine• The clinician stands with the head of the

patient resting on the abdomen in flexion.• The MP joint of the index finger contact

on the transverse process/articular pillarof C5 on the right.

Figure 8.35: Soft tissue mobilization (method 2)Figure 8.33: Ideally, the head is rotated slightlyto the right




• The other fingers mould around the neck.• The thumbs rest on the mandible• The left hand holds and cradles the occiput.

A downward pressure is exerted on thetransverse process of C5 in a diagonal planein the direction towards the opposite chest(as the joints are oriented 45 degrees). Thepressure is applied till the restriction is felt.This is termed as the barrier or the pointwhere all of the slack is taken up. The positionof the neck will now be in side-bending and

rotation to the right.Once the barrier is felt the examiner pausesfor a few seconds, asks the patient to relaxfully, and a short progressive oscillation isapplied 3 to 4 times.

This will free the facet on the left to slideforward into flexion as it was originally stuckin extension (ERS).

The same principle is applied for an ERSdysfunction of any segment from C3 throughC7.

The key for ERS dysfunctions:• If the ERS is on the left, then the downslide

is on the right.• If the ERS is on the right, the downslide

is on the left.• The neck is always in flexion.

Figure 8.37: Technique to free an FRS restrictionFigure 8.36: Technique to free an ERS restriction

Technique to Free an FRS Restriction (Figure 8.37)

Treatment for an FRS of the mid-cervical spineis in the same lines as for an ERS, with slightmodification.

Assuming the dysfunction is an FRS leftof C5.• So, the right facet of C5 is stuck in flexion

and not sliding back into extension.• Patient is lying supine• The clinician stands with the head of the

patient resting on the abdomen in slightextension.

• The MP joint of the index finger contacton the transverse process/articular pillarof C5 on the left.

• The other fingers mould around the neck.• The thumbs rest on the mandible• The right hand holds and cradles the

occiput and exerts an upward pressure tomaintain the head in extension.An upward pressure is exerted on the

transverse process of C5 on the left in adiagonal plane in the direction towards theopposite eye (as the joints are oriented 45degrees). The pressure is applied till therestriction is felt. This is termed as the barrieror the point where all of the slack is taken



Cervical Spine 69

up. The position of the neck will now be inside-bending and rotation to the right.

Once the barrier is felt the examiner pausesfor a few seconds, asks the patient to relax

fully, and a short progressive oscillation isapplied 3 to 4 times.

This will free the facet on the right to slide backward into extension as it was originallystuck in flexion (FRS). Rule out vertebral artery patency, prior to technique.

The same principle is applied for an FRSdysfunction of any segment from C3 throughC7.

The key for FRS dysfunctions:• If the FRS is on the right, then the upslide

is on the right.• If the FRS is on the left, the upslide is on

the left.• The neck is always in extension.

REFERENCES

For detail see References of Chapter 9.




9 Thoracic Spine

Dysfunctions of the thoracic spine occur inisolation but often times they are associatedwith dysfunctions of the cervical spine. Viceversa, dysfunctions of the thoracic spine

predispose to a cervical spine dysfunction.This is more with regards to the upperthoracic spine. The same principle applies tothe lower thoracic spine and dysfunctions of the lumbar spine. The upper thoracic spineis more like the cervical spine in structure andmechanical characteristics and so is the lowerthoracic spine in relation to the lumbarvertebrae.

The thoracic vertebrae are intimatelyattached to the ribs and hence predispose to

chest pain in dysfunctional states.10 It may beof interest to know that in the United States,almost 40 percent of patients going to cardiacemergencies, have chest pain of a skeletalorigin. Accurate identification and treatmentof thoracic dysfunction can alleviate painthat is often thought to arise from a visceralorigin.10

OSSEOUS ANATOMY

A typical thoracic vertebra (Figure 9.1)consists of a body, two transverse processesand a spinous process. Superiorly andinferiorly, it has two articulating facets thatarticulate with the segment above and belowit to form the facet joints. Posteriorly, betweenthe body and the articulating facets are twodemi-facets on either side, above and below.

These facets articulate with the head rib.Laterally, on the transverse processes, are twofacets on either side that articulate with thetubercle of the rib. Hence, a typical thoracic

vertebra has 12 articulations namely, 4 facets,4 for the head of the rib, 2 for the tubercleof the rib and 2 intervertebral (disc).

The uniqueness of the osseous anatomyin the thoracic spine is the relationship of thelevels of the transverse processes to thespinous process. They vary at different levelsof the thoracic vertebral column.

Figure 9.1: Typical thoracic vertebra. (1) Superior

articulating facet for rib, (2) Facet joint (superior), (3)

Costotransverse articulation for rib, (4) Transverseprocess, (5) Facet joint (inferior), (6) Inferiorarticulating facet for rib, (7), Spinous process

This is important to know for the fact thatto make a somatic diagnosis, the spinousprocess is located first to determine the leveland the corresponding transverse process is



Thoracic Spine 71

located. However, the transverse processesin the thoracic spine do not correlate to thesame level as the spinous processes. Thereason being that the transverse processes

are placed at a higher level compared to thespinous processes. The corresponding levelsare described by different authors, howeverdo not correlate well. Hence, from apalpation/diagnosis perspective, to make itpractically easier, when the palpable area of the spinous process is palpated, thecorresponding transverse process will be atthe level of the spinous process one levelabove.

The reason for this is that the palpable area

of the spinous process (especially for thesegments that extend further down) is notthe tip but the body of the spinous process.It is the tip that extends one to one and ahalf segments below (more so T5, 6, 7) andis not always the prominent palpable area.

So, from a practical perspective, if theclinician is palpating the spinous process of T8, then to locate its corresponding transverseprocess the clinician palpates one level up,which is hence corresponding to the spinous

process of T7.

LIGAMENTOUS ANATOMY

There are no specific ligaments that arise fromthe thoracic spine but rather the ligamentsthat run through the thoracic area. Theprincipal ligaments are the ALL, PLL, thesupraspinous ligament, the ligamentumflavum and the intertransverse ligaments.

MUSCULAR ANATOMY

The muscles of the thoracic spine are alsointimately related to the muscles of thecervical area. The bigger function of themuscles of the thoracic spine is to support thesegments from being exaggerated further intheir kyphotic predisposition. As this may

lead to a forward head and protractedscapulae predisposing to cervical andshoulder dysfunctions. Lower down, anincreased thoracic kyphosis may lead to an

increase in the lumbar lordosis, predisposingto lumbopelvic dysfunctions.

The musculature, for convenience may becategorized as musculature that attach thethoracic spine to the cervical area and thosethat attach the scapulae to the thoracic area.

Muscles attaching thoracic spine to thecervical area:1. Trapezius (upper)2. Splenius capitis3. Splenius cervicis

4. SemispinalisMuscles attaching thoracic spine to the

scapula:1. Rhomboideus major2. Rhomboideus minor3. Trapezius (middle and lower)

In addition the multifidi and the erectorspinae (spinalis, longismus and iliocostalis)also function to support the thoracic spine.

Thus, essentially the thoracic musclesattaching to the cervical spine, especially the

occiput, function to retract and support thehead in a neutral position. The thoracicmuscles that attach to the scapula retract thescapula backwards to maintain an erectposture with normal thoracic kyphosis. Theyalso help to maintain the patency of the space between the acromion and head of humerus.

MECHANICS

The mechanics of the thoracic spine is complex

owing to the thoracic kyphosis. Hence, thefollowing is a simplified version of themechanics to avoid confusion. The facetorientation in the upper and mid-thoracicspine are almost in the same plane as the mid-cervical spine and hence side-bending androtation occur in the same direction.




However, the facet orientation in the lowerthoracic spine are almost in the sagittal planeand hence behave more like the lumbar spine.In which case, side bending and rotation will

occur in the opposite direction.


When the function of the thoracic musculatureis disturbed secondary to overuse, fatigue,weakness or injury, it predisposes tomechanical dysfunction. The commonestcauses for dysfunctions in the thoracic areaare due to faulty posture, overuse/fatigueand weakness.9 Faulty head posture orconstant flexion, stresses the insertion sitesof the muscles that work to retract the head,which is in the thoracic spine. If prolonged,they can contract in length due to fatigue andaffect the mechanics of the thoracic facet joints, predisposing to a restriction anddysfunction. Pain in the upper back and theshoulder blades is a common symptom.Traumatic contraction of these muscles areseen due to jerky movements of the head(whiplash) and also the arm as in trying to

pull, push or lift a weight. This can predisposeto thoracic dysfunctions giving rise tosymptoms and pain.

Muscular headaches also have a originfrom the thoracic spine, especially the upperthoracic spine. The semispinalis capitis musclearises from the transverse processes of C1 andT1-6 or 7 and inserts into nuchal line of theocciput. The greater occipital nerve piercesthis muscle near its insertion into the occiput.Dysfunctional states of this muscle for the

reasons described above can irritate thegreater occipital nerve, giving rise toheadaches.

Also, forward-bending of the upperthoracic spine as seen in faulty forward headpostures can increase backward-bending atthe sub-cranial spine contracting the suboccipital muscles and giving rise to headaches.

The first rib has an attachment to T1 andis commonly a source for dysfunction andpain. The first rib usually tends to be elevateddue to faulty postures or due to excessive

activity of the accessory muscles of respiration. An elevated position of the firstrib can compromise the thoracic outlet andcause symptoms of a thoracic outletsyndrome.

The special tests for a thoracic outletsyndrome have a high incidence of falsepositives, like the Adson’s maneuver, Allenmaneuver etc. Manual therapy tests incor-porating examination of the first rib, tightnessof the scalenes and the pectoralis minor and

weakness of the upper back retractors willhelp confirm the diagnosis as dysfunctionsof these structures contribute to compromiseof the thoracic outlet.

Tissue texture abnormality is an obviousfinding in the thoracic spines. Dysfunctionalsegments will exhibit tenderness over theircorresponding transverse processes and alsoover the corresponding musculature. Green-man describes this as a layer hypertrophywhere the deeper layers of the muscles of the

back tend to be hypertrophied and tendersecondary to dysfunctional states of thethoracic facet joints. This is commonly theerector spinae.

EXAMINATION

Examination of the upper thoracic spine isdone preferably in sitting. Examination of the upper thoracic spine involves detectionof an elevated first rib and ERS, FRS dys-

functions.10

Thoracic Spine Somatic Diagnosis

Elevated First Rib (Figure 9.2)

The patient is sitting and the clinician stands behind the patient. The first rib is palpated by placing the hands on the upper trapezius



Thoracic Spine 73

and retracting the upper fibres of the trapezius backwards. The bony structure palpable between the retracted upper fibres of thetrapezius and the clavicle is the angle of the

first rib.The clinician palpates the first rib on either

side and asks the patient to inhale deeply.The first rib on both sides are felt to rise up.Now, as the patient exhales in continuationwith the breathing process, ideally both firstribs should descend downwards. In the eventof the first rib not descending downwardsand is palpated as being elevated, then thatrib is stuck in an elevated position. This isusually tender on palpation and is felt as a

palpable bony prominence.

Figure 9.2: Elevated first rib

ERS (Upper Thoracic Spine) T1-T5

(Figure 9.3)

The patient is in the sitting position and theclinician stands behind the patient. Theclinician first palpates, for example, thespinous process of T1 which is the prominent

bony projection in the center of the spine atthe base of the neck just below C7 (see Chapter6). The corresponding transverse process ispalpated between a half to one level abovethe spinous process. The patient is then askedto drop the head and shoulders forwardwithout rotating the trunk. The transverse

processes are palpated on either side to seeif there is a posteriority. Assume as the headand shoulders are flexed forward and thetransverse process of T1 appears posterior on

the right. Then one can assume that the leftfacet is sliding forward into flexion and theright is not as it is stuck in extension andappears posterior.

Figure 9.3: ERS: Upper thoracic spine

To confirm, the transverse process ispalpated in a neutral straight position and backward bent position. If the transverse

processes appear even then it can be assumedthat the facets are able to slide back intoextension (see Chapter 7). Hence, the onlypositive finding was a posteriority on theright transverse process in flexion as it is stuckin extension. Hence, the diagnosis is an ERSright of T1.

A similar principle is applied for segmentsT1 to T5, in sitting.

FRS (Upper Thoracic Spine) T1 to T5

(Figure 9.4)The patient is in the sitting position and theclinician faces the patient from the back. Thetransverse processes of T1 are palpated asabove and the patient is asked to arch backward and look up to the ceiling. Thetransverse processes are palpated on either




side to see if there is a posteriority. Assumethat the transverse process on the rightappears posterior when the upper back andhead is arched backwards. Then one can

assume that the right facet is sliding backwards and appears posterior but the leftfacet is not as it is stuck in flexion.

Figure 9.4: FRS: Upper thoracic spine

To confirm, the transverse processes arepalpated in a neutral straight position and ina forward bent position. If they appearneutral, then one can assume that the facets

are able to slide forward into flexion. Hence,the only positive finding was a posteriorityof the right transverse process in extension(arching back) as the left facet is stuck inflexion. Hence, although it is the left facet thatis stuck in flexion, the diagnosis is always bythe side of the posteriority and will hence bean FRS right of T1.

A similar principle is applied for segmentsT1-T5 in sitting.

ERS (Mid and Lower Thoracic Spine) T6-T12 (Figure 9.5)

The position and testing is as described forthe upper thoracic spine except that for themid and lower thoracic spine, the patient isasked to bend forward to a point where botharms drop between the knees.

Figure 9.5: ESR: Mid and lower thoracic spine

FRS (Mid and Lower Thoracic Spine)

T6-T12 (Figure 9.6)The patient is positioned prone and is askedto prop up on the elbows with the chin restingon the palms. Now the patient is in anextended position. The clinician is on the sidefacing the patients head diagonally. Thetransverse processes of the mid to lowerthoracic spine are palpated to observe for aposteriority.

Figure 9.6: FRS: Mid and lower thoracic spine

Assume the right transverse process of T7appears posterior. Then it can be assumed thatthe right facet can slide backward intoextension but the left does not, as it is stuckin flexion.



Thoracic Spine 75

To confirm, the patient is asked to assumean erect sitting posture and then asked to bend forward. If the transverse processappears neutral then it can be assumed that

the facets are able to slide forward into flexionand the posteriority is observed only onextension, because the left facet is stuck inflexion. Since the side of the diagnosis is bythe side of the posteriority the diagnosis will be an FRS right of T7.

TREATMENT

Soft Tissue Inhibition (Figure 9.7)

The patient is in prone lying and the clinician

faces the patient from the side. The thenareminence and the palmar surface of the thumbis used for this technique. The thumb isplaced on the long axis of the muscle justadjacent and lateral to the spinous processon the opposite side of the clinician. Now thethumb is reinforced by the palmar surface of the other hand and a gentle laterally directedpressure is applied over the erector spinaewhich is gradually increased based on patienttolerance. The pressure is held for about 10

to 20 seconds and repeated along the lengthof the thoracic spine. Care should be takento direct the pressure away from the spinousprocess and not toward.

Figure 9.7: Soft tissue inhibition

Elevated First Rib (Figure 9.8)

The patient is lying supine and the clinicianfaces the head side of the patient. Assumethe right rib is in the elevated position. Theclinician holds the occiput of the patient withthe left hand and the MP joint of the rightindex finger is placed on the right first rib.The head is now slightly side bent and rotatedto the right to relax the trapezius. The rightMP now has a better feel of the angle of thefirst rib. The patient is asked to inhale andas the patient exhales the clinician depressesthe angle of the first rib on the right withthe right MP joint and maintains it there asthe patient inhales again. This prevents thefirst rib from rising up as the patient inhalesresulting in a depression of the first rib andcorrection of the dysfunction.

Figure 9.8: Elevated first rib

ERS (Upper Thoracic Spine) T1-T5

(Figures 9.9 and 9.10)

The patient is in prone lying and the clinicianfaces the patient from the right side. Assume

the dysfunction is an ERS right of T1. Theclinician flexes the neck until T1 is felt tomove, then side bends the head to the leftand rotates the head to the left until T1 (itcan also be rotated to the opposite side whichis the right, as in Figures 9.9 and 9.10). Thislocks the spinal segments until T1. In this




position the right hand of the clinician supportthe occiput of the patient and exerts anupward stretch while the thumb of the lefthand rests on the spinous process of T1 and

exerts a lateral force from left to right. Thisfrees the right facet of T1 into flexion, whichwas originally stuck in extension

Figure 9.9

Figure 9.10Figures 9.9 and 9.10: Treating ERS: Upper

thoracic spine

FRS (Upper Thoracic Spine) T1-T5

(Figure 9.11)The patient is seated and the clinician stands behind the patient. Assume the dysfunctionis an FRS right of T1. The head is held inflexion, side bent left and then rotated to theleft to lock the spinal segments until T1. Oncethis is done, the right thumb of the clinician

blocks the spinous process of T2 on the rightwhile the left hand supports the occiput andexerts a posterior translatory force so as todraw the chin inwards. This frees the left facet

of T1 into extension, which was originallystuck in flexion.

Figure 9.11: Treating FRS: Upper thoracic spine

• Remember, the key in the upper thoracicspine is to side bend and rotate the headto the opposite side of the posteriority.

• The head is flexed for an ERS.• The head is translated posterior into

extension for an FRS.

ERS (Mid and Lower Thoracic Spine)

T6-T12 (Figure 9.12)

The patient is lying prone and the clinicianfaces the patient from the left side. Assumethe dysfunction is an ERS right of T8. Theupper trunk is flexed by bending the tableor with pillows, until T8. The upper trunk isthen side bent to the left and rotated to theleft until T8 by arranging pillows under the

left shoulder.The Figure 9.12 depicts the level and

direction of manipulation. Figure 9.13 depictsthe technique with the following descrip-tion.

The pisiform bone of the right hypothenareminence of the clinician contacts the right



Thoracic Spine 77

transverse process of T8. The left palm of theclinician is placed on the left side of the trunkto block the movement. This is now a ‘crosshand position’. As the left hand provides acounter pressure, the right hypothenar/pisiform contact exerts an inferiorly directedforce on the right transverse process of T8.This frees the right facet of T8 into flexion

which was originally stuck in extension.

FRS (Mid and Lower Thoracic Spine)

T6-T12 (Figure 9.14)

The exact same technique is adopted as in ERS(mid and lower thoracic spine) T6-T12 above,for an FRS right of T8. The only difference

being that the upper trunk is extended insteadof being flexed.

Figure 9.14: Treating FRS: Mid and lower

thoracic spine

• Remember, the key in the mid and lowerthoracic spine is to side bend and rotatethe upper trunk to the opposite side of the posteriority.

• The upper trunk is flexed for an ERS.• The upper trunk is extended for an FRS.

PROPHYLAXIS

Cervico Thoracic Complex

Exercise Prescription

The prophylaxis of mechanical dysfunctionsof the cervico thoracic complex will mostdefinitely involve stabilization of themusculature. As discussed in the principlesof management, the musculature function asropes to hold the alignment and minimizeshock of functional activities. Appropriateexercise prescription will help to address this.The one important thing that the clinician

should remember is to never make a homeexercise program too elaborate. This willdecrease motivation, considering the routineday to day schedule of work and familyresponsibilities of the average individual.Exercises addressing the target structures andmost appropriate to the dysfunction is recom-

Figure 9.12

Figure 9.13

Figures 9.12 and 9.13: Treating ERS: Mid andlower thoracic spine




mended. Since exercises are dysfunctionspecific inappropriate exercise prescriptioncan deter outcomes hence the appropriatenessis of importance.

The musculature of the upper quartersometimes span the entire length of the threeregions. They may originate at the sub-cranialspine and run across the mid-cervical spineto insert into the mid-thoracic spine. Hencestabilization will involve the entire complex.Dysfunctions may occur in a similar manner.Functionally it is the effect of the combinedmechanics of the three regions. The threeregions will need to share the work of supporting and effecting function in the upper

quarter. Hence, a restriction in one region isusually compensated by increased work orthe activity of the other. This is so often seenin the cervical spine. We often see a diagnosisof cervical spondylosis or cervical radiculo-pathy of the mid-cervical spine commonly C5,C6, up to C8, T1. But how often we have seena diagnosis involving C1, C2 or T4, T5. Thisis often missed and in many instances, inpatients with a mid-cervical diagnosis anassociated upper cervical or an upper/mid

thoracic dysfunction can be identified. Hence,as a matter of fact, altered mechanics of theupper cervical and thoracic spine can stressthe mid-cervical area as it compensates forthe altered mechanics and function. This may be picked up as the conventional cervicaldiagnosis we see in our day to day practice.An astute manual therapy diagnosis of anupper cervical or an upper/mid thoracicdysfunction may help to address the causefor the mid-cervical diagnosis rather thantreating the symptom only (e.g. traction)which is the nerve root pain arising from themid-cervical dysfunction.

Hence, as much as manual treatmentshould ideally address dysfunctions of theentire complex, exercise prescription should

also address mobility and strength of thesupporting musculature of the entire cervico-thoracic complex. The common soft tissuerestriction patterns are:

1. Backward-bending of the sub-cranial spinewith shortening of the sub-occipitalmuscles and spleneii/semispinalis.

2. Side-bending and rotation of the mid-cervical spine with shortening of the upperfibres of trapezius, scalenes and levatorscapulae.

3. Protraction of the scapulae withshortening of the pectoralis major and thepectoralis minor and increased thoracickyphosis.The above muscles are postural muscles

and as discussed earlier postural musclestighten and hence, lead to shortening leadingto the above alignment dysfunctions. Hence,it is obvious that postural muscles will needto be lengthened and most appropriatelydone with active stretching exercises to pre-vent recurrence of an alignment dysfunction.

The muscles that attach the thoracic spineto the scapulae are mostly phasic muscles andthey weaken to cause the above alignmentdysfunction. The common weakness patternsare:1. Subcranial backward-bending and mid-

cervical forward-bending secondary toweakness of the anterior cervicalmusculature.

2. Scapular protraction with roundedshoulders and increased thoracic kyphosissecondary to weakness of the mid andlower trapezius and rhomboids

3. Intervertebral instability and weaknesssecondary to weakness of the multifidi.

This weakness pattern is most appro-priately addressed by active strengtheningexercises to prevent recurrence of analignment dysfunction.



Thoracic Spine 79

Figure 9.15: Myofascial tender points: Cervicotho-racic (posterior): (1) Trapezius, (2) Splenius capitis,(3) Splenius cervicis, (4) Semispinalis, (5) Sub-

occipitals, (6) Levator scapula, (7) Rhomboids

Figure 9.16: Myofascial tender points: Cervicotho-racic (anterior): (1) Sternomastoid, (2) Scalenes,

(3) Subclavius, (4) Pectoralis minor

REFERENCES

1. Porterfield CA, CarlDeRosa. Mechanical NeckPain. Philadelphia: WB Saunders, 1995.

2. Kapral MK, Bondy SJ. Cervical manipulation atthe risk of stroke. CMAJ. 2001;165(7): 907-8.

3. Paris SV. S3 Course Notes, St. Augustine, FL:Institute Press, 1988.4. Lewitt K. Pain arising from the posterior arch

of atlas. Euro Neurol. 1977;16:263-69.5. Van Der Muelen JCH. Present state of know-

ledge on the process of healing in collagenstructures. Int J Sports Med. 1982;3: 4-8.

6. Bosomoff HL, Fishbain D, Rosomoff RS.Chronic cervical pain; Radiculopathy or

brachialgia. Spine. 1992;17:362-66.7. Sebastian D. Extracranial causes for head pain:

Clinical implications for the physical therapist. JIAP. 2002;1:9-16.

8. Travell JG, Simmons DJ, Simmons LS.Myofascial pain and dysfunction: The triggerpoint manual. Baltimore: Williams and Wilkins,1999.

9. Flynn TW. Thoracic spine and rib cagedisorders. Orthop Phys Ther Clin North Am.

1999;8:1-20.10. Flynn TW. Thoracic spine and rib cage –Musculoskeletal evaluation and treatment.Boston: Butterworth and Heineman, 1996.

11. Kunkel RS. Diagnosis and treatment of musclecontraction headaches. Med Clin North Am1991; 75(3):593-603.

MYOFASCIAL TENDER POINTS: CERVICOTHORACIC POSTERIOR/ANTERIOR





10 Lumbar Spine

The lumbar spine continues to be a clinicaldilemma from a diagnosis perspective. Thestructures involved as a source for pain areoften difficult to identify, as most symptoma-

tology are invariably identical. They predo-minantly tend to be pain in the back with painradiating down to the leg. Clinician’s oftennarrow down their conclusions to the discand a few to a foraminal compromise.3 Butthe root of the problem is not always thestructures mentioned above. As a matter of fact a discogenic pathology or a foraminalcompromise may be an end result of a sourceelsewhere.2 The lumbar spine is a regionsubjected to significant functional demands.

They are also placed between two transitionalzones namely the thoraco-lumbar junctionand lumbo-sacral junction. In addition theyare an area for an incidence of bony anomalies.This collectively increases its vulnerability todysfunction.

Back pain is an universal entity.Treatments may either address symptoms orthe cause, may be palliative or functional, may be relief-oriented or management-oriented.In any case the clinician should understand

first that it is a complex that is being dealtwith. The lumbar, pelvic and hip areaessentially work as a combination to functionand may do the same in situations of adysfunction. Not to forget that the supportingpillars of the lumbo-pelvic-hip complex arethe lower extremities and dysfunctional states

of the lower extremities, especially the footand ankle may predispose to the entity ‘backpain.’6

The strategies described in this piece of

literature, or for that matter any other chapterin this literature review is with regards toa situation that is being taken for granted thatthe source of dysfunction is mechanical andnot of a pain originating from a malignant,vascular or visceral entity. However, someof the mechanical causes are intricate and may be missed and be continuously treated withmultiple approaches including surgery. Thereasoning for back pain may be debatedendlessly and often times an enlightenment

to reality, which includes our limitations.Indeed we are humbled every single day inour respective practice environments. Thepoint that is to be made is that no back painis identical in a collective population, neitheris the cause for back pain with pain radiatingdown the leg from a single cause even if itis purely mechanical. The management be itpalliative, functional etc, is purely decidedupon the individual characteristics9 of thesolution seeking subject on your treatment

table. Hence, very subjective but one reasonfor sure that they are resting their hopes onyour ability to treat and manage.

OSSEOUS ANATOMY

The lumbar spine consists of five vertebranumbered L1 to L5. The lumbar vertebral



Lumbar Spine 81

bodies are different from the rest of thesegments in that they have a larger and thicker body. Like any other typical vertebral bodythey have two transverse processes on either

side and one spinous process in the mid line.The facet joints of the lumbar segments arealmost in the sagittal plane and the movementpatterns are accordingly determined. Thespinous process of L5 is flatter compared tothe rest of the lumbar segments and issometimes missing as a congenital anomaly.The curvature of the lumbar spine is lordoticand has a wider range of motion as it hasno ribs attached to it.

Typical Lumber Vertebra (Figure 10.1)

The lumbar vertebrae support the upper partof the body and transmit their weight to thepelvis and lower extremities. It is oftendebated that the vertebral body is the shockabsorbing agent and not the disc (Paris, 1965).It is of worth to discuss the structure and roleof the disc and the facet joints in this section,and essentially this discussion speaks for theentire spine.

Figure 10.1: Typical lumbar vertebra. (1) Facet joint(superior), (2) Transverse process, (3) Spinousprocess, (4) Vertebral body, (5) Facet joint (inferior)

Intervertebral Disc

The intervertebral disc as it is called is found between all the bodies of the vertebrae exceptthe sacral and altlanto-axial segments. Theymake up for approximately 25 percent of thewhole length of the spine and almost 50

percent at birth. The shape of the disccontours to the shape of the vertebral bodyand curvature. Hence, in a lordotic situationas in the cervical and lumbar spine they are

thicker anteriorly than posteriorly. The dischas principally three functions according toDr. Paris.11

1. They bind together the vertebral bodies.2. They permit movement within the

vertebral segments.3. They equalize and distribute loads and do

not absorb them.The disc has two parts—namely the

annulus fibrosis and the nucleus pulposis.Between the vertebral body and the disc is

a thin layer of hyaline cartilage known as thecartilaginous end plate. This is the structurefrom which the annular rings arise. The outerannulus consists of about 6 to 10 concentricallyarranged tough fibrous rings. These functionto contain the nucleus, stabilize the vertebral bodies, provide movement and offer minimalshock absorption.

The inner aspect of the disc which isencased by the annulus fibrosis is a gel likestructure called the nucleus pulposis. The

nucleus pulposis is the central part of the disc.It has principal functions as follows:1. The morphology of the nucleus pulposis

is such that it has a property of imbibitionand it is able to absorb nutrients by virtueof its osmotic properties. This occursthrough the cartilaginous end plates andthe nutrient fluids are derived from thevertebral bodies. The imbibition occurs atrest and results in an expansion of thenucleus. Once weight-bearing commences

the fluids are forced out. This is the reasonwhy one tends to be relatively taller inthe morning on waking up and graduallylose some height by the end of the day.The clinical implication is that the annulusis most stretched in the mornings andoffers a greater risk for injury.




2. The nucleus functions to transmit force,equalize stress and offer movement. It notonly provides movement but also providesa rocking action to it.

Facet Joints

These are formed by the superior and inferiorarticulating processes of the vertebra aboveand below. The facet orientation is such thatit is between the frontal and horizontal planesin the cervical region, close to the frontalplane in the thoracic region and in the sagittalplane in the lumbar region.

The facet joint4,5 consists of an articularcartilage. It is somewhat compressible in

younger individuals. It also has a tendencyto swell with brief periods of exercise andsubsides with rest. The facet joints, like anyother synovial joint, possess an articularcapsule which is partly elastic. These blendinto the ligamentum flavum which onmovement prevents them from being nipped between the bony facets. The elastic elementsof the capsule also help to maintain the facetsin close contact to each other.

The principal functions of the facet joints

are to permit, guide and limit motion withinthe segments. All movements in the segmentsinvolve the intervertebral disc and this iscontrolled by the movements of the facet joints. The intervertebral disc is described asan unique structure that permits movementand transfers loads received by it. The dischowever, has no potential for independentmovement and depends on the facet joint formobility. Hence, minor alterations of themechanics of the facet joint, as we see in ERS

and FRS dysfunctions can have a profoundeffect on the mechanics of the disc, predis-posing to injury.10 Further more, alteredmovement of the disc secondary to alteredfacet mechanics can lead to a decreased abilityof the disc to derive nutrition by imbibitionand predispose to disc degeneration.

LIGAMENTOUS ANATOMY11

The ligaments of the lumbar spine as in theother areas of the spine, function to limit andmodify movement, in addition to theirproprioceptive potential. All of the majorligaments in the lumbar area are multi-segmental in that they span the entire lengthof the spinal column. In addition there aresegmental ligaments which are specific to eachsegment in the spinal column.11

Multisegmental Ligaments

Anterior Longitudinal Ligament (ALL)

The ALL, as described previously in the

cervical spine section, has an attachment tothe anterior and lateral surface including thediscs of all the segments and finallyterminates into the periosteum of the sacrum.The ALL functions to resist distraction of thevertebrae, and backward-bending. It alsosupports the weight of the lumbar spineespecially at the lumbo-sacral junction. Themost important function that it clinicallyrelevant is that it prevents the lumbarsegments from slipping into the pelvic cavity

and is probably the principal restrainingstructure in spondylolisthesis.

Posterior Longitudinal Ligament (PLL)

This ligament is attached to all of the vertebralsegments including the discs, on theirposterior surface except the atlas. They spanover the lumbar area and extend into thesacrum and the coccyx. This ligament has acentral portion and lateral expansions. Thelateral expansions are thinner than the central

portion and hence the reason as to why thedisc moves posterolaterally following aprotrusion. Apparently the ligament isnarrow at the lowest two segments of thelumbar spine and offers little restraint to theprolapsing disc. The intervertebral spacenarrows during degeneration of this ligament



Lumbar Spine 83

and may be of significance in spinal corddisease.

Supraspinous Ligament

The supraspinous ligament is described to blend into the ligamentum nuchae. Somedescribe the supraspinous ligament as beingreplaced by the ligamentum nuchae in thecervical spine. It is often debated as to wherethe supraspinous ligament ends in the spinalcolumn and a majority of the cadavers studiedshowed that these ligaments ended at L4.

Functionally, this ligament limits forward- bending, and to a lesser degree rotation.From a clinical stand point the absence of

these ligaments in the lower two levels of thelumbar spine is indeed unfortunate as theselevels also have the weakest posteriorlongitudinal ligament and hence a higherincidence of disc protrusions. The nuchalligament prevents the flexion moment in thecervical region.

Segmental Ligaments

Interspinous Ligament

The interspinous ligaments run backwardsand upwards from the superior aspect of thespinous process below to the inferior aspectof the spinous process above. It is seen thatfollowing the age of 20 there appears cavitiesin these ligaments owing to degeneration,especially at L4, L5 and L5, S1 levels. Theytechnically run upwards and backwardsalthough some illustrations depict a forwardorientation. Since they run backwards, theyallow for a greater range while they resist

forward-bending.Ligamentum Flavum

A description of this ligament is provided inthe section on the cervical spine. The onlysignificance is that in the lumbar region, thisligament reaches a thickness of about 8 mm.Due to this, more than in any other level, this

ligament exerts a constant pull on the capsuleof the facet joint. Hence, it constantly worksto prevent the facet capsule from beingpinched between the articular surfaces of the

facet joints. This function is impaired duringdysfunctional states of this ligament leadingto facet capsule impingement. In chronicdegeneration, there is a tendency forinfolding of this ligament into the spinal canalduring backward-bending predisposing tomyelopathy.

Intertransverse Ligament

This ligament, according to Dr. Paris is barely

mentioned in many anatomy texts. It isdescribed as being interposed betweenadjacent transverse processes and well-developed in the lumbar area only. A clinicalsignificance of importance has not beendescribed except that they help to limit side- bending and rotation.

Iliolumbar Ligament

The iliolumbar ligament extends from thetransverse process of L5 to the superior aspect

of the adjacent sacroiliac joint and ilium. Inthe female, it is further reinforced by anothercord from the tip of L4. Paris described thisdifference and speculates it as an additionalreinforcement for the female pelvis ongrounds of stability.

The iliolumbar ligament is initially a musclein the early years of life and later developsinto a ligament in the twenties and maturesfully in the forties. The clinical significanceof this ligament is that it forms the roof of the iliolumbar canal as it runs from thetransverse process of L5 to the superior aspectof the sacroiliac joint and adjacent ilium.Inflammatory conditions of this ligament isdescribed to cause a compression of the L5nerve root causing radicular pain in thecorresponding leg.




MUSCULAR ANATOMY

Refer to heading muscular anatomy on page89 in Chapter 11, titled ‘Pelvic Complex.’

MECHANICS

The facet joint orihentation in the lumbar spineis in the sagittal plane hence, side-bendingand rotation always occurs in the oppositedirections. Hence, if one rotates to the leftthe lumbar spine also rotates to the left butside bends to the right. This minimizes thestress and shearing effect on the intervertebraldisc and the facet/ligamentous structures.However, in situations of a dysfunction, side-

bending and rotation can occur to the sameside and this significantly increases the stresson the corresponding soft tissue structures.The vulnerability increases further if this occursin flexion. Consider an individual bendingforward to pick up an object and rotating toone side in a flexed position to place it to theside. If this is also accompanied by side-bendingof the lumbar segments to the same side, thenthe stress on the disc increases significantly.This is also the most common mechanism for

back strains. In the presence of ERS and FRSdysfunctions in the lumbar spine, this typeof faulty mechanics tends to occur at anarthrokinematic level and needs to becorrected to minimize stress on the supportingstructures. The mechanics is described in detailin in Chapter 7.


The mechanism of dysfunction in the lumbarspine is enumerated in the Chapter 7. The

example of an alteration in the alignment of L4, L5 has been described earlier and henceis just reiterated. Abnormal alignment/mechanics, be it an ERS or an FRS can produceclinical scenarios we see in our day to daypractice. If movement continues to occur inthis abnormal position it can significantly

shear the disc (which is part of the motionsegment) and may result in a disc pathology.The size or the patency of the foramen isaltered and as the nerve exits through the

foramen it can be pinched, resulting in aradiculopathy. The facet, due to abnormalweight-bearing stresses of faulty alignmentcan be susceptible to cartilage and facetcapsule shearing. The effusion that occurs dueto this can be poured into the foramen,increasing nerve root symptoms. Hence, byfreeing the facet restriction and correcting thealignment, the patency of the foramen isrestored, the shearing of the disc is reducedand the facet joints are rendered less

susceptible to loading stresses. This cansignificantly minimize symptoms.

The large muscle groups that effectmovement in this motion segment can bestressed due to faulty mechanics. Hence,correcting vertebral alignment can reducework loads of these large spinal and pelvicmuscles, which can later be effectivelystabilized to maintain alignment.

Mechanical traction may temporarily openthe foramen. Facet injections may temporarily

relieve facet and nerve root1, 2 pain so do otheraspects of management including medication.They most definitely have their place as acutepain has to be addressed by these means, butin combination, if the mechanics andalignment are addressed, it may address the‘cause’ of the dysfunction.

EXAMINATION

Examination of the lumbar spine is done insitting and the ‘sphinx’ position. The sphinx

position is where the patient lies prone andprops up on the elbows with the chin restingon the hand. Hence, sitting is the positionfeasible for forward-bending and assessingfor ERS dysfunctions and the sphinx would be the extension position to assess FRSdysfunctions.



Lumbar Spine 85

Lumbar Spine Somatic Diagnosis

ERS (L1-L5) (Figure 10.2)

The patient is sitting on a stool and the

clinician faces the patient from behind. Theclinician then palpates the PSIS on both sidesand then moves about 30 degrees upwardsand medial towards the midline. The first bony landmark is the spinous process of L5. The clinician then moves about an inchlateral and slightly upwards to palpate thecorresponding transverse process. The patientis then asked to bend forwards by taking both arms towards the floor and between thelegs.

Figure 10.2: Lumbar spine somatic diagnosis: ERS

Assume that the clinician is palpating thetransverse processes of L4. When the patientis asked to bend forward and if the transverseprocess on the right appears more posteriorin this position then it can be assumed thatthe facet on the right is not sliding forwardand is stuck in extension. To confirm, the same

segment is checked in neutral (sitting, orprone lying with a pillow under the abdomen)and backward-bending (sphinx) positions tosee if the transverse process returns toneutral. If they appear neutral then thediagnosis will be an ERS right of L4.

FRS (L1-L5) (Figure 10.3)

The patient is lying prone in the prop upposition (sphinx). The clinician faces thepatient diagonally from the side in thedirection of the patient’s head. Assume theclinician is palpating the transverse processesof L3. In the prone prop up position thelumbar spine is technically in backward- bending. In this position if the transverseprocess of L3 appears more posterior on theright then it can be assumed that the faceton the right is sliding backward and the faceton the left is not as it is stuck in flexion. Toconfirm, the same segment checked in neutral(prone lying) and forward-bending (as abovein sitting) to see if the transverse processesreturn to neutral. If it does then the diagnosiswill be an FRS right of L3 as the diagnosis isalways by the side of the posteriority.

Figure 10.3 Lumbar spine somatic diagnosis: FRS

TREATMENT


Soft tissue inhibition of the lumbar spine issimilar to the thumb reinforcement techniquedescribed in the thoracic spine section anda similar technique is used over the lumbararea.




Figure 10.4: Soft tissue inhibition of lumbar spine

Long Axis Tissue Stretch (Figure 10.5)This is yet another technique that is effectivefor soft tissue inhibition in the lumbar areaprior to manipulative treatment.

Figure 10.5: Long axis tissue stretch

Technique

The patient is in prone lying and the clinicianfaces the patient from the side. The clinician

uses the palmar surfaces of both hands in acriss-cross fashion and one hand is placed onthe base of the sacrum and the other over thethoraco-lumbar junction, or the lower thora-cic area. A long axis stretch is imparted by theclinician moving both palmar surfaces awayfrom each other with a gentle compression.

ERS Dysfunction (L1 to L5) (Figure 10.6)

The patient is in side lying and the clinicianfaces the patient from the side.

Figure 10.6: Treating ERS dysfunction

Remember the rule:• The patient always lies on the side of the

posteriority for an ERS in the lumbarspine.

• If it is an ERS right, then the patient lieson the right.Assume the dysfunction is an ERS right

of L4.Then the patient lies on the right side and

the clinician faces the patient from the side.Since it is an ERS right the segment istechnically in right rotation and extended.Hence the treatment is to free the right facetof L4 into flexion and left rotation.

Technique

• Patient is right side lying.• The upper torso of the patient is rotated

to the left by gently pulling the upper arm

until L4 is felt to move.• The left leg is flexed at the hip andknee with the foot resting on the rightknee.

• The right leg which is extended, is gentlymoved forwards to induce flexion untilL5 is felt to move.



Lumbar Spine 87

• The left hand of the clinician is taken underthe left arm of the patient and the forearmof the clinician rests on the patients leftarm pit.

• Now the left hand (middle finger) of theclinician is used to block the spinousprocess of L4 on the superior aspect.

• The right forearm of the clinician is placedon the left hip of the patient and themiddle finger is used to block the spinousprocess of L5 on the inferior aspect. Theclinician then takes up the slack and asksthe patient to breathe in, and as the patient breathes out the slack is taken further andthe clinician imparts a stretch by exerting

a downward pressure using the leftforearm to rotate L4 towards the left, inflexion. This will free the right facet of L4into flexion and rotation to the left as itis stuck in extension on the right.

FRS Dysfunction (L1-L5) (Figure 10.7)

The patient is in prone lying and the clinicianfaces the patient from the side. Assume thepatient has an FRS right of L3.

Then technically the L4 segment is in rightrotation and stuck in flexion on the left.Treatment should hence free the left facetinto extension and left rotation.

Technique

• Patient is in prone lying, propped up inthe sphinx position.

Figure 10.7: Treating FRS dysfunction

• Clinician faces the patient from the left.

• The legs are side bent to the left untilL3.

• The right pisiform of the clinician is placedon the right transverse process of L3.

• The left hypothenar eminence/pisiform of the clinician is placed on the left transverseprocess of L4.

• The patient is asked to take a deep breatheand as he exhales the clinician takes upthe slack and imparts a spring on the righttransverse process of L3, while maintain-

ing a counter pressure on the lefttransverse process of L4.

• This will free the left facet of L3 intoextension and left rotation.

REFERENCES

For detail see References of Chapter 11.




11 Pelvic Complex

The pelvis is the link between the upper torsoand the lower extremities. In addition, it isthe area of location of the center of gravityas well. The greater functional significance

of the pelvic girdle is its role in maintainingthe mechanics of the walking cycle. It is onestructure that is often underestimated in itscapacity and if appropriately addressed, canhelp diminish back pain and radicular pain.Its close relationship to the lumbar spine isthe essential gist of this chapter in additionto the role of the sacrum.

OSSEOUS ANATOMY

The pelvic complex consists of three bones

and eight joints. The sacrum which is placedin the center is formed by the fused elementsof S1 to S5. It articulates superiorly with thelumbar spine and inferiorly with the coccyx.They are termed the lumbosacral andsacrococcygeal joints, respectively. Laterally,the sacrum articulates with the ilia orinnominate bones to form the sacroiliac joints.The two innominates are joined anteriorly bythe symphysis pubis joint.

The sacrum is a triangular structure which

has a broad upper surface and a tapering,narrow inferior surface. The upper surfaceof the sacrum is called the sacral base.Inferiorly, the lateral edge of the sacrum thatappears prominent to palpation due to thecurved ends are the Inferior Lateral Angles(ILA). The sacral base and the inferior lateral

angles of the sacrum are the two main bonylandmarks that the clinician incorporates todiagnose a sacral dysfunction. On the superiorsurface, just lateral to the midline are two

articulating facets, which articulate with theinferior articulating facets of the fifth lumbarvertebra to form the lumbosacral joints.

The ilia or the innominates are two innumber and placed laterally on either sideof the sacrum. The superior and anterioraspect of the innominates have a curvedprojection which are the anterior superior iliacspines (ASIS). Anteriorly and inferiorly is apalpable bony landmark just lateral to thegroin area which is slightly higher in the male.

These are known as pubic tubercles. Thesuperior aspect of the innominate is a curvedstructure and this area is called the crest of the ilia. These crests taper posteriorly andmedially and curve inwards forming a pal-pable depression inferiorly. These are knownas the posterior superior iliac spines (PSIS).

The greater clinical significance of thepelvic complex originates at the lumbosacral junction. Most dysfunctions of the pelviccomplex are viewed as dysfunctions at the

sacroiliac joints and may be erroneous. Asmost times dysfunctions of the sacroiliac jointare caused by a dysfunction that occurs atthe lumbosacral junction. The reason beingthat the lumbar spine is one that determinesthe mechanics of the sacrum at thelumbosacral joint which in turn determines



Pelvic Complex 89

the mechanics of the ilium or innominate atthe sacroiliac joint. Hence, the clinician shouldalways remember that when addressingdysfunctions of the pelvic complex, first

consider mechanics at the lumbosacral jointprior to addressing the sacroiliac joint whichare mechanically two different areas butcomplimentary in causing a dysfunction. Amore logical explanation to this can begleamed when the walking cycle is described.

The next area that warrants attention inthe pelvic complex is the symphysis pubis.This is an articulation that possesses move-ment and technically is an anterior attachmentof the innominate with relevance to itsposterior attachment which is the sacroiliac joint. Hence, a dysfunction in this area cancontribute to dysfunctions in the sacroiliac joint posteriorly. Overall, one should under-stand that the sacroiliac joint that receivesattention in a pelvic complex dysfunctioncould essentially be a secondary effect or beaccentuated by dysfunctions either at thesymphysis pubis or more often the lumbo-sacral joint. Thus, when addressing sacroiliac

joint dysfunctions, it behooves us to alsoaddress the lumbosacral and symphysispubis joints to globally address the problemin sight.

LIGAMENTOUS ANATOMY

Much of the integrity of the sacroiliac jointdepends upon ligamentous structures.

Iliolumbar Ligament

The iliolumbar ligament has been describedin Chapter 10 on Lumbar Spine. The lowerfibres of this ligament extend inferiorly and blend with the anterior sacroiliac ligaments.They limit anterior translation of the 5thlumbar vertebra and posterior rotation of theilium.

Posterior and Anterior Sacroiliac

Ligaments

The posterior sacroiliac ligaments have threelayers. They are the short interosseousligaments which are the deep layers and theyrun from the sacrum to the ilium. Theintermediate layer runs from the posteriorarches of the sacrum to the medial side of the ilum. The long posterior sacroiliacligaments blend together and course verticallyfrom the sacral crest to the ilium. Inferiorly,the posterior sacroiliac ligaments blend withthe sacrospinous and sacrotuberous liga-ments. All fibres of this ligament limit

posterior separation of the sacroiliac joint. Theshort fibres limit posterior rotation, internalrotation of the ilium and anterior movementof the sacral base. The long fibres limitanterior rotation of the ilium.

The anterior sacroiliac ligaments preventanterior separation of the sacroiliac joints.

Sacrotuberous and Sacrospinous

Ligaments

The sacrotuberous ligaments run from theinferior lateral angle to the ischial tuberosityabove the sacrospinous ligament, which runsfrom the inferior lateral angle to the ischialspine. These two ligaments contribute to theformation of the greater and lesser sciaticnotches, which are divided by the sacrospi-nous ligaments. The sacrotuberous ligamentslimit anterior and posterior rotation of theilium as well as sacral flexion. The sacro-spinous ligament limits posterior rotation of

the ilium and sacral flexion.

MUSCULAR ANATOMY

The musculature of the lumbar area areinterdependent with the musculature of thepelvic area and hence, are described together.




This is for the fact that the mechanics of thetwo regions are essentially interdependentas well.

The musculature, as in the cervico-thoracic

complex, are classified as postural and phasic.Their primary functions are as described inthe principles of management for theysupport alignment during function andabsorb shock of activity. Their specific actionsfrom an anatomical perspective is obvious, but their individual functions relevant tomanual therapy is worth knowing.6 Thephasic and postural muscles are as follows:

Phasic

• Abdominals• Gluteus maximus• Gluteus medius• Quadriceps

Postural

• Iliopsoas• Erector Spinae/Multifidus• Piriformis• Hip Adductors/Quadratus Lumborum

• Hamstrings

Phasic Musculature

Abdominals

The primary function of the abdominals isdescribed as the walls of a cylinder. Thiscylinder wall effect helps to contain theabdominal contents. By doing so it decreasesthe lever arm of the lumbar lordosis andminimizes its vulnerability to an anteriorshear. Thereby it maintains the lordoticcurve.

This function prevents two possibledysfunctions. Theoretically, as the lordosisincreases, the sacrum has a tendency to flex.If this is exaggerated due to weakness of theabdominal musculature, the risk of flexion

dysfunctions of the sacrum arise as in a flexedsacrum or sacral anterior torsions. When thesacrum flexes the lumbar segments move inthe opposite direction and are at the risk of

extension dysfunctions (ERS). Hence, strongabdominals help to prevent the abovedescribed dysfunctions.

The forward head and protractedshoulders posture is seen in patients withupper quarter pain. A weak abdominal wallis described as a contributing feature to thiscondition. A more caudal position of thesternum and chest results from a weak abdo-minal wall. This results in a compensatoryforward head and protracted shouldersposture. Hence appropriate management of patients complaining of upper quarter painwould include attention to the abdominalmechanism.

Gluteus Maximus

The gluteus maximus attaches to the fascialata. The fascia has a hip and a kneeattachment. Tension in the tensor fascia lataenhances stability at the hip and knee. This

brought about by effective contraction of thegluteus maximus.

The gluteus maximus is also an importantpelvic stabilizer. On weight bearing, with thefoot on the ground, contraction of the gluteusmaximus results in a posterior rotation of thepelvis. Hence weakness can result in anteriorrotation dysfunctions of the innominate.

The posterior moment creates a flexionmoment at the lumbosacral junction. Flexionof the lumbosacral articulation decreases the

lumbosacral angle and anterior shear stresses between the L5 and sacrum. Hence, thegluteus maximius should be strengthened forroutine stability of the lumbopelvic complexand specifically for anterior innominatedysfunctions.



Pelvic Complex 91

Gluteus Medius

Weakness of the gluteus medius is describedas causing a ‘Trendelenburg’ gait. Due toweakness of the this muscle, the pelvis on theopposite side tends to drop and Hence, hasa tendency to increase stresses on the lumbarfacet joints and the sacroiliac joints.

The patient has a tendency to lean to thesame side of the weakness and Hence, thestance time on the weak side tends to increase.This has a tendency to exaggerate the torsionposition of the sacrum on that side resultingin torsional dysfunctions.

Hence, as a routine for lumbar stability

and specifically following correction of asacral torsion, strengthening of the gluteusmedius is recommended.

Quadriceps

Efficient contraction of the quadriceps isrequired in low back rehabilitation. Thismuscle should have sufficient girth in orderto exert a ‘pushing’ effect to amplify tensionwithin the fascia lata to enhance stability.

The rectus femoris, being a flexor of thehip tends to cause an anterior rotatorymoment of the pelvis and an extensionmoment in the lumbosacral junction. Themanagement principles are the same asthe iliopsoas and is described in the nextsection.

Quadriceps strength is also essential forexecution of proper body mechanics.Eccentric contraction of the quadriceps helpsposition the back with an intact lordosis, to

minimize the risk of injury during activity.

Postural Musculature

The postural muscles have a significance todysfunction for the fact that they have atendency to contract. Prolonged contractioncan pull on their respective skeletal attachment

and cause a change in alignment. Hence,appropriate lengthening prior to strengthen-ing is mandatory to correct and minimize theincidence and recurrence of a dysfunction.

Iliopsoas

In a weight-bearing situation, contraction orcontracted states of the iliopsoas can producean anterior rotation of the ilium. Thisincreases the lordosis in the lumbar area andpredisposes the sacrum to flex as in weakstates of the abdominals causing dysfunctionsof sacral flexion and sacral anterior torsions.This may additionally predispose to an exten-sion moment/dysfunction of the lumbosacral joint predisposing to an ERS.

Hence, the iliospoas needs to be lengt-hened if an anterior innominate dysfunctionis identified and additionally in situations of a flexed sacrum or an ERS.

Conversly, weakness of the iliopsoas cancause the sacrum to extend predisposing toextension dysfunctions of the sacrum as inextension shears or sacral posterior torsions.This in addition, can cause a anterior flexionmoment at the lumbosacral articulationleading to FRS dysfunctions.

Erector Spinae (Superficial) 6

These muscles have no direct attachment tothe lumbar spine. However, they exert a bowstringing effect over the posterior trunk. Theypull the thorax posteriorly and create anextension moment over the lumbar spine.They also work by a lengthening contractionto control the trunk during forward bending

and by a static contraction to effect theposture of the lower thorax over the pelvis,during function.

The superficial erector spinae have aprofound effect on sacroiliac joint mechanics.The inferior attachment of this muscle is onthe sacrum. Its pullover the sacrum creates




a flexion (nutation) moment on the sacrum.Hence it’s strength contributes to the stabilityof the sacroiliac joint.

However, being a postural muscle, exces-

sive contraction of the erector spinae canincrease the flexion moment of the sacrumand contribute to sacral flexion dysfunctionsand sacral anterior torsions. In addition, itincreases the extension moment of the lumbo-sacral junction and contributes to extensiondysfunctions (ERS).

Erector Spinae (Deep)

The deep erector spinae muscle offers stabilityof the lumbar spine and lumbosacral articu-

lation in a sagittal/anteroposterior plane.Contraction of this muscle and consequentlya contraction of the contralateral iliopsoascreate a sagittal plane balance system forlumbar stability.6

Multifidus

This is a bipennate muscle that originatesfrom the mallillary process of the lumbarvertebra and runs upwards and medially toattach to the spinous process of the lumbar

vertebrae above.Injury to any of the tissues in the lumbo-

pelvic region may lead to excessive muscleactivity or muscle guarding which is to protectthe injury site from further movement.

The extensive direct attachment of themultifidus muscle to the lumbar spine makesit a prime candidate for reflex muscleguarding due to low back injury.

The muscle guarding of the multifidus canessentially cause ERS and FRS dysfunctions

by virtue of their oblique attachment toindividual vertebra, inhibition techniques likemuscle energy techniques (MET) focus tocontract or inhibit the multifidus muscle tocorrect a dysfunction. The multifidi alsoattach to the sacrum and can favor sacralextension. Contracted states of the multifidus,especially where there is muscle guarding can

attribute to dysfunctions of the sacrum inextension as in unilateral extension shears orposterior torsions.

The multifidus is considered an inner

group muscle. Due to its attachment toindividual vertebra it exerts a compressiveforce between each of them individually.

Since the lumbo pelvic unit is resistant totorsional forces on load bearing, themultifidus may be a contributing factor tospinal stability by sqeezing the vertebraltogether and locking them

Thus, following correction of lumbar dys-functions be it an ERS or an FRS, subsequentstrengthening of the multifidus minimizes the

potential for recurrence ofa dysfunction.

Piriformis

The piriformis muscle attaches to the lateral border of the sacrum and inserts into thetrochanteric fossa bilaterally. By virtue of their attachment they favor sacral flexionleading to sacral flexion dysfunctions or sacralanterior torsions. Thus, causing an extensionmoment at the lumbosacral junction leadingto an ERS dysfunction.

The sciatic nerve passes close to thepiriformis and in a smaller population,through it. Hence, dysfunctional states of thepiriformis can irritate the sciatic nerve causingsciatic symptoms.

Overall, being a postural muscle, thepiriformis has a greater tendency to tightenand is also extremely pain sensitive. Oftentimes it is the source of ‘deep buttock pain’described by patients with low back pain.

Optimal length and strength of the piriformisis essential to minimize the above describedconsequences.

Hip adductors/Quadratus lumborum

The hip adductors attach to the pubic andischial rami and extend below to attach tothe femur. When the foot is on the ground



Pelvic Complex 93

as in a weight-bearing position, the adductormuscles can cause an inferior moment at thepelvis. Thus, contributing to an inferior or‘downslip’ of the pelvis.

The quadratus lumborum attaches to theiliac crest and the lumbar transverse processesand 12th rib. In contracted or shortened states,it can cause superior translations or an ‘upslip’of the innominate.

Hamstrings

The hamstrings, by virtue of their attachmentto the ishial tuberosity control the amount of pelvic rotation during forward-bending.Tightness of the hamstrings favors posterior

rotation of the innominate. This can causeextension dysfunctions of the sacrum as inextension shears or sacral posterior torsions.As described earlier, extension dysfunctionsof the sacrum tend to cause a flexion momentat the lumbosacral articulation leading toflexion dysfunctions of the lumbar spine asin an FRS. Hence, appropriate lengthening orstretching of the hamstrings is recommended.

MECHANICS

The mechanics of the pelvis is complex owingto the several articulations working tomaintain normal mechanics of a very complexfunction, i.e. walking. Dysfunctions of thepelvis are correlated to normalizing mecha-nics relevant to the walking cycle.8 If thenormal mechanics of the cycle of events thatoccur during walking is disturbed thendysfunctions result. The mechanics that occurin the pelvic complex during normal walkingis described below, however, the basic

movements of nutation and contranutationwill first be described.

Nutation or ‘anterior nutation’ is describedas the anterior and inferior movement of thesacral base. Simply stated, despite all thecontroversies that exist in literature in thisregard, it is considered sacral flexion.

Contranutation or ‘posterior nutation’ iswhen the sacral base moves superiorly andposteriorly. Simply stated, it is sacral exten-sion. In addition the sacrum has the ability

to side bend and rotate as well.The ilia or the innominates possess an

ability to rotate forwards and backwards andis termed as anterior and posterior rotationof the ilia. In addition, they also have theability turn inwards and outwards and istermed as an inflare/outflare or a medial/lateral rotation. A superior and inferiortranslatory motion occurs when the opposingsurfaces are flatter and more parallel.

A combination of sacral and ilial

movements is what occurs during the normalwalking cycle.

Walking Cycle Relevant to PelvicMechanics8

The axis of movement is the first importantcomponent that the clinician should under-stand. All movements in the human bodyoccur in a diagonal plane as one wouldrecollect concept of patterned motion that aretaught in PNF courses. It is three dimensionaland is a combination of the frontal, sagittaland horizontal axes. The sacrum functions thesame way and Hence, the movements of thesacrum as a combination of flexion side- bending and rotation occur in a hypotheticaloblique axis. This axis is an imaginary linedrawn from the superior aspect of onesacroiliac joint to the inferior aspect of theother. For example, the line of the axis runningfrom the superior aspect of the left sacroiliac joint to the inferior aspect of the rightsacroiliac joint is the left oblique axis, and vice

versa for the right (Figure 11.1).In the normal walking cycle, the events

that occur are heel strike, foot flat or mid-stance, and heel/toe off. The cycle of eventsthat are of greater clinical significance are theones that occur during heel strike and mid-stance and are as follows:




then L5 would rotate left and sidebend tothe right.

If for any reason the mechanics describedabove is altered then a dysfunction would

result. The reason being the stresses of weight-bearing are not evenly distributedand may be localized to the area of restrictionor instability, resulting in pain. Hence, aclinician addressing mechanical dysfunctionin the lumbo-pelvic complex should primarily be concerned at restoring the normalcy of mechanics during the walking cycle.7 Thedysfunctions that may interfere with thenormal mechanics of the walking cycle isdescribed in the next section. The goal of

treatment, hence, would be to identify thesedysfunctions and correct them as appropriate,to restore normal mechanics.


Dysfunctions in the pelvic complex occur inthree regions. They occur either in the pubicsymphysis, the sacrum or the ilium. Hence,they are classified as pubic, sacral and ilialdysfunctions.7

Symphysis Pubis

Movements here are quite small. They occurduring standing and during the walking cycle.During gait, the symphysis pubis is the moststable joint in the pelvic girdle. It oscillatesup and down in a sinusoidal curve buttranslates a little from side to side. There isa shearing movement during one leggedstanding and increases if this standing timeis prolonged. It also increases when one lands

hard on one leg supporting the body weight.This predisposes to a dysfunction. Also apulling motion of one leg causes dysfunction,especially if one is thrown of a horse and isdragged by the leg. When two leggedstanding is maintained, the symphysis returnsto symmetry.

Figure 11.1: Sacrum. (1) Articulating facet for l5, (2)

Base, (3) Sacral foramen, (4) Ila, (5) Sacral cornua,(6) Coccyx, (7) Oblique axis (left)

Assuming the right leg is the one that isthe leading leg, at right heel strike, the rightinnominate rotates posteriorly and the leftinnominate rotates anteriorly. The sacrumrotates to the right.

At right midstance, the right innominate begins to rotate anteriorly. The sacrum flexesforward and rotates to the right and side-

bends to the left.In short, during one legged weight- bearing the sacrum rotates to the same sideof weight-bearing and side bends to theopposite side.

This is known as a torsional movement.The same cycle of movement occurs duringinitiation of the left leg.

The other important component of thissimplified version of the walking cycle is themovement occurring at L5. Remember as a

rule that—When not prevented from doing so, the L5 segmentalways moves in the opposite direction of the sacrum

Hence, during the walking cycle, duringone legged weight-bearing or at mid-stance,if the sacrum rotates right and sidebends left



Pelvic Complex 95

Pubic dysfunctions are often overlookedand are very common. Muscle imbalances bet-ween the abdominals above and the adductors below are contributors to dysfunction. They

frequently result from chronic posture of standing with more load on one leg. Pubicdysfunction restricts symmetrical motion of the innominate bones during the walkingcycle. Since there is an oscillatory motion of the pubis up and down the two possibledysfunctions of the pubis are:13

1. Superior pubis.2. Inferior pubis.

The causes for the above pubic dysfunctionto occur are as follows:

Superior Pubis

1. Fall on the ischial tuberosity.2. Weak hip abductors.3. Pregnancy and delivery.

Inferior Pubis

1. Hip hyperextension.2. Tight hip adductors.3. Pregnancy and delivery

The patient with a symphysis dysfunction

typically complains of symphyseal, medial hipand thigh pain. Local tenderness is usuallyevident over the hip adductors and groinarea. There tends to be tenderness over theinguinal ligament. Pregnancy is yet anothersource for pubic and for that matter pelvicdysfunction as a whole.12 Due to hormonalactivity, the ligaments of the pelvic complexappear lax during pregnancy as the pelvicinlet is required to enlarge to accommodatethe baby. Following childbirth the joint

surfaces return back to their original statesand this usually does not occur in symmetryand may predispose to faulty alignment anddysfunction.

Sacrum

The sacrum is probably the most importantcomponent of the pelvic complex and is often

missed out in a sacroiliac dyfunction as theilia receive more attention. The sacrum is thedirect link of the lumbar spine to the pelviccomplex and plays an important role in the

walking cycle. The movements available inthe sacrum are very limited for the fact thatthe center of gravity is located here andwould make sense to have one that is stable.If this negligible movement of the sacrum isaltered then a dysfunction would result. Thesacrum has been described as a significantcontributor to back pain and radicular pain.The reason being the close proximity of nervestructures to the sacroiliac joint, the ala of thesacrum and the piriformis muscle, which

attaches to the lateral border of the sacrum.The mechanics of the sacrum has been des-cribed earlier on page 93 in this chapter andsignificant to the walking cycle. This has to be maintained for normalcy from a mechanicalperspective. It has to be reiterated that thesacrum has movements in three planes as forother major joints with movements of flexion(nutation)/extension (contranutation), side- bending and rotation. A combination of alloccurs in a hypothetical oblique axis. Hence,

in all, dysfunctions of the sacrum occur asfollows:1. As a flexion/extension which are other-

wise known as unilateral dysfunctions, and2. As a combination of side-bending and

rotation, known as torsional dysfunctions.Unilateral dysfunctions are described so

because the flexion or extension that occursin the sacrum is rarely bilateral and oftenoccurs one sided, either to the left or to theright.

One should remember that although atorsional dysfunction occurs as a combinationof side-bending and rotation, it does so ina flexed or extended position. Hence, if side- bending and rotation occur with flexion, itis a anterior torsion, and when it does so inextension it is termed a posterior torsion.




Unilateral Dysfunctions

Unilateral dysfunctions of the sacrum are of two types, namely:1. Unilateral flexed sacrum2. Unilateral extension shear

Unilateral flexed sacrum: The mechanism of aflexion dysfunction is relatively simple. It isknown from basic understanding that thesacrum is a triangular structure with theupper landmark known as the base and thelower landmark known as the Inferior LateralAngle (ILA). Hence, a flexion of the sacrumwould be an anterior and inferior movementof the bases and a posterior and upward

movement of the ILA’s (Figure 11.2).

Figure 11.2: Unilateral flexed sacrum

However, this does not occur in a bilateralfashion and is often one sided. For example,in a left sided flexion, the left base flexesforward and the left ILA extends backward,and the reverse occurs on the right side.

One may be confounded by the fact thatflexion can occur on one side with the reverseoccurring on the opposite side. This is so because the movement occurs in a hypo-thetical oblique axis (with side-bending).

Thus, in a left unilaterally flexed sacrum(which is empirically more common), the left

base moves anteriorly and the left ILA movesposterior on a right oblique axis.

Causes13

1. Increased lumbar lordosis owing toposture, pot belly, pregnancy, etc.2. Sacroiliac ligamentous laxity.3. Lumbar spine hyperextension.4. Weak glutei.

Unilateral extension shear: This is the reverseof what occurs in a flexed sacrum. Thisdysfunction is empirically seen more on theright side, however, does not undermine itsability to occur on the left. As it is the reverseof a flexion, it is the right base extending

backward and the right ILA moving forward(Figure 11.3).

Figure 11.3: Unilateral extension shear

Thus, in a right unilateral extension shear,the right base extends backward and the rightILA moves forward on a hypothetical left

oblique axis.

Causes13

1. Decreased lumbar lordosis secondary toposture.

2. Flexed sitting or standing postures.3. Squatting, bending and lifting.



Pelvic Complex 97

Torsional Dysfunctions

As described earlier, a torsion of the sacrumis a combination of side-bending and rota-tion, which can occur with flexion (nutation)or extension (contranutation). Thus, torsionsoccurring in flexion are called anteriortorsions and those occurring in extension arecalled posterior torsions.

Anterior torsion: The same landmarks are usedas reference points for torsions as well,namely, the base and the ILA (Figure 11.4).

Left on left Right on right

Figure 11.4: Anterior torsion

Since a torsion is first a rotation, technically

the base and the ILA on the same side movetogether. For example, if it is a left rotation,the left base and the left ILA move posterior.This is followed by a side-bending to theright. As this is occurring, the sacrum flexesor nutates on a left oblique axis. Since therotation is to the left and the flexion is in aleft oblique axis, it is called a left on left sacraltorsion.

The exact reverse occurs in a right on righttorsion. Hence, there are two types of anterior

torsions, namely,1. Left on left sacral torsion.2. Right on right sacral torsion.

Posterior torsion: The reference points are asfor an anterior torsion namely, the base andILA (Figure 11.5).

Left on right Right on left

Figure 11.5: Posterior torsion

Again, since a torsion is first a rotation,the base and ILA move in the same direction.For example, the left base and ILA move

posterior and this is a rotation of the sacrumto the left. Then the sacrum side bends to theright. As this is occurring, the sacrum extendsor contranutates on a hypothetical right obliqueaxis. Since the rotation is to the left and theextension is on a right oblique axis it is calleda left on right sacral torsion.

The exact opposite occurs in a right on leftsacral torsion. Hence, there are two types of posterior torsions, namely,1. Left on right sacral torsion

2. Right on left sacral torsionA left on left sacral torsion is most

commonly seen among the torsions. Torsionscan occur due to the following reasons:1. Slip and fall on the buttock2. Limb length discrepancy3. Weakness of pelvic musculature, especially

the gluteus medius4. Tightness of the piriformis on the same

side5. Ligamentous instability

6. Pregnancy and postdelivery7. Torsions are also seen in patients having

undergone surgery in the lumbar spinewhereby the sacrum tries to compensatefor the altered mechanics in the lumbarspine.




The clinician should understand and rememberthat all sacral dysfunctions, unilateral and torsions,occur at the lumbosacral joints.

Innominates

As described earlier, the innominatesoscillate up and down in a sinusoidal curve,during the gait cycle. This up and downshearing movement tends to cause, indysfunctional states, what is known as an‘upslip’ or a ‘downslip’ of the innominates.

Since the innominates rotate anteriorly andposteriorly during the gait cycle there is atendency for the innominates to be restrictedin one of these positions, due to faultymechanics. Thus, in entirety, the innominatescan either be restricted as an upslip or adownslip, and an anterior or posteriorrotation. Some authors also describe restric-tion in internal and external rotation, calledinflares and outflares, however it is not of a very big focus in this text from a diagnosisperspective. The following are some causesfor the innominates to be restricted in theirrespective categories of dysfunction:13

Upslip

1. Jumping or landing hard on one leg2. Quadratus lumborum spasm (as it assists

to hitch up the hip on the same side)3. Tight hip adductors on the same side (of

dysfunction).

Downslip

1. Iliotibial band tightness on the same side2. Gluteus medius weakness on the opposite

side.

Anterior Rotation

1. Hip hyperextension on the same side2. Hip flexor tightness on the same side3. Weak abdominals and gluteus maximus on

the same side.

Posterior Rotation

1. Prolonged weight-bearing on the sameside

2. Direct fall on the ischial tuberosity3. Hamstring tightness on the same side4. Gluteus medius weakness on the same

side.Since the symphysis is the anterior joint

of the innominates, a dysfunction significantlyreduces the rotation movement of theinnominates during walking, disturbing themechanics of the walking cycle. It can alsocontribute to dysfunction of the posteriorarticulation of the innominates, which is thesacroiliac joint. When the innominate

translates up and down, or rotates anteriorand posterior the pubic tubercles go up ordown. For example, during anterior rotationof the innominate, the corresponding pubictubercle rotate downwards. This brings theacetabulum lower and the leg on the sameside appears longer. The reverse happensduring posterior rotation of the innominates.It is then quite obvious that an upslip wouldcause the pubic tubercle to go upwardscausing a short leg on the same side and vice

versa for a downslip.Hence, there are only two dysfunctions

of the symphysis pubis namely,1. Superior2. InferiorNote: The above two dysfunctions occur atthe symphysis pubis joint.

The innominates as a whole are susceptibleto the following dysfunctions:1. Posterior rotation.2. Anterior rotation.

3. Upslip.4. Downslip.Note: The clinician must understand andremember that the above four dysfunctionsoccur at the sacroiliac joints.

Dysfunctions of the pelvic complex presentas unilateral hip and buttock pain and often



Pelvic Complex 99

times groin pain as well. Radicular pain downthe leg has its origins in the pelvic complex.The sciatic nerve, with its close proximity tothe ALA of the sacrum, the inferior sacroiliac

joint, the ischial spine and the piriformismuscle can be significantly irritated indysfunctional states. Sacral dysfunctions andinnominate dysfunctions can effect this.

The piriformis muscle attaches to thelateral borders of the sacrum and the lessertrochanter of the femur and serves to anchorthe sacrum bilaterally in addition to externallyrotating the hip. Sacral dysfunctions can stressthis muscle as it may be stretched or be

contracted. The sciatic nerve runs close to thismuscle and in a small population runs throughthis muscle. This may irritate the nerve andpredispose to radicular pain.

The ala of the sacrum is a bony landmarkthat can get closer to the nerve in faultypositions of the sacrum causing radicular pain.The capsule of the sacroiliac joint, can beinflamed secondary to dysfunctional statesand can throw off effusion on to the nervecausing radicular symptoms.

Additional causes for mechanical pain inthe pelvis is enumerated on page 16 in Chapter4 in the section on “Muscle Weakness.“

EXAMINATION

Examination of the pelvic complex firstlyinvolves identification of the essential bonylandmarks namely,1. Pubic tubercles2. PSIS

3. Sacral base4. ILA5. Ischial spine6. Iliac crests

Examination procedures are in the orderof the three regions, the pubis, sacrum andilium.

Pelvic Complex Somatic Diagnosis

Preceding all diagnosis in the pelvic complex,determination of the side of the dysfunctionis important. The clinician is advised not tofollow pain but rather the dysfunction as theside of pain does not necessarily determine theside of the dysfunction. The pain can very well be on one side with the dysfunction on theopposite side. Two simple tests are performedto determine the side of the dysfunction.10,14

Sitting Flexion Test

The patient is seated and the clinician facesthe patient from behind. The clinician palpates

both PSIS. The patient is then asked to placetheir hands between the knees and flexforward by pointing their hands towards thefloor (Figure 11.6).

Figure 11.6: Sitting flexion test

When flexion of the trunk is performed,the ilia rotate forward and Hence, the PSIStechnically moves upward. Hence, as theclinician palpates both PSIS the side of the

restriction is felt to move upward first.The side that moves first is considered to

be the side of the dysfunction.

Stork Test (Figure 11.7)

The patient is standing and the clinician facesthe patient from behind. The clinician palpates




both PSIS as in the sitting flexion test. Nowthe patient is asked to flex his hip by liftingthe hip upwards.

When the hip is flexed, the corresponding

ilium tends to rotate backward, Hence, thePSIS technically should be felt to movedownward. However, in situations of arestriction the PSIS is felt to move upward asthe ilium does not rotate backward.

Thus, the PSIS on the side that is felt tomove upward, rather than downward isconsidered the side of the dysfunction.

Figure 11.7: Stork test

Pubis The patient is lying supine and the clinicianfaces the patient from the side. The clinician

places his palm on the abdomen and movesit down slowly until the heel of the handcontacts the superior aspect of the symphysispubis. Moving laterally about 2 cm, the

superior aspect of the pubic tubercles arepalpated (Figure 11.8).

The clinician looks to see if one pubictubercle is higher or lower in comparison withthe other to make a diagnosis of a superioror inferior pubis. The dysfunctional side isusually tender on palpation.

Sacrum

The base and the ILA of the sacrum are thetwo standard landmarks used for a diagnosis.The clinician faces the patient from the sideand places the palm of the hand in the lowergluteal area. As pressure is applied upwards,the palm is felt to hit on the coccyx. As thefingers are placed on the coccyx and movedlaterally and upwards, the lower sacrum isfelt to taper outwards. Now the thumbs of the clinician are brought to the superiorsurface and the ILA is palpated.

The clinician then palpates the PSIS. The

palpating thumbs are now moved 30 degreesdownward and medially to palpate the base.This is a difficult landmark to palpate andrequires a great deal of practice (Figures 11.9to 11.11).

Figure 11.9: Locating the inferior aspect of the

sacrumFigure 11.8: Locating inferior and superior

aspects of pubis



Pelvic Complex 101

Figure 11.10: Locating the ILA

Figure 11.11: Locating the base

UNILATERAL DYSFUNCTIONS

Unilateral Flexed Sacrum

The patient is lying prone and the clinicianfaces the patient from the side. The clinicianfirst palpates the base of the sacrum andrecollecting an earlier description, the sacral base moves forward during sacral flexion. If the flexion is unilateral then the base on oneside should move forward. Assuming that itis a left unilaterally flexed sacrum, on

palpation of both bases, the base on the leftappears more anterior or depressed incomparison to the right.

Now the clinician moves downward onthe sacrum to palpate the ILA and technicallyin sacral flexion, the ILA moves posterior.Hence, if it is a left unilaterally flexed sacrum

the left ILA appears more posterior orelevated in comparison to the right.

When the sacrum flexes forward and isrestricted in that position, the innominate on

that side tends to rotate forward as welltaking the acetabulum lower. This creates anapparent long leg on that side. Hence, on theside of the unilateral flexed sacrum, the legappears longer.

Thus, in a left unilateral flexion, the sacral base on the left appears more anterior ordepressed and the ILA on the left appearsmore posterior or elevated. There is anassociated long leg on the same side.

Left Unilateral Flexed Sacrum

• Base— Anterior or depressed on the left• ILA— Posterior or elevated on the left• Leg length— Long leg on the left

Unilateral Extension Shear

The patient is lying prone and the clinicianfaces the patient from the side. The clinicianpalpates the base and the ILA as above. Froman earlier recollection extension of the sacrum

causes the base to move backwards orposterior and the ILA to move forwards oranterior.

Assuming it is a right unilateral extensionshear, then the extension is localized to theright. Hence, on palpation the right baseappears more posterior in comparison to theleft. In conjunction the right ILA appears moreanterior compared to the left.

When the sacrum extends backward, moreso on the side of the extension the corres-

ponding innominate rotates posteriorly.When this occurs the corresponding acetabulum rotates upwards creating an apparentshort leg on the same side.

Thus, in a right unilateral extension shear,the right base moves posterior or appearselevated. Simultaneously, the right ILA




moves anterior and appears depressed. Thereis an associated short leg on the same side.

Right Unilateral Extension Shear

• Base— Posterior or elevated on the right• ILA— Anterior or depressed on the right• Leg length— Short leg on the rightNote: The key for unilateral dysfunctions isthat on palpation of the base and ILA of thesacrum, one of either appears either elevated(posterior) or depressed (anterior) on thesame side.

TORSIONAL DYSFUNCTIONS

Left on Left Sacral TorsionThe patient is lying prone and the clinicianfaces the patient from the side. The palpationof landmarks are the same, being the baseand the ILA.

Assuming it is a left on left sacral torsion,the left rotation makes the base and the ILAappear posterior (elevated) on the left.

On palpation of both ILA, since a left onleft torsion is a combination of left rotationand right side-bending, the ILA on the rightappears inferior on palpation.

The right side-bending tends to cause thepelvis to dip on the right and Hence, theacetabulum is lower. On palpation of theischial tuberosity it is observed to be loweron the right. This tends to make the legappear lower on the right.

The important thing to observe now iswhether it is an anterior or a posterior torsion.

To confirm this, the patient is put in prone

lying. Now both midlateral borders of thesacrum are palpated and the patient is askedto prop up in extension (sphinx). If thelandmark is felt to move more anterior(depressed) then it is considered to be ananterior torsion.

Left on Left Sacral Torsion

• Base— Posterior or elevated left• ILA—Posterior or elevated left• Leg length—Long leg right• Prone prop up (Sphinx)— midlateral border

of sacrum moves further anterior (depres-sed)The exact reverse occurs in a right on right

sacral torsion.

Left on Right Sacral Torsion

The patient is lying prone and the clinicianfaces the patient from the side. The base andthe ILA is palpated on both sides.

The clinician should remember that the

objective findings in a left on right is the sameas a left on left. For example, in a left on rightsacral torsion the base and the ILA areposterior or elevated on the left with a longleg on the right, just as in a left on left sacraltorsion. The only difference is that it is aposterior torsion.

Hence, determining whether it is ananterior or posterior torsion is the principledifference. This is done using the proneextension test as described in the section on

left on left sacral torsion.The patient is lying prone and the clinician

palpates both midlateral borders of thesacrum. Then, the patient is asked to propup into extension (sphinx). If landmarkposterior moves further posterior then it isa posterior torsion.


• Base— Posterior or elevated left• ILA— Posterior or elevated left

• Leg length— Long leg right• Prone prop up (Sphinx)—Posterior lateral

borders of sacrum moves further posterior(elevated)The exact reverse occurs in a right on left

sacral torsion.



Pelvic Complex 103

Note: The key for torsional dysfunctions isthat on palpation of the base or the ILA of the sacrum, both appear either elevated(posterior) or depressed (anterior) on the

same side.Secondly, the prone prop up test will deter-

mine if it is an anterior or posterior torsion.

Innominates

Diagnosis of an innominate dysfunctioninvolves palpation of the ASIS, PSIS, and theiliac crests. An innominate dysfunction isusually the last component of the dysfunction.It usually self corrects following correction

of a lumbar or a sacral dysfunction. However,if signs and symptoms persist followingcorrection of a sacral or lumbar dysfunction,the innominates need to be assessed forprobable dysfunction.

Anterior Innominate

The patient is sitting with the clinician facingthe patient from behind. The clinician firstperforms a sitting flexion and or a stork testto determine the side of the dysfunction. The

clinician then palpates both PSIS for levels.Assuming it is an anterior innominate on theleft, then the PSIS on the left appears higher,as the innominate has rotated anterior.

The patient is then asked to stand withthe clinician facing the patient. The clinicianthen palpates the ASIS bilaterally for levels.In a left anterior innominate, the ASIS on the

left appears lower as the innominate hasrotated anterior (Figure 11.12).

Lastly, the clinician looks for leg length.In an anterior innominate the acetabulummoves downward and Hence, the corres-ponding leg appears longer.

Posterior Innominate

The exact reverse is seen in a posteriorinnominate. Assuming it is a left posteriorinnominate, then the left PSIS appears lowerand the left ASIS appears higher, as the leftinnominate has rotated posterior. Theacetabulum tHence, has moved upward andthe leg on the corresponding side appearsshorter.

Upslip and Downslip of Innominate

In an upslip, both the ASIS and the PSIS onthe dysfunctional side appear higher, alongwith the ischial tuberosity. Obviously then

the leg on that side appears shorter.

Figure 11.13: Checking for apparent discrepancy

of leg length

Vice versa, in a downslip, both the ASISand the PSIS on the dysfunctional side appears

Figure 11.12: Diagnosing anterior innominate

dysfunction




lower, along with the ischial tuberosity. Theleg on that side will Hence, appear longer(Figure 11.13).

TREATMENT

Treatment of the pelvic complex will sequencein correcting a lumbar dysfunction if any,first. Then pubic dysfunctions should beidentified and corrected. This is followed bycorrection of sacral dysfunctions and lastlyinnominate dysfunctions are corrected.


The patient is lying prone and the clinicianfaces the side to be treated. Two structuresoften irritable are the piriformis and gluteusmedius. Using the elbow, the clinician locatesthe piriformis half way between the PSIS,ischial tuberosity and greater trochanter. Agentle compression is applied till tendernessis felt and the pressure is gradually increased.The pressure is maintained for at least 60seconds in which time, the tenderness maydecrease. A similar procedure is done for thegluteus medius, which is located lateraland superior to the piriformis (see Figure11.24 for myofascial tender points). This isusually done following inhibition of the softtissue for the lumbar spine.

Figure 11.14: Soft tissue mobilization in pelvicdysfunction

Symphysis Pubis (Figure 11.15):

Superior and Inferior Pubis (Shotgun Technique)

The patient is lying supine with the hips andknees flexed and the feet together. Theclinician stands by the side holding thepatients knees together. The patient is firstasked to abduct both legs and the clinicianresists efforts in as in a static contraction. Theclinician then places the forearm between thepatients’ knees. The patient is then asked tostatically adduct both legs, which is resisted by the forearm placed between the legs. Thisdistracts the pubis to correct the dysfunction

(sometimes with an audible release).

Figure 11.15: Shotgun technique

Sacrum

Unilateral Flexed Sacrum (Figure 11.16)

The patient is lying prone and the clinicianfaces the patient from the left, facing the headside. Assuming it is a left unilateral flexedsacrum, the left leg of the patient is abducted

and placed in a position of internal rotation.This gaps the left sacroiliac joint.The clinician places the palm of the hand

on the left ILA of the patient who is nowasked to breathe in deeply. On deepinhalation, the sacrum flexes forward andHence, the ILA moves posterior or upwards.



Pelvic Complex 105

This movement is resisted by the palm of theclinician directing a downward and forwardpressure on the left ILA. This forces the leftside of the sacrum into extension.

Figure 11.16: Managing unilateral flexed sacrum

The exact reverse is done for a rightunilateral flexed sacrum and the patientposition is the same.

Unilateral Extension Shear (Figure 11.17)

The patient is lying prone and is brought toa prone prop up position (Sphinx). The clinicianfaces the patient from the right side, facingthe leg side of the patient. Assuming it is a

right unilateral extension shear, the right legof the patient is abducted and internallyrotated. This gaps the right sacroiliac joint.

Figure 11.17: Managing unilateral extension shear

The clinician now places the heel of thepalm (or the pisiform) on the right sacral baseof the patient, which is now further extendedas the patient is in the prone prop up position.

The patient is asked to inhale deeply whichflexes the sacrum. As the sacrum flexes, theclinician applies pressure on the right sacral base with the heel of the palm to furtheraccentuate sacral flexion. This frees thesacrum on the right side into flexion. A shortstretch at the limit of the range may furtherassist the mobilization.

The exact reverse is done for a leftunilateral extension shear and the patientposition is the same.

Left on Left Sacral Torsion (Figure 11.18)

The patient is lying prone and flexion is induced by placing firm pillows under the abdomen(or flexing the treatment table). The clinicianfaces the patient from the side. Both legs of the patient are now abducted and internallyrotated. This gaps both sacroiliac joints. Theclinician now places the heel of the hand onthe left lateral border of the sacrum midway between the base and the ILA.

Figure 11.18: Managing left on left sacral torsion

The patient is now asked to inhale deeply.As the patient exhales the clinician takes upthe slack and applies a downward pressure




to hold the sacrum down. This frees thesacrum into right rotation and extension asthe sacrum is kept extended with pillowsunder the abdomen, or by flexing the table.

The exact reverse is done for a right onright sacral torsion and the patient positionis the same.

Left on Right Sacral Torsion (Figure 11.19)

The technique is the same as for a left on leftsacral torsion except that the patient is in aprone prop up position.

The patient is lying prone and the clinicianfaces the patient from the left side. The patientis asked to prop up to the ‘sphinx’ position.The legs of the patient are now abducted andinternally rotated to gap both sacroiliac joints.The clinician places the heel of the palm onthe left lateral border of the sacrum midway between the base and the ILA.

Figure 11.19: Managing left on right sacral torsion

The patient is now asked to inhale deeply.When this occurs the clinician takes up the

slack and applies a downward pressure onthe left lateral border of the sacrum to holdit down. This frees the sacrum into rightrotation and flexion as the sacrum is keptflexed by the prone prop up position.

The exact reverse is done for a right onleft sacral torsion and the patient position isthe same.

Innominates

Posterior Innominate (Figure 11.20)

Assuming it is a left posterior innominate, the

patient is then in right side lying and theclinician faces the patient from the face side.The clinician then rotates the trunk to the lefttill L5 begins to move. The left hip and kneeis flexed and the foot is placed behind theright knee.

The clinician grips the iliac crest with thepalm of the left hand and places the heel of the right hand on the ischial tuberosity of thepatient. An anterior rotation of the leftinnominate is induced by an upward pressure

on the ischial tuberosity with the right handand simultaneously pulling the iliac crestinwards.

Figure 11.20: Managing posterior innominatecomplication

Anterior Innominate (Figure 11.21)

Assuming it is a left anterior innominate, thepatient is then in right side lying and theclinician faces the patient from the face side.The clinician then rotates the trunk to the lefttill L5 begins to move. The left hip and kneeis flexed and the foot is placed behind theright knee.

The clinician places the heel of the left handanterior to the left iliac crest and the heel of the right hand posterior to the left ischialtuberosity. A posterior rotation of the left



Pelvic Complex 107

innominate is induced by a posteriorlydirected pressure on the anterior aspect inno-minate and an anteriorly directed pressureon the posterior aspect of the ischial

tuberosity.

Figure 11.21: Managing inferior innominate

complication

Upslip (Figure 11.22)

The patient is lying supine and the clinicianfaces the patient from the leg side at the endof the table. The clinician then grasps the

distal tibia and fibula above the ankle. Theleg is in slight abduction and in internalrotation to stabilize the hip joint and gap thesacroiliac joint to localize the mobilization tothe sacroiliac joint.

In this position, the clinician takes up theslack and imparts a short stretch in the longaxis of the limb. This frees the correspondinginnominate in an inferior direction.

Downslip (Figure 11.23)

The patient is right side lying assuming it isa left downslip. The left leg is flexed at thehip and knee and the foot is placed behindthe right knee. The clinician faces the patientand the left hand stabilizes the left iliac crestand the heel of the right hand is placed onthe left ischial tuberosity. The knee of thepatient is rested on the clinicians thigh tomaintain it in a neutral position.

Figure 11.23: Downslip

The clinician exerts a gentle downwardpressure (adduction) and imparts a sharp longaxis stretch in a cephalic direction. This freesthe left innominate in the direction of anupward shear.

PROPHYLAXIS

Lumbopelvic Complex


Although the principle of addressing spinalmusculature as the supporting ropes holdsgood for the lumbopelvic complex (as in thecervico-thoracic complex) there seems adifference with regards to the specificity. InFigure 11.22: Upslip




Figure 11.24: Myofascial tender points: Lumbopelvichip (posterior): (1) Quadratus lumborum, (2) Gluteusmaximus, (3) Gluteus medius, (4) Gluteus minimus,

(5) Piriformis Figure 11.25: Myofascial tender points: Lumbopelvichip (anterior): (1) Sartorius, (2) Tensor fascia lata,(3) Pectineus, (4) Adductor longus, (5) Adductor

brevis, (6) Adductor magnus, (7) Gracilisthe lumb-pelvic complex, each muscle can beresponsible for a particular dysfunction andhence, should be individually addressed. Asingle dysfunction can occur due to combineddysfunction of a postural muscle (by tighten-ing) and a phasic muscle (by weakening).Hence, knowledge of the appropriate muscleand its relevance to a certain dysfunction isfirst necessary. Secondly, the clinician mustknow whether the muscle is postural orphasic. Thirdly, applying this knowledge themuscle should be either lengthened orstrengthened.

It is essential then to first list the posturaland phasic muscles of the lumbopelvic areaand then list the dysfunctions occurring inthe lumbopelvic area with their relevance toit. The reader may then infer the appropriatepostural and phasic muscle relevant to thedysfunction and lengthen or strengthen itappropriately (Figures 11.24 and 11.25).

Postural muscles• Iliopsoas• Hamstrings• Hip adductors



Pelvic Complex 109

• Erector spinae• Piriformis• Quadratus lumborum

Phasic muscles• Quadriceps• Gluteus maximus• Gluteus medius• Abdominals• Multifidi

Dysfunctions

Anterior innominate rotation• Iliopsoas• Rectus femoris

• Hip adductorsPosterior innominate rotation• Gluteus maximus• Hamstrings• Abdominals

Sacral flexion• Piriformis

Sacral extension• Lumbar paraspinals, multifidi

Superior translation (upslip) of innominate• Quadratus lumborum.

Lumbar flexion• Abdominals• Iliopsoas can contribute to flexion dys-

functions

Lumbar extension• Erector spinae

Intervertebral instability

• MultifidiThe clinician must remember that back

pain is an entity that also involves the pelviccomplex. Not just the innominates but thesacrum as well. More of the currentphilosphies are beginning to recognize the

importance of addressing the sacrum and theinnominates as significant contributors of low back pain including radicular pain.10,13

Indeed then the stabilization component

should also address this deficit. Dynamiclumbopelvic stability is a group entity and asmuch as the abdominals and spinal extensorshave received attention in the past thedynamic pelvic stabilizers may deserve asimilar standing. Most importantly thegluteus medius and the gluteus maximus.

REFERENCES

1. Bogduk N, Twomey LT. Clinical anatomy of the lumbar spine and sacrum. Churchill

Livingstone: New York, 1997.2. Paris SV. Anatomy as related to function and

pain. Orthopedic Clinics of North America.1983;14:475-89.

3. Garfin SR, RydEvik B, Lind B, Massey J. Spinalnerve root compression. Spine. 1995;20:1810.

4. Lippit AB. The facet joint and its role in spinepain. Spine. 1984;9:746

5. Mooney V, Robertson J. The facet syndrome.Clin Orthop. 1976;115:149-56.

6. Porterfield JA, DeRosa C. Mechanical BackPain: Perspectives in functional anatomy.Philadelphia: WB Saunders, 1998.

7. Greenman PE. Syndromes of the lumbar spine,pelvis and sacrum. Phys Med Clin N Am.1996;7(4):773-85.

8. Greenman PE. Clinical aspects of sacroiliacfunction in walking. J Man Med. 1990;5:125-30.

9. Waddell G. A new clinical model for the treat-ment of low back pain. Spine. 1987;12:632-44.

10. Greenman PE. Principles of Manual Medicine.Baltimore:Williams and Wilkins, 1996.

11. Paris SV, Loubert PV. Foundations of ClinicalOrthopedics. St. Augustine: Institute Press, 1990.

12. Sebastian D. The anatomical and physiological

variations in the sacroiliac joints of the male andfemale: Clinical implications. Journal of Manualand Manipulative Therapy. 2000;8:127-34.

13. Nyberg R. S4 course notes, St. Augustine, FL;IPT, 1993.

14. Mazee D. Orthopaedic. Physical Assessment.4th ed. Philadelphia: WB Saunders, 2002.



Section 3Regional Application

(Extremity Manipulation)

Introduction

12. Ankle and Foot

13. Knee

14. Hip

15. Shoulder

16. Elbow

17. Wrist and Hand



INTRODUCTION

Management of extremity joint dysfunctionmay vary from that of the spine in that all

joints of the extremities do not function inweight-bearing. The joints of the lowerextremity, namely the hip, knee, ankle andfoot function in weight-bearing. Properarthrokinematics and muscle interplay isrequired to absorb the forces of weight- bearing. If this is not present, dysfunctionincluding mechanical orthopedic conditionsresult. Hence, their principles of managementare essentially the same as the spine as in

identifying alignment faults and subsequentlystabilizing alignment with strong muscula-ture, followed by modification of function.

The upper extremities, although consi-dered nonweight-bearing from a gravityperspective is still subjected to compressiveforces. These compressive forces are thepowerful muscle contractions. A bowler thatreleases a cricket ball is subjecting the shoulderto significant compressive forces. A typist thattypes 5 to 8 hours a day is subjecting the wrist

and fingers to compressive forces. As muchas dynamic movement causes compressiveforces, static postures do the same as well.An electrician or a painter positioning theshoulder and elbows and working with thehands and fingers is an example. Trauma of this type can be cumulative overtime.

Hence, mechanical dysfunction of theextremities may be occupational, sportsrelated or single event traumas as in slips/falls or motor vehicle accidents. In all, dys-

functions or mechanical orthopedic conditions begin as a minor joint dysfunction, connectivetissue strains or simply the process of ageing.As the stresses continue to influence the vul-nerable structures, a more serious conditionresults as in a tendonitis, bursitis, sprain/strain or nerve entrapment. Appropriate

identification of the stressors is warranted,which is invariably1. faulty alignment/mechanics.

2. inadequate muscle length/strength.3. poor functional mechanics.

If damage has already resulted as in atendon/ligament rupture, or even a fracture,the physical therapy clinician following repairof such anatomical disruptions shouldcontinue to address the above three principles.This will help to prevent a second occurrenceof the dysfunction and optimal return tofunction.

Dysfunctions in the lower extremity are

more apparent in weight-bearing, however,not an absolute rule. But it is of importanceto know that in weight-bearing, the align-ment issues are determined by the positionin which the ankle and foot contacts theground. Dysfunctions are also determined bya similar concept. The reverse can occur,however less common. Hence, the chaptersare described starting with the ankle andfoot, for a better understanding of thedynamics of a lower extremity dysfunction.

It is important to reiterate to the clinicianagain that these mechanical conditions areentities that should be considered only afterruling out the presence of a condition thatis non-mechanical in origin. All other formsof investigation should be considered. Themanual therapy techniques per se can be usedfrom a post-immobilization perspective, i.e.to restore mobility as is taught withtraditional physical therapy. However, the basis of this altered arthrokinematic motion

and faulty muscle mechanics form a basis fordiagnosis of the ‘cause’ of the symptom.

In the upper extremity the compressiveforces are secondary to excessive musclecontraction forces rather than weight-bearingas in the lower extremity. Often times the softtissue component may be more involved than



Introduction 113

the arthrokinematic component. Hence, the basis for diagnosis will be altered tissue tex-ture abnormality, which is the third principleof the somatic diagnosis triad. Several

theories exist as to why such a persistent softtissue lesion can occur secondary to overuse.The three most common theories are asfollows:1. Prolonged and excessive contraction, as

would occur with overuse, may inducefatigue in a muscle. The muscle contractsin response to fatigue and persists tocreate a local soft tissue dysfunction withlocalized tender points called ‘triggerpoints’.

2. Excessive and faulty muscle contractioncan cause injury to the myofibrils of themuscle bulk which may heal with scarring.This scarring can inhibit normalphysiological contraction and deprive thearea of nutrition and encourage chemicalaccumulation causing pain. In addition,possible nerve endings in the healed scarmay also be pain sensitive.

3. Faulty activity can influence the muscle atan intrafusal level creating a constant

aberrant gamma motor activity whichrenders the soft tissue dysfunctional.Soft tissue irritability can aid in the

diagnosis as it is obvious as palpable tenderpoints. These tender points are seen inmuscles, musculotendinous and tenoperio-steal junctions. Breaking down the scar orischaemic compression of trigger points aresuggested forms of manual therapy inaddition to restoring normal arthrokinema-tics. Routine electrotherapy is also advocated.Hence, this approach to musculoskeletaldiagnosis is a component of conventionalmethods and not a cure at all.

However, it is unique to the professionof physical therapy and a holistic approach

with the arts of traditional medicine mayresult in a more effective outcome.

The diagnosis of mechanical dysfunctionunique to this philosophy has been described

in the section on principles of diagnosis.Hence, the joint play relevant to a specificneuromusculoskeletal pathology and the jointplay required to correct and restore overallmobility in a motion segment will bedescribed. The sections on somatic diagnosiswill address pathology specific restrictions.The treatment sections hence, will addresstreatment of somatic dysfunction in theextremity joints as two categories:1. Treatment for specific somatic dys-

function.2. Treatment for overall improvement of

range of motion.

Although there may be a considerableoverlap in treatment technique between thetwo categories, the clinician must definitelyunderstand the conceptual basis as to whythey are differentiated and thereby use thetechnique in the most appropriate situations.

Prior to discuss regional principles of theextremities it is important for the clinician toknow the contraindications to manipulationof the extremities. It should essentially be thefirst thing that comes to mind before anytreatment procedure is initiated. The majorcontraindications are listed, however as mostmanual therapy guru’s would advise—

“when in doubt, don’t”

The clinician is hence advised to exercisesound clinical judgment prior to initiating

treatment. The list is as follows, but notlimited to:• Ligament insufficiency• Rheumatoid arthritis• Connective tissue disorders• Recent fractures




• Osteoporosis• Malignancy or tumors• Instability• Bone and joint disease

• Surgical joint fusion

• Haemarthrosis• Muscle holding• Acute inflammation• Joint replacement

• Anticoagulation therapy