OPP 2 CSA 2

Radiocarpal Non-Specific Articulatory Techniques: Figure of 8

"Sandwich" patient's hand in between your hands Thenar/hypothenar eminence of your hands should be contacting patient's carpal bones Operator's hands must be offset with one hand slightly more distal than the other Move the patient's hand through all ranges of motion Flexion, extension, abduction, adduction, circumduction This can be active or passive Grasp patient's hand with your thumbs on the dorsal aspect of the hand and your fingers on the palmar aspect of the hand Apply thumb pads over the dorsal surface of the affected bone Apply slight traction Move the patient's hand through all ranges of motion in a figure of eight fashion as you apply a posterior to anterior force on the dorsum of the patient's hand

Muscle Strength Testing: Lumbar and Sacral Nerve Root Levels - Myotomes Knee flexion (hamstrings)

(L4), L5, S1, S2, (S3) (Tibial N)

short lever arm

- Large force Your hand is placed over the region to be treated and becomes the fulcrum and the short lever

9 hip flexors

- these muscles also either adduct or abduct the thigh (a) iliopsoas - made up of two muscles: liacus and psoas major - major hip flexors - origin - lumbar vertebrae and iliac fossa - insertion - lesser trochanter of femur (b) sartorius - longest muscle - origin - anterior superior iliac spine - insertion - tibia (c) tensor fascia latae - also abducts the thigh by pulling on its tendon; medially rotates - origin - iliac crest - insertion- tibia by way of the iliotibial tract or IT band (d) rectus femoris - part of quadriceps (e) 3 adductors (f) pectineus

Reflex amplitude scale

0 = Absent 1/4 = Decreased but present 2/4 = Normal 3/4 = Brisk with unsustained clonus 4/4 = Brisk with sustained clonus

Three Basic Factors Affected with OMT

1. Biomechanics: Tensegrity , Musculoskeletal system, Fascia, muscles, joints, connective tissue 2. Fluid flow: Vascular, Lymphatic, Interstitial, CSF 3. Nervous system: Autonomics (sympathetic/parasympathetic balance) Peripheral nervous system (remove pressure from nerves) 10 mm mercury pressure can alter the nerve root and dorsal root ganglion's ability to function normally

SUPERIOR PUBIC SHEAR treatment

1. Patient is supine with the physician standing on the side of the dysfunction. 2. Shift the pelvis to the edge of the table being sure to maintain stability. 3. Physician places one hand on the opposite ASIS (after setting barrier) to stabilize the pelvis while placing the other hand over the distal femur on the dysfunctional side. 4. Gently extend and abduct the hip to the barrier. 5. The patient performs hip flexion and pulls the knee toward the opposite hip (Red Arrow) for three to five seconds. (crossing the leg motion) 6. After the patient relaxes, take up the slack by further extending the hip. 7. Steps 4-6 are repeated 3-5 times, or until motion has improved. 8. Retest

INNOMINATE (ILIAC) OUTFLARE (Externally Rotated)

1. Stand on the side of the dysfunction. 2. Flex the hip and knee, then roll the pelvis away from you. 3. Physician places monitoring fingers across the PSIS, then bring the pelvis back to the table to rest on your monitoring hand. 4. Maintain lateral traction on the PSIS as you ADduct the femur to the internal rotation barrier. 5. Patient pushes (Red Arrow) the knee laterally against caudad hand (attempt to abduct and externally rotate the hip) for 3-5 seconds against resistance 6. Patient relaxes; physician takes up the slack in the tissues to the new barrier. (Blue Arrow) 7. Steps 4-6 are repeated 3-5 times or until motion has improved 8. Retest

5 hip extensors

5 Hip Extensors: - originate from pelvis and sacrum and insert into femur, tibia and fibula - some also laterally rotate the thigh Hamstrings ( semimembranosus, semitendinosus, biceps femoris)- - also flexors of the knee (b) Adductor magnus, hamstring part(lowest part) (c) Gluteus maximus - major hip extensor - extension and lateral rotation of hip - pulls on iliotibial tract - origin: iliac crest, sacrum and coccyx - insertion: gluteal tuberosity on femur

False positive standing flexion test

A false-positive test can be created by: A leg-length discrepancy >½ inch A contralateral tight hamstring A contralateral tight iliopsoas muscle A unilateral sacral dysfunction. * If this test is negative, the presence of an iliosacral dysfunction is highly unlikely

HVLA indications

A somatic dysfunction with restriction of joint motion which will benefit from resetting the bony articulation resulting in: Appropriate physiologic motion Improved biomechanical function Reduced pain Reduced somatovisceral reflex Secondary systemic effects

Abduction of the Ulna

Abduction of the ulna (arrow #1A) results in a medial glide of the olecranon (arrow #1B) and causes the radius to be pushed distally (arrow #2). This results in adduction of the wrist (arrow #3). Minor Physiologic Motion Forearm abduction Distal ulna shifts laterally (abduction) Proximal ulna (olecranon process) shifts medially (adduction) Reciprocal motion of radiocarpal joint (wrist) = adduction Somatic Dysfunction Diagnosis Forearm abduction (valgus elbow) Abduction of the distal forearm Increased carrying angle Restricted proximal ulnar lateral glide

Steps in performing HVLA

Accurate diagnosis by palpatory examination and motion testing Make sure the patient understands and consents to the procedure Decide whether to do tissue preparation such as soft tissue or other techniques Gross level positioning in the direction of the restrictive barrier (sensing the increase in tension) Fine tuning with accumulation of force at the joint - take the slack out of the tissues to approach the barrier May need to use muscle energy to achieve adequate locking into the barrier Respiratory cooperation or distraction techniques may be used (e.g., patient exhales, have the patient wiggle their toes or count backwards, etc.) High-velocity, low-amplitude thrust Retest!

Upper Extremity HVLA contraindications

Acute fracture or recent dislocation at the site of pain/decreased motion Suspected ligamentous injury Ulnar collateral ligament Skin disturbances (cellulitis) Physician skill level Patient refusal (apprehension)

Adduction of the Ulna

Adduction of the ulna (arrow #1A) results in a lateral glide of the olecranon (arrow #1B) and causes the radius to be pulled proximally (arrow #2). This results in abduction of the wrist (arrow #3). Minor Physiologic Motion Forearm adduction Distal ulna shifts medially (adduction) Proximal ulna (olecranon process) shifts laterally (abduction) Reciprocal motion of radiocarpal joint (wrist) = abduction Somatic Dysfunction Diagnosis Forearm adduction (varus elbow) Adduction of the distal forearm Decreased carrying angle Restricted proximal ulnar medial glide

Secondary Effects of HVLA

Alter length and tone of connective tissue (fascia) Remove inappropriate compression of blood vessels and lymphatics Allow better blood flow Permit better lymphatic return Remove compression on nerves Decrease nociception (pain) Allow better peripheral neural function Allow improved neurotrophic flow of proteins Normalize autonomic balance (sympathetic/parasympathetic tone)

Theories of Joint dysfunction

Alteration in the relationship of opposing joint surfaces Disruption of normal tracking of opposing joint surfaces Articular capsule problems Change in the thixotropic property of the synovial fluid Fringe of synovium (meniscoid) trapped between opposing surfaces Neural control mechanisms Alteration of the neural control (afferent input), with central control being unable to determine the joint's position in space

Anatomical leg length discrepancy

Anatomic long leg Screening measurement Tape measure, ASIS to medial malleolus Do twice, separate occasions, average Definitive Orthopedic full length x-ray CT scanogram most accurate, most expensive, most radiation Treated with lift therapy, orthopedic shoes OMT as adjunct treatment

Indications of lumbar HVLA

Articular somatic dysfunction of the lumbar spine Specific Joint Mobilization To free motion in somatic dysfunction To improve biomechanical function To reduce pain To reduce somatovisceral reflex Exercise caution in cases of acute sprain/strain May need to hold off on using HVLA until inflammation resolves or while waiting for imaging studies

Dorsal Displacement of Carpal Bones

Assess overall wrist range of motion Flexion Extension This range of motion will typically be reduced as the dorsally displaced bone will prevent the wrist from fully extending Ulnar deviation Radial deviation Palpate the dorsal aspect of the hand and wrist A dorsally displaced carpal bone will feel like it is "sticking out" when palpating the posterior aspect of the wrist/hand The patient may be tender at this location

Thrust Techniques in America

At least one bone-setting family moved from Europe to America (Sweet family in New England) Andrew Taylor Still, MD, DO, originated new methods. Students of Still found it easier to do thrust techniques than what Still was generally doing. Many of Dr. Still's students wrote texts describing their manipulative techniques: High velocity high amplitude (Hulet) High velocity indirect (Hazzard) High velocity low amplitude (McConnell) D. D. Palmer, the first chiropractor Learned from Still's students

HVLA treatment summary

Avoid HVLA if ligamentous injury or fracture is suspected Use HVLA cautiously when treating acute injuries If you suspect a bony injury (pinpoint/localized tenderness!), get an x-ray Do not attempt to compensate for poor localization (focus and precision) with an excess of force or amplitude The key to good HVLA is precision, not force The more accurate and precise you are in the set-up, the less force is required to articulate a joint Most of the time, you are only trying to move a joint about 1/8 inch or less

Guidelines for HVLA

Be aware of possible complications KNOW the patient's whole story (arthritis, trauma, scoliosis, work, etc.) Make a complete diagnosis History and palpatory exam are pre-requisites for treatment Listen with your ears and fingers. If it doesn't feel right stop and collect more data If the barrier still doesn't feel right, (too soft, rubbery, not at a FIRM barrier) don't thrust! Select a different technique, and re-assess Emphasize specificity, not force If the outcome is not what you expected, re-evaluate (for another type of technique or to find a more distant restriction that is causing this SD - biotensegrity) Do HVLA to the restriction. It may not be synonymous with the area of pain

HVLA ABSOLUTE Contraindications

Cervical HVLA Down syndrome (consider alar ligament instability) (upper cervical spine without xray confirmation of an intact odontoid process) Advanced rheumatoid arthritis (consider alar ligament instability) Advance cervical arthritis Atlantoaxial instability (C spine subluxations common) Advanced carotid disease / Vertebrobasilar insufficiency Local metastatic bone disease Fracture / dislocation / spinal instability Ligamentous disruption Patient refusal (+ treatment = assault) Others dictated by clinical conditions and good judgment - Consider the risk/benefit ratio Others NOT listed in FOM: Achondroplastic dwarfism Traumatic contracture Advanced degenerative joint disease Ankylosis / Spondylosis with fusion Active Inflammatory joint disease Local Joint infection Klippel-Feil syndrome (abnormal cervical spine fusions)

long leg

Correlates with: Inferior innominate shear Anterior rotated innominate (consensus) There can be exceptions ASIS inferior on the side of the positive standing flexion test

Tissue Preparation

Critical step to help ensure that you will be able to position the patient adequately into the barrier Many other techniques can be used to relax the tissues around the joints prior to treating with HVLA General techniques Soft tissue (ST) General Articulatory (ART) Myofascial Release (MFR) Specific techniques Counterstrain (CS) Muscle Energy (ME) Still Technique

Neurologic test for S1

DTR: Achilles motor strength: Plantar flexion Light touch (volar surface): little toe

Neurologic test for L3

DTR: patellar motor strength: knee extension Light touch (volar surface): just above the knee

Neurologic test for L4

DTR: patellar motor strength: knee flexion, dorsiflexion Light touch (volar surface): medial calf

Pubic symphysis reset for compression or gapping

DX: Superior OR Inferior Pubic Shear OR Pubic Compression Step A. Patient is supine with the hips and knees flexed and feet flat on the table and together. Physician stands at the side of the table holding the patient's knees together. Physician resists the patient's attempt to abduct both knees for a three to five second. Externally rotate patient's hip slightly Repeat above steps, 3-5 times. Step B. Physician now places the forearm between the patient's knees. The patient adducts against the physician's counterforce for up to three to five seconds. Internally rotate patient's hips slightly. Repeat above steps, 3-5 times or until release is felt at the pubic symphysis. Retest

Mechanics

Direction of distal ulna movement is how the somatic dysfunction is named Distal ulna moves in the opposite direction of proximal ulna in parallelogram mechanics Proximal ulna is how varus/valgus stress of the elbow is determined Proximal ulna is where thrust applied Ulna drives the elbow in parallelogram mechanics Radius drives the wrist in parallelogram mechanics Radius shear down = Radiocarpal ulnar deviation Radius shear up = Radiocarpal radial deviation

HVLA in the USA: Direct

Evolved as a direct technique Indirect (exaggeration) was tried and consensus at the time was that it was less effective Indirect techniques survived in Europe and could be reinvestigated

Principles of Lateral Recumbent Segmental Localization for HVLA or ME

Example: SD at L2-3 segment [L2 FRSR or L1-3 NSRRL} Short answer: L2 moves with the torso and L3 moves with the motion of the hips and lower lumbar region Explanation: You are treating the somatic dysfunction of the vertebral segment of L2-L3, therefore, you are trying to correct the restriction at the joint between the two of them. The setup for the rotational and sidebending correction occur by moving the UPPER vertebra of the dysfunctional vertebral unit. Include L2, but not L3, with the torso with the rotation and sidebending. This locks L2, so that the correction will occur at the L2-3 joint space, with the movement of L3. The localization and correction (with rotation, sidebending and sagittal plane motion) occur by moving the LOWER vertebra of the dysfunctional vertebral unit. Therefore, you include L3, but not L2, when moving the hips and lumbar spine for localization and administering the correctional thrust. Not all HVLA or ME setups reverse all planes of the diagnosis. Sometimes, they are set up to achieve leverage at a specific level through primarily one or two mechanisms (sidebending or rotation), with the rest of the setup being concerned with locking out inappropriate motion above or below the joint being addressed. (Fryette's Type 3 Motion)

Lower extremitity HVLA contraindications

Fracture Tumor Osteomyelitis or other bone disease Acute rheumatoid arthritis at the joint to be treated Suspected or actual ligamentous or meniscal injury Skin or soft tissue condition which could lead to tissue damage Any other clinical condition that would normally make HVLA inappropriate

MUSCLES INVOLVED IN TREATING INNOMINATE (ILIAC) OUTFLARE (Externally Rotated) muscles involved

Gluteus medius, gluteus minimus, piriformis obturator internus and inferior gemellus

TREATMENT SEQUENCE FOR MUSCLE ENERGY OF THE PELVIS

HIPLSIT 1. Hip Long Restrictors 2. Innominate and Sacral Shears 3. Pubic dysfunctions 4. Lumbars (Non-compensated L5) 5. Sacral Torsions 6. Innominate Rotations and Flares 7. Thoracic Dysfunctions

Tibiotalor Joint Diagnosis

Have the patient lie supine on the table with the hips and knees extended Put your thumbs under the MTP joints, with your fingers anterior to the talus Dorsiflex bilaterally and compare degree of motion Then put your thumbs anterior to the MTP joints and fingers below the soles Plantar flex bilaterally and compare the degree of motion

Fibular Head Diagnosis

Hold the leg in place with one hand around it, and your thumb in front of the tibia (not shown). Grip the fibular head between your thumb and index finger Push postero-medially and pull antero-laterally along the joint path to test motion Anterolateral glide An anterior fibular head resists posteromedial motion Posteromedial glide A posterior fibular head resists anterolateral motion You may perform the test with the patient seated or supine If supine, the knee should be flexed 15°

Adducted Forearm /Varus Elbow Treatment

Hold the patient's forearm between your arm and lateral rib cage Place the patient's elbow into full extension but not hyperextension Grasp the elbow using the thenar eminence or the MCP joint of the index finger to provide a fulcrum on the lateral side of the elbow against the posterolateral aspect of the proximal radius Localize to take the tissue slack Apply a lateral to medial thrust on the posterolateral aspect of the proximal radius Retest

Screening: Standing Flexion Test

If screening test is positive, assess the following to make a specific diagnosis: "Reseat" the pelvis- supine Supine Leg Lengths ASIS compression test ASIS Level Distance from Umbilicus to ASIS Pubic rami Level "Reseat" the pelvis- prone Prone Leg Lengths PSIS Level Ischial tuberosity Level

Levers and Force Vectors in HVLA

In HVLA, mechanical force is introduced into the body with the goal of altering structural relationships by use of a lever The force introduced through the lever is aimed at the somatic dysfunction (SD) [This creates a force vector (more on this later)]

Sequence of Lumbar Examination for Somatic Dysfunction

Initial postural screening (sagittal curves) Scoliosis screen (Adams test) Neurologic exam Special Tests Straight Leg Raise (SLR or Lasègue sign) Femoral Nerve Stretch Test (FNST) Regional Exam Visual inspection AROM/PROM (F,E,S,R) TART Segmental Exam TART to identify segmental dysfunction Segmental PROM in neutral to identify segment Segmental PROM in flexion and extension to determine diagnosis

innominate rotation

Innominates rotate around the inferior transverse axis of the sacrum Located at the inferior part of the SI joint

High Velocity, Low Amplitude: Theory of action

Intrafusal muscle fiber sensors send a sharp afferent signal that causes a reflex reduction of efferent (gamma) muscle tone Golgi tendon sensors cause reflex inhibition of the stretched muscles The joint surface is gapped, and slips back into appropriate (normal, full physiologic motion range) position

Upper Thoracic Patient Arm Variations (T1-4)

It is difficult to isolate and mobilize T1-4 when both of the patient's arms are crossed across the chest, therefore, putting one or both hands behind the neck helps engage the cervical region. This is just like testing ROM and treating the same region with ME. (OPPOSITE ARM)

HVLA Relative Contraindications

Joint/ligamentous hypermobility Pregnancy (think Gumby) Patient apprehension Herniated Discs (pts with radicular symptoms) Acute whiplash / severe muscle spasm / strain / sprain Patients on Chronic Steroids (oral/inhaled) (d/t increased risk of fracture) Rheumatoid Arthritis (Early stages and Not in acute phase) Prior spinal surgery (fusion, hardware, disc repair) Osteopenia / Osteoporosis Spondylolisthesis (ask!) Pt on anticoagulation Metabolic bone disease

Biotensegrity and HVLA

Joints with poor mobility interrupt the smooth distribution of forces as the body, or a portion of it, Moves Receives an impact Falls Hits any object We use OMT to restore normal kinetics to dysfunctional joints so that they will once again have: appropriate motion maximum adaptability This treatment affects: the joint surfaces the tension elements related to them everything that passes through those tension elements

Muscle Strength Testing: Lumbar and Sacral Nerve Root Levels - Myotomes: Hip flexion (iliopsoas)

L1, L2, L3, L4 (Femoral Nerve)

Muscle Strength Testing: Lumbar and Sacral Nerve Root Levels - Myotomes: Knee extension (quadriceps)

L2, L3, L4 (Femoral N)

Light Touch Testing - Dermatomes

L2-5 and S1

Deep Tendon Reflex testing

L3-4 - Patellar L5 - Reflex typically not tested, use extensor hallucis longus extension to test S1-2 - Achilles

Muscle Strength Testing: Lumbar and Sacral Nerve Root Levels - Myotomes ankle dorsiflexion (tibialis anterior)

L4, L5 (Deep Fibular N)

Muscle Strength Testing: Lumbar and Sacral Nerve Root Levels - Myotomes GReat toe extension (extensor hallicus longus)

L5, S1 (Deep Fibular N)

Upper Extremity HVLA indications

Lateral epicondylitis Medial epicondylitis Carpal tunnel syndrome Cubital tunnel syndrome Radial nerve entrapment Hand, wrist or elbow pain accompanying restriction of motion

Navicular, Cuboid, Cuneiform Hiss Plantar Whip HVLA

Look at and observe the area to be treated Diagnose TART criteria (i.e. tenderness, TTA, ROM) in the region using your finger pads Maintain a balanced posture next to the patient who is prone on the table or standing and leaning over the table's edge Place your (reinforced) thumbs on the plantar surface of the dysfunctional bone Position the foot in a position where it feel like most of the barrier to motion has been removed Apply a thrust at the end of this motion Direct the thrust: Straight down for the navicular and cuneiforms Down and laterally for the cuboid Reassess motion of the dysfunctional bone

Posterior head HVLA

Look at and observe the area to be treated Maintain a balanced posture next to the supine patient on the table Diagnose TART criteria (i.e. tenderness, TTA, ROM) in the region using your finger pads Flex the patient's hip and knee Place the proximal phalanx or MCP of your index finger behind the fibular head as a wedge Externally rotate the tibia through the distal leg. At the same time, increase knee flexion to take out the tissue slack, applying slight lateral traction with the hand behind the fibular head When you reach the barrier, direct a short lever thrust in the anterolateral direction with the MCP joint and as you gently encourage further flexion of the knee Reassess fibular head motion

POSTERIOR INNOMINATE ROTATION ME type

ME Type: Joint mobilization using muscle force Patient may complain of inguinal/groin pain (secondary to rectus femoris dysfunction) and/or medial knee pain.

INNOMINATE (ILIAC) INFLARE (INTERNALLY ROTATED) ME type

ME Type: Post Isometric Relaxation

INNOMINATE (ILIAC) OUTFLARE (Externally Rotated) ME type

ME Type: Post Isometric Relaxation

SUPERIOR INNOMINATE SHEAR

ME Type: Respiratory Cooperation/ post isometric relaxation Stand at the end of the table. The supine patient's feet are off the table. Place your thigh against the contralateral foot (non-dysfunctional side) to stabilize the pelvis. Hold the patient's leg (dysfunctional side) just above the ankle. ABduct the lower extremity about 10-15° to loose-pack the SI joint. (Green Arrow) Internally rotate the hip to close-pack the hip joint. (Blue Arrow) Put traction on the leg. (Red Arrow) Have the patient breathe in and out deeply. Patient pulls hip superiorly (Orange Arrow) while he breathes in; resist any upward movement (Purple Arrow) when the patient relaxes and breathes out. With each exhalation, the tractional force is increased. Steps 7 and 8 are repeated 3-5 times Retest

Carrying Angle

Measured by the angle of deviation of the forearm (blue line) from the long axis of the humerus (red line) Angle between the red and blue lines The trochlear notch of the ulna has a slight spiral allowing for slight abduction of forearm allowing for this angle Typically is grossly measured by visual inspection Normal angles: Males: 5°-10° Females: 10°-15° Abnormal angles: Cubitus valgus: >15° Cubitus varus: <5°-10°

The Key Element for Success with HVLA: Localization

Memorize the anatomy of the joints Induce a force vector to the joint before you thrust Make sure you can feel the accumulation of forces at your fulcrum before thrusting "Take the slack out of the tissues" If the patient holds their breath, it does not allow the body to relax properly to allow successful HVLA In the thoracics and ribs, if the patient holds their breath, the inflated lungs function like bouncing on a ball Thoracics Feel the force vector coming from your body to your fulcrum [haptic sensing] Be sure your thrust is delivered directly over the vertebra, not from an angle laterally Ribs Feel the force vector coming from your body to the fulcrum Be sure your thrust is delivered from above the rib angle, not above the spine Lumbars Feel the tension accumulate in the region of your palpating hand, but extend your sense into the joint Cervicals Be sure that you reach the barrier at the joint, not the skin, before thrusting

humerolulner joint

Mostly a hinge joint Articulation between: Trochlea of the humerus Ulna

Ligamentous tension locking

Motion of the joints is prevented by separation of the facets, with the capsules of the zygapophyseal joints placed under tension

Motor strength scale

Motor Strength 0 (zero) No evidence of contractility 1/5 (trace) Evidence of slight contractility; no joint motion 2/5 (poor) Complete range of motion with gravity eliminated 3/5 (fair) Complete range of motion against gravity 4/5 (good) Complete range of motion against gravity with some resistance 5/5 (normal) Complete range of motion against gravity with full resistance

nonphysiological movement of innonimantes

Non-Physiologic Generally induced by trauma. It is evidenced by the joint, muscle, and connective tissue elements being in positions and/or relationships that are not part of the physiologic range of motion and do not involve the physiologic axes of motion. Innominate Shear Inferior/superior Pubic Shear Inferior/superior/compression

Radiounlar Joint

Normal motions of the radial head in relation to the humerus and ulna Pronation: The proximal radius moves posterior The distal radius moves anterior and medial Supination: The proximal radius moves anterior The distal radius moves posterior and lateral

Anterior Radial Head HVLA

Note: Correct humeroulnar somatic dysfunctions prior to treating radial head somatic dysfunctions Contact the anterior portion of the radial head with your hypothenar eminence or finger pads Grasp your patient's distal radius and ulna with your other hand and flex the forearm at the elbow as you induce pronation through the long lever of the forearm Fine tune using pronation and flexion to localize to the joint and remove tissue slack Apply a corrective thrust: Short lever: Apply an anterior to a posterior thrust to the anterior aspect of the radial head as you reach the end of pronation Long lever: Apply a quick pronation thrust to the forearm with your hand that is on the distal radius and ulna Retest

INFERIOR INNOMINATE SHEAR treatment

Patient is prone with the physician standing on the same side as the dysfunction 2. The patient's foot is held by the physician's hand, the patient's knee is flexed while the other hand is placed on the patient's ipsilateral ischial tuberosity 3. The leg is abducted to about 10-15° to loose-pack the SI joint 4. A cephalad force is placed on the ipsilateral ischial tuberosity while the patient performs a series of deep inhalation and exhalation efforts 5. Additionally, the patient attempts to straighten the ipsilateral arm (Blue Arrow), that is holding on the table leg during inhalation. This results in a caudal force through the trunk. During exhalation, the patient stops straightening the ipsilateral arm while the physician takes up the slack by pushing cephalad on the ipsilateral ischial tuberosity. 6. Steps 4-5 are repeated 3-5 times. 7. Retest

Physiological movement of innominates

Physiologic The muscles, connective tissue, and joints remain in positions that are normally a part of physiologic motion but are dysfunctional when the body should have returned to a neutral position but did not do so. Rotation Anterior or Posterior Flare Inflare or Outflare

cuniforms

Physiologic Motion Inversion and eversion Somatic Dysfunction Dropped, or inferior intermediate cuneiform (most common)

cuboid

Physiologic Motion Inversion and eversion Somatic Dysfunction Eversion with plantar flexion Flattened longitudinal arch Tenderness and palpable protrusion of medial edge of cuboid

Navicular

Physiologic Motion Inversion and eversion Somatic Dysfunction Inversion with plantar flexion Flattened medial arch Tenderness and palpable protrusion of lateral edge of navicular

locking

Positioning the joint into the direction of restriction, just short of being fixed in place, so that a small range of motion is possible, but less than at the joints above and below

Supination Somatic Dysfunction

Pronation restriction Greater ROM with supination compared to pronation The radial head is "stuck" in an anterior position

Straight Leg Raise [SLR] (Lasègue Test)

Provocative maneuver for diagnosis of sciatic nerve root irritation lumbar disc herniation (most specifically for L5-S1) Patient supine (preferred) or seated Stabilize the ipsilateral hip on the table Lift leg up while keeping knee extended Positive test = 30-70° flexion - pain that radiates down the posterior thigh to below the knee due to nerve root tension. Pain <30 ° is not considered to be related to nerve root irritation. Pain >70 ° may be indicative of tight hamstring or gluteal muscles, sacroiliac pain or lumbar facet joint pain. Seated test may be used to outwit malingerers. Bilateral leg pain or crossed-over results in response to either of these tests may be suggestive of central disc herniation or cauda equina involvement.

Adductor magnus

Proximal Attachment Adductor part: inferior ramus of pubis, ramus of ischium Hamstrings part: ischial tuberosity Distal Attachment: Adductor part: gluteal tuberosity, linea aspera, medial supracondylar line Hamstrings part: adductor tubercle of femur Innervation: Adductor part: obturator nerve (L2, L3, L4), branches of posterior division Hamstrings part: tibial part of sciatic nerve (L4) Main Action: Adducts thigh Adductor part: flexes thigh Hamstrings part: extends thigh

Adductor brevis

Proximal Attachment Body and inferior ramus of pubis Distal Attachment Pectineal line and proximal part of linea aspera of femur Innervation Obturator nerve, branch of, anterior division (L2, L3, L4) Main Action Adducts thigh; to some extent flexes it

Pectineus

Proximal Attachment: Superior ramus of pubis Distal Attachment: Pectineal line of femur, just inferior to lesser trochanter Innervation: Femoral nerve (L2, L3); may receive a branch from obturator nerve Main Action: Adducts and flexes thigh; assists with medial rotation of thigh

Radioulnar joint somatic dysfunctions: Anterior radial head

Radial head is anterior in relation to the humerus and ulna Tenderness at articulation Restricted pronation range of motion Supination dysfunction

Radioulnar joint somatic dysfunctions: posterior radial head

Radial head is posterior in relation to the humerus Tenderness at articulation Restricted supination range of motion Pronation dysfunction

Nursemaid's Elbow

Radial head subluxation from the annular ligament Typically etiologies: Catch a child by the hand to stop a fall Lift a child up by the hands or wrists Pull a child's arm through a jacket sleeve Swing a child by the arms or hands Yank on a child's arm to make him/her walk faster Child typically will not use/move the arm until the radial head is reduced Treatment: Application of slight traction on the forearm Supination of the forearm as the forearm is flexed at the elbow Radial head subluxation from the annular ligament Typically etiologies: Catch a child by the hand to stop a fall Lift a child up by the hands or wrists Pull a child's arm through a jacket sleeve Swing a child by the arms or hands Yank on a child's arm to make him/her walk faster Child typically will not use/move the arm until the radial head is reduced Treatment: Application of slight traction on the forearm Supination of the forearm as the forearm is flexed at the elbow

Reciprocal motions of fibular head

Reciprocal motions: External rotation of the tibia (C) moves the distal fibula posteriorly (B) and reciprocally is associated with the fibular head moving anteriorly (B1) The opposite is true (A, A1) with internal rotation (D) of the lower leg

Contraindications of lumbar HVLA

Refer to the Absolute and Relative Contraindications on the History and Principles of HVLA lecture Anatomic/pathologic changes such as: Fracture Traumatic contracture Advanced degenerative joint disease Ankylosis Severe osteoporosis Herniated lumbar disc Vertebral infection Metastatic disease (especially breast, kidney, lung, thyroid, and prostate cancers) Patient refusal

Muscle Strength Testing: Lumbar and Sacral Nerve Root Levels - Myotomes Ankle plantar flexion (gastocnemius)

S1, S2 (Tibial N)

Barriers and the Importance of End-Feel

Sense of increasing tension when approaching the barrier to motion A barrier can be: A solid impediment to motion A tethering effect that restrains motion from occurring (this is the kind of barrier we are trying to get past with HVLA) The barrier is 3D The barrier you feel prior to HVLA should have a "crisp" or "distinct" end-feel, rather than a "rubbery" end-feel A rubbery end-feel probably means you should try a different type of technique

HVLA Principles

Setup must be specific - Position patient directly into the barrier Need diagnosis in three planes to find the "sweet spot" Position into the barrier in all 3 planes - sidebending and rotation, flexion and extension Thrust directly into barrier "Quick 1/8th inch" Low Amplitude means Low Amplitude: You are treating Facets! Direction of thrust after correct position is the challenge It is all about the vectors "Never pay for the same real estate twice" The sweet spot is the position where your fingers feel the dysfunction will resolve with a tiny thrust If you have it right, the patient and you may feel it move before you thrust

long lever arm

Small force Your hand is holding the arms and using the patient's body as the long lever

Somatic dysfunction diagnosis of the fibular head

Somatic Dysfunction Diagnosis Anterior fibular head Fibular head prefers anterior movement/position Fibular head has restricted posterior movement Posterior fibular head Fibular head prefers posterior movement/position Fibular head has restricted anterior movement

Radiocarpal HVLA

Somatic dysfunction may be named by: Motion restriction Specifying which bone is dorsally displaced Grasp patient's hand with your thumbs on the dorsal aspect of the hand and your fingers on the palmar aspect of the hand Apply thumb pads over the dorsal surface of the affected bone Apply slight traction Extend and abduct/adduct the patient's hand at the wrist to localize to the dysfunctional segment and to remove tissue slack Apply a posterior to anterior thrust to the dorsal surface of the affected bone (further extension of the wrist may occur) Retest

HVLA Possible Side Effects

Soreness, stiffness Most common Myalgias/muscle aches and achy pain (NOT sharp pain) Vertigo (if treating the cervical spine) Treatment reaction (flare) More serious side effects 1-2/1,000,000

ASIS COMPRESSION TEST

Stand at the level of the patient's hips Place your palms or thenar eminences on/inferior to ASIS's. Compress with mild/moderate A-P/medial force at about a 45° angle through ASIS's. Sequentially induce an impulse to spring the joints. Blocked relative motion indicates a positive test on that side. Useful especially when standing or seated flexion tests can't be done. NOTE: This motion is MINUTE. "Blocked relative motion" has a hard end-feeling to it.

POSTERIOR INNOMINATE ROTATION

Standing on the dysfunctional side, bring the patient's sacrum to the edge of the table (freeing the SI joint). Place the patient's near leg off the table, and stabilize the contralateral ASIS with your other hand. Put your other hand on the thigh above the patella and passively extend the patient's dysfunctional hip. Have the patient try to flex the hip for 3-5 seconds while you resist. After the patient relaxes, find the new feather edge by pushing the thigh slightly lower. This will pull the dysfunctional innominate toward anterior rotation. Steps 4-5 are repeated 3-5 times or until motion has improved. Retest.

Prpnation somatic dysfunction

Supination restriction Greater ROM with pronation compared to supination The radial head is "stuck" in a posterior position

Three Primary Unifying Systems in Body Unity

Systems of communication Neurologic Cardiovascular Endocrine The body primarily uses these systems for its communication Naturally, other systems are interactive and involve communication Connective tissue may be considered another, but in a different way

Anterior Tibia on Talus or Posterior Talus

The ankle prefers dorsiflexion (has restricted plantar flexion) The tibia: is anterior on the talus has restricted posterior glide on the talus

Anterior Talus or Talus in Plantar Flexion

The ankle prefers plantar flexion (has restricted dorsiflexion) The tibia is posterior relative to the talus has restricted anterior glide on the talus

Joint Play - Small movements at the synovial joints

The body's synovial joints have approximately 1/8" of movement (may be slightly more) This potential movement is not controlled by (is independent of) voluntary muscle contraction It is necessary in order to have normal, pain-free, non-restricted vertebral movement When these motions are absent, movement becomes restricted and may be painful Term described by John Mennell, MD

Facet apposition locking

The facets (zygapophyseal joints) are forced against each other at right angles to their normal range of motion

Combined Leverage

The force is imparted simultaneously through the physician's body part which is near the structure to be treated (short lever) in this case, the metacarpophalangeal or proximal interphalangeal joint being near a cervical facet joint ...and the patient's body part which is farther away from the structure to be treated (long lever) in this case, the head and neck ...to induce a small amount of motion to the structure to be treated in this case, a right cervical zygapophyseal joint

long lever technique

The force is imparted through your body part in this case, your epigastrium ...and the patient's body in this case, his arms and thorax ...which is/are farther away from the joint to which you are addressing the force

Why Dysfunctional Segments Won't Move

The joint is inhibited from completing its full normal motion External or internal force has caused local segmental irritation to create focal edema and swelling This causes a tightening of the fascial structures, myofascial and capsular components of a specific arthrodial joint The articular distortion results in reflex hypertonicity of the muscles crossing the joint A resultant decrease of ROM occurs

What is the most commonly fractured carpal bone

The most commonly fractured carpal bone is the scaphoid

Tips of LUMBAR HVLA

The patient is lateral recumbent, with the posterior transverse process(es) down. Stand in front of the patient at the level of the lumbar spine Keep the patient's shoulder and hip perpendicular to the table. Use the shoulder closest to the table to move the torso to induce rotation and sidebending to the segment from above. Localize to the joint to be treated by flexing the hips until motion reaches the appropriate level Fine tune the localization with a little bit of muscle energy if necessary.

Basic Tips for lumbar HVLA

These techniques can also be done with many patients as far superior as T10-12. Initial practice is easier if you start learning with someone approximately your own size; over time, you learn to adapt for larger and smaller people. "The pop is not the criterion..." (A. T. Still) Retest, to be sure the articulation had the desired effect.

Pubic symphysis reset for compression or gapping ME type

Type of ME: Joint mobilization using muscle force

SUPERIOR PUBIC SHEAR ME type

Type of ME: Joint mobilization using muscle force

INFERIOR INNOMINATE SHEAR ME type

Type of ME: Post Isometric Relaxation and Respiratory Cooperation

INFERIOR PUBIC SHEAR ME type

Type of ME: Post Isometric Relaxation/ Joint mobilization using muscle force

ANTERIOR INNOMINATE ROTATION ME type

Type of ME: Post Isometric Relaxation/Joint mobilization using muscle force

Common elbow injuries

UCL commonly injured in baseball pitchers due to violent valgus torque during pitching

Muscles involved in pubic symphysis reset technique

USE INTERNAL VS. EXTERNAL ROTATORS & ABDUCTORS VS. ADDUCTORS TO"WIGGLE" PUBES FREE

What is the sound?

Vernacular: pop, click, or crack Cavitation: formation of vapor bubbles of a flowing liquid in a region where the pressure of the liquid falls below its vapor pressure Low pressure is created in synovial fluid during rapid gapping action Bubbles have been seen in joint spaces on post-aspect radiologic studies pre and post-thrust Theorized to be nitrogen bubbles drawn out of suspension by creation of partial vacuum

innominate inflare/outflare

Visualize a line from each ASIS to umbilicus Is the side with the positive standing flexion test relatively farther (outflare) or closer (inflare) to umbilicus?

INFERIOR PUBIC SHEAR

With the patient supine, stand on the dysfunctional side with the patient's hip and knee flexed. Place the heel of your caudad hand on the ischial tuberosity while placing the PSIS between your middle and ring fingers. Place the hip in flexion, internal rotation, and adduction to engage the barrier while close packing the SI joint. Ask the patient to push the knee toward you (extend the hip) for 3-5 seconds against your resistance, simultaneously your caudad hand places a cephalad and medial force on the ischial tuberosity. After the patient relaxes, find the new "feather edge" of the barrier by further flexing the thigh. Steps 4-5 are repeated 3-5 times, or until motion has improved. Retest.

Muscles involved in superior pubic shear

adductors (arrow points to longus)

What ligaments are you treating with a superior innominate shear

iliofemoral, pubofemoral, pubocapsularis,

sacral axes of movement for innominate rotations

inferior transvers

What is the most commonly dislocated carpal bone

lunate

Neurologic test for L5

motor strength: Extensor hallicus longus extension Light touch (volar surface): lateral calf, top of foot

Neurologic test for L2

motor strength: hip flexion and knee flexion Light touch (volar surface): anterolateral thigh

Dorsalis pedis

palpate just lateral to the Extensor Hallucis Longus

Posterior tibial pulse

palpate just posterior to, and on the inferior aspect of, the medial malleolus.

Muscles involved in treating inferior muscle shears

rectus abdominis, linea alba, hamstrings

muscles involved in treating a posterior innominate rotation

rectus femoris

Pubic Rami compression somatic dysfunction

standing flexion test can be positive or negative: ASIS, PSIS are equal, bilateral tender pubic rami, tender pubic symphysis

Femoral Nerve Stretch Test [FNST]

"The femoral nerve stretch test is probably the single best screening test to evaluate lumbar radiculopathy secondary to an upper lumbar disc herniation." Provocative maneuver for diagnosis of high lumbar disc herniations (L2-L3, L3-L4 or L4-L5) Patient prone Examiner places a palm in the popliteal fossa and the knee is fully flexed (so as to compress on the examiner's hand.) Positive test = severe pain in the anterior aspect of the thigh and/or back.

INNOMINATE (ILIAC) INFLARE (INTERNALLY ROTATED)

1. Stand on the side of the dysfunction. 2. Flex the ipsilateral hip and knee, place the foot below the opposite knee, and externally rotate the hip toward you. 3. Put one hand over the contralateral innominate to stabilize the pelvis 4. With the other hand over the medial aspect of the dysfunctional side's knee, externally rotate the hip until the barrier is engaged. (Blue arrow) 5. Have the patient push the knee against your hand (attempt to internally rotate the hip), as you resist for 3-5 seconds. (Red arrow) 6. Patient relaxes, take up the slack in the tissues to the new barrier. 7. Steps 4-6 are repeated 3-5 times or until motion has improved. 8. Retest

LEG LENGTH, SUPINE

After the patient reseats the pelvis: Pull the legs straight, then relax traction. Place thumbs on the inferior aspects of the medial malleoli. Without putting traction on either side, observe the position (superior, inferior) of the malleolus on the side of the positive standing flexion test. Indicates leg length discrepancy, functional or anatomic. Patient lies supine on the table Place your thumbs on the inferior aspects of the medial malleoli bilaterally Using your dominant eye, observe the medial malleolus height on the side of the positive standing flexion test and compare it to the other side Be sure not to put excessive traction on either side

Caveats of HVLA

Avoid HVLA if ligamentous injury or fracture is suspected Use HVLA cautiously when treating acute injuries Do not attempt to compensate for poor localization (focus and precision) with excess force or amplitude "The operator's force is inversely proportional to their knowledge of the problem." The key to good HVLA is precision, not force. The more accurate and precise you are in the setup, the less force is required to articulate a joint Most of the time, you are only trying to move a joint about 1/8 inch

Lower extremity HVLA indications

Foot, knee, or ankle pain with restriction motion Plantar fasciitis Minor ankle sprains

Abducted forearm/valgus elbow:

Ease of motion when applying a lateral to medial force to the posterolateral aspect of the proximal radius and resisted motion with a hard "end-feel" when applying a medial to lateral force to the posteromedial aspect of the proximal ulna

Adducted forearm/varus elbow

Ease of motion when applying a medial to lateral force to the posteromedial aspect of the proximal ulna and resisted motion with a hard "end-feel" when applying a lateral to medial force to the posterolateral aspect of the proximal radius

Functional leg length discrpancy

Functional long or short leg Supine and prone assessment Contributing factors: Innominate shear Innominate rotation LE somatic dysfunction Sacral somatic dysfunction Lumbar somatic dysfunction Treated with OMT to resolve dysfunction Lift therapy used if after functional situation is treated, slight anatomical difference remains (usually without extensive studies)

Theory of HVLA

Gaps a joint that does not permit normal physiologic motion The body automatically resets articular surface apposition Theory: As the thrust is delivered, and the joint surface apposition resets to normal Rapid input is thought to overload the CNS with too much information The CNS is then theorized to reset parameters of muscle tension based on new positional reporting of the joint Two primary effects: Joint surface apposition is reset to allow normal (or improved) range of motion Length and tension of involved muscles are reset to normal (or closer to normal)

Assessment of Varus/Valgus Motion in the elbow

Hold the patient's forearm between your arm and lateral rib cage Place the patient's elbow into full extension but not hyperextension Grasp the elbow and motion test: Localize to the joint by taking out any tissue slack Use the thenar eminence or the MCP joint of the index finger to provide a fulcrum on the medial side of the elbow against the posteromedial aspect of the proximal ulna Apply a medial to lateral force to the posteromedial aspect of the proximal ulna Simultaneously you can gently apply a lateral to medial force to the distal forearm which is against your rib cage Assess for the quality of motion Use the thenar eminence or the MCP joint of the index finger to provide a fulcrum on the lateral side of the elbow against the posterolateral aspect of the proximal radius Apply a lateral to medial force to the posterolateral aspect of the proximal radius Simultaneously you can gently apply a medial to lateral force to the distal forearm which is against your rib cage

Abducted Forearm /Valgus Elbow Treatment

Hold the patient's forearm between your arm and lateral rib cage Place the patient's elbow into full extension but not hyperextension Grasp the elbow using the thenar eminence or the MCP joint of the index finger to provide a fulcrum on the medial side of the elbow against the posteromedial aspect of the proximal ulna Localize to take the tissue slack Apply a medial to lateral thrust on the posteromedial aspect of the proximal ulna Retest

Anterior Talus HVLA

Look at and observe the area to be treated Maintain a balanced posture next to the supine patient on the table Diagnose TART criteria (i.e. tenderness, TTA, ROM) in the region using your finger pads Dorsiflex the foot, with your crossed fingers on the talus NOT the distal tibia Apply gentle traction and use the crossed fingers as a wedge, inducing slightly more dorsiflexion to take out tissue slack Induce a rapid inferior tug on the foot, simultaneously increasing dorsiflexion with a slight downward scooping motion Reassess tibiotalor joint motion

Anterior Tibia on Talus

Look at and observe the area to be treated Maintain a balanced posture next to the supine patient on the table Diagnose TART criteria (i.e. tenderness, TTA, ROM) in the region using your finger pads Grasp the heel to stabilize it with one hand Apply traction to the calcaneus while dorsiflexing the foot slightly to a more neutral position Without dorsiflexion, the calcaneus will block the tibia from moving backward Grasp the distal end of the tibia with your other hand, palm down Apply pressure through the tibia down toward the table to take out the tissue slack Apply a posterior thrust through the heel of your hand on the distal tibia while using the other hand to increase traction and dorsiflexion of the foot and ankle Reassess tibiotalor joint motion

Anterior fibular head HVLA

Look at and observe the area to be treated Maintain a balanced posture next to the supine patient on the table Diagnose TART criteria (i.e. tenderness, TTA, ROM) in the region using your finger pads Place your thenar eminence over the anterior fibular head with the patient's hip and knee extended Invert and slightly plantar flex the foot to disengage the fibular head Internally rotate the tibia through the distal leg and take out the tissue slack Direct your thrust posterior and a bit laterally This avoids compressing the joint Reassess fibular head motion

Supine Thoracic HVLADiagnosis and Positioning

Look at and observe the soft tissue to be treated Evaluate the region with TART Diagnose the thoracic spine with a triplanar diagnosis (like with Muscle Energy) Physician ALWAYS stands on the side of the patient OPPOSITE of the posterior transverse process (opposite of the somatic dysfunction's rotation) Stand with feet about shoulder-width apart, one foot in front of the other and well balanced, facing your patient & turned slightly toward their head Have the patient lie supine on the table with arms beside their body Slide your patient to the edge of the table adjacent to you

Tips on Performing HVLA

Make an accurate diagnosis ... This is key Be sure that the patient is close to the edge of the table adjacent to you Prepare the tissues with soft tissue or other techniques This helps prevent the tight tissues from pulling the vertebrae back into the previous somatic dysfunction In the supine thoracic treatment, roll the patient's weight directly over the posterior transverse process, which is directly over your fulcrum (NOT over the spinous process) Position the affected segment at the restrictive barrier (sensing the increase in tension) Localize your forces and fine tune to reach the restrictive barrier "lock out" the motion in all planes This allows you to use less force Localization and fine tuning are CRITICAL for an efficient treatment Be sure the patient is relaxed prior to delivery of the high-velocity, low-amplitude thrust Use respiratory cooperation (thrust during patient exhalation) Remember, the longer the patient is held in position, the more tense they will become Always reassess - the popping noise is not always indicative of correction

Pronation restriction Greater ROM with supination compared to pronation The radial head is "stuck" in an anterior position

Note: Correct humeroulnar somatic dysfunctions prior to treating radial head somatic dysfunctions Place the patient's elbow into full extension but not hyperextension Use your thumb pad on the posterior aspect of the radial head Grasp your patient's distal radius and ulna with your other hand and induce supination through the long lever of the forearm Fine tune using supination and extension to localize to the joint and remove tissue slack Apply a corrective thrust: Short lever: Apply a posterior to anterior thrust to the posterior aspect of the radial head using your thumb as you reach the end of supination Long lever: Apply a quick supination thrust to the forearm with your hand that is on the distal radius and ulna Retest

elbow assessment

Patient may complain of elbow pain Epicondyles Olecranon process Antecubital area Observation may indicate a change in the carrying angle of the affected side compared to the side without dysfunction/pain Assess range of motion at the elbows bilaterally Passive abduction/adduction at the ulnohumeral joint Done with the elbow in full extension but not hyperextension Passive pronation/supination of the forearm Done with the elbow at 90° flexion Assess for any wrist compensation If there is an abducted wrist, it may be compensating for an adducted forearm/varus elbow If there is an adducted wrist, it may be compensating for an abducted forearm/valgus elbow

Pronation Dysfunction/Posterior Radial Head

Patient's humerus is perpendicular to the ground with the elbow flexed to 90° Supinate and pronate the forearm with the one hand while monitoring the motion of the radial head with the other hand Diagnosis: There is greater pronation range of motion compared to supination and the radial head has a more posterior position Usually produced by a fall forward onto the palm of an outstretched hand (FOOSH) because the anterior motion of the distal radius, started by the pronation, is accentuated Though a fall forward is on the hand, the hand is in a pronated position, and the forward vector of the hand and body pushes the distal radius into a more anterior rotation, thus causing the radial head (proximal) to move posteriorly

Supination Dysfunction/Anterior Radial Head

Patient's humerus is perpendicular to the ground with the elbow flexed to 90° Supinate and pronate the forearm with the other hand while monitoring the motion of the radial head with the other hand Diagnosis: There is greater supination range of motion compared to pronation and the radial head has a more anterior position Usually produced by a fall backward onto the palm of an outstretched hand because the posterior motion of the distal radius, started by the supination, is accentuated Though a fall backward is on the hand, the hand is in a supinated position, and the backward vector of the hand and body pushes the distal radius into a more posterior rotation, thus causing the radial head (proximal) to move anteriorly

Motion of the fibular head

Physiologic Motion The proximal fibula moves in anterolateral and posteromedial directions, relative to the proximal tibia Reciprocal Motions When the proximal fibula moves posteriorly, the distal fibula moves anteriorly (and vice versa) Related Motion External rotation of the tibia causes the proximal fibula to move anteriorly (and the distal fibula, posteriorly)

PUBIC RAMI LEVELS Assessing the anterior aspects of the pubic rami

Place your fingers on the anterior aspects of the pubic rami. Move the fingers side to side a couple times to palpate for evidence: (A): 1. Tenderness of pubic symphysis 2. Palpable bulging of the symphyseal cartilage Diagnosis: Fixed compression of the pubic symphysis (Adducted pubic bones) Or (B): 1. Tenderness of pubic symphysis 2. Sulcus deeper than normal at the pubic symphysis Diagnosis: Fixed gapping of the pubic symphysis (Abducted pubic bones)

Lumbar Roll in a Nutshell - Basic Flow

Posterior transverse process down. Monitor at that level and the joint space below. Pull the table-side-shoulder toward you to rotate and sidebend the torso down to and through the dysfunctional vertebra to the dysfunctional joint space. Type I: Pull the shoulder caudad. (induces sidebending toward table) Type II: Pull the shoulder cephalad. (induces sidebending toward ceiling) Localize by flexing up to the dysfunction from below, using both legs as long levers and then extend the lower leg on the table (you may use only the top leg to do all of this if you are smaller than the patient). Stabilize the legs and pelvis by keeping the pelvis perpendicular to the table. Place your caudad forearm just below the iliac crest, the other on the chest wall under the arm, and be sure again that your monitoring hand is in position. Roll the body as a unit toward you, and take out the slack. The "log roll" You may use a distraction technique (breathing out, wiggling the toes of one foot, etc.,) to relax the patient as you take out the final slack and achieve complete localization of your forces. Perform the thrust Retest (even if you heard an audible articulation).

Semimembranosus

Proximal Attachment: Ischial tuberosity Distal Attachment: Posterior part of medial condyle of tibia; reflected attachment forms oblique popliteal ligament (to lateral femoral condyle) Innervation: Tibial division of sciatic nerve part of tibia (L5, S1, S2) Main Action: Extend thigh; flex leg and rotate it medially when knee is flexed; when thigh and leg are flexed, these muscles can extend trunk

Quadratus femoris

Proximal Attachment: Lateral border of ischial tuberosity Distal Attachment: Quadrate tubercle on intertrochanteric crest of femur and area inferior to it Innervation: Nerve to inferior gemelli (L5, S1) Main Action: Laterally rotates thigh; steadies femoral head in acetabulum

Sartorius

Proximal Attachment: Anterior superior iliac spine ` and superior part of notch inferior to it Distal Attachment: Superior part of medial surface of tibia Innervation: Femoral nerve (L2, L3) Main Action: Flexes, abducts, and laterally rotates thigh at hip joint; flexes leg at knee joint, (medially rotating leg when knee is flexed)

Tensor fasciae latae

Proximal Attachment: Anterior superior iliac spine; anterior part of iliac crest Distal Attachment: Iliotibial tract, which attaches to lateral condyle of tibia Innervation: Superior gluteal nerve (L5, S1) Main Action: Abduct and medially rotate thigh; keep pelvis level when ipsilateral limb is weight-bearing and advance opposite (unsupported) side during its swing phase

Piriformis

Proximal Attachment: Anterior surface of sacrum; sacrotuberous ligament Distal Attachment: Superior border of greater trochanter of femur Innervation: Branches of anterior rami of S1, S2 Main Action: Laterally rotate extended thigh and abduct flexed thigh; steady femoral head in acetabulum

Gracilis

Proximal Attachment: Body and inferior ramus of pubis Distal Attachment: Superior part of medial surface of tibia Innervation: Obturator nerve (L2, L3) Main Action: Adducts thigh; flexes leg; helps rotate leg medially

Adductor longus

Proximal Attachment: Body of pubis inferior to pubic crest Distal Attachment: Middle third of linea aspera of femur Innervation: Obturator nerve, branch of, anterior division (L2, L3, L4) Main Action: Adducts thigh

Gluteus minimus

Proximal Attachment: External surface of ilium between anterior and inferior gluteal lines Distal Attachment: Anterior surface of greater trochanter of femur Innervation: Superior gluteal nerve (L5, S1) Main Action: Abduct and medially rotate thigh; keep pelvis level when ipsilateral limb is weight-bearing and advance opposite (unsupported) side during its swing phase

Gluteus medius

Proximal Attachment: External surface of ilium between anterior and posterior gluteal lines Distal Attachment: Lateral surface of greater trochanter of femur Innervation: Superior gluteal nerve (L5, S1) Main Action: Abduct and medially rotate thigh; keep pelvis level when ipsilateral limb is weight-bearing and advance opposite (unsupported) side during its swing phase

Iliacus

Proximal Attachment: Iliac crest, iliac fossa, ala of sacrum, and anterior sacro-iliac ligaments Distal Attachment: Tendon of psoas major, lesser trochanter, and femur distal to it Innervation: Femoral nerve (L2, L3) Main Action: Act conjointly in flexing thigh at hip joint and in stabilizing this joint

Superior gemelli

Proximal Attachment: Ischial spine Distal Attachment: Medial surface of greater trochanter (trochanteric fossa) of femur Innervation: Nerve to obturator internus (L5, S1) Main Action: Laterally rotate extended thigh and abduct flexed thigh; steady femoral head in acetabulum

Semitendinosus

Proximal Attachment: Ischial tuberosity Distal Attachment: Medial surface of superior part of tibia Innervation: Tibial division of sciatic nerve part of tibia (L5, S1, S2) Main Action: Extend thigh; flex leg and rotate it medially when knee is flexed; when thigh and leg are flexed, these muscles can extend trunk

Inferior gemelli

Proximal Attachment: Ischial tuberosity Distal Attachment: Medial surface of greater trochanter (trochanteric fossa) of femur Innervation: Nerve to inferior gemelli (L5, S1) Main Action: Laterally rotate extended thigh and abduct flexed thigh; steady femoral head in acetabulum

Biceps femoris

Proximal Attachment: Long head: ischial tuberosity; short head: linea aspera and lateral supracondylar line of femur Distal Attachment: Lateral side of head of fibula; tendon is split at this site by fibular collateral ligament of knee Innervation: Long head: tibial division of sciatic nerve((L5, S1, S2); short head: common fibular division of sciatic nerve (L5, S1, S2) Main Action: Flexes leg and rotates it laterally when knee is flexed; extends thigh (e.g., accelerating mass during first step of gait)

Obturator externus

Proximal Attachment: Margins of obturator foramen and obturator membrane Distal Attachment: Trochanteric fossa of femur Innervation: Obturator nerve (L3, L4) Main Action: Assists hip adduction; laterally rotates thigh; steadies head of femur in acetabulum

Obturator externus

Proximal Attachment: Margins of obturator foramen and obturator membrane Distal Attachment: Trochanteric fossa of femur Innervation: Obturator nerve (L3, L4) Main Action: Laterally rotates thigh; steadies femoral head in acetabulum

Obturator internus

Proximal Attachment: Pelvic surface of obturator membrane and surrounding bones Distal Attachment: Medial surface of greater trochanter (trochanteric fossa) of femur Innervation: Nerve to obturator internus (L5, S1) Main Action: Laterally rotate extended thigh and abduct flexed thigh; steady femoral head in acetabulum

Psoas minor

Proximal Attachment: Sides of T12-L1 vertebrae and intervertebral discs Distal Attachment: Lesser trochanter of femur Innervation: Anterior rami of lumbar nerves (L1, L2) Main Action: Act conjointly in flexing thigh at hip joint and in stabilizing this joint

Psoas major

Proximal Attachment: Sides of T12-L5 vertebrae and discs between them; transverse processes of all lumbar vertebrae Distal Attachment: Lesser trochanter of femur Innervation: Anterior rami of lumbar nerves (L1, L2, L3) Main Action: Act conjointly in flexing thigh at hip joint and in stabilizing this joint

HVLA History

Systems of communication Neurologic Cardiovascular Endocrine The body primarily uses these systems for its communication Naturally, other systems are interactive and involve communication Connective tissue may be considered another, but in a different way "I want to make it plain that there are many ways of adjusting bones. Every operator should use his own judgment and choose his own method of adjusting all bones of the body." "The pop is no criterion to go by." This is why we always retest: to find out if we achieved the objective of the OMT The popping sound may come from a different level (or even your hand)

Short lever technique

The force is imparted through your body part (generally your hands), which is close to the joint to which you are addressing the force

Supine Thoracic HVLA: Type I (Neutral) (T6-8 N SRRL ) Technique

The physician has the patient cross his/her arms over the chest, with the arm furthest from the physician on top, and grasp themselves The physician's cephalad hand rotates the patient's opposite shoulder and thorax toward her The physician reaches across the patient and places the fulcrum, (i.e.. thenar eminence) of her hand on the patient's left T7 transverse process The physician positions the patient's elbows in her epigastric area or chest (or a small pillow is placed between the patient's elbows and the physician's epigastric or chest area) The physician supports the patient's head, neck, and shoulders with the cephalad hand and flexes the patient through the dysfunctional vertebra (readjust the fulcrum if needed) The physician side bends the patient's spine to the left, away from the physician, down to the T7-8 joint space (direction of restriction) Lower the patient down to rest the SD and fulcrum on the table, but maintain the flexion of the region cephalad to the SD so as to "lock out" the those vertebrae The flexion, side bending, and rotation forces are now "fine-tuned" into the direction of restriction by the physician at the T7 fulcrum (thenar eminence) by adjusting her body weight through her epigastric region through the patient's elbows The patient is asked to inhale - the physician increases the localization as the patient exhales This step may be repeated several cycles as the slack is being taken out with fine tuning the localization At the end of exhalation, the physician applies a high-velocity/low-amplitude thrust through the epigastric contact, aimed straight toward the fulcrum hand (usually straight down toward the floor) This thrust passes through the patient's elbows, the thorax, and to T7 at the fulcrum This is accomplished by a momentary drop of the physician's weight rather than a squeezing or compression of the patient Reassess the somatic dysfunction

Supine Thoracic HVLA: Type II, EXTENSION (T7 E RLSL) Treatment

The physician has the patient cross his/her arms over the chest, with the arm furthest from the physician on top, and grasp themselves The physician's cephalad hand rotates the patient's opposite shoulder and thorax toward her The physician reaches across the patient and places the fulcrum, (i.e.. thenar eminence) of her hand on the patient's left T7 transverse process The physician positions the patient's elbows in her epigastric area or chest (or a small pillow is placed between the patient's elbows and the physician's epigastric or chest area) The physician supports the patient's head, neck, and shoulders with the cephalad hand and flexes the patient through the dysfunctional vertebra (readjust the fulcrum if needed) The physician side bends the patient's spine to the right, toward the physician, down to the T7-8 joint space (direction of restriction) Lower the patient down to rest the SD and fulcrum on the table, but maintain the flexion of the region cephalad to the SD so as to "lock out" the those vertebrae The flexion, side bending, and rotation forces are now "fine-tuned" into the direction of restriction by the physician at T7-8 joint space by adjusting her body weight through her epigastric region through the patient's elbows The patient is asked to inhale - the physician increases the localization as the patient exhales This step may be repeated several cycles as the slack is being taken out with fine tuning the localization At the end of exhalation, the physician applies a high-velocity/low-amplitude thrust through the epigastric contact, aimed straight toward the fulcrum hand (usually straight down toward the floor) This thrust passes through the patient's elbows, the thorax, and to T7 at the fulcrum This is accomplished by a momentary drop of the physician's weight rather than a squeezing or compression of the patient Reassess the somatic dysfunction

Supine Thoracic HVLA: Type II, FLEXION (T7 F RLSL) Technique

The physician has the patient cross his/her arms over the chest, with the arm furthest from the physician on top, and grasp themselves The physician's cephalad hand rotates the patient's opposite shoulder and thorax toward her The physician reaches across the patient and places the fulcrum, (i.e.. thenar eminence) of her hand on the patient's left T8 transverse process (By placing the fulcrum on the vertebra BELOW the SD, the thrust through the force vector will encourage extension of T7 at the T7-8 joint space) The physician positions the patient's elbows in her epigastric area or chest (or a small pillow is placed between the patient's elbows and the physician's epigastric or chest area) The physician supports the patient's head, neck, and shoulders with the cephalad hand and flexes the patient through the dysfunctional vertebra (readjust the fulcrum if needed) The physician side bends the patient's spine to the right, toward the physician, down to the T7-8 joint space (direction of restriction) Lower the patient down to rest the SD and fulcrum on the table, but maintain the flexion of the region cephalad to the SD so as to "lock out" the those vertebrae The flexion, side bending, and rotation forces are now "fine-tuned" into the direction of restriction by the physician at T7-8 joint space by adjusting her body weight through her epigastric region through the patient's elbows The patient is asked to inhale - the physician increases the localization as the patient exhales This step may be repeated several cycles as the slack is being taken out with fine tuning the localization At the end of exhalation, the physician applies a high-velocity/low-amplitude thrust through the epigastric contact, aimed straight toward the fulcrum hand (usually straight down toward the floor) This thrust passes through the patient's elbows, the thorax, and to T7 at the fulcrum This is accomplished by a momentary drop of the physician's weight rather than a squeezing or compression of the patient Reassess the somatic dysfunction

1. Supine Thoracic HVLABasic Tx Instructions for ALL SD Types

The physician has the patient cross his/her arms over the chest, with the arm furthest from the physician on top, and grasp themselves The physician's cephalad hand rotates the patient's opposite shoulder and thorax toward her The physician reaches across the patient and places the fulcrum, (i.e.. thenar eminence) of her hand on the posterior transverse process of the patient's SD The physician positions the patient's elbows in her (physician's) epigastric area or chest The physician supports the patient's head, neck, and shoulders with the cephalad hand and flexes the patient through the dysfunctional vertebra (readjust the fulcrum if needed) The physician side bends the patient's spine into the direction of restriction, down to the dysfunctional thoracic segment Lower the patient down to rest the SD and fulcrum on the table, but maintain the flexion of the region cephalad to the SD so as to "lock out" the those vertebrae The flexion, side bending, and rotation forces are "fine-tuned" into the direction of restriction by the physician at the fulcrum by adjusting her body weight through her epigastric region, through the patient's elbows The patient is asked to inhale - the physician increases the localization as the patient exhales This step may be repeated several cycles as the slack is being taken out with fine tuning the localization At the end of the last exhalation, the physician applies a high-velocity/low-amplitude thrust through the epigastric contact, aimed straight toward the fulcrum hand (usually straight down toward the floor) The thrust is accomplished more by a momentary drop of the physician's weight rather than a squeezing or compression of the patient The thrust passes through the patient's elbows, the thorax, and to the fulcrum at the SD Retest the somatic dysfunction

ANTERIOR INNOMINATE ROTATION

With the patient supine, stand on the dysfunctional side with the hip and knee flexed. Place the heel of your caudad hand on the ischial tuberosity, with fingers monitoring the SI joint. Place the hip in flexion, external rotation, and abduction to engage the barrier while loose packing the SI joint. Ask the patient to push the knee toward you (extend the hip) for 3-5 seconds against your resistance, simultaneously your caudad hand places a cephalad and lateral force on the ischial tuberosity. After the patient relaxes, find the new "feather edge" by further flexing the thigh which encourages further posterior rotation of the innominate. Continue to monitor the loose-packed position of the innominate with your caudad hand. Steps 4-6 are repeated 3-5 times, or until motion has improved. Retest. Patient may complain of ipsilateral hamstring tightness, spasm, or sciatica.