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Soft Tissue Injuries 116

Hours 7-9

Instructor: Linda Simon, DC

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Hour 7

Section 31: Examination of the TMJ:

A thorough history of the pain and symptomatology is vital. Onset, palliative factors, quality of

pain or numbness, radiations, location or site, and timing of symptoms are important to

determine if this condition is within the scope of the practitioner. Within the dental field are

“TMJ specialists” and as a referring physician, one must be cautious as to whether these

practitioners are necessary and/or are skilled and qualified for alleviation of the patient’s

problem. These practitioners range from highly skilled with excellent results to not so skilled

with poor results and can be very expensive, with the correction being lengthy and painful. The

goal is usually increased opening for the TMJ as well as occlusion alignment. In many cases,

occlusion alignment is not a problem. If that is the case, correction by manual and soft tissue

methods may be the preferred course of treatment.

Passive Examination:

History:

Has the patient had dental problems or been to their dentist recently for examination and/or

correction? Has the patient had a procedure in which their mouth was open for an extended

period of time? Has the patient bit into something hard and felt pain? Does the patient chew gum,

grind their teeth or bruxate? Does the patient suffer from headaches or neck or back pain? Was

the TMJ a problem before their accident?

Observation:

The mandible must be centered with the cranium. Any lateral shift may indicate a possible

misalignment of the articular condyle and/or disc and can sometimes be seen on X-ray. Also

observed is the thickness of the tissues near the mandible angle and ramus indicating masseter

fascitis or spasm.

Palpation:

Joint misalignment can be palpated passively when the TMJ is at rest or 3-5 mm open. Muscle

spasm and inflammation of the masseter and temporalis can be palpated. To palpate the lateral

pterygoid, the patient must open their mouth. Use a finger cott on the index finger and reach

inside the patient’s mouth when their TMJ is in the open position 60-75 %. The muscle is

palpated between the upper and lower ends of the last molars where they meet the soft flesh of

the inside of the cheek. Be gentle, it can be very painful to palpation. The medial pterygoid is

just medial to the lateral pterygoid and is palpated between the last molars. These are more

tender. Care must be taken to not press with too much force on these muscles which can cause

them to contract, the patient’s mouth clamp shut and they could bite your finger.

Active Examination:

Observation of the patient opening and closing their jaw demonstrates condylar tracking. A

visible lateral shift upon opening the jaw can indicate TMD. An audible pop or click can indicate

articular disc displacement or improper disc tracking. There can be a break in the smooth

continuity of joint movement upon opening and closing. There may be an audible noise

accompanying it.

Palpation of the TMJ is assessed bilaterally. Places an index finger on the temporal fossa of the

temporal bone where the mandibular condyle articulates. Place the middle fingers on the

patient’s mandibular condylar heads. The patient’s initial position is with the TMJ at rest (3-5

mm open). The patient is instructed to open their jaw slowly to full open. Palpate for the

smoothness of motion, tracking of movement and comparison to the other side. With a lateral

shift, audible pops or clicks, difference in the rotation or translation of the condyles from one

side to the other, there is a problem and further investigation is warranted. The patient is then

told to slowly close their jaw as the practitioner palpates. Any issues found on opening will

usually be found in closing. Repeat several times for evaluation.

Palpate the masseter as the patient opens and closes their jaw. Spasms, inflammation, swelling

can all be observed. Palpate the lateral and medial pterygoids carefully. The patient’s jaw can be

open 60% upon initial palpation, then opened further to 100%, then back to 60%. Palpate just

above the zygomatic arch during opening and closing to assess the temporalis which may cause

headaches or TMD.

Mandibular gait analysis: VROM scale (vertical range of motion)

Mandibular gait analysis consists of observation and documentation of the mandibular range of

motion in active and passive phases. It also accounts for the dynamic relationship between the

mandible and the cranium. This analysis is combined with timing of joint sounds and various

clinical signs to determine TMD. Maximum opening from a fully closed position, deviations

from the vertical midline, lateral and/or protrusion deviations, restrictions, deflections, existence

and timing of joint sounds, and other test results all make up the analysis. Mandibular gait is

measured in millimeters as well as sounds produced.

31-1

VROM scale is made up of crossing lines which represent normal mandibular gait without

measurement of the end ranges. Intersection lines represent the closed position of the mandible

(intercuspal position). The horizontal line represents mandibular movement of laterotrusion. The

vertical line below the intersection represents the opening and closing of the jaw. The extension

of the line inferiorly represents the maximal opening distance. The vertical line above the

intersection line denotes protrusion. Abnormal sounds (eg. popping, clicking, crepitus) are

represented along the lines where they occur.

The VROM scale is used to record protrusion, opening, and laterotrusion in millimeters. Using a

clear plastic ruler or clear plastic flexible ruler, the practitioner records the distance of these

ranges of motion. Because the ruler comes into contact with the patient’s saliva, sterilize the

ruler between uses or use an inexpensive flexible ruler that can be disposed. Deflections or

deviations for protrusion and opening are noted. Abnormal sounds, the side of occurrence (right

or left), their appearance in the gait cycle are recorded next to the grid. Upon the grid or scale,

there is a notation of end range of motion which is usually an “X”.

Disc derangements such as ankylosis, subluxation, dislocation can alter condylar movement. The

VROM scale determines if there is disc derangement by the movement of the condyle, any

audible sounds and to what point in the opening/closing cycle the derangement occurs.

TMD is a serious condition and must be treated as such. It is necessary to determine which

structures of the TMJ are involved and to what extent to properly assess the success of proper

treatment. It is also important to understand the complicating factors such as dental conditions,

recent surgeries or abscesses, current dental correction procedures, dynamics of the motor

vehicle accident and chronicity or acuteness of the condition. It is not necessary to know specific

dental procedures, but to understand the consequences of these conditions and procedures that

would have an effect on the TMJ so that complications can be ruled in or out.

Remaining in one’s scope of practice and within the laws of their governing state is important

with TMJ. Soft tissue manipulation and joint manipulation is usually within the scope of

practice. Corrective procedures such as mouth guards and bite plates should be evaluated to

determine if these tools can be dispensed in your office. If not, they are easily acquired at a

dentist’s office and referral for these corrective tools can be made. Treating the TMJ is not

difficult, however appropriate diagnosis requires skill and a thorough understanding of the

mechanisms of jaw function.

It is prudent to fully evaluate the TMJ after acceleration/deceleration impact whether there are

immediate symptoms or not. Diagnosing TMD early on can assist in reducing serious symptoms

early on in the patient’s care and also provide explanations for some of the patient’s symptoms

such as headaches associated with temporalis or masseter spasm and inflammation.

Section 32: Examination of the Thoracic Spine and Rib Cage


Observation:

The thoracic spine is best observed standing for shoulder height, head tilt and hip heights,

hyperkyphosis, Dowager’s hump, sloping shoulders, slouching and scoliosis. Lumbar

hyperlordosis could indicate weak abdominal muscles or a spastic iliopsoas. Observe the rib cage

for bilateral even rise and fall upon respiration. Assess the sternum for concavities or

convexities. Evaluate the clavicle for association with the sternum and scapula. Note deep or

strained breathing for accessory muscle use in inspiration. Adam’s Tests should be performed for

scoliosis. Patients with scoliosis can have lateral and rotary alterations in their spinal column

with associated rib torquing. Rib instability is a common cause of back pain and breathing issues

in patient with scoliosis. It is this region that is most affected from an unstable curvature giving

into periodic increased rotation of the spinal column.

Static palpation:

Prone: From T1 – T12, palpate the spinous and transverse processes, and costovertebral joints for

alignment, anomalies and pain. Assess paraspinal musculature for spasm, inflammation, swelling

and pain. The trapezius, quadratus lumborum, latissimus dorsi, rhomboids, splenius and erector

spinae can all be palpated. The semispinalis, rotatores, intertransverse and interspinalis cannot be

readily palpated as they are deep. The serratus posterior can be felt along the rib cage inferior to

the scapula.

Supine: Palpate the anterior and lateral rib cage, sternum, xiphoid and clavicle. Ribs under the

axilla are difficult to feel. The costosternal joints can be felt but the costochondral regions are

difficult to discern. The intercostalis external can be felt. The intercostalis internal and

innermost, and subcostals, transversus thoracic, levatores costorum and sternocostalis cannot be

felt. Palpate the diaphragm under the rib cage anterior and lateral to the mid axilla line. Palpate

the psoas and iliacus below and above the inguinal ligament along the anterior ilium to the mid

axilla line. Palpate the serratus anterior above ribs 6-9 mid axillary. Feel for accessory muscles

of inspiration in the cervical spine (scalene group) and anterior chest (pectoralis group). Feel for

the accessory muscles of expiration on the abdomen from the rib cage to the pubic bone.

Motion Palpation:

32-1a 31-2b

Seated: The patient’s arms should be clasping the opposite shoulders. From T1 – T12, each

vertebral joint is challenged in flexion, extension, lateral flexion and rotation by passively

moving the torso. Costovertebral joints are challenged in flexion, extension, lateral bending and

rotation. Palpate intersegmental rib spaces for muscular inhibitions.

Percussion:

Prone: Percuss spinous processes from T1 – T12. With suspicion of rib fracture, use tuning fork

to determine any breaks, follow up with imaging studies.

Thoracic organ evaluation:

The heart, major blood vessels and lungs are out of the scope of this course. However, it is

important to note labored breathing or wheezing, a rapid or irregular heartbeat, chest pain,

elevated blood pressure and pulse quality which can indicate pulmonary or cardiac maladies that

require referral to a specialist or an emergency situation.

Passive Functional Testing:

Passive rotation: Perform active ranges of motion. The extreme of passive rotation is most likely

to produce pain indicative of a disc lesion.

Soto Hall: This determines vertebral body disease and/or compression injury and was previously

covered in Section 27.

Reflexes:

Abdominal reflex is superficial performed by running a blunt object medial from the umbilicus

to superolateral (T7-9) or inferolateral (T10-12) to evaluate the segmental nerve roots.

Ulnar reflex: Some fibers of T1,2 nerve roots join the brachial plexus and form part of the ulnar

nerve innervating the lateral aspect of the forearm, wrist and hand. With the patient seated, their

hands on their knees palm down, the practitioner strikes the ulna styloid process. The reflex

causes the hand to slightly pronate and ulnar deviate.

Signs:

Thomas’ Sign demonstrates a spinal cord lesion if there is a gooseflesh reaction upon pinching of

the trapezius muscle.

Dermatome evaluation assesses C8 and T1 together at the ulnar region of the forearm and 5th

digit.

Active Examination:

Active ranges of motion:

Flexion is limited and difficult to isolate as most occurs in the lumbar spine.

Extension is limited due to the angle of the spinous processes abutting one another.

Lateral bending is minimal but opening of the intercostal spaces and thorax elevation does occur.

Rotation is 37 degrees each direction.

With disc protrusion, there is asymmetrical pain and/or limitation on 2-4 movements.

Resisted movements can indicate muscular dysfunction. Lateral bending and flexion can be

performed seated as the practitioner braces the patient’s knees between theirs and resists.

Rotation is performed standing as the practitioner braces the patient’s body to theirs and resists.

Extension is performed prone as the practitioner resists holding the scapula and ilia.

Active functional testing:

Spine:

32-2a 32-2b 32-2c

Adam’s positions are diagnostic for lateral curvature. There are three Adam’s positions;

standing, sitting and kneeling. These tests indicate structural scoliosis. In functional scoliosis as

caused by short leg or unstable pelvis, these tests would be limited.

Dural roots can be stretched by flexion. With pain upon flexion (all other cervical ranges of

motion are painless and full), attention is to the thoracic spine. Approximating the scapulae

relieves dural stretch and alleviates symptoms of a T1,2 lesion. However, if pain persists, the

lesion is a central or lateral thoracic disc. In cases of primary posterolateral protrusion, unilateral

pain is confined to the anterior chest or abdomen. Cardiac conditions must be ruled out.

Rib cage:

Chest expansion can determine normalcy of breathing. Upon inspiration, transverse and

anteroposterior diameters increase as ribs swing outward increasing the transverse diameter and

raise at the sternal ends. Upon expiration, vertical diameter increases when the diaphragm

contracts and moves inferior.

Chest Expansion Test can detect thoracic fixation and ankylosis. Place a tape measure around the

patient’s chest over the 4th

intercostal space. The patient exhales and a measurement is taken.

The patient inhales and the measurement is taken again. Normal chest expansion is 2 inches for

men and 1 ½ inches for women.

32-3

Costoclavicular Test: With the patient standing, their arms in abduction and external rotation,

elbows bent, the patient is told to extend their arms further back. This extension compresses the

clavicle against the 1st rib. Numbness and/or tingling are positive signs of costoclavicular

compression.

Motor Testing

T1 nerve root: Strength of the 5th

digit as it opposes the thumb. Patient performs a pincer grip.

Beevor’s Sign indicates a transverse spinal cord lesion at T10. With the patient supine, they flex

their neck and elevate their legs or sit up. The abdominal muscles are palpated and the umbilicus

is observed. With T10 paralysis there will be a contralateral shift.

Diagnostic Imaging of the Thoracic Spine and Rib Cage:

Plain film X-ray: The following views are routine for the thoracic spine and are taken when the

patient is holding an inspired breath.

A-P: Vertebral bodies of T1-12, disc spaces, endplates, spinous processes, transverse processes

and costovertebral articulations as well as ribs. Vertebral rotation, lateral flexion can be seen and

spinal curvature can be viewed.

Lateral: Thoracic curve, disc spaces, vertebral end plates, anterior and posterior longitudinal

ligaments. Rib associations can be seen but are better viewed A-P.

Swimmer’s View: This slightly oblique view of the lateral thoracic spine is taken with the arms

in a “swimmer’s posture” so that the upper two ribs can be better visualized. This uncommon

view is used in suspicion of fracture or tumor in the upper lung quadrants.

P-A and Lateral: Note the mediastinum (trachea, aortic arch diameter, pulmonary artery and

general cardiac outline), diaphragm, pleura, respiratory structures, pulmonary parenchyma,

diaphragm domes, costophrenic angles, pleura and lateral lung.

Section 33: Passive Examination of the Lumbopelvic Spine


Observation:

Shoulder and hip height, muscle symmetry, posture should be observed posteriorly and laterally.

Weak abdominal muscles can cause hyperlordosis, spastic lumbar muscles can cause

hypolordosis. Evaluate for leg length discrepancy. With pelvic instability, observe the arches of

their feet.

Palpation:

Static palpation is performed prone and supine.

Prone: L4,5 junction at the iliac crest, spinous processes at the vertebral bodies, S2 at PSIS level,

the coccyx, iliac crest from the PSIS to the ASIS, ischial tuberosities at the junction of the

buttocks and leg, greater trochanters can all be palpated.

Supine: L4,5 and S1, articulation of sacrum and L5, ASIS, iliac crests and tubercles.

Motion Palpation: seated

Lumbar spine: The patient’s knees are together, arms crossed in front of them.

33-1

Flexion: Contact the spinous process and test the motion with gentle and slow P-A movement.

33-2

Extension: Extend the low back and contact the mamillary process of the particular segment.

Test the motion with gentle and slow P-A movement slightly cephalid.

33-3

Lateral flexion: Laterally bend the patient and contact the lateral aspect of the ipsilateral spinous

process. Movement is tested as the practitioner gently pushes the spinous process contralaterally.

Repeat for the other side.

33-4

Rotation: Rotate the patient’s torso to lock out this range of movement. Contact the contralateral

mamillary process of the lumbar vertebra and push it further into rotation. Repeat for the other

side.

Motion palpation of the pelvis will be covered in Section 34 on Active Examination since it is

an active procedure.

Soft tissue palpation: prone

Stanley Hoppenfeld divides the lumbopelvic spine into 5 zones for evaluation;

Zone 1- Midline:

Supraspinous ligament: The supraspinous ligament can be palpated over and between spinous

processes. Interspinous ligaments are too deep to palpate.

Paraspinal muscles (spinalis, longissimus and iliocostalis): The standing patient is asked to place

their head in extension to relax the fascia. The muscles should be palpated bilaterally and as a

unit lateral to the midline.

Zone 2 – Iliac crest:

Gluteal muscles can be palpated under the PSIS anterior to the ASIS.

Zone 3 – PSIS:

Sacrotuberous and sacrospinous ligaments can be palpated as they form an attachment with the

PSIS.

Zone 4 – Sciatic region:

The sciatic nerve exits the pelvis under the piriformis and passes between the greater trochanter

and the ischial tuberosity. Feel the sciatic nerve with the patient standing, their hip flexed and

knee bent.

Zone 5 – Anterior abdominal wall and inguinal region:

The abdominal muscles can be palpated supine and is best felt if the patient contracts them.

Palpate the psoas inside the iliac crest along the ASIS, their leg in a figure 4 to its attachment at

the lesser trochanter in the medial thigh. The inguinal ligament can be clearly palpated between

the ASIS and pubic bones.

Percussion:

With the patient prone, the spinous processes of the lumbar spine can be percussed for pain. This

can indicate fracture, neurological components or periosteal reactions.

Passive functional testing:

Tests for the lumbar spine

33-5

Laseuge’s Test (Straight Leg Raise) - with the patient supine, their knee extended and braced by

the practitioner’s hand, their leg is lifted toward 90 degrees. The angle which produces radicular

pain is recorded. Pain at 80 degrees indicates irritation of the L5 nerve root.

Braggard's Sign – with the patient in a straight leg raise, their foot is dorsiflexed. A positive

finding is increase in radicular pain.

Well Leg Raise - straight leg raise of the unaffected limb. Lift the unaffected leg. If there is no

pain in the affected leg, dorsiflex the big toe of the unaffected leg. If pain is produced in the

affected leg by either of these maneuvers, this is positive for sciatica and disc lesion.

Duchene’s Sign – paralysis of the peroneus longus from a lesion of the superficial peroneal nerve

or L4,5,S1. With the patient supine, push up the head of the first metatarsal and ask the patient to

plantar flex their foot. The sign is present when the medial border of the foot dorsiflexes, lateral

border plantar flexes.

33-6

Kemp’s Test – disc protrusion or prolapse. With the patient standing or seated, the practitioner

anchors the pelvis and grasps the opposite shoulder forcing it obliquely backward, downward

and medially. A positive sign is pain into the lower extremity. With medial disc prolapse or

protrusion, the patient leans into the side of disc compression. Kemp’s Test is positive when

leaning away from the involved side. With lateral disc prolapse or protrusion, pain is produced

when the patient leans into the side of pain. With an inferiorly placed disc, the patient resists

bending to either side.

Tests for the pelvis

Leg Length Test - the most accurate test for leg lengths is plain film X-ray, A-P view of the

lumbopelvic spine. The top of the acetabulum can be compared from one side to another for

discrepancy.

33-7

Ely’s Sign – with the patient prone, their knee is flexed toward their ipsilateral buttock. When the

pelvis rises from the table and the thigh goes into abduction at the hip, there is a contracture of

the rectus femoris and/or TFL.

33-8

Gaenslen’s Test – with the patient supine, the affected side at the edge of the table, hip and knee

of the other side flexed with the patient bracing their knee. The leg of the affected side is

extended over the edge of the table at the hip. The practitioner applies downward pressure

against both knees. Exacerbation of pain from the pelvis indicates sacroiliac lesion.

33-9

Goldthwaite’s Test – with the patient supine, palpate their lumbosacral joint and perform a

straight leg raise of the affected side. If pain occurs before the lumbosacral joint opens in flexion,

a lesion of the sacroiliac joint is presumed. If pain does not occur until the lumbosacral spine

moves, the problem is lumbosacral. Repeat with the opposite leg. If symptoms are produced

when the other leg is raised to the same height, the lesion is lumbosacral. If the other leg can be

raised higher than the affected side before pain is produced, then the problem is at the sacroiliac

joint.

33-10

Hibb’s Test – with the patient prone, stabilize the pelvis by placing one hand on the iliac bone,

the other around the patient’s ankle. Flex the opposite knee and internally rotate their leg.

Perform bilaterally. A positive finding is the reproduction of pelvic pain indicating sacroiliac

lesion in the absence of hip lesion.

33-11

Ober’s Test – the patient is on their unaffected side as the practitioner provides firm pressure

over the ilia and grasps the patient’s ankle to abduct and extend the superior limb. Allow the

limb to fall into adduction. A positive finding of hip contracture or short iliotibial band is when

the limb remains in abduction or falls very slowly.

33-12

FABERE Patrick Test – place the patient’s leg into the FABERE position (Flexion, Abduction,

External Rotation, and Extension – figure 4). Exert downward pressure on the thigh. A positive

test of psoas inflammation or hip disease is hip pain.

Neurological testing:

Sensory Testing: dermatome

L1 is an oblique band on the upper anterior thigh below the inguinal ligament.

L2 is on the anterior of the mid thigh.

L3 is an oblique band on the anterior thigh near the knee.

L4 covers the anterior medial of the leg inferior to the knee.

L5 covers the anterior lateral of the leg inferior to the knee.

S1 covers the lateral malleolus, lateral and plantar surface of the foot.

S2,3,4,5 dermatomes create concentric rings around the anus with S2 being the outermost ring;

S3, the middle ring and S4,5 the inner most ring.

Deep Tendon Reflex Testing:

There are no testable deep tendon reflexes for L1,2,3.

L4 is the patellar reflex.

L5 is the tibialis posterior reflex.

S1 is the Achilles tendon reflex of the gastrocnemius muscle.

Muscle Testing: nerve root

L2,3 - psoas. With the patient supine, their hip and knee flexed, the practitioner contacts the

patient’s shoulder and knee and applies pressure to them both.

L3 - quadriceps. With the patient prone, their knee is flexed 90 degrees and leg extension is

resisted.

L4 - anterior tibialis. Resisted dorsiflexion of the foot.

L5 - extensor hallucis longus. Resist dorsiflexion of the big toe.

S1 – peroneus. Resisted eversion.

S2 - hamstrings. With the patient prone, the upper buttock is stabilized, knee bent 75 degrees.

Resisted extension.

Pathological Reflexes: These have been previously covered in Section 28.

Section 34: Active Examination of the Lumbopelvic Spine

Active examination:

Ranges of Motion:

Flexion: The patient bends forward to touch their toes. Normal is 60 degrees.

Extension: The patient extends their torso as their pelvis is stabilized the pelvis. Normal is 35

degrees.

Lateral Flexion: The patient reaches for their lateral thigh as their ilia is stabilized. Normal is 20

degrees.

Rotation: The patient’s pelvis is stabilized as they rotate. Normal is 5 degrees.

Motion palpation of the sacroiliac joints: standing with support

The right side will be considered for explanation purposes:

34-1

For the upper (right) sacroiliac joint, the practitioner stands behind the patient, contacts the right

PSIS with their right thumb, the 2nd

sacral tubercle with their left. The patient flexes their right

hip by lifting their right leg as if walking up a big step. The practitioner feels for movement

under their thumbs. Normally, the PSIS moves posteriorly, inferiorly and slightly medial, and the

right lateral sacrum will pivot anteriorly and inferiorly. The patient brings their right leg down

and the opposite motion is felt as the pelvis is returned to neutral.

34-2

With practitioner’s hands as above, the patient raises their left leg. Normally, the sacral tubercle

moves lateral, inferior and posterior as the right PSIS moves with it. The patient brings their left

leg down and the practitioner feels as the sacrum and PSIS return to neutral.

34-3

For the lower right sacroiliac joint, the practitioner contacts the posterior inferior iliac spine

(PIIS) with their right thumb and 4th

sacral tubercle with their left. The patient lifts their right leg.

Normally, the PIIS will move anterior and inferior, and the 4th

sacral tubercle will move posterior

and superior.

34-4

The patient lifts their left leg while the practitioner maintains contact on as above. The sacral

base should move posterior and superior along.

The practitioner places their left thumb on the left PSIS and right thumb on the 2nd

sacral

tubercle. The patient lifts their left leg, then their right leg. The lower left sacroiliac joint follows

suit with the left leg lifted then the right.

Functional Testing:

Tests for the lumbar spine:

Adams Positions: Previously reviewed in Section 32.

Bechterew’s Sitting Test: With the patient seated, their legs over the edge of a table, they extend

one knee straight out. This is done bilaterally. If the patient cannot do this due to low back or

radicular leg pain, or if the patient can extend either leg or both only by leaning backwards, this

is positive for intervertebral disc protrusion.

Dejerine’s Sign: This is present upon sneezing, coughing, straining at the stool or any other

compression that exacerbates low back pain and/or radicular pain. It is indicative of herniated

disc, tumor or stenosis.

Valsalva’s Maneuver: This was previously covered in Section 28.

Test for the pelvis:

34-5

Belt Test: The patient forward flexes to create symptomatology. Then, with the patient standing,

the practitioner stands behind them, places their arms around the patient’s waist interlocking

fingers below the iliac crest and braces the patient’s sacrum to their leg. The patient flexes the

spine forward. With a pelvic lesion, this will not cause pain. With a spinal lesion, forward flexion

causes pain.

Minor’s Sign: When the patient rises from a seated position, with a sacroiliac lesion, there will

be difficulty standing straight up. The patient places their hand over the involved sacroiliac joint

to stabilize their pelvis in order to rise as well as reacting to pain.

34-6

Trendelenberg: This test determines gluteal insufficiency. The standing patient lifts their

unaffected knee above the waist. If the pelvis is lowered on the side of the raised leg, there is

gluteal weakness.

Muscle Strength Evaluation (muscle testing):

34-7a 34-7b 34-7c

Abdominal muscles: With the patient seated on a table, their knees bent and arms crossed in

front of them, the practitioner contacts their legs with one arm and their elbows with the other.

The patient resists their push against the patient’s elbows. The patient leans back 30 degrees and

resists a backwards push. The patient leans back 60 degrees and the test is repeated.

34-8

Back extension muscles: With the patient prone, they raise their legs and chest off the table

simultaneously against resistance from the practitioner.

34-9

Lateral flexors: With the patient seated or standing, they laterally bend 15 degrees. The

practitioner contacts their trunk with one hand and pelvis with the other and the patient resists

movement of their torso.

34-10

Hip flexors: With the patient supine, the leg flexed 30 degrees, abducted 15 degrees and

externally rotated 15 degrees. The practitioner contacts the patient’s leg with one hand and

stabilizes the patient’s opposite pelvis with their other. The patient resists the downward and

lateral push on their leg keeping their knee straight.

34-11

Hip extensors: With the patient prone and knee bent, they lift their thigh off the table resisting

downward pressure on their thigh so their leg does not touch the table.

Neurological Testing (motor):

L1,2,3: iliopsoas muscle as above for hip flexor.

L2,3,4: quadriceps femoris (femoral nerve) and hip adductor group (obturator nerve)

The quadriceps is tested with the patient seated on the edge of a table. The distal end of their

thigh is stabilized and the patient extends their knee while resistance is applied to their leg.

Hip adductors are tested with the patient seated. They abduct their legs as the practitioner

contacts their medial thigh near the knee. The patient adducts their legs against resistance.

L5: Extensor hallucis longus (deep peroneal nerve), gluteus medius (superior gluteal nerve),

extensor digitorum longus and brevis (deep peroneal nerve).

Extensor hallucis longus: With the patient seated, the practitioner’s thumb is placed on the

dorsum of the patient’s foot. The patient dorsiflexes their big toe against resistance.

Gluteus medius: With the patient on their side, their pelvis stabilized by the practitioner, the

patient abducts their leg. After full abduction, further abduction is resisted by the practitioner

pushing against the lateral thigh at the knee joint.

Extensor digitorum longus and brevis: With the patient seated on the edge of a table, their

calcaneus secured, practitioner’s thumb is on the dorsum of their foot. The patient dorsiflexes

their foot against resistance.

S1: Peroneus longus and brevis (superficial peroneal nerve), gastrocnemius-soleus muscles

(tibial nerve), gluteus maximus (inferior gluteal nerve)

Peroneus longus and brevis: Plantar flexion and eversion is opposed by pushing against the head

of the fifth metatarsal.

Gastrocnemius-soleus: Ask the patient to walk on their toes.

Gluteus maximus: Test as hip extensors as mentioned above.

Diagnostic Imaging of the Lumbopelvic Spine:

Plain film X-ray:

A-P: View vertebral bodies of L1-L5, disc spaces, endplates, spinous processes, transverse

processes, lateral masses, arches, vertebral rotation, lateral flexion and spinal lateral curvature.

Evaluate the pelvis for rotations, degeneration of the acetabulum, sacroiliac joint integrity, and

pubic symphysis integration. Leg lengths can be measured by the height of the acetabulum

bilaterally.

Lateral: Assess lumbar lordosis, lateral masses, spondylolisthesis, disc spaces, vertebral

endplates, anterior and posterior longitudinal ligaments, sacral base angle and pelvic angle. A

break in the continuity of the anterior or posterior longitudinal ligaments may indicate disc

bulging or tear.

34-12

Lumbar angle: A line across the superior of L1 body and inferior of L5 body. The intersection

determines the lumbar curve. Normal is 35-45 degrees.

34-13

Gravitational line: hyperlordosis or hypolordosis. Drop a vertical line from the center of L3

body. This line should strike the anterior ¼ of the sacral base. Anterior of the sacral base is

hyperlordosis, posterior indicates hypolordosis.

34-14

Lumbosacral angle: A line across the superior of the first sacral segment. This line is intersected

by a horizontal. In women, normal is 28-36 degrees. In men, normal is 34-40 degrees. Anything

else indicates lumbosacral instability.

34-15

George’s line is along the posterior bodies of the lumbar spine following the posterior

longitudinal ligament. Stair-stepping indicates flexion or extension dysfunction. A break in the

line indicates disruption of the ligament and possible spondylolisthesis or retrolisthesis.

34-16

Oblique views: View the intervertebral foramen and lateral arch. This view is used almost

exclusively to determine spondylolysis and/or spondylolisthesis. A break in the “neck” of the

“Scotty Dog” is indicative of these conditions.

Section 35: Examination of the Shoulder

Passive examination:

Observation:

Clavicle contour, humerus and scapula placement, arm position, shoulder height are important to

note.

Palpation:

Bicipital tendon (long head) can be found with 90 degrees of elbow flexion and internal and

external shoulder rotation. Palpate the coracoid process for pectoralis minor, the short head of the

biceps and coracobrachialis tendons. Subcoracoid bursa is under the coracoid process. The

anterior capsule is lateral to the coracoid process. Palpate for trigger points. Determine crepitus

by holding the acromion while moving the shoulder.

Passive Ranges of Motion: standing

There are three planes of motion for the shoulder; coronal, scapular and sagittal. In the coronal

plane, capsular and ligamentous structures undergo the most stress. The least stress is in the

scapular plane. A painful arc is indicative of: inflammation of supraspinatus, infraspinatus,

subscapularis tendons, subacromial bursitis; osteoarthritis of the acromioclavicular joint,

coracoacromial ligament or acromioclavicular joint capsular hypertrophy, imbalance in

supraspinatus and deltoid indicating a weak supraspinatus.

Palpate the posterior glenohumeral joint as above. Push the shoulder into extension. Pain

indicates instability of the glenohumeral joint. Anterior dislocation, impingement, rupture of the

supraspinatus tendon, injury to the subscapularis and pectoral muscles, acromioclavicular

ligament, posterior-superior glenoid labrum or posterior capsule, arthritis, posterior dislocation,

subcoracoid bursitis, subscapular nerve injury.

Internal rotation will stress the posterior inferior glenohumeral ligament and capsule,

infraspinatus and teres minor, excessive scapula movement.

Adduction will stress the acromioclavicular joint, postero-inferior capsule, anterior labrum,

posterior deltoid, infraspinatus, teres minor, supraspinatus, subscapularis, coracoid process and

subcoracoid bursa.

Scapulothoracic instability is observed as winging. The causes are long thoracic nerve trauma,

deformity, trapezius paralysis, weak serratus anterior.

Active Examination:

Active range of motion: supine

Flexion - 160 -170 degrees

Extension – 45 degrees

Abduction - 150 – 160 degrees

During abduction in the coronal plane, the scapula begins to rotate at 30 degrees. From 30 - 170

degrees, the scapula rotates 12 degrees for every 30 degrees of abduction.

Isometric Muscle Testing:

It is important to do passive testing of the bursa, capsules or ligaments prior to active testing of

muscles because these structures may be stressed and need to be ruled out as a causative factor.

Pain is a positive finding. Tests are performed seated.

Abduction:

35-1

The supraspinatus can be isolated in abduction at 90 degrees in the scapula plane. Resist further

upward movement of the patient’s arm by resisting downward on their forearm.

Adduction:

35-2

Pectoralis major, latissimus dorsi, teres major and anterior deltoid; the patient’s arm is neutral,

their elbow flexed. Stabilize the anterior inferior acromion as they resist abduction of the

shoulder.

External rotation:

35-3

Infraspinatus and teres minor; the patient’s elbow is flexed 90 degrees, their shoulder internally

rotated 45 degrees, arm braced to their waist. Resist external rotation with resistance on the

dorsum of the wrist.

Internal rotation:

35-4

Subscapularis, pectoralis major, latissimus dorsi and teres major; the patient’s arm is in neutral,

elbow flexed 90 degrees, thumb up. Stabilize the elbow and contact the wrist as they attempt

external rotation with resistance.

Shoulder/elbow flexion:

35-5

Biceps brachii; the patient’s arm is at 90 degrees flexion, palm up. Push down inferior to the

elbow as the patient pushes upward.

Impingement tests:

Impingement occurs during shoulder movement as the humerus approximates the acromion of

the scapula. Injured tissues can be subacromial bursa and/or supraspinatus tendon.

35-6

Neer’s Impingement Test: seated

Stand behind the patient. Press down on the scapula to prevent rotation. Raise the patient’s arm

into maximum forward flexion to abut the greater tuberosity against the acromion or

coracoacromial arch. Pain in the last 10 to 15 degrees is indicative of an inflamed bursa or

injured supraspinatus tendon

35-7

Hawkins Test: seated

Flex the patient’s elbow 90 degrees and shoulder 80 degrees. Internally rotate the patient’s

shoulder by grasping the forearm and rotating it laterally while stabilizing their scapula. The

coracoacromial ligament will impinge on the supraspinatus tendon and greater tuberosity.

Glenohumeral Stability:

Stability for the glenohumeral joint is defined by normal rotator cuff and scapula muscles with

anterior, posterior, inferior or multidirectional compression of the joint. Glenoid labrum,

glenohumeral ligaments, acromioclavicular joint and fibrous capsule are all evaluated with these

tests.

The following grades anterior and posterior humeral head translation:

0: No movement of the humeral head.

+1: Humeral head shifts anteriorly or posteriorly without moving past the glenoid rim.

+2: Humeral head glides over rim of the glenoid cavity spontaneously.

+3: Humeral head dislocates over glenoid rim without spontaneous reduction is clinical

dislocation.

0 to +2 can be considered within normal.

The following grades inferior humeral head translation.

0: No movement of the humeral head.

+1: Less than 5mm humeral head translation.

+2: 5-10 mm humeral head translation.

+3: More than 10 mm humeral head translation.

Stability Tests:

The following are evaluated:

1. Capsular rupture or laxicity of +3

2. Glenoid labrum rupture

3. Impacted compression fracture of the humeral head

4. Avulsion of the greater tuberosity

5. Ruptured or compromised rotator cuff muscles

Compared with the opposite (normal) shoulder as laxicity is inconsistent from patient to patient.

Anterior Stability Tests: supine

Anterior Drawer Test:

35-8

Their arm is placed into 70 degrees of abduction in the scapula plane, elbow flexed, patient’s

forearm placed into the axilla of the practitioner. Stabilize the scapula by pressing the thumb into

the coracoid process and the fingers into the superior spine. Press the head of the humerus into

the labrum with a slight stabilizing force medial to the patient’s body. Pull the head of the

humerus anteriorly noting the grade of instability (0 to +3).

Anterior Release Test:

35-9

Abduct the patient’s arm 90 degrees, elbow flexed 90 degrees and place over the edge of the

exam table. Exert a posterior force on the humeral head while rotating their arm into the end

range external rotation. Release the humeral head. Pain upon release is positive.

Posterior Stability Tests:

Posterior Drawer Test: supine

35-10

Abduct the arm 70 degrees and internally rotate 45 degrees. Flex elbow and forearm into

practitioner’s axillary region. Flex shoulder 60-80 degrees. Apply pressure posteriorly with the

thumb on the anterior head of the humerus testing for laxicity.

Posterior Inferior Pressure Test: seated.

35-11

Abduct the patient’s arm 90 degrees, elbow flexed, internally rotated and horizontally adducted.

Stabilize the scapula and push on the elbow toward the humeral head. Pain indicates posterior

inferior instability.

Inferior Stability Tests: seated

Sulcus Sign:

35-12

This test determines the stability of the anterior superior capsule and superior glenohumeral

ligament. With the arm in a neutral, palpate the anterior humeral head inferior to the acromion.

Pull on the arm inferiorly. A gap or sulcus is observed. The measurements of this gap indicate

laxicity from 0 to +2 and instability at +3 as described above. Each patient is different and a

laxicity of +2 in one patient may be instability in another, therefore compare with opposite

shoulder.

Glenoid Labrum Tear. Positive testing produces an audible “pop” or “click”.

O’Brien’s sign: standing

35-13

This test can be positive for superior labrum tear or acromioclavicular joint instability. The

differentiation is determined by where the patient feels the pain. Deep pain indicates labrum, top

of the shoulder indicates acromioclavicular. Flex the arm 90 degrees, horizontally adduct 10 to

15 degrees and maximally internally rotate. Put a downward force onto the arm. The patient

maximally eternally rotates the arm with consistent downward force. Pain increases when the

arm is internally rotated and relieved when the arm is externally rotated.

Anterior Slide Test: Standing with their hand on their hip.

35-14

Push superiorly on the elbow. Pain indicates tear at the superior of the labrum.

Crank Test: supine

35-15

The shoulder is in maximum flexion. The practitioner axially loads the humerus and internally

and externally rotates the arm.

Diagnostic Imaging of the Shoulder:

Shoulder plain film X-ray can be reviewed for DJD and dislocation. CT/MRI combination is best

for soft tissue evaluation. Arthroscopy may be necessary to observe tendon, ligament, labrum

and cartilage tear.

Hour 8

Section 36: Examination of the Elbow Wrist and Hand

Passive Examination of the Elbow:

Observation:

36-1

Observe the elbow in extension and forearm supination. The normal carrying angle presents with

a valgus deviation of the forearm of 15 degrees in men and 20-25 degrees in women (less in

children). Alteration is indicative of previous trauma, growth plate disturbances or ligament

deterioration.

Palpation:

Determine atrophy from neurological sequela and/or swelling from muscle injury, tendinosis,

ligament injury, bursitis, rheumatoid arthritis or dislocation. Heat with swelling can indicate

sprain/strain, arthritis or bone injury. Determine trigger points and/or fascial torsion.

Passive Range of Motion:

Flexion - 160 degrees

Extension - 0 degrees

Pronation - 90 degrees

Supination - 90 degrees

Passive Stress Tests:

36-2

Valgus stress (elbow abduction) is applied to an elbow in 30 degrees flexion. Support the

patient’s arm and place their shoulder in 70 degrees of abduction. With the patient’s arm in 45

degrees of supination, valgus stress is applied to the lateral elbow medially.

36-3

Varus Stress (elbow adduction) is applied to an elbow in 20 degrees flexion. With the patient’s

humerus in internal rotation and pronation, varus stress is applied to the patient’s lateral forearm.

Passive Examination of the Wrist:

Palpation:

Pain is indicative of fracture, carpal instability, joint anomalies, ligamentous tear, tendon injury.

Inflammation will be found with all above injuries and RA.

Ranges of Motion: seated

Pronation of the distal radioulnar joint:

36-4

With the patient’s elbow flexed to 90 degrees, palpate the radioulnar joint and pronate the

forearm to stress the radioulnar ligament and joint capsule. If the ulna head is more prominent

than the normal side; the fibrocartilage complex and radioulnar ligament, or fracture of ulna

styloid may be involved (a click may be heard upon movement).

Supination of the distal radioulnar joint:

36-5

Supinate the patient’s forearm to stress the radioulnar ligament, joint capsule and extensor carpi

ulnaris. Pain is indicative of injury to the joint.

Pronation of the carpals:

36-6

Contact the dorsal of the carpal bones and pronate the patient’s wrist to stress the dorsal

radiocarpal and interosseous ligaments. Palpation of the two regions assists in determining which

ligaments are involved.

Supination of the carpals:

36-7

Contact the palmar surface of the wrist and supinate the forearm to stress the palmar radiocarpal

and interosseous ligaments. Palpation determines which ligaments are involved.

Wrist palmar flexion:

36-8

Pronate the patient’s forearm and flex their wrist to stress the dorsal ligaments, capsules and a

possible injury at the scapulolunate region.

Wrist extension:

36-9

Supinate the patient’s forearm and extend their wrist to stress the ligaments of the palmar region.

Pain would indicate a dislocation or fracture of the scaphoid, triquetrum and/or hamate. This is

the most vulnerable region of the wrist for injury.

Radial deviation:

36-10

Supinate and stabilize the patient’s forearm and laterally deviate their wrist to stress the ulnar

collateral ligament and flexor and extensor carpi ulnaris muscles. Injury here is common in

golfers.

Ulnar deviation:

36-11

Medially deviate their wrist is deviated to stress the radial collateral ligament, triangular

fibrocartilage complex and the flexor and extensor carpi radialis muscles.

Passive Examination of the Hand:

Palpation:

Osteoarthritis can be found in the distal phalanges but can also exist in the articulations with the

carpal bones. Rheumatoid arthritis can be found in the metacarpalphalangeal joint and between

the carpals.

Range of Motion:

The middle finger acts as the median plane of the hand. Deviation away is abduction; deviation

toward adduction. The following ranges of motion are exclusive of the thumb.

Metacarpalphalangeal joints:

flexion - 85 degrees

extension – 30 degrees

abduction – 20 degrees

adduction – 5 degrees

Proximal interphalangeal joints:

flexion -115 degrees

extension – 0

Distal interphalangeal joints:

flexion – 80 degrees


Thumb ranges of motion are as follows:

Carpal-metacarpal joint:


abduction – 60 degrees

Metacarpal-phalangeal joint:



Interphalangeal joint:



Active Examination of the Elbow:

Range of motion:

Flexion – 145 degrees


Supination – 90 degrees

Pronation – 90 degrees

Resisted testing: standing

36-12

Biceps brachii - the patient flexes their elbow to 20 degrees, with their forearm supinated. Push

down on the patient’s forearm as they resist.

36-13

Brachioradialis – the patient’s forearm is neutral during resisted elbow flexion.

36-14

Brachialis - the patient’s forearm is pronated during resisted elbow flexion.

36-15

Triceps – the patient’s elbow is flexed at 45 degrees, arm abducted 90 degrees. Resist forearm

extension.

36-16

Pronator teres and pronator quadratus – the patient’s elbow is flexed 90 degrees, arm against

their trunk, forearm neutral. Resist pronation by stabilizing the radius palmar surface ulna dorsal

surface.

36-17

Supinator and biceps brachii - With the patient’s shoulder in 45 degrees adduction, full internal

rotation and extension, stabilize the humerus. There is resistance against forearm supination.

Active Examination of the Wrist:

Resisted testing: seated

36-18

Common flexor tendon and flexor carpi ulnaris – The patient’s elbow is extended, thumb and

fingers relaxed. Resist flexion of the wrist by pressing against the palm.

36-19

Flexor carpi radialis – flex the patient’s elbow, their forearm between supination and neutral.

Resist flexion by pushing on the patient’s thenar structures.

36-20

Flexor carpi ulnaris - With the patient’s elbow flexed, forearm is supinated, hand is in slight

ulnar deviation. Resist flexion against the ulnar metacarpal region.

36-21

Common extensor tendon - With the patient’s elbow and wrist extended; resist wrist extension

with a contact on the dorsum of the hand.

36-22

Extensor carpi radialis longus and extensor carpi radialis brevis - With the patient’s elbow

flexed, forearm pronated, hand is slightly radially deviated. Resist against the dorsal metacarpal-

phalangeal joint of the index finger.

36-23

Extensor carpi ulnaris - With the patient’s elbow flexed, forearm pronated, hand slightly ulnar

deviated, the examiner resists extension by pressing against the dorsum of the fifth metacarpal.

Active Examination of the Hand:

Range of Motion:

The order of fist clench for maximum strength is metacarpal-phalangeal, proximal

interphalangeal then distal interphalangeal. Finger extension occurs in unison past neutral.

Resisted Testing:

Resisted finger flexion - This can occur with an individual finger or with all fingers as a unit.

Resisted finger extension – This can occur with an individual finger or with all of the fingers as a

unit.

Resisted finger abduction - interosseous muscles. This can occur with an individual finger or

with all of the fingers as a unit.

Resisted finger adduction - palmar interosseii muscles except the middle finger as there are no

adductor muscles to that finger.

Resisted thumb flexion - flexor pollicis longus and flexor pollicis brevis.

Flexor pollicis longus - the patient’s thumb is extended and abducted. Resist against the palmar

surface of the distal phalange while stabilizing the proximal thumb.

Flexor pollicis brevis - the patient’s thumb is extended and abducted. Resist against the palmar

surface of the proximal phalange while stabilizing the metacarpal region.

Resisted thumb extension - extensor pollicis longus, extensor pollicis brevis, abductor pollicis

longus.

Extensor pollicis longus – Extend the patient’s thumb at the metacarpal-phalangeal joint and flex

at the interphalangeal joint. Resistance is provided against extension at the metacarpal-

phalangeal joint.

Extensor pollicis brevis – Flex the patient’s thumb at the metacarpal-phalangeal joint and extend

at the interphalangeal joint. Resistance is provided against extension at the interphalangeal joint.

Abductor pollicis longus - Resist extension at the lateral surface of the distal end of the thumb.

The abductor pollicis brevis is a good indicator in Carpal Tunnel Syndrome.

Abductor pollicis brevis - With the patient’s thumb at a right angle to their palm; resist against

the proximal phalange in adduction toward the palm while stabilizing the wrist.

Adductor pollicis and dorsal interosseous - the patient’s thumb resists adduction against the

ulnar/palmar portion of the thumb at the metacarpal bone.

Diagnostic Imaging of the Elbow, Wrist and Hand:

Plain film X– ray can be an effective tool evaluating the bony and joint structure of the wrist and

hand. Advanced imaging may be required for the soft tissue structures of the elbow.

Section 37: Examination of the Hip


Inspection:

Observe the patient’s stance to see if the ASISs are in the same horizontal plane. Observe lumbar

lordosis. The angle of the sacrum will determine the structural lordosis of the lumbar spine. A

sacrum that is more flexed will present with an increased lordosis, one that is less flexed will

present with a decreased lordosis. Hyperlordosis can be present with a fixed flexion deformity of

the hip. Excessive lordosis can be functional and compensate for true hip extension. Determine

muscle atrophy, pelvic distortion and/or leg length deficiency. Hamstring tension will also

determine pelvic distortion. The best means to determine leg length deficiency is with A-P X-ray

study and a measurement of the acetabulum.

Palpation:

The bilateral ASIS, iliac crests, iliac tubercles, greater trochanters and pubic tubercles can be

observed and palpated anteriorly. Posteriorly, the PSIS, greater trochanters, ischial tuberosities

and sacroiliac joints can be palpated. Note the TFL bilaterally to determine if fibrosis has altered

the iliotibial band to maintain an anterior presentation. This will alter pelvic distortion and may

contribute to hyperlordosis and lower back and gluteal pain.

37-1

Femoral triangle: Formed by the inguinal ligament, adductor longus and sartorius. Its floor is

formed by the adductor longus, pectineus and iliopsoas muscles. This region is best evaluated

supine with the leg in a figure 4. The femoral artery, nerve and vein as well as lymph lie within

this region.

Greater trochanter: This is palpated with the patient on their side. The trochanteric bursa is found

to the posterior of the greater trochanter. The gluteus medius inserts into the upper lateral portion

of the trochanter. The tensor fascia lata can be palpated inferior to the trochanter.

Sciatic nerve: The patient is on their side, the sciatic nerve is located midway between the greater

trochanter and the ischial tuberosity. Flexion of the hip will move the gluteus maximus out of the

way for better palpation.

Iliac crest: Posteriorly, the gluteal muscles are just inferior to the crest and anteriorly the

sartorius is inferior.

Ranges of motion:

Flexion – 120 degrees


Abduction – 45-50 degrees

Adduction – 20-30 degrees

Internal rotation – 35 degrees

External rotation – 45 degrees

Active examination:

Resisted movements:

Flexion: Supine, the patient’s hip and knee is at 90 degrees. Brace the patient’s ipsilateral

shoulder and push their knee inferiorly to decrease flexion as the patient resists. This strains the

psoas and quadriceps muscles.

The following tests strain the glutei group and can indicate gluteal bursitis:

Medial rotation: Prone, the patient’s knee is at 90 degrees and medially rotated. Brace their

ipsilateral buttocks and push their leg into lateral rotation as the patient resists.

Lateral rotation: Prone, the patient’s knee is at 90 degrees and laterally rotated. Brace their

ipsilateral buttocks and push their leg into medial rotation as the patient resists.

Extension: Supine, their hip flexed 30 degrees and their knee straight. Support their foot and leg

under their knee and push their leg into extension as the patient resists.

Abduction: Prone, their leg is abducted 20 degrees. Contact the lateral of the thigh and as they

support the other thigh, they will attempt to push the thigh into adduction against resistance.

Adduction: Supine, the practitioner contacts their medial knee and supports their contralateral

thigh. Abduct the patient’s thigh as the patient resists this movement.

Neurological evaluation:

Muscle Testing:

L2,3 roots – this tests the psoas. With the patient supine, their hip and knee flexed, the

practitioner contacts the patient’s shoulder and knee and applies pressure to them both as the

patient applies counter pressure.

L3 root – this test the quadriceps. With the patient prone, their knee is flexed 90 degrees and leg

extension is resisted.

L4 root – this tests the anterior tibialis. Resisted dorsiflexion of the foot.

L5 root – this tests the extensor hallucis longus. Resisted dorsiflexion of the big toe.

S1 root – this tests the peroneus. Resisted eversion.

S2 root – hamstrings. With the patient prone, the upper buttock is stabilized, knee bent 75

degrees and resisted extension is observed. Toe walking will also test for S1,2 nerve roots by

testing the gastrocnemius.

Deep Tendon Reflex Testing:

There are no testable deep tendon reflexes for L1,2,3.

L4 - patellar reflex.

L5 - tibialis posterior reflex.

S1 - Achilles tendon reflex of the gastrocnemius muscle.

Sensory Testing: dermatomes

L1,2,3 - anterior thigh between the inguinal ligament and knee.

L4 - anterior medial aspect of the leg inferior to the knee. The tibial crest is the divide between

the L4,5 dermatomes.

L5 - anterior lateral aspect of the leg inferior to the knee.

S1 - lateral malleolus and the lateral side and plantar surface of the foot.

S2,3,4,5 - concentric rings around the anus with S2 being the outermost ring; S3, the middle ring

and S4,5 the inner most ring.

Orthopedic tests:

Muscle testing: Test for strength and responsiveness:

Grade 5 is normal - complete range of motion against gravity with full resistance.

Grade 4 is good - complete range of motion against gravity with some resistance.

Grade 3 is fair - complete range of motion against gravity.

Grade 2 is poor - complete range of motion with gravity eliminated.

Grade 1 is trace - evidence of slight contractility, no joint motion.

Grade 0 demonstrates no evidence of contractility.

Flexors:

37-2

Iliopsoas – the patient is seated with legs their dangling. The patient flexes their hip raising their

thigh off the table against resistance.

Extensors:

37-3

Gluteus Maximus – the patient is prone. The patient flexes their knee and raises their thigh from

the table against resistance.

Abductors:

37-4

Gluteus medius – the patient is on their unaffected side. Stabilize their pelvis by placing your

hand over their iliac crest. The patient abducts their leg against resistance.

Adductors:

37-5

Adductor longus – the patient is on their unaffected side with leg abducted. Pull their leg into

further abduction as they resist.

Functional Tests:

37-6

Trendelenberg – test for gluteal insufficiency (previously covered in Section 34).

37-7

Ober’s Test – test for shortening of the iliotibial band (previously covered in Section 33).

Allis Test - dislocation of the femoral head or shortening of one femur bone. Supine, both knees

flexed to 90 degrees, feet flat on the table. Compare the levels of the knees. If the femoral head is

dislocated posteriorly in relation to the hip, the knee on that side will be inferior and proximally

displaced.

37-8

Ely’s Sign – prone, their knee is flexed toward their ipsilateral buttock. When the pelvis rises

from the table upon knee flexion and the thigh goes into abduction at the hip joint, there is a

contracture of the rectus femoris and/or lateral thigh fascia (TFL).

37-9

FABERE Patrick Test – supine, place the patient into a figure 4). Exert downward pressure on

the thigh. A positive test is revealed when hip pain, mainly irritation of the psoas muscle is

brought on by inflammation.

37-10

Phelp’s Test – prone, their knees extended, thighs maximally abducted. Use pain and resistance

as the criteria for the degree of end movement. Flex the patient’s knees bilaterally to 90 degrees

and note if this will allow for further hip abduction. This is positive for gracilis contracture if

knee flexion increases hip abduction and knee extension decreases hip abduction.

37-11

Hibb’s Test – prone, stabilize the pelvis on the side nearest to you by placing one hand on the

iliac bone and the other hand around the patient’s ankle. They flex the opposite knee and

internally rotate their leg. This test is done bilaterally. A positive finding is the reproduction of

pelvic pain indicating a sacroiliac lesion in the absence of a hip lesion.

Diagnostic Imaging of the Hip:

The hip can be viewed on plain film X-ray for fracture, degeneration of the acetabulum and

femur head as well as for hip height to evaluate for true short leg length. Advanced studies may

be required if hip replacement is considered.

Plain film X-ray:

Hip Views:

A-P lumbopelvic - with bilateral femur heads will assist in diagnosing structural anomalies,

functional anomalies such as pelvic rotations, degeneration of the acetabulum, femur head angle,

sacroiliac joint integrity, and pubic symphysis integration. Leg lengths can be measured as the

height of the acetabulum and compared for leg length deficiency.

Lateral – lateral view will provide information on the sacral base angle and pelvic angle. Hip

degeneration and/or dysplasia can also be viewed.

Oblique – fracture can be detected with this view.

Section 38: Examination of the Knee


Inspection:

The patient’s gait should be observed. The knee should be flexed during the stance and swing

phase of gait and fully extended at heel strike. Swelling is observed as either localized or

generalized. Muscle contour should be observed for atrophy. Note symmetry in patellae upon the

patient standing and the valgus angle of the knee. Genu varum or “bowed legs” is a reverse of

the valgus knee presentation. Genu valgum is “knocked knees”. Genu recurvatum is

hyperextension of the knee termed “back knee”.

Palpation: Palpate in flexion.

38-1

Medial tibial plateau (point of attachment of the medial meniscus), tibial tubercle, medial

femoral condyle and adductor tubercle (distal of the vastus medialis and hamstrings) are palpated

medially.

38-2

Infrapatellar tendon, lateral tibial tubercle, lateral tubercle, lateral femoral condyle and fibular

head are all palpated laterally.

Quadriceps can be palpated as a group at the superior and medial borders of the patella.

Infrapatellar tendon can be palpated from the inferior of the patella to the tibial tubercle.

Superficial infrapatellar bursa lies anterior to the infrapatellar tendon. Prepatellar bursa overlies

the patella. Pes Anserine Bursa is between the tendons of the sartorius, gracilis, semitendinosus

muscles and the upper medial portion of the tibia medial to the tibial tubercle.

38-3

Medial meniscus is difficult to palpate in a normal state. The anterior margin can be felt deep

within the joint space. Medial collateral ligament cannot be palpated. Sartorius, gracilis,

semitendinosus tendons form a visible ridge on the postero-medial side of the knee.

38-4

Lateral meniscus can be palpated with the knee in slight flexion. Lateral collateral ligament can

be palpated laterally and posteriorly along the joint line. Anterior superior tibiofibular ligament is

in the crevice between the tibia and fibula head. Biceps femoris tendon can be palpated when the

knee is flexed. Iliotibial tract can be palpated where it inserts into the lateral tibial tubercle.

Common peroneal nerve is palpable where it crosses the neck of the fibula.

Popliteal fossa is bordered superiorly by the biceps femoris tendon laterally and the tendons of

the semimembranosus and semitendinosus medially. Posterior tibial nerve is the most superficial

structure in the fossa. Popliteal vein is under the posterior tibial nerve. Popliteal artery is the

deepest structure and runs next to the posterior joint capsule. Gastrocnemius can be palpated at

their origin on the posterior femoral surface just above the medial and lateral condyles during

knee flexion against resistance.

Range of motion:

Flexion - 135 degrees.

Extension - 0 degrees.

Internal and external rotations - 10 degrees each.

Adduction/abduction - 0 degrees in extension. Increases as the knee approaches 30 degrees of

flexion.

Active Examination:

Resisted movements: prone

38-5

Flexion: hamstrings. Contact the patient’s heel and flex it to 90 degrees while bracing their

popliteal fossa. The patient flexes further against resistance.

38-6

Extension: quadriceps. Contact the anterior of the patient’s ankle and flex the leg to 90 degrees

while bracing their thigh. The patient extends their leg against resistance.

38-7

Medial rotation: semimembranosus, semitendinosus or popliteus. The patient’s leg is flexed 90

degrees and foot is contacted medially, ankle is contacted laterally. The patient turns their foot

inwards against resistance.

38-8

Lateral rotation: biceps femoris. The patient’s leg is as above. Contact the lateral aspect of the

foot and brace their ankle laterally. The patient turns their foot laterally against resistance.

Neurological evaluation:

Muscle testing:

L3 root - quadriceps muscle.

L5 and S1 root - hamstrings. Prone patient flexes their knee against resistance.

Deep tendon reflexes:

L2,3,4 roots - patellar reflex.

L3,4 roots - adductor reflex.

S1,2 - Achilles reflex.

Sensation tests: The dermatome patterns at the knee are L2,3,4 and S2 and have been previously

reviewed in Section 43.

Pathological reflexes: Most have been previously covered under neurological evaluation of the

lumbar spine in Section 28.

Duchene’s Sign: Paralysis of the peroneus longus from a lesion of the superficial peroneal nerve

or L4,5,S1 nerve roots. Pushes the head of the 1st metatarsal and ask the patient to plantar flex

the foot. This is positive when the medial aspect of the foot dorsiflexes when the lateral border

plantar flexes.

Toe walking demonstrates the integrity of S1,2 nerve roots.

Orthopedic tests:

Posterior Instability Tests: These should be performed initially to rule out false positive readings

of involved ACL that may occur from injury to the PCL.

Posterior Sag Sign - if the tibia is posterior from a PCL tear, the anterior draw test may show a

false positive. The following should be performed to differentiate. The patient is supine, knees

flexed 90 degrees and feet on the table. Observe tibial tuberosities. With a PCL tear, the involved

tibia should appear dropped posteriorly.

Posterolateral Drawer Test - increased external rotation at 30 degrees of flexion indicates injury

to the posterolateral structures, lateral meniscus, posterolateral capsule and arcuate complex.

Increased external rotation at 90 degrees flexion indicates injury to the above as well as the PCL.

Anterior Instability Tests:

Lachman’s Test and Anterior Drawer Test determine anterior cruciate ligament integrity. If both

tests are positive, there is probably a complete tear of the ACL. If only Lachman’s Test is

positive, there is probably a rupture of the posterolateral band leaving the antero-medial band

intact.

38-9

Lachman’s Test - evaluate the hamstrings as spasm could negate this test. Seated, the patient

leans back, knee flexed 20 degrees hanging over the table. Grasp the patient’s ankle cup their

posterior proximal tibia to exert a posterior to anterior pull. Palpate the amount of movement

between the femoral condyle and tibial plateau.

Anterior Draw Test - perform as above however, the knee is flexed 90 degrees. Do not perform

with severe swelling.

38-10

Abduction Stress Test (valgus stress test) - stability of the medial knee structures. Supine, their

leg is off the table, knee flexed to 30 degrees. Cup the lateral knee and hold the foot and tibia

neutral to stress the medial collateral ligament.

38-11

Adduction Stress Test (varus stress test) - patient’s knee is at 30 degrees with the patient’s leg

braced against the practitioner. Introduce lateral stress. Tests for the lateral collateral ligament,

posterolateral capsule, arcuate- popliteus complex, iliotibial band and the biceps femoris tendon.

38-12

Reverse Pivot Shift Test - posterolateral rotational instability. Externally rotate the tibia, knee

flexed and apply valgus stress to the proximal tibia. While maintaining valgus stress, extend the

externally rotated tibia. At 40 degrees of flexion, there is an audible clunk. With an anterior

cruciate injury, there will be another clunk at 20 – 30 degrees flexion.

38-13

McMurray’s Test - meniscus injury: Supine patient flexes their knee and hip to approximate the

heel to the buttocks. Externally rotate the foot putting pressure on the medial meniscus. Slowly

extend the knee while exerting slight varus force. Positive produces an audible snap. Repeat with

the foot in medial rotation and a valgus force applied to lateral meniscus.

38-14

Wilson’s Sign - osteochondrosis. Supine patient, knee flexed to 90 degrees with leg internally

rotated. The knee is gradually extended while maintaining internal rotation. At 30 degrees, the

patient will feel pain over the anterior of the medial femoral condyle. External rotation relieves

this pain.

Patellarfemoral joint:

38-15

Fouchet’s Sign - chondromalacia patella. Supine patient, Compress the patella against the femur.

Pain and tenderness is indicative of this condition.

38-16

Dryer’s Sign - patella fracture. Supine patient, knee extended, the patient is unable to actively

raise the leg. Anchor the quadriceps by applying extension to the thigh and have the patient raise

their leg. If the patient can only raise their leg when the quadriceps is stabilized, it indicates a

patella fracture.

Q Angle - Normally, quadriceps is directed medially and the patellar ligament is directed

laterally creating a valgus presentation. Average range is 20 degrees in women and 15 degrees in

men. The angle is determined standing or sitting with a line drawn from the ASIS to the middle

of the patella compared to another line drawn from the tibial tuberosity through the middle of the

patella. An increase in the angle may be due to femoral anteversion, tibial torsion, laterally

inserted patellar tendon, or foot pronation. A chronically lateral patella would decrease the angle.

Diagnostic Imaging of the Knee:

Plain film X-ray of the knee is taken A-P, lateral and P-A tunnel view. However, due the location

of the patella, plain film X-ray is a poor means to determine injury to this complex joint system.

MRI and/or CT are better means to determine injury.

Section 39: Examination of the Ankle and Foot


Observation:

Note toes for irregularities. Note angle at which the feet rest non-weight bearing, it should be in

slight plantar flexion and inversion. View the medial longitudinal arch for a normal domed

appearance. Observe for swelling. Unilateral swelling would indicate local trauma. Bilateral

swelling could indicate cardiac, lymphatic or kidney issues, or pelvic obstruction to venous

return.

Palpation:

With the patient seated, their feet dangling free, hold the calcaneus with one hand and palpate

with the other.

Medially:

39-1a 39-1b

1st metatarsal and metatarsophalangeal joint is the most involved in gout and bunions. Navicular

tubercle is proximal to the 1st metatarsocuneiform junction. Head of the talus is proximal to the

navicular tubercle by inverting and everting the forefoot (head is more prominent). Medial

malleolus is proximal to the talus head.

Laterally:

39-2

5th

metatarsophalangeal joint and 5th

metatarsal are found at the lateral ball of the foot. Here the

peroneus brevis attaches. The calcaneus is past a soft tissue depression proximal from the 5th

metatarsal. The peroneal tubercle is distal to the lateral malleolus. It separates the peroneus

brevis and longus tendons around the lateral calcaneus. The lateral malleolus is proximal and

superior to the calcaneus. Upon dorsiflexion, the dome of the talus can be palpated distal to the

lateral malleolus.

Hindfoot:

39-3

To palpate the hindfoot, grasp the patient’s forefoot and pinch the region at the calcaneus at

either side of the inferior Achilles tendon. The medial tubercle on the plantar surface of the

medial calcaneus is where heel spurs arise.

Plantar surface:

39-4

Palpate with their foot in dorsiflexion. Sesamoid bones can be palpated at the

metatarsophalangeal joint at the ball of the foot. These bones are within the flexor hallucis brevis

tendon. The deltoid ligament can be palpated inferior to the medial malleolus.

There are several important ligaments associated with the lateral malleolus.

39-5

Anterior talofibular ligament is the most likely to get injured as it is the first to undergo strain

upon inversion and plantar flexion. It can be found from the anterior of the lateral malleolus to

the lateral of the talus. Calcaneofibular ligament stretches from the fibula to the lateral of the

calcaneus. It is torn in severe sprains after the anterior talofibular ligament is injured. Achilles

tendon can be palpated posteriorly. To test the continuity of the tendon, have the patient prone

and squeeze the calf to determine if there is plantar flexion of the foot. Rupture will not allow

plantar flexion.

Retrocalcaneal bursa is between the Achilles tendon and posterior superior angle of the

calcaneus. The soft tissue anterior to the Achilles tendon is where the bursa can be found.

Calcaneal bursa can be found by lifting the skin posterior to the Achilles tendon as it is found

between the fingers.

The plantar surface is the site of plantar fascia originating at the calcaneus, continues over the

sole and inserts into ligaments near the metatarsal heads in the forefoot. It supports the structures

of the foot as a tie-beam for support of the medial arch. Neuromas can be found near the

metatarsal heads most commonly between the 3rd

and 4th

metatarsal heads.

Claw toes, hammer toes, corns and ingrown toenails can be found.

Active Testing:

Ranges of Motion:

Ankle dorsiflexion - 20 degrees

Ankle plantar flexion – 50 degrees

Subtalar inversion – 5 degrees

Subtalar eversion – 5 degrees

Forefoot adduction – 20 degrees

Forefoot abduction – 10 degrees

1st metatarsophalangeal joint flexion – 45 degrees

1st metatarsophalangeal joint extension – 70 – 90 degrees

Phalangeal joints move in flexion not extension

Functional testing:

Rigid or supple flat feet:

Observe the arches upon sitting and standing. If the arch is absent during standing but present

during sitting, then the flat feet are supple and correctible with orthotics. If the arch is absent

during sitting then the flat feet are rigid and not correctible.

Tibial torsion test:

Toe-in may be due to excessive internal rotation of the tibia. Locate the tibial tubercle below the

knee and the two malleoli at the ankle. Normally a line between the malleoli is rotated externally

15 degrees from a perpendicular line drawn from the tibial tubercle to the ankle. With internal

tibial torsion, the malleolar line may face anteriorly.

Ankle dorsiflexion test:

This determines whether the gastrocnemius or soleus is causing limitation in ankle dorsiflexion.

Flex the knee. If ankle dorsiflexion is possible with knee flexion then the gastrocnemius is the

cause. If ankle dorsiflexion is not possible with knee flexion then the soleus is causing the

problem.

Anterior foot draw:

39-6

This test is for anterior talofibular ligament instability secondary to rupture. With the patient

seated, their legs dangling and feet in a few degrees of plantar flexion, the practitioner places one

hand around the anterior aspect of the lower tibia above the ankle while gripping the calcaneus in

the palm of the other hand. While pushing the tibia posteriorly, the calcaneus and talus is drawn

anteriorly. Normally, there is no movement from this action. The sign is present when the talus

slides anteriorly from under the ankle mortise.

Neurological testing:

Muscle testing:

Dorsiflexors:

Tibialis anterior (L4,5) is tested as the patient walks on their heels with their feet inverted. Foot

drop or steppage gait indicates weakness.

Extensor hallucis longus (L5) is tested by having the patient walk on their heels with their foot

neutral. Extensor digitorum longus (L5) is tested as the patient is instructed to walk on their

heel with the foot neutral.

Extensor digitorum brevis is tested the same way as the longus but cannot be isolated

specifically.

Plantar flexors:

Peroneus longus and brevis (S1) are tested as the patient walks on the medial borders of their

feet.

Gastrocnemius and soleus (S1,2) are tested together as the patient walks on their toes.

Flexor hallucis longus (L5) is tested as the patient produces a smooth toe-off during gait.

Flexor digitorum longus (L5) is tested with the patient seated and toe plantar flexion is resisted.

Tibialis posterior (L5) is tested with the patient seated and their foot is plantar flexed and

inverted against resistance.

Sensory testing:

Dermatome testing with pinwheel or pin is performed on the medial, dorsum and lateral aspects

of the foot. L4 dermatome is to the medial of the foot and ankle, L5 dermatome is to the top of

the foot and ankle and S1 dermatome is to the lateral foot and ankle.

Reflex testing:

The Achilles reflex (S1) is tested with the patient seated, their legs dangling and the tendon is

slightly stretched by dorsiflexion of the foot. Tap the tendon with a neurological hammer.

Orthotics evaluation:

The most obvious means to determine if the patient would benefit from orthotics is a quick foot

scan. With the patient standing facing away, their pant legs lifted up, evaluate the angle of the

medial malleolus and Achilles tendon. In a normal foot, the Achilles tendon is vertical and the

medial malleolus does not ride over the medial arch. With pronation or flat feet, the Achilles

tendon is bowed medially and the medial malleolus rides over the medial arch and is inferior to

where it should be. The medial arch itself has splayed. Pronation is usually bilateral but can be

worse on one side versus the other. Look for medial rotation of the knee and strain of the medial

soft tissue structures. Look for pelvic distortion as well as uneven shoulder heights and head tilt.

Diagnostic Imaging of the Ankle and Foot:

Plain film X-ray:

Depending upon the patient’s history and exam findings, the practitioner should determine which

films will provide them with the most accurate information. Fracture, dislocation and possible

disruption of ligaments can be seen in plain film. However, foot films are usually a poor

indicator of internal injury and MRI or CT is preferred. Metastasis, infection, and calcification of

arteries, ligaments, joints, muscles and glands can also be viewed.

Section 40: Treatment of Soft Tissue Injuries after Acceleration/Deceleration Impact

With acceleration/deceleration injury patients, case histories and examination findings are

usually involved and lengthy. The quantity of soft tissue injury as well as quality of soft tissue

injury can sometimes seem daunting. The sometimes slow progression of their recovery can

challenge even the best skilled among us. It is even more concerning for the patient who is in a

great deal of pain and worried about their future health and costs. As practitioners who treat

these patients on a daily basis, we understand that they need at times advocacy and some

knowledge in how to maneuver a system designed to their disadvantage. A patient that feels

confident that their practitioner and legal advisors are working as a team to their best advantage

will go a long way in their healing process. This peace of mind provides incentive to make each

day a better day.

Communication with the patient once all diagnostic information has been received is vital so that

the patient can understand what tissues are affected, what treatments are necessary,

approximately how long for recovery, complicating factors, and possible permanent conditions

with or without treatment. The patient also needs to understand what role they must take for their

own healing, whether it is ice or heat regimen or exercise or avoidance of work duties or daily

activities.

Reassessing their work and/or home ergonomics may be required for optimal healing. An

ergonomic keyboard is a great place to start as it relieves tension on the trapezius, levator

scapulae, forearm and wrists. Speaker phones should be encouraged as to avoid static prolonged

posture of the neck. Repetitive lifting, pushing, pulling, bending, sweeping, should be limited.

Proper mechanics should be taught for lifting such as holding weight close to the body and using

the legs instead of the back. Weight training and sports should be modified or avoided until

stability is achieved.

Exercises such as neck retraction, stretching, isometric strengthening and standing postural

exercises should be performed for strengthening and proprioception. Additional postural

strengthening exercises can be recommended such as lateral bend, pelvic tilt, back extension,

prone leg lifts and abdominal crunches with the focus being the small of the back pressing

against the floor.

Nutrition can be affective in assisting healing in muscles, ligaments joints and nerves. Anti-

inflammatory nutritional supplements like Vitamin C, bromelain and papain have been used.

Arnica has been shown to be affective in decreasing inflammation and pain. Glucosamine and

chondroitin have been used for joint health. Valerian root and lavender has been found effective

for sleep disturbances. Vitamin B12 has been effective for energy levels. Vitamin B6 and

magnesium have been shown to be affective for nerve health. Antioxidants and multivitamin and

mineral supplements have shown to assist in the overall health of the patient during this

physiological stressful time.

Communication throughout the patient’s care will reassure them that they can return to their

normal way of life or help them to prepare for any long term conditions that may alter that.

Informing the patient of healing times, complicating factors that would increase healing time as

well as lifestyle, diet, ability to rest, compliance with the treatment schedule, referrals and

exercises are all considerations in the patient’s care and must be discussed on regular bases.

Regularly scheduled reexaminations will also help your patient to understand that they are

making progress albeit maybe not as quickly as they would have liked. Whole Man Impairment

Ratings may be required as well as Quantitative Functional Analysis to assess functionality for

rehabilitation.

The following are healing stages for soft tissue injury. Muscle tissue heals faster than ligaments.

Ligament tears can be permanent and may need surgical repair. Muscle tears can heal with scar

tissue and adhesions which need physical means of reduction. All of this takes time. A patient

that understands that it may take anywhere from a few months to over a year for their treatment

to be completed will usually exhibit greater compliancy.

Stages of Healing:

Stage I is the acute inflammatory stage lasting 0-72 hours. This period of time is crucial in

bringing down swelling from inflammation. It is the inflammation that leads to a great deal of

tissue damage from hypoxia and the physical stretch of swelling. It is during this time that

patients, except diabetics, should use ice. Modalities such as galvanic, microcurrent,

interferential, cold laser, and even ultrasound can move fluids, make the tissues more permeable

to oxygen exchange and reduce swelling in tissues. Injury to organs, glands, esophagus, pharynx;

fractures, dislocations, disc ruptures, concussions should be referred for treatment.

Stage II is the repair stage from 72 hours to 14 weeks. It is during this time that gentle stretching,

isometrics, balance and proprioception and light weight use begins to benefit the patient.

Inflammation can still be present so continue to treat any inflammation that remains. Once

inflammation begins to recede, the presentation of stiffness and spasm will be the overriding

complaint. Neurological or vascular entrapment will continue to present until the offending

structures are released. Those in muscle and fascia, tendon sheaths can be reduced by the

mechanical methods described in the following sections. Those with bony factors may require

surgery. Discerning the difference can prevent unnecessary permanent treatment which may not

relieve their complaints. It is also during this time that fibromyalgia can set in. Recognizing the

symptoms early on can prevent this condition with aggressive and specifically corrective care.

Stage III is the remodeling stage from 14 weeks to 12 months. It is during this time that the

patient’s condition is settling into a new normal that is not acceptable. Contracted and twisted

soft tissue structures which may have atrophied must be addressed at this time. These tissues are

constantly pulling on bone keeping the joints functioning in an inappropriate manner. Local

dysfunction leads to a greater regional dysfunction which may affect the entire spine and can

incorporate extremities as well. It is during this time that the patient’s exercise program

continues to advance until a program that addresses all of their issues is established.

Stage IV is chronic and permanent. After one year, the patient may still be suffering headaches,

pain, and/or weakness. This does not mean that these symptoms will not be relieved with

continued care. This depends on the patient’s preexisting complicating factors, age, state of

health, severity of injury and scar tissue development. It does, however, mean that the patient

should be aware that there is the possibility that they may be challenged with weakness or a

different function of a particular region of their body. A patient must never be discouraged from

working on their condition for the goal of improvement no matter how serious. Even spinal cord

injured patients can continue to improve after an acute trauma. In Rehabilitation 111, Linda

Simon, DC, there are two case histories thoroughly discussed in which a spinal cord injured

patient and a head injured patient made significant strides with soft tissue treatment.

Adjuncts may or may not be required such as cervical pillows, cervical collar, cervical traction,

home exercise equipment, nutritional supplementation. According to Arthur C Croft, DC, the

following is a useful guide for adjuncts:

Cervical pillow is recommended for all stages of healing.

Soft cervical collar is recommended for grade II and III injury in stage I of healing.

Rigid cervical collar is recommended for grade II-V injury in stage I and II of healing.

Home traction is recommended for grades II-IV injury in stage II-IV healing.

Home exercise is recommended for grades II-III injury in stage II-III healing.

Nutritional supplementation is recommended for all stages of healing.

Deep tissue massage is recommended for grades I-IV injury in all stages of healing.

An even greater ability for a practitioner is to help prevent long term effects and future

conditions such as fibromyalgia, osteoarthritis, functional scoliosis, atrophy, migraines, TMD,

functional instabilities. Treating soft tissue in addition to correcting functional distortions in the

joints of the body that have been altered, will make the greatest strides toward the fullest

recovery the patient can achieve. Some of the techniques that will be discussed take a little bit of

time to perform; for instance, strain/counterstrain takes 90 seconds for each point, friction

massage takes 5 minutes. The results far outweigh the use of time in results, patient appreciation

and enthusiasm for you and your staff.

For the treatment sections of this course, the techniques are briefly described. For detailed

treatment protocols for each technique mentioned, refer to Soft Tissue Injury 103, Introduction to

Soft Tissue Injury and Treatment, Linda Simon, DC. For a greater understanding of how to

perform each technique for a particular region please refer to Soft Tissue Injury 114 - Deep

Tissue Muscle and Fascial Release, Linda Simon, DC; Soft Tissue Injury 115 - Active

Myofascial Rehabilitation, Linda Simon, DC and Soft Tissue 113 – Stretching and Exercise

Rehabilitation, Linda Simon, DC.

Hour 9

Section 41: Treatment of the Cervical Spine after Acceleration/Deceleration Impact

Treatment of the Cervical Spine:

Be wary of preexisting conditions such as RA which can weaken the transverse ligament or

Down’s Syndrome in which the patient may not have a transverse ligament. Use caution with

patients that have osteoporosis, osteoarthritis, or those that present with neurological findings or

possible disc issues.

Bones:

Treatment for fractures is outside the scope of this course. However, you must be able to

recognize them as the patient would be a medical emergency and must be taken to an emergency

room immediately.

Joints:

Capsular lesions:

Injury to the joint capsule can be mild or dangerous depending upon the level and extent of tear.

Minor sprains can be treated with ice and EMS to reduce inflammation. Depending upon how

many capsules are injured, the electrical stimulation can vary from microcurrent for one joint, to

interferential (quadpolar or bipolar) for a greater area. Cold laser can be beneficial. If the capsule

is intact, once the inflammation has receded, gentle mobilization can be introduced as well as

gentle manipulation. Range of motion exercise can be introduced after swelling has receded.

Mild capsular tear presents with pain, secondary muscle splinting and inflammation. For

moderate capsular tear, stability of the joints and extent of tear determine if conservative

methods are safe. Physiotherapeutics can assist with healing. Use of cervical collar may be

necessary. Mobilization and traction should not be used if a moderate capsular tear is suspected.

The ligaments are too vulnerable for any force at this time. Gentle range of motion exercises and

very gentle stretching can assist with healing but must not challenge the range of joint

movement. Mobilization, may be introduced when stability and ligament strength has been

restored. Manipulation may or may not be advised until full stability is reached and inflammation

has subsided. If manipulation is required, it may be prudent to use non force or low force

techniques for several months until if and when it is determined the joint can benefit from

osseous manipulation. Severe capsular tear could present with dislocation and is out of the scope

of this course.

Vertebral joint Dysfunction:

Motion and static palpation to identify joint fixation can indicate non-force, low force, and

adjustive thrust as long as there is minimal risk. Risk factors should be assessed during

examination and include neurological and vascular implications as well as possible ligament tear.

Corrections of vertebral joint dysfunctions help rehabilitate joint proprioception, ligamentous

scar tissue, and muscular compensations that may have resulted in spasm, adhesions and trigger

points. Nerve root compression from osteophyte formation, disc degeneration and foraminal

encroachment must be considered before a course of treatment is initiated. These conditions may

contraindicate quick adjustive thrusts and a more low force technique or gentle cervical traction

may be preferred.

Contraindications for osseous manipulation of the cervical spine:

+ George’s Test

History of stroke

Oral contraceptives

Abdominal aortic aneurysm

Vertebrobasilar syndrome

Metastatic Cancer

Disc herniation

Spondyloarthropathy and spondylosis

Severe osteoporosis

Metabolic bone disease

Osteomyelitis

Fracture

Severe atherosclerosis

Osteogenesis imperfecta

Clotting disorders

Acute spinal cord injury

Acute vertebral joint dysfunction benefits from ice, gentle passive stretch, strain/counterstrain,

post-isometric relaxation, electrical muscle stimulation to reduce spasm and joint swelling. Once

inflammation has been decreased, spinal manipulation can be introduced in either non-force, low

force or, if not contraindicated, adjustive thrusts. Also utilize combinations of wet heat,

stretching (active, passive and/or postfacilitation), strain/counterstrain, post-isometric relaxation,

electrical muscle stimulation, ultrasound, trigger point ultrasound, cold laser and massage.

Exercise will strengthen the area once proper biomechanics has been restored. These techniques

will be briefly discussed in the next few sections.

Dislocation is a serious medical emergency and out of the scope of this course.

Intervertebral Disc Disease:

Disc prolapse or herniation can be a surgical situation with upper and/or lower motor neuron

lesions, nerve or nerve root involvement. The extent of disc matter compromising the

neurological structures should be determined by MRI or CT or both. Minor disc protrusions can

be conservatively treated depending on where the protrusion exists. With an anterior protrusion,

there will be no impact on neurological structures. A posterior or postero-lateral disc protrusion

can affect neurological structures. Non-force techniques should be used to treat this patient and

only when the condition is mild. If there are positive nerve root findings, with mild cases,

traction and ice can be affective. Low or non-force techniques can be applied to the vertebra for

treatment of fixation and loss of motion but the disc cannot be treated directly.

Microcurrent can decrease inflammation of local ligamentous tissues. For secondary muscle

involvement, gentle range of motion and stretching can be applied but take caution not to

aggravate or weaken the disc. Management of a cervical disc disease must not be taken lightly.

Working in conjunction with a neurologist is wise and in the best interest of the patient.

Intervertebral Foramen Compression:

Compression of nerve roots at the intervertebral foramen can be caused by mechanical

interference from vertebral joint dysfunction, inflammation, osteophytes, fracture, or dislocation.

Fracture and dislocation are out of the scope of this course. However, healed fracture can still

lead to compression of nerve roots and this mechanical obstacle may require surgical

intervention. Osteophyte compression may require surgical reduction but must be verified by

MRI because inflammation can also cause nerve root compression and proper course of

treatment must be established.

If there are no bony obstacles to the nerve root, inflammation can be reduced by ice, traction,

microcurrent, fascial release, and cold laser. Vitamin B6 and magnesium have been found to

reduce inflammation of nervous tissue. Vertebral joint dysfunction can be corrected with

manipulative therapeutics but the presence of osteophytes will define whether the procedure will

be low force.

Scoliosis:

For functional deficits as seen with acceleration/deceleration impact, correction of the vertebrae

that have fixated in rotation and/or lateral flexion will allow the spine to readapt to a more

correct biomechanics. Periodic plain films should be taken to properly assess the progress of

treatment and/or deterioration. An adolescent female patient that is developing a scoliosis at the

time of impact may be more challenging as the trauma could accelerate the process.

Atrophy is best treated with Russian stimulation, stretching and exercises. Treatment for spasm

can include bipolar interferential, galvanic, sine wave, strain/counterstrain, postisometric

relaxation, massage, fascial release, ultrasound, or trigger point ultrasound. The scoliosis will not

be limited to the cervical spine and all aspects of distortion should be addressed so the adaptation

of the spine and its soft tissue structures can be eased.

For helpful exercises for scoliosis refer to Section 46: Treatment of the Thoracic Spine and Rib

Cage after Acceleration/Deceleration Impact.

Ligaments:

Ligaments can take from 8 – 24 weeks to heal depending on the extent of injury. Complete tears

of the transverse, alar, apical, atlanto-occipital and atlanto-axial ligaments are out of the scope of

this course. Damage to the ALL and PLL must be treated with caution as the intervertebral disc

can be involved with posterior compression of the cord. Tears of the ligamentum nuchae,

ligamentum flavum and interspinal ligaments are very common in acceleration/deceleration

injuries. These and capsular ligaments including the joints of Luschka can be treated with ice,

rest, cervical collar, and microcurrent. Movement is necessary to avoid muscle atrophy but

caution must be taken to prevent further ligament damage. Traction should be avoided even if

there is neurological compression because it can further damage ligaments. Mobilization can be

beneficial if gentle. If there is minimal tearing, manipulation should be low force once the

inflammation has been reduced. Motion palpation is a good tool to determine the improvement

of capsular ligament tears. Strengthening of muscle groups around the ligament will assist in

supporting the spinal structures as the ligaments are healing.

Section 42: Treatment of the Cervical Spine after Acceleration/Deceleration Impact (continued)

*Note: For all regions of the body covered in the remainder of this course, acute conditions of

the muscles can best be treated with ice or ice massage (contraindicated in diabetes), electrical

muscle stimulation, continuous ultrasound (contraindicated over bone and organs), cold laser,

strain/counterstrain and stretching. Chronic conditions of the muscles are best served by wet

heat, EMS, ultrasound (continuous or trigger point), massage, cold laser, mobilization and

manipulation. These will not be mentioned for each specific muscle but consider as a vital part of

any treatment protocol. Specific treatments for each region or muscle such as postisometric

relaxation, strain/counterstrain, friction massage, postfacilitation stretch, strength exercises will

be discussed specific to an area or particular muscle group. These are in addition to those

mentioned above. Stretches, somatic technique and strain/counterstrain can be performed for

both acute and chronic conditions and is highly beneficial when performed for acute

acceleration/deceleration impact injuries. Trigger points will be discussed separately for the

muscles discussed. For a complete review of strength training and stretch for muscle

rehabilitation refer to Soft Tissue Injury 113: Stretching and Exercise Rehabilitation, Linda

Simon, DC.

Muscles:

Suboccipital: rectus capitus anterior, rectus capitus lateralis

These muscles flex the upper cervical spine bilaterally and laterally flex the head on the cervical

column. The rectus capitus posterior major and minor and obliquus capitus superior and inferior

are posterior and extend, laterally flex and rotate the head on the upper cervical spine. Spasm and

microtears are common with acceleration/deceleration impact. Treatment for acute injury to

muscles must focus on decreasing inflammation, allowing for stretch, and strengthening to

decrease the likelihood of scar tissue and adhesion formation.

Acute:

* Strain/counterstrain – For the upper cervical spine there are anterior and posterior points.

Palpation will identify points of tenderness that require treatment. The mechanism of injury is

important to understand because the antagonist muscle that was violently contracted when in a

shortened state is the one that requires treatment. With this technique, the position of maximum

comfort usually found by passively shortening the muscle must be attained. Point tenderness will

decrease once the position is achieved. The treatment lasts 90 seconds and the patient is returned

to neutral passively and very slowly. For a full description of Strain/Counterstrain and treatment

for the full body please refer to Soft Tissue Injury 112, Strain/Counterstrain, Linda Simon, DC.

42-1a 42-1b

All cervical points are performed with the patient supine. The points above show the anterior and

posterior treatment points for the entire cervical spine. Those identified as 1 and 2 refer to the

upper cervical spine.

Anterior cervical point 1 can produce ear and eye pain, nausea or represent TMJ dysfunction.

The practitioner places the patient’s head in full rotation away from the point with possibly 5-10

pounds of pressure in over-rotation.

Anterior cervical point 2 can produce pain in the forehead or around the eye. The patient’s

head is rotated fully with some lateral bending.

Posterior cervical point 1 is treated with full extension of the occipito-atlantal joint with

lateral bending and rotation away from the side of tenderness.

Posterior cervical point 2 is treated in the position mentioned for posterior point 1.

Chronic:

*Postfacilitation stretch is performed with the patient supine and the practitioner standing behind

them. One hand is behind the occiput and the other is on the patient’s forehead with their neck

slightly flexed. The patient tilts their head back against you and resists for 7 seconds, then

releases. Exert traction on their occiput and push down against their forehead to bring C1,2 into

flexion. Stretch for 12 seconds. Repeat twice increasing stretch each time.

*Somatic technique – With the patient supine, the practitioner is seated behind them. The patient

extends their upper cervical spine so that the chin points toward the ceiling approximating the

occiput and atlas. Cradle their occiput and cover the superior aspect of the frontal bone. The

patient contracts their suboccipital muscles by tipping their chin fully back toward the ceiling.

Apply resistance against their occiput in the direction of the forehead. After a few seconds, the

patient brings their chin toward their chest 1/3 the way down against increased resistance. The

patient tips their head back 1-2 inches. Repeat until the patient’s chin approximates their chest

and suboccipital muscles are stretched.

* Continuous ultrasound for spasm, trigger point ultrasound to reduce scar tissue and adhesions

from microtears.

*Exercise – Isometric contraction. The patient retracts their posterior cervical spine against a ball

behind their head on a wall. This can be adapted for the suboccipital muscles if the patient

slightly tips their chin to the ceiling.

Intersegmental: intertransverse and the interspinalis muscles

These muscles are best treated along with other muscles in the region. Manipulation can ease

spasticity.

Long flexors: longus cervicus group and scalenes

Acute:

*Stretch – These muscles are best stretched actively with the patient’s neck in extension, lateral

flexion and contralateral rotation. For the scalenes, rotation of the head determines which scalene

will benefit from the stretch. Ipsilateral rotation stretches the anterior scalenes, no rotation

stretches the medial scalenes and contralateral rotation stretches the posterior scalenes. These

muscles benefit from a gentle head pull. Be careful of overstretch in acute conditions.

*Strain/counterstrain – The points are anterior to the transverse process for C3-6. The techniques

for the lower anterior cervical spine are as follows:

Anterior cervical 3 can produce vertigo as well as eye pain and headaches. The patient’s head

is flexed to C3, laterally flexed and rotated away. However, the position of most comfort may be

with the neck laterally flexed toward the treatment side. This is to be determined at the time of

treatment.

Anterior cervical 4 can produce vertigo and frontal headaches. The patient’s head is placed

over the edge of the table and their neck is flexed to C4,5 junction. Their head is laterally flexed

and rotated away.

Anterior cervical 5 can produce parietal headaches and posterior neck pain. The patient’s

head is flexed to C5,6 junction and laterally flexed and rotated away.

Anterior cervical 6 can produce suboccipital headaches. The patient’s neck is flexed to C6,7

and laterally flexed and rotated away.

Anterior cervical 7 can be found with levator scapulae and rhomboid spasms. The point is on

the superior medial clavicle between the attachments of the SCM. The patient’s head is flexed to

C7,T1 with lateral flexion towards and rotation away.

Anterior cervical 8 refers to the point (not a vertebra) and is associated with lower neck and

upper shoulder pain commonly found with acceleration/deceleration injury. It is located on the

medial clavicle. The patient’s head is flexed, rotated away and slightly laterally flexed.

*EMS cannot be performed on the anterior long muscles because of the underlying glandular and

soft muscle structures.

Chronic:

*Wet heat – Be careful not to place the heat over the esophagus and pharynx.

42-2

*Postisometric relaxation for the scalene group; the patient slightly flexes their head and laterally

bends and rotates away. Contact the patient’s head on the opposite side and gently resist further

rotation for a count of 8. The patient further rotates away against resistance for a count of 8.

Repeat again.

42-3

*Ultrasound cannot be performed on the anterior structures. However, the medial and posterior

scalenes can be treated laterally with continuous ultrasound or trigger point ultrasound. Trigger

points are usually found in the belly of the muscle closest to the rib cage and radiate pain into the

chest, top and posterior of shoulder and arm into thumb, and medial scapular region.

*Exercise – Isometric contraction of the anterior spinal musculature is helpful in strengthening

this area.

Long extensors: semispinalis, splenius and longissimus groups.

Acute :

*Stretch – These muscles are best stretched actively with the patient’s neck in flexion. Lateral

flexion and rotation can be added as the patient attempts to put their chin to their contralateral

shoulder. A gentle head pull can increase the stretch.

*Strain/counterstrain

Posterior cervical 3 has two locations, one at the inferior of the spinous of C2 and the other on

the posterior aspect of the transverse process of the vertebral body of C3. The patient’s head is

extended with lateral flexion and rotation away. This can also be treated with the patient’s head

in flexion which must be determined by the position of greatest comfort.

Posterior cervical 4 – 7 can be found in the posterior aspects of the transverse processes of the

associated vertebra. They can also be found inferior to the spinous processes of the named

vertebrae. The patient’s head is extended with lateral flexion and rotation away.

Posterior cervical 8 is also named for a point. The patient’s neck is minimally extended and

laterally flexed away with marked rotation away.

Chronic:

*Continuous ultrasound and trigger point ultrasound are useful in this region. Trigger points are

found in the belly of the muscle closest to the suboccipital region as well as mid cervical and

radiate pain into the top of the shoulder, neck and lateral head.

*Exercise rehabilitation – Isometric contraction is helpful in rehabilitating this area.

Sternocleidomastoid:

This muscle is often injured in acceleration/deceleration impacts. It will severely contract and

can be strained or torn. Severe injury to this muscle that is not considered a surgical condition

may require cervical collar.

Acute:

*Stretch – Passive stretch to the SCM can occur with the patient’s head in extension, lateral

flexion and upward rotation.

*Strain/counterstrain as mentioned for anterior cervical musculature.

*Ultrasound can be performed as continuous or pulsed on the SCM as long as the patient’s head

is rotated and extended so that the glandular and smooth muscle structures of the neck are not

exposed to the sound head. Trigger points are common in this muscle and can cause dizziness,

tinnitus, supraorbital and frontal head pain. Trigger point ultrasound can be performed but

caution must prevail to avoid glandular structures and throat.

Chronic (inclusive of torticollis):

*Exercise – Isometric contraction is the best exercise for this muscle.

Section 43: Treatment of the Cervical Spine after Acceleration/Deceleration Impact (continued)

Muscles (continued):

Levator scapulae:

43-1

This is commonly injured during acceleration/deceleration impact.

Acute:

*Stretching – Passive stretching consists of laterally flexing the patient’s neck along with slight

flexion and slight lateral rotation. Active stretching consists of the patient grasping their arm

behind them and pulling it to the small of their back while they laterally flex their neck. Another

technique is for the patient to be seated and place their palm on the seat behind their ipsilateral

buttocks and push into the seat as they laterally flex their neck. The patient can also use their free

hand to assist the lateral flexion.

43-2

*Strain/counterstrain – With the patient seated, contact the tender point near the attachment to

the scapula. Grasp under the patient’s axilla lifting their shoulder and arm until there is no further

pain.

Chronic:

*Friction massage – The contact for friction massage is at the insertion of the levator scapulae

into the scapula. The direction is across the attachment.

43-3

*Post-isometric relaxation – With the patient supine, their neck is flexed, slightly laterally bent

and slightly rotated. Their arm is abducted with their elbow into the abdomen of the practitioner.

Stabilize their head with one hand and with the other hand a downward pressure is applied to the

elbow as they resist.

43-4

*Continuous or trigger point ultrasound. Trigger points can be found in the belly of the muscle

near the top of the shoulder and radiate inferiorly along the medial border of the scapula as well

as into the posterior aspect of the shoulder and upper arm.

*Exercise – With light weights in both hands, the patient is told to shrug their shoulders.

Trapezius:

This is commonly injured acutely.

Upper trapezius:

Acute:

*Stretching:

Passive - contacts the patient’s head and shoulder with opposite hands and laterally flex their

neck while compressing their shoulder.

Active: The patient is seated and compresses their hand into their seat while laterally bending

and flexing their neck.

43-5

*Somatic technique – With the patient seated, they shrug their shoulders. Press down on their

shoulders for a few seconds. The patient allows the shoulders to drop one third of the way and

then raises them slightly against resistance. Repeat until the shoulders are relaxed.

Chronic:

43-6a 43-6b

*Post-isometric relaxation – Patient is seated in a chair with arms interlocked behind the

backrest. Isometric phase is a shoulder shrug as they extend their head upward, relaxation is to

drop the shoulders and flex head downward.

*Somatic technique as described above.

43-7

*Continuous or trigger point ultrasound. Trigger points are found in the belly of the muscle

nearer to the spinous process and radiate into the lateral arm and lateral forearm.

*Exercise – shoulder shrugs with light weights.

Treatment for the middle and lower trapezius are covered in Section 48: Treatment of the

Thoracic Spine and Rib Cage After Acceleration/Deceleration Impact.

Injury to the infrahyoid, suprahyoid and platysma can occur in acceleration/deceleration impact

and are difficult to treat due to their location. Trigger points in the platysma can radiate pain to

the lower jaw. Ice can be applied to acute conditions. Wet heat, manual massage and stretching

can offer improved circulation and function.

Nerves:

Spinal cord injured patients will be treated in an emergency room then transferred to a

rehabilitation facility. These patients will be under the supervision of several specialty

practitioners for complications including blood clots, edema, hypertension, body temperature

irregularities, pneumonia, pain or dysfunction from muscle spasticity and atrophy, mental

distress, etc. The severity of their condition will be determined by the level and extent of injury,

immediate treatment received and complicating factors. Atrophy sets in very quickly as nitrogen

balance is altered from muscle protein breakdown therefore exercise becomes vital for

preventing osteoporosis which usually develops below the level of injury.

The patient that seeks conservative care is usually semi-functional and either in pain or desperate

to regain some function. These patients should never be discouraged. In Rehabilitation 111,

Linda Simon, DC, acupuncture, ayurveda, chronologically controlled developmental therapy,

craniosacral therapy, herbal medicine, homeopathy, qigong and spinal manipulative therapeutics

as alternative treatment methods for spinal cord and head injury are discussed.

Not all spastic dysfunctional muscles are a direct result of upper motor neuron lesion. Some

patients develop shortened fixated muscle/tendon complexes from disuse or chronic unnatural

postural consequences of their illness. This can be corrected as long as the patient has some

motor control. Understanding muscular behavior after upper motor neuron lesions such as slow

flailing of fingers upon movement into extension, fasciculations and pathological reflexes will

help. These conditions are permanent.

Stretching and range of motion is introduced to stimulate function and reeducate joint

proprioception; active movement through the full range with gravity eliminated, then gravity

applied for contraction against resistance. Trigger point ultrasound, Russian stimulation, post-

isometric relaxation, fascial release, strain/counterstrain, friction massage, active release,

mobilization, manipulation, stretching and tapotement assist in muscle proprioception for

strength training. These patients can regain some use of their motor skills. Assist them in

preventing joint contractures with the above techniques along with exercise.

Nerve root injury is usually the result of a decrease in the size of the IVF. Identify the

compression level and reduce pressure at that level. For nonsurgical cases, traction, fascial

release, and correction of possible vertebral fixations are important. For nerve or muscle

inflammation; ice, electrical stimulation, and cold laser can assist. For spasm; stretching, somatic

technique, strain/counterstrain, post-isometric relaxation, electrical muscle stimulation,

ultrasound, trigger point ultrasound, massage, active release, mobilization, manipulation and

exercise therapy can all be affective tools. Strength training is also crucial to the rehabilitation of

this patient.

Nerve compression or elongation of a peripheral nerve can be caused by spastic muscles, fibrous

adhesions or compartment syndromes. Spasticity and fibrous adhesions need to be released to

alleviate tug on the nerve. Trigger point ultrasound is effective for this goal. Ice, electrical

stimulation and cold laser can assist in the acute phase. Treatment of spasm is as listed for nerve

root injury above. For atrophy, Russian stimulation, tapotement for muscle strengthening and a

strength training program are necessary.

Blood Vessels:

Vertebral Artery entrapment must be ruled out prior to manipulation of the cervical spine. The

best test for this is as follows:

43-8

With the patient supine, their eyes open, contact the transverse processes of the atlas medial to

the longissimus capitis bilaterally with the first two fingers. Move the splenius and semispinalis

capitis medially while pressing just past the lateral mass of the atlas inferior to the superior

oblique. Hold tension medially and superiorly just inferior to the superior oblique and superior to

the atlas while slowly rotating the patient’s head ipsilaterally. Hold the rotated position for 10

seconds or until symptoms appear. Positive symptoms will be prolonged vertigo at the end range,

and nystagmus. Vertigo normally occurs but in normal conditions will diminish when the end

range is held. Treatment of the superior oblique, rectus capitus posterior, longissimus capitus and

splenius capitus can alleviate symptoms, however, follow up with a vascular specialist is

recommended prior to manipulation or mobilization of this region with a positive test.

Thoracic Outlet Syndrome is common after acceleration/deceleration impact. Usually scalene or

pectoralis major spasm or inflammation can affect the brachial plexus creating constriction of the

subclavian or radial artery. Complicating factors of cervical rib, elongated C7 TP or shortened

scalene must be identified. Inflammation can be treated with ice, electrical muscle stimulation

and stretching. Scalene spasm can be treated as previously discussed. Atrophy must be treated

with Russian stimulation and/or strength training exercises.

Fascia:

Tears, adhesions and scar tissue are common after trauma and must be identified and treated.

Acute fascial injury is treated with ice as any acute muscular injury. Once inflammation has

subsided, fascial tissue mobilization is recommended. Trigger point ultrasound is the most

effective means of identifying and treating fascial damage. Massage, active release, mobilization

and manipulation will stretch tissues and physically break up scar tissue and adhesions.

43-9

Myofascial release can be applied to the cervical region for generalized fascial release. For

flexion, stand behind the patient with knees bent. With the patient supine, their head is flexed as

it is cradled into your hands. Straighten your knees and lift the patient’s head, their body resting

against your own. Be wary not to flex the patient’s head too much. Then, with the patient’s head

steady, bend your knees again and straighten them again to further stretch the patient’s cervical

and thoracic spine.

To stretch the SCMs and levator scapulae, grasp the patient’s head with your arm and use the

other arm to press the patient’s shoulder toward the floor.

43-10

To release for extension, lateral flexion and rotation, the patient is supine, their back is to the

edge of the table at the level of T5 with their head in extension cradled by your hand. Cup their

occiput and pull it cephalid with one hand and push on their sternum caudally with the other.

Maintain this posture for 3-5 minutes until there is a release of the pectoralis, hyoid and antero-

postero cervical spine. Then allow the head to drop further into extension. Place your caudal

hand on the patient’s shoulder pressing inferiorly while laterally bending and/or rotating their

head. No force is used in this technique.

Section 44: Treatment of the TMJ after Acceleration/Deceleration Impact

There are many approaches to the treatment of Temporal Mandibular Dysfunction (TMD).

Dental treatments can vary from simple mouth guards to complicated extractions, braces and a

series of bite plates. Conservative treatment can also vary but can be straight-forward once the

specific tissues causing dysfunction are identified. This can range from muscular treatment to

manipulation to a combination including or excluding mouth guards. Again, diagnosis and skill

of the practitioner is an important combination in the effective treatment or referral of TMD.

Bones:

Two conditions covered in this course regarding the bones associated with the TMJ are fracture

and periostitis. Treatment of these conditions is out of the scope of this course. However,

identification continues to be important.

Teeth:

Broken, avulsed or intruded teeth are out of the scope of this course. However, it is important to

know when to refer a patient to their dentist to determine if their teeth need repair. Once the

repairs are done, the patient can be referred back to your office for further evaluation and

possible treatment of TMD if it still exists.

Joints:

There are several conditions of the joint that can benefit from manipulative or mobilization

therapeutics, physiotherapy or corrective appliances such as mouth guards. Acute inflammation

of an injured TMJ must be first decreased by ice, ice massage and/or microcurrent directly on the

TMJ. Inflammation can be reduced in secondary muscle spasm by icing the temporalis

attachment at the zygomatic arch or the masseter muscle, or the medial and lateral pterygoids

inside the mouth.

Fibrous ankylosis of the disc is the development of adhesions creating an alteration of joint

opening and an audible pop. Full assessment of the TMJ should be made to rule out acute

conditions or dental concerns. Once it has been established that the disc is not functioning in its

full range of motion, the joint should be assessed as per the VROM scale as well as the muscles

that may be spastic.

The cause of the alteration of bite and jaw movement should be assessed for clenching,

bruxating, excessive gum chewing or if suspected, abnormal bite. Abnormal bite should be

evaluated by a dentist. Gum or hard food chewing should be ceased. If the patient is trying to

quit smoking, then alternatives to gum chewing should be suggested. Bruxating and clenching

can occur during the day as well as night. If the patient is aware that they grind or clench, then a

mouth guard may be warranted. If the patient is unaware if they grind or clench at night, they are

going to need some assistance in learning if this is fact.

Mouth guards can come in many forms. The most effective mouth guard is the one that is custom

made by a dentist. These range from $100-$200 depending upon the dentist. If the patient had

them made for teeth whitening and still has them, with no serious change to their dental structure

as in braces or extraction, then this will suffice. If the patient cannot afford a custom mouth

guard, there are alternatives. Aqualizer is a product that is water-filled and fits into the patient’s

mouth to prevent clenching. It is usually a temporary device because the sharp edges of the teeth

can puncture the water filled cavities. The patient can buy a mouth guard used for sports in any

sporting goods store. This upper plate guard is heated then somewhat molded to the patient’s

upper teeth. They tend to be cumbersome but they can work to prevent bruxating and/or

clenching and can possibly allow the patient to break the habit over time. Usually, mouth guards

are worn at night, however, if the patient clenches or grinds during the day, they will need to

wear one during the day. If this is the case, I strongly recommend custom dental guards. They are

smaller and can be used during the day. Some dentists will even use Invisilign products for

daytime use which are thinner and stronger.

Acute closed lock is an anterior dislocation of the articular disc with discernible restrictions in

opening the jaw. The patient may be able to temporarily “correct” it themselves by moving the

jaw in a particular way. After full assessment of the TMJ and musculature, a treatment plan of

ice/heat, manipulation, stretching and myofascial release can be performed.

Acute open lock is an anterior dislocation of the articular condyle locking the jaw in an open

position. There will be secondary muscle strain. After full assessment of the TMJ and

musculature, a treatment plan of ice/heat, manipulation, stretching and myofascial release can be

performed.

Manipulation of the TMJ can be performed for fibrous ankylosis of the disc, acute closed lock

and acute open lock. There are several techniques that can be applied. The determination of

which techniques will be most affective depends upon the extent of the condition, patient

tolerance and practitioner comfort.

The TMJ can be treated manually in one of three different positions. Depending upon the

problem’s restrictions, the jaw can be adjusted fully open, relaxed (partially open) or closed.

Palpation, nature of condition or such diagnostic techniques as Applied Kinesiology can be used

to assist the practitioner in determining which jaw position is best for treatment.

With fibrous ankylosis, introducing a force can break up scar tissue and adhesions. A low force

adjusting tool can be very affective in adjusting the TMJ. The contact point is the posterior of the

superior aspect of the articular condyle. The line of drive is inferior and medial.

Manual manipulation of the TMJ can be done in several different ways. For fibrous ankylosis,

once jaw position has been determined for the adjustive thrust, the technique is as follows:

44-1a 44-1b 44-2c

With the patient supine, the practitioner cradles the patient’s opposite occiput in their palm. The

patient’s neck should be lifted off the table, and rotated away from the side being adjusted. The

cervical spine should be in slight lateral flexion and slight extension where the spine is “locked

out”.

44-2a 44-2b

With a pisiform contact on the offending posterior aspect of the superior condyle, (the patient’s

mouth in open, relaxed or closed – not clenched – position) the thrust is slightly inferior and

toward the patient’s chin. It should be quick with low amplitude. There is usually an audible

release. This is a very effective and powerful adjustment and the patient may need a little time to

relax after it is done.

Reevaluation after treatment can often exhibit dramatic change in jaw movement pattern and disc

noise. Secondary muscle spasm must be addressed. Treatment may need to be repeated

periodically for stabilization as well as reassessed.

With acute closed lock, the TMJ will be restricted to about 5-10 mm opened. The correction can

only be done in the closed or relaxed position. A low force adjusting tool can be used to

osseously adjust the anterior of the articular disc. The line of drive would be posterior and

inferior along the line of the articular eminence. The following techniques to reposition the disc

are manual and intraoral. With any intraoral technique, proper infectious barrier guidelines must

be followed. The practitioner must wear a glove or finger cott and there should be padding

usually by gauze to protect the practitioner from sharp teeth and biting.

An intraoral distraction technique is as follows:

44-3

With the patient supine, the practitioner’s thumb (with a finger cott) is placed on the patient’s

last mandibular molar of the involved side and the mandible is tractioned downward. The

practitioner can also thrust downward. A forward traction can be used as well, pushing the

condyle under the disc.

Another intraoral thrust technique can also assist in repositioning the disc. With the patient

supine, the practitioner must first determine the slope of the articular eminence. Once this is

determined, the thrust is 90 degrees to the slope. The practitioner places their thumb on the last

mandibular molar of the involved side. The mandible is then gently grasped with the

practitioner’s hand. Traction of the joint is taken prior to thrust. The direction of the gentle quick

thrust is perpendicular and away from the slope of the eminence. The jaw must be immediately

released and allowed to return to rest.

44-4

Lawrence H Jones, developer of strain/counterstrain suggests a technique similar to

postisometric relaxation. With the patient seated, the practitioner holds the patient’s jaw shut and

asks them to try to open their jaw against force. The patient attempts this for 20 second intervals

three times. This seems to address secondary muscle spasm and proprioception.

For acute open lock, the low force adjusting tool can be used as well as the manipulative

technique described for fibrous ankylosis of the disc. Acute inflammation must be decreased

prior to any adjustive technique.

Section 45: Treatment of the TMJ after Acceleration/Deceleration Impact (continued)

Joints (continued):

Contraindications of manipulation:

Conditions that weaken the mandible;

extreme bony reabsorbtion

cystic lesions

infections

tumors

osteoporosis

Conditions that weaken the dentition;

periodontal disease

dental caries

temporary restorations such as fillings and crowns

Patients that are very tense and contracting their muscles are not candidates for manipulation

unless they can relax their jaw muscles. Any attempt to correct TMD with manual manipulation

with spastic muscle fibers can lead to injury of the ligaments, joint capsule and musculature of

the jaw.

Synovitis is an intracapsular inflammation affects mostly the retrodiscal tissue. This is due to a

condyle that has become positioned too far posteriorly. Grinding, clenching, chronic gum

chewing as well as systemic diseases such as infections, rheumatoid arthritis and lupus are all

common causes of TMJ synovitis. The pain is usually ipsilateral and the jaw is shifted to the

opposite side.

Treatment is as follows for this acute inflammatory condition:

Ice

Ultrasound - pulsed

Microcurrent

Distraction mobilization of the TMJ without adjustive thrust.

Mouth guard or similar device

Capsular Contracture can lead to a painless contracture of the capsular structures of the jaw.

Opening the jaw becomes limited and it will deviate contralaterally. The muscles will become

spastic due to tension of limited opening.

Wet heat, microcurrent, pulsed ultrasound are all good modalities for this condition.

Manipulation, either manual or low force will assist in the release of adhesions. Treatment for

the secondary muscle spasms will be discussed later in this section.

Ligaments:

Capsulitis is an acute inflammation of the joint capsule due to chronic excessive repetitive

opening will overstretch the capsule. Localized pain upon opening of the jaw and swelling at the

joint with pain over the condyle is characteristic.

Treatment is as follows:

Ice.

Pulsed ultrasound.

Microcurrent.

Distraction mobilization as above.

Temporomandibular ligament inflammation or a tear can alter tracking of the articular condyle

or intrusion of fluid into the retrodiscal space. Diagnosis of tear in this ligament is difficult due to

its position and symptomatic similarities to other conditions. X-ray or CT scan may be warranted

to view the tear or inflammation. A complete tear may require more invasive treatment methods

and referral may be warranted. Inflammation or incomplete tear may respond to treatment as

described for capsulitis. However, caution must be made with any mobilization technique as to

not further injure the affected tissues.

Muscles:

Muscles of mastication:

Temporalis:

45-1

The temporalis is difficult to treat due to its relationship to the cranium. If the muscle is

inflamed, ice or brief ice massage can reduce swelling. Massage of the muscle can be affective

once inflammation has been reduced. Trigger points here do affect the face and jaw. Friction

massage can be performed just above the mandibular condyle on the temporal bone at the

attachment of the temporalis muscle. This is beneficial for tendinosis, myofascitis, trismus and

contracture of this muscle. Craniopathy to address fixated cranial bones is also recommended.

Masseter:

45-2

This muscle is greatly responsible for much TMJ dysfunction. If inflamed, then ice or ice

massage is recommended. Microcurrent, pulsed ultrasound or cold laser can be performed on this

muscle to decrease inflammation and increase blood flow for healing. Friction massage is very

effective in treating the masseter. There will usually be a spasm anterior to the angle of the jaw

along the ramus. It will be tender to palpation and fibers will be contracted. The friction line

should be along the inferior ramus.

Trigger points in this muscle affect the face, jaw and ear.

45-3

Strain/counterstrain can be performed supine on two points. The first is in the masseter anterior

to the ascending ramus. The practitioner cups the relaxed mandible and pushes it toward the side

of the masseter injury while holding this point for 90 seconds. The second point is behind and

inferior to the angle of the jaw. The practitioner cups the patient’s chin and places a gentle force

laterally and rotated toward the point while they counter pressure with the palm of their hand.

The point is held for 90 seconds. These treatments are beneficial for tendinosis, myofascitis,

trismus and contracture of this muscle.

Lateral pterygoid:

45-4

This muscle can be iced by the patient by an ice pop. This muscle can be stretched passively by

the practitioner or actively by the patient. The most effective way to passively stretch this muscle

is by manual massage. Using a finger cott, the practitioner contacts the lateral pterygoid and

massages it caudally and cranially stretching the fibers. Passively, the patient can exercise the

lateral pterygoid by opening their jaw to increasingly greater distances. These treatments are

beneficial for tendinosis, myofascitis, trismus and contracture of this muscle. Of course, if acute

closed lock is an issue, the patient is limited to what they can do. The patient may respond to

craniopathy in easing the spasm of the lateral pterygoid since one of its attachments is at the

sphenoid bone.

Medial pterygoid:

45-5

This muscle can be treated as described for the lateral pterygoid.

Strain/counterstrain of the either the medial or lateral pterygoid can be performed as follows:

With the patient supine, the practitioner contacts the ascending ramus and contacts a point near

the angle of the jaw. While grasping the chin, the practitioner pushes the jaw toward the contact

point.

Trigger points exist in the medial pterygoid and affect the region of the TMJ directly. Massage is

the best means to reach these regions.

45-6

The accessory muscles of the jaw are difficult to treat due to their location under the jaw and

near the throat. Trigger points can exist in the platysma and digastric and radiate to the jaw and

neck.

It is difficult to reach the digastric. The platysma can be stretched but physiotherapy modalities

should not be used due to the proximity to glands and the throat.

Stretching of the neck in which the chin is forced ceilingward will stretch the platysma. Some

practitioners find it beneficial to adjust the hyoid with a low force adjusting tool to affect

imbalanced musculature.

45-7

Trigger points in the sternocleidomastoid and upper trapezius can refer pain into the jaw. Once

all other causes of jaw pain are ruled out, trigger points can be treated in these muscles. The most

effective method that can be used is trigger point ultrasound. Caution must be made when

treating the sternocleidomastoid as to not allow the sound head to affect the throat. With the

patient’s head turned away, the SCM can be treated affectively without contact of the glands and

throat.

45-8a 45-8b

Nerves:

Bell’s Palsy:

This CN 7 disruption causing unilateral paralysis of the face is usually treated by a neurologist

and the patient should be referred. This condition has been known to resolve within 3-4 weeks.

Trigeminal neuralgia:

This very painful condition of CN 5 has usually been treated aggressively with prescription

opiates or Dilantin and/or surgery to cut the nerve. Many cases do not respond to treatment as the

success rate of surgery is approximately 50 %. There has been clinical evidence that adjusting

the cervical spine at the level of C2 will affect the spinal ganglion and relationship to the 5th

cranial nerve. When a patient has this condition they are desperate for relief and a 3 - 6 week

course of adjustments is worth the opportunity to avoid surgery that can lead to permanent

paralysis or loss of sensation, or not be affective at all.

Arteries:

The condition discussed is temporal arteritis and treatment is out of the scope of this course. If a

patient is suspected with this condition they should be referred to a rheumatologist.

Fascia:

Internal tears to the fascia should be addressed by a dentist. External tears to the fascia about the

masseter muscle can be treated as directed above. Caution must be made during friction massage

as to not worsen the tear. Temporal fascia may respond to friction massage at the temporalis

attachment on the zygomatic arch.

Whiplash injury to the TMJ can affect the bones, teeth, joint, muscles, ligaments and fascia. This

all encompassing trauma must be thoroughly evaluated. Any suspicion of dental infraction

should be referred to a dentist. The joint, ligament, muscles and fascia can all be treated as

above. Use of mouth guard should be determined and if necessary, then prescribed. It is common

that a patient who has never clenched or bruxated before may do so after a whiplash injury. This

may or may not be due to the jaw itself but can be directly related to reflexes within the cervical

spine. Whatever is causing the clenching or bruxating must be evaluated and treated.

The intimate relationship of the jaw with the cervical spine and cranium is neurological as well

as physical. There are direct reflexes and proprioceptive feedback between jaw movement and

the upper cervical spine. There is also a physical relationship as well. When the atlas is flexed

anteriorly, there is a mechanical barrier to jaw movement. This relationship between the atlas and

ascending ramus and condyle of the jaw can be seen on X-ray. When a patient has been

diagnosed with TMD, a full evaluation of the cervical spine, including its biomechanics and

muscular function is warranted. A patient with cervical spine dysfunction with or without

headaches should also be evaluated for TMD.

Dysfunction and tension from TMD as well as cervical spine disorders can cause or contribute to

posttraumatic headache. Craniopathy is an excellent treatment tool for balance of proprioception,

muscle pull and excessive pressures against the cranial bones altering function. Excellent

techniques for craniopathy are found in Applied Kinesiology and SOT methods.

If acceleration/deceleration injury has been experienced, TMJ function should be evaluated along

with the spinal exam. Only with complete information and understanding of the affects of the

TMJ on the cervical spine and vice versa can the patient receive the best quality care for their

condition. And with a thorough knowledge of the TMJ, a patient can be successfully treated in

your office or referred to a specialist that you feel has the best treatment available for your

patient.

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