eMI7 ADJUSTING AND EVALUATION Original © 1984 © 2000DEDICATION ‘This book is dedicated to my grandfather, Dr. Robert E. Burns. Grandpa was a 1924 graduate of Palmer College of Chiropractic and practiced his beloved profession until his passing in 1983. While growing up, I can remember my grandfather working many hours at his office. Living in a farming community, grandpa would many times be at the office late into the night, especially during plant- ing and harvest seasons, Qn many holidays I can remember grandpa going to the office after the family dinner to see patients. Ability for a patient to pay was never a criterion for a patient to be seen by my grandfather. To the best of my knowledge, grandpa never sent out a bill in his 59 years of practice. His theory was, a patient would pay if they were able, so why waste time sending a bill? My grandfather was also very civic minded. Besides maintaining a full-time practice, he spent 16 years on the city of Tuscola’s City Coun- cil. He served both as an Alderman and as the Mayor of Tuscola, Il- linois. It is with a great deal of pride that 1 have chosen to practice my grandfather's profession. I know that he was equally proud of his pro- fession and alma mater. J, Richard Burns, D.C.ACKNOWLEDGMENT 1 would like to thank all chiropractic pioneers that took the time and effort to develop and teach corrective procedures for biomechanical alterations, These pioneers have been a great inspiration to me. I am also very grateful for the many students I have had over the years that have encouraged the writing of this text and have made teaching extremely enjoyable. Miss Joanne Benninghoven is graciously thanked for carefully and laboriously typing several drafts of this manuscript. Special thanks is extended to Dr. Patrick Keefe, Jr., for offering sug- gestions for the text and serving as the “patient” through long photographic sessions. Most of all, I would like to thank my wife, Vickie, and my children, Keith and Kelly. Through the years they have been very supportive of my profession. Many times I was unable to give them the necessary time at home due to my dedication to practicing and teaching chiropractic. It is for this I thank them greatly for their understand ing.TABLE OF CONTENTS Dedication .. Acknowledgement . . Introduetion Key to Abbreviations Contact Points. .... Chapter T History ... Chapter IT Examination Chapter 111 X-ray Chapter IV Shoulder Chapter V Chapter VI Elbow Chapter VII Wrist Chapter VIII Hand swosnsees Chapter IX Hip...... Chapter X Knee re Chapter XI Ankle... Chapter XIT Foot:........ se: es Extremity Moves and Listings ....0.6 6605600000000 Index 16 19 23 28 32 36 44 50 54KEY TO ABBREVIATIONS sis — Signs and symptoms — These are the criteria that are used to indicate the need for an adjustment. BP: — Patient placement DS. — Doctor's stance CP. — Contact point — This is the anatomical part of the doc- tor that is used to make the adjustive thrust. S.CP. — Segmental contact point — This is the anatomical part of the patient that is contacted by the contact: point. L.O.C. — — Line of correction — This is the direction of corrective force that is used by the doctor to adjust the involved extremity. ROM — Range of motionCHIROPRACTIC CONTACT POINTSINTRODUCTION The contents of this text are not necessarily original. It is a compilation of evaluation and ad- justive methods which will enable the chiropractor to fully understand all aspects involved with ex- tremity care, The main emphasis of this book has been placed on examination as this is an area which is vitally important. The chiropractor should always thoroughly understand indications and contrain- dications before rendering care to the extremities. Before the chiropractor begins to utilize this text, a review of the anatomy of the appendicular skeleton is in order. Once the doctor fully understands the anatomy, it will be much easier to understand the biomechanics involved with the evaluation and adjustive methods of the ex- tremities. When a patient has an extremity complaint, the chiropractor should always examine the spine as well. A great majority of extremity complaints may be corrected by adjusting only the spine, Even if the extremity needs corrective care, it will heal much faster with proper blood and nerve supply. General- ly speaking, if the spine and an extremity are both involved, the chiropractor should adjust the ex- tremity before the spine. If the chiropractor chooses to adjust the spine first, an extremity adjustment. may adversely affect the spinal adjustment, If the chiropractor finds multiple involvements on the same extremity, it is usually best to adjust the distal joint first and then proceed proximally. ‘There are a few exceptions to this rule. ‘The chiropractor should always keep the biomechanics of the adjustment in mind and evaluate how one ad- justment may affect another. All of the nomenclature in this book is discussed regarding the normal anatomical position of the pa- tient. The misalignments of the extremities are listed primarily in relationship to their proximal at- tachment, If the chiropractor uses this work effectively, many patients will be saved from suffering needlessly and possibly undergoing surgery needlessly. It is also important that the chiroprac- tor understands when a patient may have the need of orthopedic evaluation and makes the appropriate referral. I would like to ask that the chiropractor utilizing this work point out to patients that this is a special- ty. This will save the patient from asking a spine on- ly chiropractor for an extremity adjustment. It will also maintain a due place of high esteem for the spine only chiropractor. It should always be remembered that adjusting the spine is the common denominator amongst all chiropractors, and we should spend more time talking about areas in which we are similar than in those areas where we differ. It is my hope that this work will serve to better mankind for years to come. J. Richard Burns, D.C.Chapter I HISTORY A thorough history should always be taken on the patient. Taking a good history is like being a good reporter. The doctor should always ask specific questions and dig for information. The first question the doctor should ask is, “What hurts?” This may sound like a very simplistic question, but it is very important to en- courage the patient to be specific. The patient may say that they have wrist pain when it is in fact a brachial neuritis with the pain ending in the wrist. This will help the doctor determine if they are dealing with a spinal involvement, extremity involvement, or a combination of the two. Generally speaking, extremity involvements will cause localized pain, where pain that travels along the extremity is usually caused by spinal involvement. “When did the pain begin?” is another question the doctor must ask and obtain complete answers. It is not unusual for a patient to have a dull ache in a joint for many months or years, on- ly to relate to the doctor the acute episode which happened but a couple of days ago. The doctor should also follow up with the question, “Have you had involvement with this joint before?’” The preceding questions will help the doctor in deter- mining whether an acute or chronic condition is involved. The time needed to correct a chronic condition usually is longer than on the acute con- dition. There are obviously exceptions to this statement. “How did the injury occur?” can be a very im- portant question in determining what type of misalignment may have occurred. Certain types of injuries will produce extremity involvements in a specific direction. An inversion sprain of the ankle, for example, will many times result in a lateral tipping of the superior portion of the caleaneous away from the talus. The doctor should also determine what posi- tions give relief to the involved joint and what positions aggravate the joint. Generally speak- ing, the patient will experience the most relief the closer the joint is to the normal position. The doctor should also ask, ‘“What other treat- ment have you had for this condition?” Certain types of therapies and home treatments may ac- tually slow down or interfere with the amount of correction time needed for certain extremity in- volvements. By taking a thorough history, the doctor many times will determine the type of misalignment, the extent of involvement, and the correction time needed. It is then very important to confirm these findings by examination and x-ray.Chapter II EXAMINATION ‘The doctor should have a step by step examina- tion which is followed routinely with all ex- tremities. By establishing a set examination pat- doctor will be insured of covering all possibilities of involvement. ‘The first step to any examination is visualiza- tion. Whatever the patient’s complaint, the body part should always be observed before proceeding with the examination. If an extremity shows an obvious disfigurement or a great amount of swell- ing, x-rays should be taken before any further ex- amination is performed. Static palpation is the next portion of the ex- amination, The doctor will palpate for any swell- ing or edema which may be found in or around the articulation, The doctor will also statically palpate for misalignment of the bony parts of the articulation. After static palpation, the doctor will perform motion palpation. Motion palpation will be broken down into range of motion measurements, active motion, passive motion, and fluid motion. ‘The range of motion examination should always be done with a goniometer and recorded in degrees. This will give the doctor an objective measurement so that progress may be charted or impairment evaluated. The proper procedure and normal ranges of motion will be covered in the respective chapters. Active motion is when the patient moves the body part through a range of motion. The doctor will observe for smoothness of motion as well as asking the patient if any pain or discomfort is noted while performing the motion. Generally, pain on active motion will indicate a strain of a muscle or tendon. Passive motion is when the doctor moves the part for the patient through a range of motion. ‘The doctor will again ask the patient if they ex- perience any pain or discomfort. Generally, pain on passive motion indicates sprain of a ligament. Obviously, knowing the anatomy around the ar- ticulations will also be helpful in differentiating ligament from tendon involvement. Extremity in- volvements may also cause discomfort on active and/or passive motions. Crepitation may be found as well on active and passive motions, Crepitation may be caused by a disruption of the soft tissue or bony parts in the acute injury; whereas, with chronic injury, scar tissue in and around the joint may be the causative factor. Certain extremity involvements may also cause crepitation. Fluid motion is the last part of the motion palpation examination, All normal functioning joints will have a fluid give at the end of passive motion, This movement is also known as joint play or end play of the joint. A loss of fluid mo- tion is one of the major analytical tools used to determine if a joint is in need of an adjustment. Orthopedic tests are also used when evaluating the patient for extremity involvement. Many ex- tremity involvements may give false positives on certain orthopedic tests. Performing the or- thopedic tests may also give the doctor informa- tion concerning the need for further care, The specific orthopedic checks will be covered in the respective chapters. ‘The doctor that can perform, interpret, and record a thorough examination will know exactly what care the patient needs. Once the doctor has learned the step by step procedure, a very thorough examination can be performed in only a matter of minutes.Chapter III X-RAY X-ray is a very integral part of the evaluation process for extremity care. Besides being val- uable for finding fractures or disease processes, x-rays are helpful in determining misalignment which will assist the doctor in giving the best line of correction with the adjustive thrust. When evaluating the x-ray, the doctor should study all joint surfaces thoroughly. All joints throughout the body will have equal spacing be- tween all parts of the two opposing articular sur- faces. If the joint spacing is closer together or fur- ther apart at one portion of the joint compared to another this may indicate the need for extremity care. If degeneration is found in the joint, this in- dicates a chronie condition. This joint may need to be adjusted more conservatively in the begin- ning as joint mobility is usually lacking. It is extremely important that the doctor per- sonally views the xrays before care is rendered. It is not an impossibility that another doctor that took a patient’s x-rays could have missed very important information which could adversely af- fect your care. If there is any doubt as to what you are seeing on an x-ray, it is more judicious to take additional films rather than experiment with a patient's health.Chapter IV SHOULDER ‘When examining a patient with a shoulder com- plaint, the doctor should routinely examine all com- ponents of the shoulder girdle. The structures making up the shoulder girdle are the: 1. Sternoclavicular joint 2. Acromioclavicular joint 3. Glenohumeral joint 4, Scapulothoracie articulation ‘The most commonly involved joint in the shoulder girdle is the glenohumeral joint with the acromioclavicular joint being the next most commonly involved. ‘The doctor should do a thorough examination as outlined earlier, followed by the following examination procedures specifically designed for the shoulder. It is also important to keep in mind areas which may refer pain into the shoulder region. 1. Spinal subluxation Figure 2 2. Organic disorders Extension (Figure 2) a. Heart Zero point — ‘The patient's side b. Lung Pivot point — The head of the humerus. ¢. Diaphragm Reference point — ‘The shaft of the humerus d. Gall Bladder R-O-M — 50° e. Liver 3. Elbow Shoulder Range of Motion Examination L “ Figure 1 Figure 3 Flexion (Figure 1) Abduction (Figure 3) Zero Point — The patient’s side Zero point — The patient’s side Pivot point — The head of the humerus Pivot point — The head of the humerus Reference point — The shaft of the humerus Reference point — The shaft of the humerus R-O-M — 180° R-O-M — 180° 4Adduction (Figure 4) Zero point — The patient's side Pivot point — The head of the humerus Reference point — The shaft of the humerus ROM — 50° Figure 5 Internal Rotation (Figure 5) Zero point — A line extending from the elbow parallel with the floor Pivot point — The elbow Reference point — The forearm R-O-M — 90° Figure 6 External Rotation (Figure 6) Zero point — A line extending from the elbow parallel to the floor Pivot point — The elbow Reference point — The forearm R-O-M — 90° Orthopedic Examination of the Shoulder Figure 7 A. The Yergason's Test (Figure 7) To conduet this test, instruct the patient to flex the elbow to 90°. Then grasp the patient's flexed elbow in one hand while holding their wrist with your other hand. To test the stability of the biceps tendon, externally rotate the patient's arm as they resist, and, at the same time, pull downward on the elbow, If the biceps tendon is unstable in the bicipital groove, it will pop out of the groove and the patient will experience pain. If the tendon is stable, it will remain secure and the patient will ex- perience no discomfort. A positive would indicate an unstable bicipital tendon. ‘A minor instability may be corrected by ad- justing an inferior humerus. Pain while performing this test without slipping of the biceps tendon may also indicate an inferior humerus. Figure 9 B. Dawburns’s Test (Figures 8 & 9) Palpate the subacromial bursa by passively ex tending the humerus. (Figure 8) If the bursa is pain- ful abduct the humerus 90°. (Figure 9) If the pain 5disappears, it is a positive test. A positive test would indicate subacromial bursitis. If the test was negative and pain remained throughout movement this may indicate an inferior humerus. Figure 10 : Dugas’ Test (Figure 10) ‘The patient places their hand on the opposite shoulder and attempts to touch the chest with their elbow. The test is positive if the patient cannot touch the chest wall with the elbow. A positive could indicate a shoulder dislocation or subluxa- tion. Figure 11 ). Drop Arm Test (Figure 11) Instruct the patient to fully abduct their arm. ‘Then ask the patient to slowly lower it to their sid If there are tears in the rotator cuff (especially in the supraspinatus muscle), the arm will drop to the side from a position of about 90° abduction. The pa- tient still will not be able to lower the arm smoothly and slowly no matter how many times they try. If the patient is able to hold the arm in abduction, a gentle tap on the forearm will cause the arm to fall ‘to the side if a tear is present. (Figure 11) A positive -would indicate a rotator cuff tear. Figure 12 E. Apprehension Test for Shoulder Dislocation (Figure 12) Abduet, and externally rotate the patient's arm to a position where it might easily dislocate, and apply a posterior to anterior pressure. If the shoulder is ready to dislocate, the patient will have a noticeable look of apprehension or alarm on their face and will resist further motion. A positive would indicate chronic shoulder dislocation. Analytical Examination of the Shoulder ‘The analytical examination begins with visualize tion. The order of examination will be first the ster clavicular joint followed by the acromioclavicular joint, glenohumeral joint, and scapulothoracic articula tion. Figure 13, The doctor will observe the proximal ends of the clavicles to see if they are sitting at the same level (Figure 13) If one clavicle is sitting higher than the other it may indicate a superior clavicle. ‘The doctor next relates the distal ends of the clavicle to the trapezius muscle on each side checking for sym- metry. (Figure 13) If one clavicle is sitting higher than the other this may indicate a posterior superior clavi- cle, ‘The roundness of the shoulder is then compared to the distal end of the claviele. (Figure 13) If the shoulder is sitting lower in relationship to the distal end of the clavicle, this may indicate an inferior humerus. Figure Lastly, the vertebral borders of the scapulae are observed to see if they are in normal relationship to the spine. (Figure 14) If the vertebral border has flared laterally, it may indicate a lateral scapula, Likewise, if the vertebral border has flared medially, it may in- dicate a medial scapula. The doctor will next perform a motion examination in the same order as the visualization examination.‘The doctor will place the fingers at the sternoclavicular joints and ask the patient to shrug their shoulders. (Figure 15) The doctor will feel for aberrant motion or a loss of motion at the sternoclavicular joint which would indicate involvement of this articulation. Figure 17 ‘To examine the acromioclavicular joint the doctor will block the patient’s humerus against the side of the body to prevent glenohumeral motion. While maintain- ing this pressure, the doctor will apply a superior to in- ferior and slight posterior to anterior pressure onto the distal end of the clavicle. (Figure 16) Normallly, there should be a smooth fluid motion at the joint. If the joint was restricted this would indicate a posterior — superior clavicle. ‘The glenohumeral joint is examined by the doctor blocking the acromioclavicular joint with one hand to prevent acromioclavicular motion. While maintaining this pressure the doctor will grasp the patient’s elbow and apply an inferior to superior pressure on the humerus, (Figure 17) Normally, there should be a smooth fluid motion from inferior to superior. If this motion is lost and the shoulder visualizes as being low, this would indicate an inferior humerus. This would be confirmed by point tenderness at the anterior aspect of the glenohumeral joint. If the joint. has lost its fluid motion and visualizes normally, the doctor should suspect a posterior humerus. A posterior humerus will have point tenderness at the posterior aspect of the glenohumeral joint. Figure 19 The scapulothoracic articulation is examined by the doctor placing the thumbs at the medial portion of the inferior angle of the scapula and applying a medial to lateral pressure. (Figure 18) Normally, there should be a smooth and equal motion from medial to lateral. If this motion is restricted it would indicate a medial scapula. The doctor will then place the thumbs at the lateral portion of the inferior angle of the scapula and apply a lateral to medial pressure, (Figure 19). Normal- ly, there should be a smooth and equal motion from lateral to medial. If this motion is restricted it would indicate a lateral scapula. Tt should be noted again that with any shoulder com- plaint the doctor should routinely examine all four components of the shoulder girdle. It is possible that the doctor will have to correct more than one joint in order to totally correct the shoulder involvement. The doctor should usually choose to work on the joint with the most fixation first. No other adjustment should be made that may interfere with the major involvement. 7sis SCP. Stab, L.0.C. Figure 20, Sternoclavicular Joint Figure 21 Traction — Sitting (Figures 20 & 2i) ‘The doctor will palpate a loss of motion or crepitation at the sternoclavicular joint as the patient shrugs their shoulders. There is not necessarily any misalignment. ‘There may be point tenderness at the sternoclavicular joint. ‘The patient is sitting. ‘The doctor stands behind the patient slightly favoring the side of involvement. ‘The tips of the forefinger and chiroprac- tic index finger (#5 & #6) of the hand on the side of involvement. ‘The proximal head of the clavicle where it attaches to the manubrium of the ster- num, ‘The thenar (#10) of the hand on the op- posite side of involvement. Medial to lateral and slightly inferior to superior. Procedure ‘Tissue pull is taken from medial to lateral onto the clavicle with the fingers of the contact hand. The patient's humerus on the side of involvement is supported by the doctor's forearm. The doctor's thenar of the stabilization hand is placed on the fingers of the contact hand to maintain contact. ‘The doctor will stabilize the posterior aspect of the patient's thoracic cage with the chest. The doctor then rotates the patient's shoulder girdle posterior and superior until the ster- noclavicular joint opens. (Figure 21) No thrust is given. The doctor will then return the patient back to the neutral position slowly. sis Figure 22 Sternoclavicular Joint Figure 23 Traction — Supine (Figures 22 & 23) ‘The doctor will palpate a loss of motion or crepitation at the sternoclavicular joint as the patient shrugs their shoulders. There is not necessarily any misalignment. ‘There may be point tenderness at the sternoclavicular joint. BP, DS. ‘The patient is supine with the shoulder girdle off the side of the table. The doctor stands on the side of in- volvement facing toward the head of the table.OP, The pisiform (#1) of the inferior hand with the fingers pointing along the shaft of the clavicle. It is important to remember that the doctor's arm is kept as close to the patient's chest as possi- ble to avoid an anterior to posterior pressure to the chest cavity. ‘The proximal head of the clavicle where it attaches to the manubrium of the sternum, Medial to lateral and slightly inferior to superior. Procedure ‘Tissue pull is taken from medial to lateral onto the clavicle with the pisiform of the inferior hand. The doc- tor's superior hand grasps the patient's elbow on the side of involvement and moves the patient's arm posterior and superior. As the patient's arm is moved posterior and superior, the doctor in- creases pressure with the contact: hand until the sternoclavicular joint opens. (Figure 23). No thrust is given. The doc- tor will then return the patient back to the neutral position slowly. sis Figure 24 Sternoclavicular Joint Clavicle — Superior (Figure 24) ‘The doctor will palpate a loss of motion at the sternoclavicular joint. The prox- imal head of the clavicle is visualized as being more superior than the opposite side. There may be point tenderness at the sternoclavicular joint. PP. DS. GR. SCP. LOC. Procedure ‘The patient is sitting. ‘The doctor is behind the patient favor- ing the opposite side of involvement. ‘The thenar (#10) of the hand on the op- posite side of misalignment. ‘The superior portion of the proximal portion of the clavicle. Superior to inferior and clockwise torque for a right involvement and counter- clockwise torque for left involvement. Tissue pull is taken from superior to in- ferior with the thenar of the contact hand. On initial contact the fingers of the contact hand will point inferior. The doctor will then apply roll in in accor- dance with torque so that the contact fingers point just below the axilla. The doctor's opposite hand will then abduct the patient's arm to a point of tension (usually between 70° and 90°). The doc- tor will then thrust and torque in accor- dance with the line of correction. sis PP. CP, S.C.P. Figure 25 Acromioclavicular Joint Figure 26 Claviele — Posterior Superior (Figures 25 & 26) The doctor will palpate a loss of fluid motion from superior to inferior. The distal end of the clavicle will visualize as being more superior to the trapezius muscle as compared to the opposite side. Point tenderness may be elicited at the acromioclavieular articulation. The patient is sitting. ‘The doctor will stand behind the patient favoring the side of involvement. ‘The second metacarpophalangeal joint (#8) of the hand on the opposite side of involvement. ‘The superior portion of the distal end of the clavicle. L.O.C. Procedure Superior to inferior, slightly posterior to anterior. The doctor contacts the distal end of the clavicle with the contact hand. The doctor applies a very firm pressure from superior to inferior with the contact hand while the opposite hand abducts the patient’s arm until it comes to a complete lock. (Usually 70°). (Figure 26), The patient’s arm is then externally rotated. (Figure 26) With only a few degrees of external rotation the doctor will feel the movement of the clavicle with the contact hand.sis PP. Glenohumeral Joint Figure 28, Traction — Supine (Figures 27 & 28) This move would be indicated for any glenohumeral misalignment. It is designed to introduce motion into the joint. This move is especially beneficial for the osteoarthritic joint. ‘The patient is supine with the glenohumeral joint off the side of the table. The doctor stands on the side of in- volvement facing toward the head of the table. ‘The proximal end of the doctor's tibia. ‘The axilla of the patient. Medial to lateral. Procedure ‘The doctor will apply an inferior to superior pressure with the proximal end of the tibia into the patient's axilla. The doctor will place one hand on the pa- tient’s elbow and apply a lateral to medial pressure until the forefinger of the opposite hand feels the humeral head move away from the acromion. (Figure 28) The humerus is used as a lever. This move would be repeated three times. It is important to note that there is no thrust but a slow traction both in and out. sis Figure 29 Glenohumeral Joint Figure 20 Traction — Sitting (Figures 29 & 30) This move would be indicated for any glenohumeral misalignment. It should be noted that this move is not preferred over the supine traction move. ‘The patient is sitting. ‘The doctor is seated or kneeling next to the patient on the side of involvement. The doctor's forearm. The axilla of the patient. Medial to lateral. Procedure The doctor will place the forearm into the patient's axilla applying an inferior to superior pressure. The doctor's op- posite hand will hold the patient's arm at the elbow. The patient’s arm is held in supination and adducted until the humeral head is visualized as separating from the acromion. (Figure 30) There is no thrust but only a slow traction.sis PP. DS. CP. SCP. Stab, LOC, Figure 31 Figure 32 Figure 33 Glenohumeral Joint Humerus — Inferior (Figures 31, 32, and 33) ‘The patient will have a loss of motion from inferior to superior at the glenohumeral joint. The humerus will also visualize as being inferior in rela- tionship to the distal end of the clavicle. ‘There is also a pain spot at the anterior aspect of the glenohumeral joint. ‘The patient is sitting. ‘The doctor is standing behind the pa- tient. ‘The doctor's hand on the side of in- volvement superimposed over the hand ‘on the opposite side of involvement. ‘The elbow. ‘The doctor's chest is stabilized against the scapula on the side of involvement. Inferior to superior and slight lateral to medial. Procedure The doctor will grasp the patient's fore- arm just below the elbow with the hand on the side of involvement and fully supinate the patient's arm. (Figure 31) ‘The doctor's opposite hand then grasps the patient's elbow and adducts the pa- tient’s arm while the hand on the side of involvement flexes the elbow. (Figure 32) The doctor will stabilize the seapula with the chest while lifting the humerus from inferior to superior to bring the glenchumeral joint to a point of tension, (Figure 33) A quick thrust is given from inferior to superior. SiS PP. CP. SGP, Figure 34 Glenohumeral Joint Figure 35 Humerus — Posterior — Prone (Figures 34 & 35) ‘The patient will have a loss of normal motion but the humerus will usually visualize as being normal. A pain spot is located at the posterior aspect of the glenohumeral joint. ‘The patient is prone. The doctor stands on the side of in- volvement. The pisiform (#1) of the hand on the op- posite side of involvement. ‘The posterior aspect of the humeral head. LOC. Procedure Posterior to anterior. The doctor contacts the posterior aspect of the humeral head with the pisiform and applies pressure from posterior to anterior into the table. The opposite hand will slightly abduct and extend the patient’s humerus until a point of tension is felt, (Figure 35) A short quick thrust is given from posterior to anterior with the contact hand. No thrust is given with the op- posite hand. inGlenohumeral Joint Humerus — Posterior — Sitting (Figure 36) sis ‘The patient will have a loss of normal motion but. the humerus will usually visualize as being normal. A pain spot is located at the posterior aspect of the glenohumeral joint. This move is not preferred over the prone move. ‘The patient is sitting. The doctor is standing behind the pa- tient favoring the side of involvement. The pisiform (#1) of the hand on the op- posite side of involvement. The posterior aspect of the humeral head. Posterior to anterior. The doctor contacts the posterior aspect of the humeral head with the pisiform and applies pressure from posterior to anterior. The opposite hand z will slightly abduct and extend the pa- Figure 96 tient’s humerus until a point of tension ig felt. A short quick thrust is given from posterior to anterior with the con- tact hand. No thrust is given with the opposite hand. Glenohumeral Joint Frozen Shoulder (Figure 37) sis The patient will have a complete loss of motion at the glenchumeral joint, This procedure is used to increase motion so the shoulder may be more accurately analyzed. PP. The patient. is sitting sideways in a chair with the axilla supported by the padded back of the chair. DS. ‘The doctor is kneeling next to the pa- tient on the side of involvement. CP. Both hands of the doctor are utilized. S.CP. ‘The patient's upper and lower arm. Stab. ‘The back of the chair in the patient's ax- illa, LOC. Superior to inferior. Procedure ‘The doctor grasps the patient's arm and applies a very firm and steady pressure from superior to inferior for approx- imately forty five (45) seconds. A short quick thrust may be used at the end of traction but it is not usually needed. 12sis PP. DS. ce. S.C.P. Procedure Glenchumeral Joint Kocher Manewver (Figures 38, 39, 40, and 41) This maneuver is indicated for a shoulder dislocation. ‘The patient is sitting. ‘The doctor stands on the side of in- volvement. Both hands of the doctor are utilized, The flexed elbow and the wrist of the patient. on the side of involvement. The doctor grasps the patient's wrist and the patient's elbow which is flexed at ninety degrees (90°). The patient is passive throughout the procedure. The doetor first applies a steady pressure from superior to inferior. (Figure 38) ‘The humerus is then externally rotated. (Figure 39) While maintaining the ex ternal rotation the humerus is then ad- ducted. (Figure 40) The reduction will take place at this time. The patient's hand is then placed on the opposite shoulder for support. (Figure 41) 13sis PP. DS. CP. S.C.P. Figure 42 Scapulothoracic Articulation Figure 43 Scapula — Medial Side lying (Figures 42 & 43) The doctor will find a loss of motion as the scapula is moved from medial to lateral. There may also be a dull ache anterior to the scapula. ‘The patient is side lying with the in- volved side up. The patient’s humerus is placed along the patient’s anterior chest wall to flair the scapula from medial to lateral. The doctor stands anterior to the pa- tient. The pisiform (#1) of the inferior hand with the fingers pointing from medial to lateral. The medial aspect of the inferior angle of the scapula. Stab. LOC. Procedure ‘The superior hand palm is placed over the humeral head and the fingers are placed over the acromioclavicular joint. Medial to lateral with clockwise torque for left. involvement and counterclock- wise torque for right involvement. ‘The doctor will take tissue pull from medial to lateral with the contact hand. Stabilization is taken with the stabiliza- tion hand on the glenohumeral and acromioclavicular articulations. (Figure 42) The doctor will then prestress the scapula in the direction of torque. (Figure 43) A short quick thrust is given from medial to lateral and in the direction of torque. sis. 14 Scapulothoracic Articulation Scapula — Medial — Prone (Figure 44) ‘The doctor will find a loss of motion as the scapula is moved from medial to lateral. There may also be a dull ache anterior to the seapula. PP. DS. OP. SCP. Stab. Lc, Procedure The patient is prone with the gleno- humeral articulation off the side of the table. ‘The doctor stands straight away on the opposite side of involvement. ‘The pisiform (#1) of the inferior hand with the fingers pointing from medial to lateral. ‘The medial aspect of the inferior angle of the scapula. ‘The superior hand is wrapped around the wrist of the contact hand in a modified toggle stabilization. Medial to lateral with clockwise torque for left involvement and counterclock- wise torque for right involvement. ‘The doctor will take tissue pull ‘from medial to lateral with the contact hand. The doctor will then prestress the scapula in the direction of torque. A short quick thrust is then given from medial to lateral and in the direction of torque.SiS PP. DS. CP. S.CP. Stab. Scapulothoracic Articulation Figure 46 Seapula — Lateral — Side lying (Figures 45 & 46) ‘The doctor will find a loss of motion as the scapula is moved from lateral to medial. There may also be a dull ache anterior to the scapula. ‘The patient is side lying with the arm on the side of involvement behind the patient’s back to flair the scapula from lateral to medial. ‘The doctor stands anterior to the pa- tient. ‘The pisiform (#1) of the inferior hand with the fingers pointing from lateral to medial, ‘The lateral aspect of the inferior angle of the scapula, ‘The superior hand palm is placed over the acromioclavicular articulation and the fingers are placed over the humeral head. L.0.C. Procedure Lateral to medial with clockwise torque for right involvement and counterclock- wise torque for left involvement. ‘The doctor will take tissue pull from lateral to medial with the contact hand. Unless the patient has a large thoracic cage the doctor will have to put the con- tact arm underneath the patient's arm in order to achieve the appropriate line of correction. Stabilization is taken with the stabilization hand on the glenohumeral and acromioclavicular ar- ticulations. (Figure 45) The doctor will then prestress the scapula in the direc- tion of torque. (Figure 46) A short quick thrust: is given from lateral to medial and in the direction of torque.Chapter V RIBS ‘This discussion will cover the ribs as they misalign ‘on the anterior at the sternocostal articulation. Primarily, involvement may be found on the upper five pairs of ribs. Involvement is usually unilateral, but it is not impossible for bilateral involvement to occur. It is very common to find a thoracic subluxation at the same level of involvement of the rib. ‘The floating ribs obviously do not misalign at the anterior, The doctor will however, find pain on the lower ribs which may be the result of torn cartilage. ‘The patient will also have a history of trauma. The ribs may also misalign at the posterior. It is very rare for these to misalign without involving the adjacent vertebral segment. Adjusting the involved vertebra will usually correct the costovertebral misalignment. Analytical Examination of the Ribs ‘The patient will be in the seated posture and the doc- tor will be standing behind the patient. The doctor will palpate the rib being examined with one hand while the opposite hand palpates the corresponding rib on the opposite side. The patient is asked to breathe in and out fully. Normally, as the patient inspires, both ribs should rise the same distance. If one rib does not rise as high as the opposing side, the rib is fixed inferiorly (expira- tion fixation). Likewise, when a patient fully expires both ribs should drop the same distance. If one rib does not drop as far as the opposing side, the rib is fixed superiorly {inspiration fixation). Point tenderness will usually be found at the in- volved sternocostal articulation. The pain may also radiate from the involved sternocostal articulation to tthe patient's side. If the pain follows the entire course of the intercostal nerve from posterior to anterior, a thoracic subluxation should be expected. Sternocostal Articulation Traction — Sitting (Figures 47 & 48) sis ‘The doctor will palpate a loss of motion at the sternocostal articulation as the patient is taking full inspirations and expirations. There may be point 16 tenderness at the sternocostal articula- tion. Occasionally, pain may radiate from the sternocostal articulation to the lateral margin of the patient.PP. oP. SOP. Stab. L.O.. Procedure ‘The patient is sitting. ‘The doctor stands behind the patient slightly favoring the side of involve ment. ‘The tips of the forefinger and chiroprac- tic index finger (#5 and #6) of the hand on the side of involvement. ‘The sternocostal articulation of the in- volved rib. ‘The thenar (#10) of the hand on the op- posite side of involvement. Medial to lateral. Tissue pull is taken from medial to lateral onto the sternocostal articula- tion with the fingers of the contact hand. The patient's humerus on the side of involvement is supported by the doc- tor's forearm. The doctor's thenar of the stabilization hand is placed on the fingers of the contact hand to maintain contact. The doctor will stabilize the posterior aspect of the patient's thoracic cage with the chest. The doctor then rotates the patient's trunk poste- rior and superior until the sternocostal joint opens. (Figure 48) No thrust is given. The doctor will then return the patient back to the neutral position slowly. The lower the involved rib, the higher the doctor will have to lift the pa- tient’s elbow. SIS, PP. DS. OP. Figure 49 Sternocostal Articulation Figure 50 Traction — Supine (Figures 49 & 50) ‘The doctor will palpate a loss of motion at the sternocostal articulation as the patient is taking full inspirations and expirations. ‘There may be point tenderness at the sternocostal articula- tion. Occasionally, pain may radiate from the sternocostal articulation to the lateral margin of the patient. ‘The patient is supine with the shoulder girdle on the side of involvement off the table. ‘The doctor stands on the side of in- volvement facing toward the head of the table. ‘The pisiform (#1) of the inferior hand with the fingers pointing from medial to lateral. It is important to remember that the doctor's arm is kept as close to the patient's chest as possible to avoid an anterior to posterior pressure to the chest cavity. SCP. Loc. Procedure The sternocostal articulation of the in- volved rib, Medial to lateral. Tissue pull is taken from medial to lateral onto the sternocostal articula- tion with the pisiform of the inferior hand. ‘The doctor's superior hand grasps the patient's elbow on the side of involvement and moves the patient's arm posterior and superior, As the pa- tient’s arm is moved posterior and superior, the doctor increases pressure with the contact hand until the ster- nocostal joint opens. (Figure 50) No thrust is given. ‘The doctor will then return the patient back to the neutral position slowly. ‘The lower the involved rib, the more superior the doctor will have to lift the patient's arm. 7Figure 51 Sternocostal Articulation Superior — Inspiration fixation (Figure 51) SIS PP. OP. SCP. Stab. LOC, Procedure 18 ‘The doctor will note that: the patient's rib does not return to normal position ‘on full expiration of the patient. ‘The patient is supine. ‘The doctor stands straight away on the side of involvement, ‘The pisiform (#1) of the superior hand with the fingers pointing inferior. ‘The superior aspect of the involved rib. Any portion of the opposite hand, The stabilization hand is used only to hold the contact hand tight to the patient's chest, No thrust comes out of the stabilization hand. Superior to inferior. The doctor takes tissue pull from superior to inferior onto the involved rib, The patient is asked to take a deep breath in and then all the way out. The patient is asked to hold their breath on full expiration, The doctor then gives a short quick thrust from superior to in- ferior. Figure 52 ‘Sternocostal Articulation Inferior — Expiration Fixation (Figure 52) Sis PP. DS. OP. S.C.P. Stab. L.O.C. Procedure ‘The doctor will note that the patient's rib does not rise fully when the patient fully inspires. ‘The patient is supine, ‘The doctor stands straight away on the side of involvement. ‘The pisiform (#1) of the inferior hand with the fingers pointing superior. ‘The inferior aspect of the involved rib. Any portion of the opposite hand. The stabilization hand is used only to hold the contact hand tight to the patient’s chest. No thrust comes out of the stabilization hand, Inferior to superior. ‘The doctor takes tissue pull from in- ferior to superior onto the involved rib. The patient is asked to take a deep breath in and hold. The doctor then gives a short quick thrust from inferior to superior.Chapter VI ELBOW The elbow is composed of three articulations: 1, Humeroradial joint 2, Humeroulnar joint 3. Radioulnar joint. ‘The most commonly involved joint is the humer- oradial joint. This is generally due to a torquing action such as throwing a curveball or turning a doorknob. In- volvement of this joint many times will mimic a tennis elbow. ‘Areas which may refer pain to the elbow are: 1. Spinal subluxation 2. Shoulder 3. Wrist Elbow Range of Motion Examination Flexion (Figure 53) Zero point — Aline extending distally from the humerus Pivot point — Humeroulnar joint Reference point — Forearm R-O-M — 160° 4 Figure 54 Extension (Figure 54) Zero point — A line extending from the humerus Pivot Point — Humeroulnar joint Reference point — Forearm ROM — 0° Figure 55 Supination (Figure 55) Zero point — A line perpendicular to the floor Pivot point — The center of the long axis of ek the forearm 'eference point — a pencil held in t) ient's fi Ficereets pol Pp in the patient's fist Pronation (Figure 56) Zero point — A line perpendicular to the floor Pivot point — The center of the long axis of the forearm Reference point — A pencil held in the patient's fist R-O-M — 90° 1920 Orthopedic Examination of the Elbow Figure 57 Figure 58 Figure 59 Mills’ Test (Figures 57, 58, & 59) ‘The patient is instructed to flex the forearm, ful- ly flex the fingers and wrist, (Figure 57) then pro- nate the forearm (Figure 58) and attempt to extend forearm. (Figure 59) The test is positive if elbow pain increases and is indicative of humeroradial (lateral) epicondylitis (tennis elbow.) ‘A posterior radius may also give a positive test. ‘A true lateral epicondylitis will have pain where the extensor tendons attach to the lateral epicondyle. A posterior radius will have point tenderness on the radial head. Figure 60 B. Cozen Test (Figure 60) ‘The patient makes a fist and extends the wrist. ‘The doctor will attempt to flex the wrist against the patient's resistance while palpating the exten- sor tendons and checking for pain. A positive would indicate a humeroradial (lateral) epicon- dylitis (tennis elbow), ‘A posterior radius may also give a positive test. A true lateral epicondylitis will have pain where the extensor tendons attach to the lateral epicondyle, ‘A posterior radius will have point tenderness on the radial head. Figure 61 Figure 62 C. Lift Test (Figures 61 & 62) ‘The patient is asked to lift an object (back of a chair) first in pronation which checks the exten- sors, (Figure 61) then in supination, which checks the flexors. (Figure 62) A positive finding would be pain. A positive on pronation would indicate lateral epicondylitis (tennis elbow) whereas a positive on supination would indicate medial epicondylitis (golfer's elbow). ‘A posterior radius may also give a positive test while lifting on pronation, A true lateral epicon-dylitis will have pain where the extensor tendons attach to the lateral epicondyle. A posterior radius will have point tenderness on the radial head. ‘A posterior ulna may give a positive test while ifting on supination. A true medial epicondylitis will have pain where the wrist flexors attach to the medial epicondyle. A posterior ulna will have pain ‘one to one and a half inches distal to the medial epicondyle. Analytical Examination of the Elbow ‘A patient having humeroradial involvement (posterior radius) will usually have point tenderness over the radial head. The doctor will notice a loss of fluid motion at the humeroradial joint. This motion is checked by applying a posterior to anterior pressure onto the radial head while the patient's forearm is passively extended and pronated. A patient having humeroulnar involvement will have a loss of fluid motion at the humeroulnar joint. This motion is checked by the doctor applying a posterior to anterior pressure on the olecranon while the patient's elbow is passively extended. There may also be a loss of full extension. A patient with humeroulnar invelve- ment may have a posterior ulna which is more common or a posterior medial ulna. These misalignments are differentiated by the location of pain. A posterior ulna will exhibit point tenderness one inch (1") to one and one half inch (1") distal to the medial epicondyle. A posterior medial ulna will have point tenderness in the olecranon fossa. It is possible to have both a humeroradial and a humeroulnar involvement on the same elbow. There is usually no problem with correcting both mis- alignments during the same office visit unless one ar- ticulation has much more fixation than the other. If this were the case, the doctor should correct the major fixation first. Figure 63 Elbow Traction — Supine (Figure 63) This move would be indicated for in- volvement of the humeroradial or humeroulnar involvement, especially if the patient has limited extension of the elbow. The patient is supine. The doctor stands on the side of in- volvement, The doctor's wrist corresponding to the side of involvement. The elbow fossa of the patient. The doctor takes tissue pull from superior to inferior rolling the wrist into the elbow fossa. The doctor's opposite hand will approximate the patient's wrist toward their shoulder until expan- sion of the elbow is noted. This pro- cedure is repeated three to five times within the tolerance of the patient. Figure 64 Radius Figure 65 Posterior (Figures 64 & 65) sis ‘The doctor would note a loss of fluid DS. ‘The doctor is sitting or kneeling on the motion at the humeroradial joint. There side of involvement. is usually point tenderness on the radial OP: ‘The thumb (#9) of the hand on the op- head. posite side of involvement. P.P. The patient is sitting. S.C.P. ‘The posterior aspect of the radial head. 21LO. Posterior to anterior. slightly off full extension. The doctor Procedure The doctor takes tissue pull from will then give a short quick thrust from posterior to anterior onto the radial posterior to anterior while extending head. The doctor's opposite hand will the elbow and pronating the wrist, grasp the dorsum of the patient's wrist. (Figure 65) ‘The doctor will start with the elbow Figure 66 Ulna Figure 67 Posterior (Figures 66 & 67) sis The doctor would note a loss of fluid olecranon. motion at the humeroulnar articulation. Loc. Posterior to anterior. Point. tenderness will be noted approx- Procedure ‘The doctor will take tissue pull from in- imately one inch (1") to one and one half ferior to superior toward the olecranon inch (1¥4") distal to the medial epicon- with the thumb web. The opposite hand dyle of the humerus. will grasp the volar surface of the pa- PP. ‘The patient is sitting. tient’s wrist. The patient's forearm is DS. ‘The doctor is sitting or kneeling on the held in supination. The doctor will start side of involvement. with the elbow slightly off full exten- CP. ‘The thumb web on the hand on the op- sion. The doctor will then give a short posite side of involvement. quick thrust from posterior to anterior. SCP. Slightly inferior to the point of the (Figure 67) Figure 68 Ulna Figure 69 Posterior — Medial (Figures 68 & 69) sis The doctor would note a loss of fluid 1.06, Posterior to anterior and medial to motion at the humeroulnar articulation. lateral. Point tenderness will be noted at the Procedure The doctor will take tissue pull from olecranon fossa. posterior to anterior. The opposite hand PP. ‘The patient is supine. will grasp the volar surface of the pa- DS ‘The doctor stands on the side of in- tient’s wrist. The doctor will start with volvement facing toward the head of the patient’s arm slightly off full exten- the table, sion. The doctor will then give a short cP. The second metacarpophalangeal joint quick thrust from posterior to anterior (#8) of the hand on the side of involve- and medial to lateral while extending ment. the elbow and supinating the wrist. S.OP. Slightly medial to the olecranon. (Figure 69) 22Chapter VII WRIST ‘The wrist is comprised of eight éarpal bones which are responsible for producing the many types of mo- tion required by the wrist. The proximal row of carpals from radius to ulna is comprised of the navicular, lunate, triquetrum, and pisiform. ‘The pisiform is located anterior to the triquetrum. ‘The distal row of carpals from the radius to ulna is comprised of the trapezium, trapezoid, capitate, and hamate, ‘The lunate is the most commonly involved carpal with the triquetrum being the second most common. It should also be noted that the most commonly frac- tured carpal is the navicular. If patient has had an in- jury to the wrist in which the wrist was extended and swelling is present in the anatomical snuff box, the doctor should always suspect navicular fracture. Areas that may refer pain to the wrist are: 1. Spinal subluxation 2, Shoulder 3. Elbow ‘The carpal tunnel syndrome is another very common wrist complaint. It has been the author's experience that most. carpal tunnel syndromes are the result of spinal subluxations. Other conditions which may pro- duce carpal tunnel syndrome symptoms include cer- vical rib, scalenus anticus syndrome, hyperabduction syndrome, and costoclavicular syndrome. ‘Wrist Range of Motion Examination Figure 70 Flexion (Figure 70) Zero point — A line extending distally from the forearm Pivot point — The center of the wrist Reference point — The metacarpals ROM — 90° Figure 71 Extension (Figure 71) Zero point — A line extending distally from the forearm Pivot point — The center of the wrist Reference point — The metacarpals ROM — 70° Figure 72 Radial deviation (Figure 72) Zero point — A line extending distally from the forearm Pivot point — The center of the wrist Reference point — Third metacarpal R-0-M — 20° 23Figure 73 Ulnar deviation (Figure 73) Zero point — A line extending distally from the forearm Pivot. point — The center of the wrist Reference point — Third metacarpal R-O-M ~ 55° Orthopedic Examination of the W: Figure 74 A. Tinel Tap Test (Figure 74) ‘The doctor taps rapidly over the volar carpal liga- ment for approximately ten seconds seeing if pain or paresthesia can be reproduced over the distribu- tion of the median nerve. A positive test would in- dicate carpal tunnel syndrome. B. Phalen’s Test (Figure 75) ‘The patient places the dorsum of each hand against one another and flexes the wrists to their maximum degree. This position is held for up to one minute seeing if any paresthesia develops. A positive finding would indicate carpal tunnel syn- drome. Figure 76 Figure 77 C. English or British Test (Figures 76 & 77) "The examiner forcibly compresses the forearm of the patient proximal to the wrist (Figure 76) and the patient is then asked to make a fist and then ex- tend the fingers six or eight times. (Figure 77) Usually, the radial and ulnar arteries are sufficient- ly compressed so that this maneuver will result in a pale hand, and usually within a minute, the median nerve numbness and paresthesia will be produced. A positive test would indicate carpal tunnel syn- drome. Orthopedic Examination of the Wrist ‘The following tests would be performed if the patient was experiencing carpal tunnel syndrome symptoms.Figure 78 A. Adson's Test (Figure 78) ‘The doctor takes the patient's pulse and the pa- tient is instructed to take a deep breath, elevate the chin and turn their face toward the side being ex- amined, The patient should hold their breath for five to ten seconds. A positive finding is a decrease in the volume of the radial pulse and would indicate a possible scalenus anticus syndrome or cervical rib. Figure 80 B. Wright's Test (Figures 79 & 80) Palpate the patient’s pulse with the other hand underneath the patient’s elbow. Abduct the arm and see if the pulse disappears and note the degree of the arm. If it is the same degree on both sides the test is negative. A unilateral positive would in- dicate hyperabduction syndrome. Figure 81 Eden's Test (Figure 81) ‘The examiner palpates the radial pulse. ‘The pa- tient is requested to take a deep breath and hold it, while pulling their shoulders posterior and inferior, ‘The test. is positive if a weakening or loss of the pulse occurs, or pain increases. A positive test in- dicates costoclavicular syndrome. Figure 82 Figure 83 D. Allen's Test (Figures 82 & 83) The patient’s hands are on their lap with the palms up. Have the patient clench the fists bilaterally, then compress either the radial or ulnar artery bilaterally. (Figure 82) Have the patient release their fists and observe the amount of time it takes for the palms to return to normal color. (Figure 83) Up to 10 seconds is normal. Both the radial and ulnar arteries should be checked. A positive would indicate a loss of patency in the respective artery. (The patency of the ulnar artery is being examined in Figures 82 & 83.) ‘A positive Allen's test on the radial artery may negate the doctor's findings on the Adson’s, Wright's, and Eden's tests. 25Analytical Examination of the Wrist Even though the lunateis by far the most commonly involved carpal bone the doctor should routinely ex- amine all of the carpals on a patient with a wrist com- plaint. ‘The doctor will first visualize the patient's wrist which is held in flexion. The dorsum of the wrist should have a smooth contour with no elevations or depres- sions. The doctor will also statically palpate the wrist checking for bony malposition. ‘The fluid motion examination is performed by the doctor grasping the carpal being examined between the thumb and forefinger. Each carpal is examined in- dividually with the exception of the triquetrum and pisiform which are examined as one unit. Each carpal should exhibit a smooth fluid motion from anterior to posterior and posterior to anterior. Any aberrant or restricted motion would indicate a need for adjust- ment. Figure 85 Wrist Traction (Figures 84, 85, & 86) Figure 84 sis ‘This move would be indicated for any carpal misalignment. PP. ‘The patient is sitting, DS. ‘The doctor is seated on the side of in- volvement. cP. ‘The doctor's hand that corresponds to the side of involvement. S.C.P. The patient’s hand on the side of in- volvement. Stab. The doctor's hand corresponding to the opposite side of involvement grasps the patient at the distal end of the radius and the ulna. ‘The doctor grasps the patient's hand in a handshake position while stabilizing the distal forearm with the opposite hand. The doctor first applies a superior to inferior traction. (Figure 84). While maintaining this traction, the doctor flexes the wrist (Figure 85) extends the wrist (Figure 86) returns the wrist to the neutral position (Figure 84) and releases slowly. This move is done within the tolerance of the patient. Procedure Figure 87 Wrist Figure 88 Single thumb (Figures 87 & 88) s/s ‘The doctor will find a loss of fluid mo- tion on the involved carpal. There may also be point tenderness on the involved 26 carpal. (The example illustrated in Figures 87 & 88 is correction for a lunate misalignment).EP, DS. GOP: S.C.P. Stab. L.0.€. ‘The patient is sitting. ‘The doctor is seated or kneeling on the side of involvement. ‘The thumb (#9) of the hand that cor- responds to the side of involvement. The posterior aspect of the involved car- pal. ‘The doctor’s hand corresponding to the opposite side of involvement grasps the patient at the distal end of the radius and ulna. Lunate and capitate — posterior to anterior. Triquetrum and hamate — posterior to anterior and medial to lateral. Navicular, trapezium, and Procedure trapezoid — posterior to anterior and lateral to medial. ‘The doctor takes superior to inferior tissue pull onto the involved carpal, The doctor first applies a superior to inferior traction. (Figure 87) While maintaining this traction the doctor will extend the wrist for the lunate and capitate, (Figure 88) extend and ulnar deviate the wrist for the triquetrum and hamate, and extend and radial deviate the wrist for the navicular, trapezium, and trapezoid. The doctor should feel the carpal reduce at the end of wrist mo- tion. sis Figure 89 ‘The doctor will find a loss of fluid mo- tion on the involved carpal. There may also be point tenderness on the involved carpal. (The example illustrated in Figures 89 & 90 is correction for a junate misalignment.) ‘The patient is sitting or supine. ‘The doctor is seated or kneeling on the side of involvement. The thumbs (#9) of the doctor's hands superimposed over one another. The posterior aspect of the involved car- pal. ‘The doctor may choose to have an assis- tant stabilize the patient's forearm. Lunate and capitate — posterior to anterior. Triquetrum and hamate — Wrist Double thumb (Figures 89 & 90) Procedure posterior to anterior and medial to lateral, Navicular, trapezium, and trapezoid — posterior to anterior and lateral to medial. The doctor takes superior to inferior tissue pull onto the involved carpal. The doctor first applies a superior to inferior traction (Figure 89). While maintaining this traction the doctor will extend the wrist for the lunate and capitate, (Figure 90) extend and ulnar deviate the wrist for the triquetrum and hamate, and extend and radial deviate the wrist for the navicular, trapezium, and trapezoid. The doctor should feel the carpal reduce at the end of wrist mo- tion. 27Chapter VIII HAND ‘The hand is comprised of the: 1. Carpometacarpal joints 2. Metacarpophalangeal joints 3, Interphalangeal joints ‘The most common area of involvement is the first carpometacarpal joint. This is primarily due to the many directions of movement and actions that this joint assumes. The first metacarpophalangeal joint is considered the most important joint, particularly when it comes to rating impairment. ‘reas that may refer pain to the hand a 1. Spinal subluxation 2, Shoulder 3. Elbow Hand Range of Motion Examination Thumb (metacarpophalangeal) Figure 91 Zero point — A line extending distally from the first metacarpal Pivot point — The metacarpophalangeal joint Reference point — The first phalanx R-O-M — 50° Flexion (Figure 91) Extension (Figure 92) 28 Zero point — A line extending distally from the first metacarpal Pivot. point — The metacarpophalangeal joint Reference point — The first phalanx R-O-M — 50° Figure 98 Abduction (Figure 93) Zero point, — A line extending distally from the first metacarpal Pivot point — The metacarpophalangeal joint Reference paint — The first phalanx R-O-M — 70° Figure 94 Adduction (Figure 24) Zero point — A line extending distally from the first: metacarpal Pivot point — The metacarpophalangeal joint Reference point — The first phalanx R-O-M — 0° Thumb (interphalangeal) Flexion (not pictured) Zero point — A line extending distally from the proximal phalanx Pivot point — The interphalangeal joint Reference point — The shaft of the distal phalanx R-O-M — 90°Extension (not pictured) Zero point — A line extending distally from the proximal phalanx Pivot point — The interphalangeal joint Reference point — ‘The shaft of the distal phalanx R-O-M — 20° Fingers (metacarpophalansreal) Flexion (not. pictured) Zero point — A line extending distally from the metacarpal Pivot point — The metacarpophalangeal joint, Reference point — ‘The first phalanx R-O-M — 90° Extension (not pictured) Zero point — A line extending distally from the metacarpal Pivot point — The metacarpophalangeal joint Reference point — The first phalanx R-O-M — 30° Abduction (not pictured) Zero point — A line extending distally from the metacarpal Pivot point — The metacarpophalangeal joint Reference point — The first phalanx R-O-M — 20° Fingers (interphalangeal) Flexion (not pictured) Zero point — A line extending distally from the proximal phalanx Pivot point — The interphalangeal joint Reference point — The distal phalanx R-O-M — 80° Extension (not pictured) Zero point — A line extending distally from the proximal phalanx Pivot point — The interphalangeal joint Reference point — ‘The distal phalanx R-O-M — 0° Orthopedic Examination of the Hand Figure 95 A. Finkelstein's Test (Figure 95) ‘The patient flexes the thumb to the distal end of the fifth metacarpal, If this maneuver cannot be performed it is positive for ulnar nerve palsy. It may also be positive if pain is aggravated at the dorsum of the radial side of the wrist. This would indicate stenosing tenosynovitis of De Quervain. Figure 97 B. Froment’s Sign (Figures 96 & 97) ‘The patient is asked to grasp a piece of paper or cardboard firmly with the thumb and index finger. (Figure 96) The test is positive if the patient cannot, hold the cardboard firmly, or flexes the distal phalanx of the thumb when an attempt is made by the examiner to pull the cardboard from the fingers. (Figure 97) A positive test is indicative of ulnar nerve palsy. In ular palsy, the thumb of the affected limb is involuntarily flexed by the flexor pollicus longus. Analytical Examination of the Hand ‘The doctor will examine for fluid motion at the car- pometacarpal joint by grasping the proximal portion of the metacarpal and gliding the bone from posterior to anterior. Any loss of motion would indicate a need for an adjustment. When this joint is involved there will usually be a sharp pain at the carpometacarpal joint. The pain may extend along the shaft of the metacarpal. ‘The metacarpophalangeal joints and the inter- phalangeal joints are examined in the same manner, ‘The doctor may check for gliding of the joint from posterior to anterior, from medial to lateral and lateral to medial, and in the rotational plane, A fixation in any direction would indicate the need for an adjustment, 29Figure 99 First Metacarpal Double thumb (Figures 98 & 99) sis ‘The doctor will find a loss of fluid mo- ‘Stab. ‘The doctor may choose to have an assis- tion from posterior to anterior. There tant stabilize the patient's forearm. may also be point tenderness at the first. _L.O.C. Posterior to anterior. carpometacarpal joint. Procedure The doctor will contact the posterior PP. ‘The patient is sitting. aspect of the first metacarpal. The doc- DS. ‘The doctor is kneeling next to the pa- tor first applies a superior to inferior tient on the side of involvement. traction. (Figure 98) While maintaining cP. ‘The thumbs (#9) of the doctor's hands this traction, the doctor will extend the superimposed over one another. metacarpal. (Figure 99) ‘The doctor SCP. ‘The posterior portion of the proximal should feel the metacarpal reduce at the end of the first metacarpal. end of extension. Figure 100 Figure 101 Second and Third Metacarpal ‘Single thumb (Figures 100 & 101) SiS ‘The patient will experience a sharp pain the doctor’s hand that corresponds to at the carpometacarpal joint. The pain the side of involvement. may extend along the shaft of themeta- —S.C.P. ‘The posterior and the anterior aspects carpal. This is a rotational misalign- of the proximal portion of the involved ment. metacarpal. PP. ‘The patient is sitting. Stab. ‘The doctor's hand corresponding to the DS. ‘The doctor is sitting or standing next to opposite side of involvement grasps the the patient on the side of involvement. patients carpals. CR. ‘The thumb (#9) and the forefinger (#6) ofLOC. Procedure ‘The metacarpal is rotated medially and laterally. ‘The doctor will grasp the proximal por- tion of the metacarpal between the thumb and the index finger of the con- tact hand. The doctor first applies a superior to inferior traction. (Figure 100) While maintaining this traction the doctor will slightly extend the metacarpal and rotate it medially and laterally. (Figure 101) There should be immediate reduction of the symptoms. sis PP. DS. CP. S.CP. Stab. Metacarpophalangeal Joint Traction (Figures 102 & 103) ‘The doctor will notice a loss of fluid mo- tion at the involved metacarpopha- langeal joint. There may also be pain at the involved joint ‘The patient is sitting. The doctor is standing next to the pa- tient on the side of involvement. ‘The thumb (#9) and the forefinger (#6) of the doctor's hand that corresponds to the side of involvement. ‘The posterior and anterior aspects of the first phalanx. ‘The doctor will grasp the metacarpal LO. Procedure Figure 103, between the thumb and forefinger of the opposite hand. Superior to inferior. The doctor will grasp the first phalanx between the thumb and index finger of the contact hand, The doctor first ap- plies superior to inferior traction. (Figure 102) While maintaining this traction the doctor will flex the phalanx using the forefinger asa fulcrum to open the joint. (Figure 103) This move may also be used for any inter- phalangeal joint involvement. 31Chapter IX HIP The hip consists of the articulation between the femur head and the acetabulum of the innominate, ‘The main indication for adjusting the hip is a loss of, fluid motion or a loss of motion on Fabere-Patrick or Hibb’s test, The patient's symptomatology may range from a dull ache to a sharp pain at the hip. Lying on the involved side may also produce symptoms. The doctor will obviously x-ray the patient to insure that the ad- justment can be safely delivered. ‘Areas that may refer pain into the hip are: 1. Spinal subluxation 2, Sacroiliac subluxation 3, Knee Hip Range of Motion Examination Figure 104 Flexion (Figure 104) Zero point — A line extending distally from the patient's trunk Pivot point — ‘The femur head Reference point — The shaft of the femur R-O-M ~ 120° Figure 105 Extension (Figure 105) 32 Zero point — A line extending distally from the patient's trunk Pivot point — The femur head Reference point — The shaft of the femur R-O-M — 30° Figure 106 Abduction (Figure 106) Zero point — A line extending distally from the patient's trunk Pivot point — The femur head Reference point — The shaft of the femur R-O-M — 45° Figure 107 “Adduction (Figure 107) Zero point — A line extending distally from the patient's trunk Pivot point — The femur head Reference point — The shaft of the femur R-O-M — 30°Figure 108 Internal Rotation (Figure 108) Zero Point — A line extending distally fram the patient's trunk Pivot point — The knee over the hip which is flexed 90° Reference point — The shaft of the tibia R-O-M — 40° Figure 109 External Rotation (Figure 109) Zero point — A line extending distally from the patient's trunk Pivot point — The knee over the hip which is flexed 90° Reference point — The shaft of the tibia R-O-M — 45° Orthopedic Examination of the Hip A. Thomas Test (Figure 110) The patient lies supine on the examining table. ‘The doctor flexes the leg and thigh on the side op- posite that being examined, while observing the knee on the side being examined. A positive finding is for the hip on the side being examined to flex and would indicate a flexion deformity of the hip. The flexion deformity could be secondary to Calve- Lege-Perthes, slipped capitol epiphysis of the femur, or synovitis in children. On adults, a flexion deformity could be secondary to osteoarthritis or il iopsoas bursitis. Figure 111 B. Trendelenburg Test (Figure 111) ‘The patient is standing and the doctor is behind the patient stabilizing the patient's hips while plac~ ing the right thumb on the right posterior superior iliac spine (P.S.S.) and the left. thumb on the left. posterior superior iliac spine (P.8.S.). The patient is asked to raise one femur so that it is parallel to the floor. Normally, the P.S.S. on the side being raised will rock posterior and inferior. If it rocks anterior and inferior, it is positive for the side on which the patient is standing. A positive would indicate a weakness of the extensor mechanism of the pelvis. The extensor mechanism may be weak due to paresis or paralysis of the extensors such as the gluteus medius caused by polio. A femur head dislocation would also give a positive finding. 33Figure 113 C. Hibb’s Test (Figures 112 & 113) The patient is prone. The doctor flexes the pa- tient’s knee approximating the heel toward the but- tocks. (Figure 112) The doctor then rotates the low- er leg outward causing internal rotation of the hip. (Figure 113) If the patient experiences pain in the hip, it is positive and indicates that the patient has lost the normal functional biomechanics of the hip. Figure 114 34 Figure 116 D. Fabere-Patrick Test (Figures 114, 115, & 116) ‘The patient is supine and the doctor stands to the side being examined. This test consists of three distinct steps. Step 1. The patient flexes the hip to 45° and places their foot flat on the table. The doctor holds the medial and lateral aspects of the distal end of the femur and applies a firm pressure into the hip. (Figure 114) Step 2. The patient crosses the leg into a figure 4 position placing their ankle above the op- posite knee. (Figure 115) Step 3. With the patient in the position of Step 2, the doctor stabilizes the anterior superior iliac spine on the side opposite that being examined. The doctor then applies a slight pressure floorward on the flexed knee. (Figure 116) If the patient experiences pain during any phase of the test, it is positive, and the test should be discontinued. A positive test would indicate the pa- tient has lost the normal functional biomechanics of the hip possibly due to inflammatory disease or arthritic changes in the hip.sis Figure 117 Traction (Figures 117 & 118) The doctor will find a loss of motion at the hip joint when performing Hibb's test or Fabere-Patrick test. The patient may notice anywhere from a dull ache to. a sharp pain at the hip. This move is also very beneficial for the osteoarthritie pa- tient. ‘The patient is supine. ‘The doctor is standing on the opposite side of involvement, ‘The forearm of the doctor's superior arm. The posteromedial portion of the prox- imal thigh on the side of involvement. ‘The doctor's inferior hand is placed on the patient's involved knee. Medial to lateral. Procedure Figure 118, ‘The doctor will flex the hip on the side of involvement to 90° and place the forearm of the superior arm in against the ischium, with the hand grasping the side of the table. The doctor will then bring the hip down to 45°, placing the patient's foot flat against the table. The doctor will place the inferior hand at the lateral aspect of the knee on the side of involve- ment. (Figure 117) The doctor will pull the knee on the side of involvement from lateral to medial while visualizing the greater trochanter to impress against the skin. (Figure 118) This move will be repeated three to five times within the tolerance of the patient. 35Chapter X KNEE ‘The knee is comprised of the femur and the tibia as they articulate with each other. Other components that may affect the function of the knee are the patella and the fibula. ‘The tibia that rotates anterior on the medial side is the most common misalignment of the knee. Involve- ment of the fibula may elude the doctor as it will usual- lyonly present itself as.a dull ache over the fibular head. If the patient has torn either of the menisci, it is usually best for the patient to have an orthopedic evaluation. A patient that has a mild or moderate tear of one or two of the major ligaments of the knee may be handled very well by conservative measures. Should a patient have a severe tear of any of the major ligaments of the knee or any tears in three of the major ligaments of the knee, they should have an orthopedic evaluation. ‘Areas that may refer pain to the knee are: 1. Spinal subluxation 2, Sacroiliac subluxation 3. Hip 4. Ankle Knee Range of Motion Examination Flexion (Figure 119) Pigs 9 Zero point — A line extending distally from the femur Pivot point — The knee Reference point, — The tibia R-O-M — 130° Figure 120 Extension (Figure 120) Zero point — A line extending distally from the femur 36 Pivot point — The knee Reference point — The tibia R.O-M—0° Orthopedic Examination of the Knee Figure 123 A. Apley’s Compression or Grinding Test (Figures 121, 122, & 123) ‘Ask the patient to lie prone on the examining table with the leg flexed to 90°. The doctor will grasp the distal end of the tibia and fibula and ap- ply a pressure tableward to compress the medialand lateral menisci between the tibia and the femur. (Figure 121) The doctor then rotates the tibia internally (Figure 122) and externally (Figure 123) on the femur while maintaining firm compres- sion, If this maneuver elicits pain, there is probably meniscal damage. Ask the patient to describe the location of the pain as accurately as possible. Pain on the medial side may indicate a possible torn medial meniscus. Pain on the lateral side may in- dicate a possible torn lateral meniscus. The pain will be equally proportional to the degree of tear- ing. Figure 128 B. Apley’s Distraction Test (Figures 124, 125, & 126) ‘The distraction test helps to distinguish between meniscal and ligamentous problems of the knee joint. This test should follow a positive Apley’s compression test. The doctor remains in the same position described for the compression test and places the knee on the patient’s posterior thigh, (Figure 124) The doctor applies traction to the leg while rotating the tibia internally (Figure 125) and externally (Figure 126) on the femur. This maneuver reduces pressure on the meniscus and puts strain upon the lateral and medial ligamen- tous structures. If the ligaments are damaged, the patient will complain of pain. If the meniscus alone is torn, the test should not be painful. Pain on the medial side indicates a medial collateral ligament tear. Pain on the lateral side indicates a lateral col- lateral ligament tear. Figure 128 | McMurray Test (Figures 127 & 128) ‘Agkk the patient to lie supine with their legs flat and in the neutral position. With one hand take hold of the patient's heel and flex the leg fully, ‘Then, place your free hand on the knee joint with your fingers touching the medial joint line and your thumb and thenar eminence against the lateral joint line, and rotate the leg internally and exter- nally to loosen the knee joint. Push on the lateral side to apply valgus stress to the medial side of the joint, while at the same time, rotating the leg exter- nally. (Figure 127) Maintain the valgus stress and external rotation, and extend the leg slowly as you palpate the medial joint line. (Figure 128) If thi maneuver causes a palpable or audible “click” within the joint, there is a probable tear in the medial meniscus, most likely in its posterior half. A tibia that has rotated anterior on the medial side may produce a similar “click”. 37Figure 130 D. “Bounce Home” Test (Figures 129 & 130) This test is designed to evaluate a lack of full knee extension, most often secondary to a torn meniscus, a loose body within the knee joint, or an intracapsular joint swelling. With the patient supine on the table, cup the patient's heel in your palm and bend the knee into full flexion. (Figure 129) Now, passively allow the knee to extend. The knee should extend completely or “bounce home” into extension with a sharp end-point. (Figure 130) However, if the knee falls short offering a rubbery resistance to further extension, there is probably a torn meniscus or some other blockage. 38 Figure 131 E. Drawer Sign (Figure 131) To test the integrity of the anterior cruciate liga- ment, have the patient lie supine on the examina- tion table with the knee flexed to 90° and the foot, flat on the table. The doctor is positioned on the edge of the table to stabilize the patient's foot by sitting on it. The doctor cups both hands around the proximal aspect of the knee, with the fingers on the area of insertion of the media) and lateral hamstrings and the thumbs on the medial and lateral joint lines. The doctor then pulls the tibia anteriorly. If the tibia slides forward from under the femur (positive anterior drawer sign), the anterior cruciate ligament may be torn. A few degrees of anterior draw are normal if an equal amount is present on the opposite side, Test the posterior cruciate ligament in a similar manner. The doctor stays in the same position and pushes ‘the tibia posteriorly. If the tibia moves posteriorly on the femur, the posterior cruciate liga- ment is probably damaged (positive posterior drawer sign). The anterior drawer sign is more com- mon than the posterior sign, since the incidence of damage to the anterior cruciate is much higher than to the posterior cruciate. In fact, an isolated tear of the posterior cruciate ligament is rare. Figure 132 ’. Abduction/Valgus Stress Test (Figure 132) The patient is sitting or lying supine on the table. The doctor supports the patient's ankle between the thighs and the knee in the hands. The patient's knee is flexed just enough so that it unlocks from full extension. The doctor applies a lateral to medial pressure to the knee (Valgus Stress). Normally, thejoint space opens a slight amount. If the joint ‘opens an excessive amount, the patient has lost the integrity of the medial collateral ligament. If the joint space does not open this indicates a tibia which has rotated anteriorly on the medial side. Figure 133 G. Adduction/Varus Stress Test (Figure 133) ‘The patient is sitting or lying supine on the table. ‘The doctor supports the patient’s ankle between the thighs and the knee in the hands. The patient's knee is flexed just enough so that it unlocks from fullextension, The doctor applies a medial to lateral pressure to the knee (Varus Stress). Normally, the joint space opens a slight amount. If the joint opens an excessive amount, the patient has lost: the integrity of the lateral collateral ligament. If the joint space does not open, this indicates a tibia which has rotated anteriorly on the lateral side. Figure 134 H. Patella Femoral Grinding Test (Figure 134) “The test is designed to determine the quality of the articulating surfaces of the patella and the trochlear groove of the femur. The patient. should be supine on the examining table with the legs relaxed in the neutral position, First, pull the patella distally in the trochlear groove. Then in- struct the patient to tighten the quadriceps while palpating and offering resistance to the patella as it, moves superiorly, The movement of the patella should be smooth and gliding. Any roughness in its articulating surfaces causes a palpable crepitation when the patella moves. If the test is positive, the patient usually complains of pain or discomfort. Chondromalacia patellae, osteochondral defects, or degenerative changes within the trochlear groove itself can yield a positive test. Figure 135 I. Apprehension Test for Patellar Dislocation and Subluxation (Figure 135) Ask the patient to lie supine on the examining table with their legs flat and the quadriceps re- laxed. If the doctor suspects that the patella may dislocate laterally, pressure is applied against the medial border of the patella with the thumbs. If everything is in order, this will produce little reac- tion; however, if the patella begins to dislocate, the expression on the patient's face will become one of apprehension and distress. Analytical Examination of the Knee ‘The doctor will examine for rotation of the tibia by applying valgus and varus stress to the knee. A knee in which the joint does not open on valgus stress would indicate a tibia that has rotated anterior on the medial side. This would usually be confirmed by point tenderness over the anterior aspect of the medial meniscus. ‘A Imee in which the joint does not open on varus stress would indicate a tibia that has rotated anterior on the lateral side. This would usually be confirmed by point tenderness over the anterior aspect of the lateral meniscus. If the tibia loses its fluid motion from posterior to anterior, a posterior tibia would be indicated. A dull ache will usually be found in the popliteal fossa with this misalignment. ‘The fluid motion of the fibula will be examined by the doctor grasping the fibular head and gliding the head from posterior to anterior and anterior to posterior, This is usually performed with the patient supine and the knee flexed to 90° Any loss of motion would indicate the need for a fibular adjustment. It must be remembered that the fibula must first move laterally away from the tibia before any other misalignment may take place. The patella would need adjusted when it has dislocated. A shallow trochlear groove is usually the causative factor of patellar dislocations. A superior lateral dislocation is the most common dislocation. ‘After correcting the dislocation, the quadricep muscle should be strengthened to hold the patella tight within the trochlear groove. ‘The quadriceps muscle may begin to atrophy as soon as 48 hours after a knee injury. With any knee injury it is important to maintain tone in the quadriceps mus- cle. The most important muscle to keep strong within the quadriceps group is the vastus medialis. 39sis PP. DS. OP. Figure 136 Patella Figure 137 Traction (Figures 136 & 137) This move will be indicated for a patellar dislocation. The patella may dislocate superior medially or superior laterally, with the superior lateral misalignment being the most common. ‘The patient is supine with the ankcle on the side of involvement between the doctor's thighs. ‘The doctor will stand on the side of in- volvement. ‘The thumbs (#9) of both hands. CP. L.0.C. Procedure ‘The superior portion of the patella. Superior to inferior and medial to lateral, or lateral to medial. ‘The patient’s ankle on the side of in- volvement is placed between the doctor's thighs. The doctor will contact, the superior portion of the patella, ‘The doctor will slowly straighten the leg guiding the patella back to its normal position. (Figure 137) v iy Figure 138 Knee a Figure 139 Traction — Supine (Figures 138 & 139) ‘This move would be indicated for any knee involvement in which the patient could flex the knee. ‘The patient is supine. ‘The doctor stands on the opposite side of involvement. ‘The wrist of the doctor's superior hand. ‘The popliteal fossa. ‘The doctor’s inferior hand is placed on the distal aspect of the tibia. The doctor will place the wrist of the superior hand in the popliteal fossa of the knee on the side of involvement, and let the leg hang over the wrist. (Figure 138) The doctor will place the inferior hand on the distal tibia and approx- imate the heel toward the buttocks, (Figure 139) while noting the expansion of the knee joint. This move is repeated three times, trying to increase flexion each subsequent time.sis cP. S.CP. Stab. Figure 140 Knee Figure M41 Traction — Prone (Figures 140 & 141) This move would be indicated for any knee involvement in which the patient could flex the knee. ‘The patient is prone. The doctor will stand on the opposite side of involvement. Thumb web of the doctor's superior hand. The popliteal fossa. ‘The doctor's inferior hand is placed on Procedure the distal aspect of the tibia. The doctor will place the thumb web tight into the popliteal fossa. The doc- tor will then grasp the patient’s distal tibia and approximate the heel toward the buttocks within the tolerance of the patient. while noting expansion of the nee joint. This move would be repeated five times, trying to increase flexion with each subsequent try. SiS DS. CP. SCP. LOC. Procedure Figure 142 Knee Traction — limited flexion (Figure 142) This move would be indicated for any Imee involvement in which the patient had limited flexion. ‘The patient is prone. ‘The doctor is at the inferior portion of the table favoring the side of involve- ment. ‘The fingers of both hands. ‘The posterior aspect of the proximal tibia. Posterior to anterior. ‘The patient's ankle on the side of in- volvement is placed on the doctor's shoulder, and the knee is flexed within the tolerance of the patient. The doctor will place both hands on the posterior portion of the proximal tibia. The doc- tor will apply a steady pressure from posterior to anterior trying to open the knee joint, and then release slowly. The doctor then increases flexion within the tolerance of the patient, and repeats the procedure. The procedure is continued to be repeated until no more flexion can be made on that visit. 41sis PP, DS. CP. S.CP. Stab. LGC. Figure 143 Tibia Figure 144 Anterior — Mediat (Figures 143 & 144) ‘The patient will have a loss of joint open- ing on the medial side while valgus stress is applied to the knee. There will usually be point tenderness at the anterior aspect of the medial meniseus. ‘The patient is supine or sitting with the ankle on the side of involvement held be- tween the doctor's thighs. ‘The doctor is standing on the side of in- volvement. The second metacarpophalangeal joint, (#8) of the hand corresponding to the side of involvement. The anterior aspect of the medial tibial plateau just below the medial meniscus. The hand on the opposite side of involve- ment will stabilize the posterolateral por- tion of the patient's tibia. Anterior to posterior with a slight torqu- Procedure ing type thrust. The doctor will take tissue pull from lateral to medial until the contact point is placed on the medial tibial plateau. The doctor's opposite hand supports the posterior aspect of the tibia favoring the lateral side. These contacts are made with the knee slightly flexed. (Figure 143) The doctor will then slowly take the knee into full extension to measure the depth of thrust. The doctor will then take the knee off full extension for relaxation of the patient. A short quick thrust is then given from anterior to posterior with the contact hand taking the knee in- to full extension while the stabilization hand supports the posterior aspect of the tibia favoring the lateral side. (Figure 144) sis 42 Figure 15 Tibi Figure 146 Anterior — Lateral (Figures 145 & 146) ‘The doctor will notice a loss of normal joint opening on the lateral side as a Varus stress is placed on the knee. There will also be point tenderness over the anterior aspect of the lateral meniscus. PP. DS. ‘The patient is supine or sitting with. the ankle on the side of involvement held be- tween the doctor's thighs. The doctor will be standing on the side of involvement.CP. SCP. Stab, LO.c. Procedure The second metacarpophalangeal joint (#8) of the hand corresponding to the op- posite side of involvement. ‘The anterior aspect of the lateral tibial plateau just below the lateral meniscus. ‘The doctor's hand corresponding to the side of involvement is placed at the posterior aspect of the tibia, favoring the medial side. Anterior to posterior with a slight torqu- ing action. The doctor will take tissue pull from medial to lateral until the contact point is on the lateral tibial plateau. The stabilization hand is placed supporting the posterior aspect of the tibia on the medial. side. These contacts are taken with the knee slightly flexed. (Figure 145) The doctor will slowly take the knee into full extension in order to measure the depth of thrust. The knee is then taken off full extension. A short quick thrust is then given with the contact hand from anterior to posterior while the stabilization hand holds the posterior aspect of the tibia on the medial side, (Figure 146) Figure 147 Tibia Posterior (Figure 147) ‘The doctor will notice a loss of fluid mo- tion from posterior to anterior. There will usually be a dull ache in the popliteal fossa. Occasionally, discom- fort is noticed in an arc below the knee- cap spanning from medial to lateral. The patient is prone. ‘The doctor is inferior to the table favor- ing the side of involvement. ‘The fingers of both hands. ‘The posterior aspect of the proximal end of the tibia. Anassistant may stabilize the posterior aspect of the femur Posterior to anterior. ‘The doctor will flex the knee to 70° or the patient's tolerance, placing the ankle on the doctor's shoulder. Contact is then taken with both hands, placing hand over hand on the posterior aspect: of the tibia, The doctor will take all the slack out of the tissue and then give a very firm thrust, setting the tibia from posterior to anterior, sis PP. DS. OP. SCP. Stab, LOC. Procedure Figure 148, Fibula Lateral (Figure 148) ‘The doctor will notice loss of fluid motion at the articulation. There may also be a dull ache over the fibular head. ‘The patient is supine with the ankle on the side of involvement between the doc- tor's thighs. ‘The doctor is standing on the side of in- volvement. ‘The second metacarpophalangeal joint (#8) of the hand corresponding to the op- posite side of involvement. ‘The inferior aspect of the fibular head. The doctor's hand corresponding to the side of involvement stabilizing across the knee joint on the medial side. Lateral to medial. Occasionally, a slight anterior to posterior or posterior to anterior thrust is needed as well. ‘The patient's leg is held in full extension ‘The doctor will take tissue pull from in- ferior to superior contacting the fibular head. ‘The doctor’s stabilization hand stabilizes the knee joint on the medial side, The doctor will give a short quick thrust from lateral to medial setting the fibula back against the tibia, 43Chapter XI ANKLE ‘The ankle is comprised of seven bones. The keystone to the ankle is the talus which sits in the ankle mortice. ‘The calcaneus is located just inferior to the talus. Distal to the talus on the medial side of the foot is the navicular. Distal to the calcaneus on the lateral side of the foot is the cuboid. Distal to the navicular is the first cuneiform. Lying from medial to lateral between the first cuneiform and the cuboid are the second and third cuneiforms, ‘The most common injury to the ankle is inversion sprain. This results in a lateral calcaneus which is the most common misalignment in the ankle. The talus is the second most common site of involvement in the ankle, Of the cuneiforms the third is the most common- ly involved. Areas that may refer pain into the ankle are: 1. Spinal subluxation 2. Hip 3. Knee 4. Foot Ankle Range of Motion Examination Figure 149 Plantar flexion (Figure 149) Zero point — A line perpendicular to the shaft of the tibia Pivot point — The posterior inferior aspect of the heel Reference point — The shaft of fifth metatarsal R-O-M — 45° 44 Figure 150 Dorsiflexion (Figure 150) Zero point — A line perpendicular to the shaft of the tibia Pivot point — The posterior inferior aspect of the heel Reference point — The shaft of fifth metatarsal R-O-M — 20° Figure 151 Inversion (Figure 151) Zero point — A line perpendicular to the shaft of the tibia Pivot point — The lateral aspect of the heel Reference point — The bottom of the foot R-O-M — 30°Figure 152 Eversion (Figure 152) Zero point — A line perpendicular to the shaft, of the tibia Pivot point — ‘The medial aspect of the heel Reference point — The bottom of the foot R-O-M — 20° Orthopedic Examination of the Ankle Figure 158 A, Draw Sign (Figure 153) ‘The patient will lie supine on the table with the ankle hanging over the end of the table. The doctor places one hand on the anterior aspect of the lower tibia and grips the caleaneus in the palm of the other hand. The doctor then pulls the calcaneus (and talus) anteriorly, while pushing the tibia posteriorly, Normally, the anterior talofibular liga- ment is tight in all positions of the ankle joint, and there should be no forward movement of the talus on the tibia. Under abnormal conditions, however, the talus slides anteriorly from under the cover of the ankle mortise. This is a positive draw sign and indicates the anterior talofibular ligament has lost its stability. 3. Lateral Stability Test (Figure 154) ‘The doctor turns the patient's ankle into plantar flexion and inversion while stabilizing the tibia with the opposite hand. If inversion stress in- creases the patient's pain, there is a distinct possibility that the anterior talofibular ligament is sprained or torn, Figure 155 C. Medial Stability Test (Figure 155) ‘The doctor stabilizes the patient's leg around the tibia with one hand while the other hand everts the patient’s ankle, If the deltoid ligament is torn, the doctor may feel a gross gapping at the ankle mor- tise. Analytical Examination of the Ankle The fluid motion of the talus is examined by the doc- tor stabilizing the tibia with one hand while gliding the talus from anterior to posterior. If the talus has a loss of this motion, the talus has misaligned anteriorly. A patient with an anterior talus will also have a loss of normal dorsiflexion, Point tenderness may also be pre- sent at the anterior aspect of the ankle mortice. If the patient has a loss of eversion the patient will have a laterally tipped calcaneus. Likewise, a patient with a loss of inversion will have a medially tipped calcaneus, Point tenderness will be found at the talocalaneal joint on the side of misalignment. ‘The navicular, cuboid, and cuneiforms are examined individually by grasping them between the thumb and forefinger of the doctor's hand. The fluid motion is then checked by gliding the bones from posterior to anterior for the cuneiforms and anterior to posterior for the cuboid and navicular. For the cuboid a little lateral to medial glide is added and with the navicular a little medial to lateral glide is added. Any loss of fluid motion would indicate the need for an adjustment. Point tenderness will usually be located over the in- volved tarsal tysis PP. DS. CP. SCP. Figure 156 The patient will have a loss of fluid mo- tion at the ankle joint from anterior to posterior. There will also be a loss of dor- siflexion of the ankle. There may also be point tenderness at the anterior aspect of the talus. Occasionally, there is also edema at, the anterior aspect. of the ankle joint. The patient may also have a history of chronic ankle sprains. ‘The patient is supine. The doctor is standing at the foot of the table. ‘The little finger on the hand correspond- ing to the side of involvement. ‘The anterior aspect of the talus. Talus Traction (Figures 156 & 157) Stab. L.0.C. Procedure Figure 157 ‘The doctor's hand corresponding to the opposite side of involvement will grasp the patient's heel. Anterior to posterior The doctor will grasp the patient's ankle with both hands and will hold the ankle chest high for mechanical advan- tage. The doctor first will apply a superior to inferior traction opening the ankle mortice. (Figure 156) While main- taining this traction, the doctor will ap- ply an anterior to ‘posterior pressure with the contact hand until a release of the talus is felt. (Figure 157) SiS PP. DS. cr. 46 Figure 158 ‘The patient will have a loss of fluid mo- tion at the ankle joint from anterior to posterior. There will also be a loss of dor- siflexion of the ankle. There may also be point tenderness at the anterior aspect of the talus. Occasionally, there is also edema ai the anterior aspect of the ankle joint. The patient may also have a history of chronic ankle sprains. ‘The patient is placed supine with the ankle just off the end of the table. ‘The doctor is standing at the inferior por- tion of the table, ‘The second metacarpophalangeal joint (#8) of the hand corresponding to the side of involvement, superimposed with the opposite hand. Talus Anterior (Figures 158 & 159) S.C.P. Stab. L.O.C. Procedure Figure 159 ‘The anterior aspect of the talus. ‘The assistant will stabilize the tibia by placing an anterior to posterior pressure into the adjusting table. Anterior to posterior. ‘The doctor will take tissue pull from anterior to posterior until the contact point is resting at the anterior aspect of the talus. The fingers of the contact hand will wrap around to the plantar surface of the patient's foot. The opposite hand is then used to reinforce the contact hand. (Figure 158) The doctor will dorsiflex the ankle bringing the talus to a point of ten- sion. A short quick thrust is then given from anterior to posterior. (Figure 159)sis PP. DS. CP. S.C.P, Stab. LOC. Figure 160 Calcaneus Lateral (Figures 160 & 161) The patient will have a history of inver- sion sprain, Point tenderness is generally noticed just below the lateral malleolus. ‘There will be a loss of eversion. ‘The patient is supine with the ankle off the end of the table. ‘The doctor is standing at the end of the table. ‘The thenar (#10) of the hand correspond- ing to the opposite side of involvement. Superior lateral portion of the calcaneus. The assistant stabilizes the patient's tibia into the table. Lateral to medial and slight inferior to superior. Procedure Figure 161 ‘The doctor will take tissue pull from in- ferior to superior with the thenar of the contact hand up to the talocalaneal ar- ticulation. The fingers of the contact hand will wrap around the bottom of the patient's heel favoring the inferior por- tion of the medial aspect of the calcaneus. The doctor's opposite hand is, used to dorsiflex and evert the ankle while the doctor thrusts from lateral to medial and slightly inferior to superior. At the same time the fingers of the con- tact hand will pull from medial to lateral. (Figure 161) SiS PP. DS. S.C.P. Stab. LO. Figure 162 ‘The patient will have a history of ever- sion sprain. Point tenderness will usually be elicited just below the medial malleolus. The patient will have a loss of normal inversion, ‘The patient is supine with the ankle off the end of the table. ‘The doctor will stand at the end of the table. ‘The thenar (#10) of the hand correspond- ing to the side of involvement. ‘The medial superior portion of the calcaneus. ‘The assistant will stabilize the tibia into the table. Medial to lateral and slight inferior to superior. Calcaneus Medial (Figures 162 & 163) Procedure Figure 163, ‘The doctor will take tissue pull from in- ferior to superior with the contact hand ‘onto the medial superior portion of the calcaneus. The fingers of the contact hand will wrap around favoring the in- ferior portion of the lateral side of the caleaneus. The doctor's opposite hand will be used to dorsiflex and invert the patient's ankle while the thrust is made with the contact hand from medial to lateral and slightly inferior to superior. At the same time, the fingers of the con- tact hand will pull from lateral to medial. (Figure 163) 47sis PP, DS. CP. S.CP. Stab. Figure 164 Navieular Anterior — Medial (Figures 164 & 165) ‘The patient will have a loss of fluid mo- tion of the navicular bone. Point tender- ness will be noted at the navicular tuber- osity. The patient will usually have a history of a kicking type injury. ‘The patient is supine with the ankle off the end of the table. ‘The doctor stands at the inferior portion of the table. ‘The second metacarpophalangeal joint (#8) of the hand corresponding to the side of involvement superimposed with the opposite hand. ‘The navicular tuberosity. ‘The assistant will stabilize the tibia into the table. LOC. Procedure Anterior to posterior and medial to lateral. The doctor will take tissue pull from lateral to medial until the contact point arrives at, the navicular tuberosity. The fingers of the contact hand will wrap around the foot to the plantar surface. The contact hand is superimposed with the doctor's opposite hand. (Figure 164) The foot will be inverted and slightly dor- siflexed at that articulation. The doctor will then give a short quick thrust from anterior to posterior and medial to lateral. (Figure 165) sis 48 Figure 166 ‘Cuboid Figure 167 Anterior — Lateral (Figures 166 & 167) ‘The doctor will find a loss of fluid motion. Point tenderness will generally be found over the involved cuboid. The patient may also have a dull ache in the posterior aspect of the calf of the leg.PP. DS. op. SCP. Stab. L.O.C, Procedure ‘The patient is supine with the ankle off the end of the table. ‘The doctor is kneeling at the inferior por- tion of the table favoring the opposite side of involvement. ‘The distal phalanx of the third finger of the hand corresponding to the opposite side of involvement. ‘The dorsum of the cuboid. ‘The assistant will hold the tibia into the table. Anterior to posterior and lateral to medial. The doctor will take tissue pull from medial to lateral with the contact point onto the dorsum of the cuboid. The finger of the doctor's opposite hand will sup- port the contact point to prevent slip- ping. The thumbs of both the doctor's hands will be applying a posterior to anterior pressure against the cuneiforms. (Figure 166) The doctor will first apply superior to inferior traction to the joint and then invert the foot bringing the joint to a point of tension. A short quick thrust is then given from anterior to posterior and lateral to medial. (Figure 167) sis PP. op. SGP: Figure 168 ‘The doctor will notice a loss of fluid mo- tion at the involved cuneiform. Point tenderness will generally be found on the plantar surface of the involved cunei- form. ‘The patient is prone. ‘The doctor stands at the inferior portion of the table. ‘The thumb (#9) of the hand correspond- ing to the opposite side of involvement superimposed with the thumb of the op- posite hand. ‘The plantar surface of the involved cuneiform. Cuneiform Posterior (Figures 168 & 169) LOC. Procedure Figure 169 Posterior to anterior. ‘The doctor will take tissue pull from superior to inferior onto the involved cuneiform with the thumb. The fingers of the contact hand will wrap around the dorsum of the metatarsals. The thumb and fingers of the doctor's opposite hand will reinforce the contact hand. (Figure 168) The doctor will plantar flex the metatarsals bringing the joint to a point of tension. A short quick thrust is then given with the thumbs from posterior to anterior. (Figure 169) 49Chapter XII FOOT ‘The foot is comprised of the: A. Morton's Test (Figures 170 & 171) 1, Tarsometatarsal joints ‘The doctor palpates the soft tissues between each 2. Metatarsophalangeal joints of the distal metatarsal heads seeing if there is 3. Titerhalangost joint tenderness and swelling. (Figure 170) Next, the The f m 2 nti paeclneniectwnaawe tie ait doctor places the hands on the medial and lateral e feet can have many involvements due to the dif- sides of the patient's foot and applies a com- ferent stresses placed on the feet in day to day life. If : : nd 8D on ot Ny to ay pressive force, (Figure 171) [f pain is elicited, this is the. ae oe ee {corres ey way ae @ positive test and would indicate a possible Mor- : D ramenk ton’s neuroma, Morton's neuroma is most common- the widest portion of the foot should fit the widest por- He found ia Eos ace bobweee the thi oa Ina tion of the shoe. oe . its ul he . Major involvements of the feet include the dropped smetatarsel bade, metatarsal and the bunion. Both of these conditions may be due to shoes that are too narrow. Areas that may refer pain into the foot are: 1. Spinal subluxation 2. Hip 3. Knee 4. Ankle Orthopedic Examination of the Foot Figure 172 B. Strunsky’s Test (Figure 172) The doctor quickly flexes the patient's toes. Nor- mally this procedure is painless. If pain results, this is a positive test and would indicate an inflam- matory lesion of the metatarsal arch. Analytical Examination of the Foot The fluid motion of the tarsometatarsal joint is ex- amined by the doctor grasping the proximal portion of the metatarsal and gliding the bone from anterior to posterior. Any loss of motion would indicate a need for an adjustment. Point tenderness will usually be noted at the involved joint. ‘The metatarsophalangeal and interphalangeal joints may be examined by having their fluid motion checked from anterior to posterior, posterior to anterior, lateral 50to medial, medial to lateral, and in rotation. Any loss of motion would indicate a need for adjustment. A distal metatarsal head which has dropped will havea great loss of motion at the metatarsophalangeal joint. A soft tissue callus formation will usually be found over the involved metatarsal, ‘A valgus formation (bunion) of the great toe will generally exhibit a loss of motion in all directions. A soft tissue callus formation will generally be found over the medial portion of the first. metatarsopha- langeal joint. ‘After adjusting the feet the patient should walk barefooted for a short while to increase mobility in the foot before it is returned to the shoe. Figure 173 Tarsometatarsal Joint Anterior (Figure 173) SiS ‘The doctor will find a loss of fluid motion at the involved joint. Point tenderness will generally be found at the involved joint. PP. ‘The patient is supine, DS. ‘The doctor is standing at the inferior por- tion of the table. CP. ‘The distal interphalangeal joint of the third finger (#5) of the hand correspond- ing to the side of involvement. SOP, ‘The anterior aspect of the proximal end of the involved metatarsal. Anterior to posterior ‘The doctor will take tissue pull from superior to inferior with the contact point onto the involved metatarsal. The fingers of the opposite hand are used to support the contact point. The thumbs of both of the doctor's hands are placed on the distal end of the involved metatarsal on the plantar surface. ‘The doctor will take a superior to inferior traction bring- ing the involved joint to a point of ten- sion, A short quick thrust is then given from anterior to posterior. LO. Procedure Figure 174 Metatarsophalangeal Joint Figure 175 Posterior (Figures 174 & 175) sis ‘The doctor will find a loss of fluid motion at the involved joint. Point tenderness will be found over the involved joint. A soft tissue callus formation will be built up over the metatarsal head which has dropped. PP, ‘The patient is prone. DS. ‘The doctor stands at the inferior portion of the table. cP. ‘The thumb (#9) of the doctor's hand cor- responding to the side of involvement. SCP. ‘The posterior aspect of the involved metatarsal head. LOC. Procedure Posterior to anterior The doctor will take tissue pull from superior to inferior onto the involved metatarsal head. The thumb of the op- posite hand will support the contact point. The fingers of both the doctor's hands will be placed on the posterior aspect of the phalanges. (Figure 174) The doctor will flex the patient's toes to bring the joint to a point of tension. (Figure 175) A short quick thrust is then given from posterior to anterior.Figure 176 Metatarsophalangeal Joint Figure 177 Bunion — Part I (Figures 176 & 177) sis ‘The patient will exhibit a valgus forma- anterior. tion of the great toe. Callus formation Procedure The doctor will grasp the first phalanx of will generally be at the medial portion of the great toe between the thumb and the the first metatarsophalangeal joint. A forefinger of the contact hand. The doc- great amount of fixation is found at the tor's opposite hand will grasp the first joint in most directions. metatarsal. The doctor will apply a PP. ‘The patient is prone with the knee flexed superior to inferior traction to open the 90°. joint. (Figure 176) While maintaining DS. The doctor will stand on the side of in- this traction, the doctor will apply a volvement. posterior to anterior pressure into the GP. The thumb (#9) and the forefinger of the joint with both thumbs. (Figure 177) hand corresponding to the opposite side ‘This procedure will be repeated until of involvement. most of the aberrant. motion is removed S.O.P. ‘The first phalanx of the great toe, from the joint. This may take from one to Stab. The doctor's hand corresponding to the numerous visits. The patient must have side of involvement will stabilize the first this freedom before the second part of the metatarsal. move is attempted. L.O.€. Superior to inferior and posterior to Figure 178 Metatarsophalangeal Joint Figure 179 Bunion — Part II (Figures 178 & 179) sis The patient will exhibit a valgus forma- joint in most directions. tion of the great toe, Callus formation PP. The patient is prone with the knee flexed will generally be at the medial portion of to 90°. the first metatarsophalangeal joint. A Ds. ‘The doctor is standing on the side of in- great amount of fixation is found at the volvement.‘OR! S.C.P, Stab. L.O.C. Procedure ‘The thumb (#9) and the forefinger of the doctor's hand corresponding to the side opposite of involvement. ‘The first phalanx of the great. toe. ‘The doctor's hand corresponding to the side of involvement will wrap around the medial aspect. of the first metatarsal. Lateral to medial. ‘The doctor will grasp the great toe with the contact hand while stabilizing the first metatarsal with the opposite hand. Superior to inferior traction is first taken to open up the joint. (Figure 178) The doctor will then give a quick snapping thrust from lateral to medial to align the phalanx onto the metatarsal head. (Figure 179) SIS PP. DS. CP, SCP. Stab. Figure 180 ‘The doctor will find a loss of fluid motion at the involved joint. Point tenderness may also be found at the involved joint. ‘The patient is supine. The doctor is kneeling at the inferior por- tion of the table. The thumb (49) and the forefinger of either hand. ‘The first phalanx of the involved joint. ‘The doctor's hand opposite of the contact hand will grasp the metatarsal of the in- volved joint. Metatarsophalangeal Joint Traction (Figures 180 & 181) Procedure Figure 181 ‘The doctor will grasp the first phalanx of the involved joint with the contact hand while the opposite hand stabilizes the in- volved metatarsal. The doctor will first apply a superior to inferior traction to open up the articulation, (Figure 180) While maintaining this traction the toe will be flexed and stretched over the forefinger of the contact hand to expand the joint. (Figure 181) This move could also be used for any interphalangeal joint involvement,Shoulder Sternoclavicular Joint (St-C1) Traction sitting ‘Traction supine Superior (S) Acromioclavicular Joint (A-C) Posterior Superior (PS) Glenchumeral Joint (G-H) ‘Traction supine ‘Traction sitting Inferior (1) Posterior (P) prone Posterior (P) sitting Frozen Shoulder Kocher Maneuver Scapulothoracie Articulation (S-T) ‘Medial (M) prone Medial (M) side lying Lateral (L) side lying Ribs Sternocostal Joint (St-Co) ‘Traction Sitting ‘Traction Supine Inspiration-Superior (8) Expiration-Inferior (I) Elbow Traction Radius Posterior (P) Ulna Posterior (P) Posterior Medial (PM) Wrist ‘Traction Lunate (or other carpal) — single thumb Lunate (or other carpal) — double thumb Hand Carpometacarpal Joint (C-MC) First — double thumb Second (or third) — rotational 4 ‘Metacarpophalangeal Joint (Mc-P) ‘Traction Interphalangeal (I-P) ‘Traction Hip ‘Traction Knee Patella traction ‘Traction supine ‘Traction prone ‘Traction prone limited flexion ‘Tibia ‘Anterior Medial (AM) Anterior Lateral (AL) Posterior (P) Fibula Lateral (L) Ankle ‘Talus ‘Traction Anterior (A) Caleaneus Lateral (L) Medial (M) Navicular Anterior Medial (AM) Cuboid Anterior Lateral (AL) Cuneiform ‘Third (or first or second) Posterior (P) Foot ‘Tarsometatarsal Joint (T-MT) First (second-fifth) Anterior (A) ‘Metatarsophalangeal Joint (MT-P) First (second-fifth) Posterior (P) Bunion ‘Traction Interphalangeal (I-P) ‘TractionAbduction Stress Test Acromioclavicular Joint: Examination Posterior-Superior Adduction Stress Test ‘Adson Test Allen's Test Ankle Examination Apley’s Compression Test Apley’s Distraction Test Apley’s Grinding Test Apprehension Test-Patella Apprehension Test-Shoulder “Bounce Home" Test British Test Caleaneus-Lateral Calcaneus-Medial Clavicle Posterior-Superior Superior Cozen Test Cuneiform-Posterior Dawburn's Test. Draw Sigh Drawer Sign Drop Arm Test Dugas Test Bden’s Test Elbow Examination Elbow Traction English Test Examination Ankle Elbow Foot. Hand Hip Knee Ribs Shoulder Wrist Fabere Patrick Test Fibula-Lateral Finkelstein's Test Foot Examination Froment's Sign Gleno-humeral Joint Frozen Shoulder Kocher Maneuver Inferior Posterior-Prone Posterior Sitting ‘Traction-Sitting ‘Traetion-Supine 44,45 1. 12 10 10 NDEX Hand Examination Hibb’s Test Hip Examination History Humerus Inferior Posterior-Prone Posterior Sitting Knee Examination ‘Traction-limited flexion ‘Traction prone ‘Traction supine Lateral Stability Test Lift Test MeMurray’s Test Medial Stability Test Metacarpal Double Thumb Single Thumb Traction Metatarsophalangeal Joint Bunion Posterior Traction Mills Test. Morton's Test Navicular-Anterior-Medial Patella Femoral Grinding Test Patella Traction Phalen’s Test Radius-Posterior Range of Motion ‘Ankle Elbow Hand Hip Knee Shoulder Wrist Ribs Scapulothoracic Articulation Medial-Prone Medial-Side lying Lateral Shoulder Examination Sign Draw Drawer Froments Sternocostal Articulation Inferior Superior ‘Traction Sitting ‘Traction Supine 28-29 34 32-34 1 10-13 ul il 12 55Sternoclavieular Joint Superior ‘Draction Sitting ‘Traction Supine Strunsky’s Test ‘Talus Traction ‘Talus Anterior ‘Tarsometatarsal Joint-Anterior Test. ‘Adson’s ‘Allen's ‘Apley’s Compression Apley's Distraction Apley’s Grinding ‘Apprehension-Patella ‘Apprehension-Shoulder “Bounce Home” British Cozen Dawburn’s Drop Arm| Dugas Eden's English Fabere-Patrick Finkelstein's Hibbs Lateral Stability Lift McMurray's Medial Stability Mill's 56 Morton's Phalen’s Strunsky’s ‘Thomas ‘Tinel Tap ‘Trendelenberg Valgus Stress Varus Stress Wright's Yergason’s ‘Thomas Test ‘Tibia Anterior-Medial Anterior-Lateral Posterior ‘Tinel Tap Test ‘Trendelenberg Test: Ulna Posterior Posterior-Medial Valgus Stress Test Varus Stress Test Wright's Test Wrist Double Thumb Single Thumb Traction Xray Yergason's Test